Every finding on record at Brickyard Healthcare - Brookview Care Center

Based on observation, interview, and record review, the facility failed to timely develop and update behavior plans of care and to document behaviors on behavior tracking logs for 3 of 3 residents reviewed for behaviors (Resident 12, Resident 50, and Resident 1). Findings include: 1. The clinical record for Resident 50 was reviewed on 1/23/26 at 10:20 a.m. The resident's diagnosis included, but were not limited to, schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels, ranging from manic highs to depressive lows). A Quarterly Minimum Data Set (MDS) Assessment, completed 8/11/25, indicated the resident was able to make herself understood and understand others. She had severely impaired decision making and was independent with transfers and ambulation. A Change of Condition Situation progress note, dated 9/1/25 at 3:12 p.m., indicated Resident 50 had told staff that a male resident (Resident 1) went inside her room, touched her breast and private parts, and slapped her face. However, the male resident (Resident 1) was on his bed when staff checked his room. Resident 50 had repeated the same story to the writer (of the progress note). The male resident was on his bed asleep. A head-to-toe assessment was done and no redness or swelling noted on the resident's face. Resident 50 had no reports of discomfort or pain. A physician's progress note, dated 9/2/25, indicated Resident 50 was seen due to reports/allegations of inappropriate contact by another resident on 9/1/25. Resident 50 had alleged male resident came to her room, touched her inappropriately and slapped her face. Staff reports that male resident was resident in his bed in his own room at the time of the report/allegation. Resident 50 had no apparent evidence of acute injury noted at the time. The assessment and plans indicated Resident 50 had paranoid schizophrenia chronic fluctuating psychosis with labile mood as well as delusions and apparent hallucinations, acutely anxious and paranoid with recent allegations against another resident. No physical evidence of assault as resident reported to staff over weekend. A Behavior Charting note, dated 9/25/2025 at 1:39 p.m., indicated Resident 50 reported a false interaction with another resident. Resident 50 with noted delusional thinking. Prior to behavior, Resident 50 was walking in the hallway and up in communal space. The intervention attempted by staff was to return the resident to her room. Effectiveness of intervention indicated Resident 50 was able to be redirected at that time. A Physician's Progress note, dated 11/6/25, indicated Resident 50 had poor judgement and poor insight in her medical condition due to her diagnosis of paranoid schizophrenia. She had delusional symptoms and was unable to make firm and consistent decisions for herself. A General Note created by Registered Nurse (RN) 20 on 12/15/25 at 11:44 a.m. as a late entry for 12/13/25 at 10:45 a.m., indicated Resident 50 approached RN 20 with a video of another resident (Resident 1) exposing himself to Resident 50. When Resident 50 was asked why Resident 1 was in her room and Resident 50 indicated she invited him but did not state why. RN 20 educated Resident 50 about recording someone without permission and nursing staff would monitor both parties for 72 hours following event. Resident 50's clinical record contained a Capacity to Consent assessment, dated 12/13/25, that indicated Resident 50 could tell you what it means to engage in sexual activity. She had the ability to avoid exploitation, the ability to say yes or no to sexual activities at any time, understood that they could change their mind about engaging in sexual activity at any time. Resident 50 had the ability to identify who they are having a relationship with. Resident 50's sexual behaviors were consistent with her formally held beliefs and understood that sexual activity can have physician, emotional, and health consequences. Resident 50's clinical record did not include a physician's assessment of her cognitive ability and insight to engage in a sexual relationship. Resident 50's clinical record contained a General Note, dated 12/29/2025 at 10:30 a.m., that indicated the nurse was alerted to Resident 50's room. When the room was entered, Resident 50 was sitting on the floor on her knees, with her feet behind her and was undressed from the waist down. Male resident (Resident 1) was noted to be on the floor, fully dressed. Resident 50 then became agitated and started yelling at staff to leave her room. A General Note, dated 12/29/2025 at 10:30 a.m., indicated Resident 50 was in the hallway partially dressed in her bra but had removed her shirt. Resident 50 was gesturing to a male resident (Resident 1) who was also in the hallway. Resident 50's clinical record contained a Physician Note written by NP 21, dated 12/29/2025 5:13p.m., that indicated when provider walked into room, Resident 50 was sitting on the floor with bra on and unknown if undergarments were present. NP 21 and Licensed Practical Nurse (LPN) 22 attempted to educate Resident 50 on sexual behavior, STDs, and possible pregnancy. Offered Resident 50 birth control, however Resident 50 became verbally abusive to NP 21 and repeatedly stated to get the F*** out of her room. To prevent Resident 50 further distress, NP 21 left room. Staff reported that Resident 50's guardian had returned call and agreed to placing Resident 50 on Depo Provera birth control shots. The physician has ordered labs and Depo Provera would not be started until lab results are obtained. Resident 50 had a previous episode of sexual behavior noted by staff on 12/13/2025 and per staff note resident had recorded another resident (Resident 1) exposing himself to her. Resident 50's clinical record contained a Progress Note from the physician, dated 1/1/26 at 8:00 a.m., indicated Resident 50 was being evaluated due to her request she and a male resident at the facility wish to participate in intimate sexual activities. Resident 50 was not cooperative during interaction and was rather very agitated and yelling and grabbing the physician's document and apparatus and threw them away. This was after we had been communicating by writing for approximately 45 minutes. Some of the things Resident 50 had said were that she did not initiate this and that it was the male resident who had approached her about the relationship. Resident 50 eventually told the physician that she would like to engage in intimate sexual relationship with a male, but she does not want any birth control. Resident 50 indicated she does not want to have any birth control treatments. Resident 50 was educated in writing that a serum pregnancy test, hepatitis b and c test, and HIV test were ordered. She was informed at this time that birth control was a must have if she wanted to have any intimate sexual relationship with a male. The impression the physician got was that she had an acute flareup of her manic episode with her bipolar disorder. Resident 50 does not have any decision-making capability to engage in sexual activity with a male as requested. The physician's conclusion was that Resident 50 did not have the decision-making capability to have any sexual relationship with a male resident at this facility because she had no insight in her decision. Resident 50's clinical record did not contain a care plan that indicated she was unable to consent to sexual activity. During an interview on 1/23/26 at 2:06 p.m., Certified Nursing Assistant (CNA) 23 and CNA 24 indicated they worked with Resident 1 and Resident 50 often. The nurse had informed them, sometime around New Years, to try to keep them out of each other's rooms. During an interview on 1/23/26 at 2:29 p.m., Social Worker (SW) 1 indicated she had not been made aware that Resident 50 had video tapped Resident 1 exposing himself. SW 1 should have been made aware of these incidents. During an interview on 1/23/2026 at 2:50 p.m., the Staff Development Coordinator (SDC) indicated on 12/13/25 she had been made aware that Resident 50 had videotaped Resident 1 with his hands down his pants. The ED had been made aware. SDC had not seen the video. The SDC could not recall if any specific interventions were set up for either resident after the incident. The staff did look in on them often to ensure they were not together. During an interview on 1/27/25 at 10:03 a.m., the DON indicated that she had updated Resident 50's history of behaviors care plan on 1/5/26. During an interview on 1/27/26 at 11:10 a.m., Qualified Medication Aide (QMA) 25 indicated he had not been informed to try to keep Resident 1 out of Resident 50's room. Resident 1 often went to Resident 50's room and Resident 50 would come to Resident 1's room. During an interview on 1/23/26 at 3:22 p.m., RN 20 indicated the staff were told to keep Resident 1 and Resident 50 separated and to keep an eye on them. Resident 50 often went to Resident 1's room and asked Resident 1 to come with her. The facility had done an Inservice about respecting the resident's right to be sexual and to provide privacy for resident's who were being sexual. During an interview on 1/27/26 at 12:27 p.m., SW 1 indicated Resident 50 did not have a care plan about redirecting others from her room or what to do if a resident may want to visit with her privately. Resident 50's clinical record did not include a care plan related to Resident 50 identifying herself as different people. 2.The clinical record for Resident 1 was reviewed on 1/21/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to, vascular dementia (losing touch with reality, characterized by hallucinations and delusions caused by brain damage) with behavior disturbance, schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and chronic hepatitis C (a long-term, contagious liver infection caused by the hepatitis C virus). A care plan, initiated 5/20/25, indicated Resident 1 had impaired cognition function/dementia and communications deficits related to dementia and a history of stroke (blood flow to the brain was interrupted or blood vessels burst causing brain cells to die). The goal was for him to maintain current level of cognitive function. The interventions was for staff to reorient and supervise as needed; keep his routine consistent and try to provide consistent care givers as much as possible to decrease confusion; use task segmentation to support short term memory deficits; break tasks into one step at a time as needed to promote understanding. A care plan, initiated 6/24/25, indicated Resident 1 had a behavior problem of intrusive wandering or exit seeking related to his vascular dementia with behavior disturbance. He was known to propel his wheelchair backwards with potential to bump into objects or people. The goal was for him to have no evidence of behavior problems, and he would have no injury to self or others. The intervention was for staff to redirect Resident 1 from others resident's rooms as needed, initiated 6/24/25. A Quarterly MDS Assessment, completed 9/27/25, indicated Resident 1 was able to make himself understood and to understand others. He was severely cognitively impaired. The resident required set-up assistance and supervision for transfers from his bed to his wheelchair. A Psychiatric Subsequent Assessment, dated 10/15/25, indicated Resident 1 was seen to manage a chronic condition. Resident reported that his mood was okay. Resident 1 believed the year was 2002 and the month was March. A General Note, created by RN 20 on 12/15/25 at 11:45 a.m. as a late entry for 12/13/2025 at 10:45 a.m., indicated Resident 1 was in another resident's [Resident 50] room exposing himself when asked what he was doing in the other resident's room Resident 1 indicated she told me to come in there. Resident 1 was removed from Resident 50's room and will be monitored for 72 hours. Resident 1's clinical record contained a Capacity to Consent assessment, dated 12/13/25, that indicated Resident 1 was able to tell you what it means to engage in sexual activity. He was able to avoid exploitation and had the ability to say yes or no to sexual activity at any time. He understood that they could change their mind about engaging in sexual activity at any time and had the ability to identify who they are having a relationship with. Resident 1's sexual behaviors were consistent with his formally held beliefs, and he understood that sexual activity can have physical, emotional, and health consequences. The clinical record did not contain a physician's assessment of Resident 1's cognitive ability to consent to a sexual relationship Resident 1's clinical record contained a General Note, dated 12/28/2025 at 6:30 p.m., that indicated Resident 1 was found in another resident's room. Both residents appeared calm. Resident 1 had his clothes and shoes on and was sitting in his wheelchair. Resident 1 was redirected back to his own room and provided education about the importance of asking consent prior to going into another resident's room. Resident 1's clinical record did not contain a care plan related to Resident 1's wishes to be in a sexual relationship with another resident at the facility. Resident 1's clinical record contained a Progress note from the physician, dated 1/1/2026 at 8:00 a.m., that indicated the provider was asked to evaluate Resident 1, who wishes to engage in intimate sexual relationship with a female resident (Resident 50) at the same facility. Resident 1 was unable to provide detailed treatments that he had for hepatitis C. He was informed he was at risk of passing this sexually to the female resident. The physician did not approve that Resident 1 engage in any sexual activities with this female because she did not have the mental capacity to consent to sexual relationship. Resident 1 was told that the female partner he was trying to engage in sexual activity with did not have decision-making capability to engage in sex. She does not have good insight and the consequences of what she was trying to get into, so it was up to him not to engage in any sexual activity with this female resident. Resident 1's mental capacity was also impaired as he could not tell the physician what he had in mind to prevent a pregnancy or STD. Resident 1's clinical record did not contain a care plan that indicated he was unable to consent to sexual activity. A General Progress Note, dated 1/4/2026 at 3:30 p.m., indicated Resident 1 continued to go into another resident's room after being redirected back to his own room. Management was made aware. Staff would continue to monitor. A General Progress Note, dated 1/5/25 at 6:00 p.m., indicated family and unit manager made aware that Resident 1 was transferred to another room. During an interview on 1/23/26 at 2:06 p.m., Certified Nursing Assistant (CNA) 23 and CNA 24 indicated they worked with Resident 1 and Resident 50 often. The nurse had informed them, sometime around New Years, to try to keep them out of each other's rooms. During an interview on 1/23/26 at 2:29 p.m., Social Worker (SW) 1 indicated she had not been made aware that Resident 1 had exposed himself to Resident 50. SW 1 should have been made aware of these incidents. During an interview on 1/23/2026 at 2:50 p.m., the Staff Development Coordinator (SDC) indicated on 12/13/25 she had been made aware that Resident 50 had videotaped Resident 1 with his hands down his pants. The ED had been made aware. SDC had not seen the video. The SDC could not recall if any specific interventions were set up for either resident after the incident. The staff did look in on them often to ensure they were not together. Resident 1 had impaired cognitive ability and did not make rational decisions. During an interview on 1/27/26 at 11:47 a.m., SW 1 indicated Resident behaviors are tracked by behavior notes and charting by the CNAs in Point Click Care (PCC). The Behavior Note Report and the behavior notes were reviewed in morning meeting. The behavior notes were used more for new behaviors. The PCC behavior charting was more for behaviors that had already been identified. Behavior care plans were made by social services and with an IDT team. On 1/27/26 at 10:03 a.m., the DON provided the current Behavioral Health Services Policy that read .It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being.3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.5. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being.7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person0centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will.b. Obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health. c. Monitor the residents closely for expressions or indications of distress. d. Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable.f. Assess and develop a person-centered care plan for concerns, identified in the resident's assessment. g. Share concerns with the interdisciplinary [IDT] to determine underlying causes of mood and behavior changes, including differential diagnosis. h. Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record. i. Ensure appropriate follow-up assessment, if needed. j. Discuss potential modifications to the care plan. k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the residents.8. The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: a. Have interventions that are person-centered, evidenced-based, culturally competent, trauma-informed, and in accordance with professional standards of practice.c. Reflects the resident's goals for care.e. maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety.h. Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition.12. The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside r=sources such as physician psychiatrists, or neurologists On 1/27/26 at 9:13 a.m., the ED provided the Sexual Expression of Residents policy, that read .1. The staff will document observations of residents engaging in intimacy and/ or sexual activity and notify social services and the Director of Nursing. 2. The social services staff will notify the interdisciplinary team. 3. The social services staff will educate the residents about any disease processes and the residents' rights. a. Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/ or sexual expression. b. Resident with decisional capacity have a right to privacy, including private space for sexual expression. c. Resident with decisional capacity have a right to confidentiality. 4. The physician will be notified regarding all residents participating in se for a clinical and cognitive evaluation to determine intact cognitive decision-making-capacity and capacity to give consent.6. Care plan meeting with the interdisciplinary team shall be scheduled as soon as possible from the initial notification of the social services staff. a. The interdisciplinary team shall conduct a review of situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of and protects those involved. B. Outcomes of the interdisciplinary team review will be shared with the residents involved and documented in the plan of care. On 1/30/26 at 2:30 p.m., the Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists ©American Bar Association Commission on Law and Aging - American Psychological Association from the American Psychological Association web site which read .There are no generally accepted approaches or criteria for the assessment of consent to sexual activity. [NAME] et al., [1999] suggest that the following be considered by the examining clinician, with the understanding that some individuals with capacity to consent would not meet all of these criteria: Is an adult, as defined by state law; demonstrates an awareness of person, time, place, and event; possesses a basic knowledge of sexual activities; possesses the skills to participate safely in sexual activities; i.e., whether the person understands how and why to effectively use an appropriate method of birth control, and whether the person chooses to do so; understands the physical and legal responsibilities of pregnancy; is aware of sexually transmittable diseases and how to avoid them; demonstrates an awareness of legal implications concerning wrongful sexual behaviors [e.g., sexual assault, inappropriateness of sex with minors, exploitation, etc.]; can identify when others' rights are infringed; learns that 'no' from another person means to stop [i.e., understands that it is always inappropriate to have sex or engage in other activities with someone who says no or otherwise objects by words or action]s; knows when sexual advances are appropriate as to time and place [e.g., different places and times may apply to dancing, touching, sexual intercourse]; does not allow his or her own disability to be exploited by a partner; knows when both parties are agreeing to the same sexual activity; does not exploit another person with a lower functioning who might not be able to say no or defend oneself; expresses understandable responses to life experiences [i.e., can accurately report events]; can describe the decision-making process used to make the choice to engage in sexual activity; demonstrates the ability to differentiate truth from fantasy and lies; possesses a reasoning process that includes an expression of individual values; can reasonably execute choices associated with a judgmental process; is able to identify and recognize the feelings expressed by others, both verbally and nonverbally; expresses emotions consistent with the actual or proposed sexual situation; rejects unwanted advances or intrusions to protect oneself from sexual exploitation; identifies and uses private areas for intimate behavior; is able to call for help or report unwanted advances or abuse [[NAME] et al., 1999, p. 63-64]. [NAME] Lichtenberg offers the following suggestions for assessing sexual consent capacity: 1. Patient's awareness of the relationship: a. Is the patient aware of who is initiating sexual contact? b. Does the patient believe that the other person is a spouse and, thus, acquiesces out of a delusional belief, or [is he/she] cognizant of the other's identity and intent? c. Can the patient state what level of sexual intimacy [he/she] would be comfortable with? 2. Patient's ability to avoid exploitation: a. Is the behavior consistent with formerly held beliefs/values? b. Does the patient have the capacity to say no to any uninvited sexual contact? 3. Patient's awareness of potential risks: a. Does the patient realize that this relationship may be time limited [placement on unit is temporary]? b. Can the patient describe how [he/she] will react when the relationship ends?' These authors note that while being able to state the level of sexual activity or intimacy is wanted is an important consideration, one must also assess the ability to refuse or resist sexual advances. Lichtenberg et al., also emphasized Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists ©American Bar Association Commission on Law and Aging - American Psychological Association 67 the importance of residents understanding that the ending of a relationship might be one of the potential risks of entering into a sexual relationship. Residents can leave facilities for a variety of reasons [e.g., transfer due to illness], thereby terminating the relationship . 3.The clinical record for Resident 12 was reviewed on 1/21/26 at 1:30 p.m. The resident's diagnosis included, but was not limited to, metabolic encephalopathy (change in how brain works. Fluctuating confusion and attention issues). The Quarterly Minimum Data Set (MDS) Assessment, dated 10/3/25, indicated Resident 12 was moderately cognitively impaired. The Quarterly MDS Assessment, dated 12/30/25, indicated Resident 12 was cognitively intact. A discharge care plan for Resident 12, initiated date of 4/16/25 and revised on 12/16/25, indicated the resident required 24 hour supervision and care. Plans of discharging was uncertain at this time. A care plan, dated 4/16/25, indicated Resident 12 had diagnoses of depression and anxiety. The interventions in place, dated 4/16/25 and revised on 12/16/25, indicated the staff were to administer medications as ordered, provide psychiatric services, and discuss any concerns the resident had. A care plan, revision date of 1/9/26, indicated Resident 12 had a diagnosis of cognitive communication deficit evidence by becoming forgetful and needed reminders or verbal cues for daily decision-making. The following interventions, with an initiated date 4/14/25, indicated, but were not limited to: staff were to Cue, reorient and supervise as needed, encourage resident to go to dialysis as scheduled, and report suspected worsening of cognition or memory to the Medical Doctor. A intervention with a revision date of 12/15/25, indicated to discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers. An elopement assessment, dated 12/9/25, indicated Resident 12 was not an elopement risk. A nursing note, dated 12/27/25 at 4:24 p.m., indicated Resident 12 attempted to leave the building. The resident appeared to be agitated and verbalized I am leaving. The resident was redirected back in the building by another staff member. A behavior note for Resident 12, dated 12/27/26, indicated around 2:45 p.m., the resident was taling and happy then at 4:30 p.m., the resident was found to be attempting to leave the facility unaccompanied. The physician assistant (PA) on call was notified and ordered alprazolam (used for short-term relief of anxiety and panic disorders by slowing down the central nervous system) 0.5 mg (milligrams) every 8 hours for anxiety and agitation x 3 days. A medical provider note, dated 12/27/25, indicated Resident 12 had exhibited exit-seeking behavior this afternoon. He was redirected without incident. Will continue to monitor. A medical provider visit note, dated 12/29/25, indicated Resident 12 was being seen that day for making attempts to get out of the facility by himself over the weekend. The resident had reported to the medical provider he would like to leave and go back to (another State). The resident was unable to provide who he would be staying with, other than friends nor how he would continue with his dialysis treatments in the other State. The resident did not have family that resided in the other State. The resident had poor judgment, and poor insight in his medical condition. He suffered from some cognitive challenges which was likely related to his previous polysubstance use disorder causing encephalopathy (a diagnosable mental health condition where a person compulsively uses three or more different classes of substances, leading to significant impairment in their life). A physician's order, dated 12/30/25, indicated Resident 12 was to receive 0.5 milligrams of Xanax every 8 hours as needed (PRN) for agitation and anxiety. A care plan for elopement was not developed with interventions for Resident 12. A behavior note, dated 12/30/25, indicated, the resident was found near the employee log-in area. The resident was .pressing [a keyless digital lock] keypad near the employee log-in area. Staff had attempted to redirect the resident and the resident started cursing and refusing to be redirected. The unit manager was able to intervien. A behavior note, dated 12/31/25, indicated, the resident was agitated, yelling in the dining room, calling staff names and was screaming loudly in the dining room. The staff tried to redirect the resident and the resident screamed louder calling staff more names and threw self on the floor out of wheelchair in the dining room. Resident 12's behavior care plans were not updated with new interventions to address behaviors. An elopement evaluation, dated 1/4/26, indicated Resident 12 did not have a history of elopement and wandering. He was not an elopement risk. A social services note, dated 1/7/26, indicated the resident reported that he did not plan to be in this State. He stated he was traveling when he experienced a medical emergency, was taken to a hospital in this State. An elopement evaluation, dated 1/9/26, indicated Resident 12 did have a history of elopement and wandering. The resident scored a five on the assessment indicating he was an elopement risk. A nursing note, dated 1/9/26, indicated the resident called 911 (emergency services) without informing the nurse at 2:45 p.m. The emergency service team (911) arrived at the facility since the resident indicated he wanted to kill himself to the 911 caller. Hospital discharge report, dated 1/9/26, indicated, the resident arrived at the emergency department related to suicidal ideation. The resident was trying to leave his facility and had threatened to kill himself if he was not able to leave. A nursing note, dated 1/10/26, indicated the resident returned from hospital with no new orders. The hospital noted indicated they had conversations with him about different coping mechanisms while feeling angry about things. The resident indicated he was just mad and was not really going to do anything. The resident was to be checked on every 30 minutes for 72 hours

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program for 2 of 4 residents reviewed for activities (Resident C and Resident B). Findings include:1.During an observation, on 1/21/26 at 11:38 a.m., Resident C was lying in bed with his eyes open. There was no music or television on in the resident's room. During an observation, on 1/22/26 at 11:56 a.m., Resident C was lying in bed with his eyes open. There was no music or television on in the resident's room.During an observation, on 1/23/26 at 11:18 a.m., Resident C was sitting in his room in a high back wheelchair with his eyes open. There was no music or television on in his room. Review of the clinical record of Resident C, on 1/23/26 at 2:09 p.m., indicated the resident's diagnoses included, but were not limited to, anoxic brain damage (the brain was completely deprived of oxygen, leading to severe physical, cognitive, and emotional issues), persistent vegetative state (consciousness resulting from sever brain damage where awake but showing no signs of awareness), muscle weakness, and sleep disorder (conditions that impair the amount of sleep resulting in daytime distress).The care plan for Resident C, dated 7/24/25, indicated the resident was in a persistent vegetative state and was unable to communicate. The resident was dependent on staff to anticipate his needs. The resident's family indicated the resident enjoyed music and being read to. The interventions included, but were not limited to, leave music and television on for the resident to hear during the day. During an interview with the Activity Director, on 1/23/26 at 1:34 p.m., she indicated she thought the CNA's were responsible to ensure Resident C's television or radio was on. 2.During an observation and interview with Resident B on 1/21/26 at 11:59 a.m., Resident B was sitting in her room with no self initiated activities occurring. The resident indicated the facility did not have enough activities and there was no variety of activities offered. The resident indicated she stayed in her room most of the time because there was no activities occurring. The resident indicated the facility did have bingo.During an observation and interview with Resident B on 1/23/26 at 10:50 a.m., Resident B was sitting in her room watching the television. The resident indicated she would like the facility to offer arts and crafts, play cards, have music and go outside when the weather was nice. Review of the clinical record of Resident B on 1/22/26 at 10:51 a.m., indicated the resident's diagnoses included, but were not limited to, end stage renal disease (irreversible phase of kidney failure), heart failure (chronic, progressive condition where the hear muscle was too weak) and weakness. The annual Minimum Data Set (MDS) for Resident B, dated 11/4/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. It was somewhat important to the resident to read the newspaper, books, magazines, be around animals, listen to music and keep up with the news. The care plan for Resident B, dated 11/13/25, indicated the resident enjoyed group programs such as bingo, cards, outings, resident council, going outdoors and attending church. The preference evaluation for Resident B, dated 1/21/26, indicated the resident enjoyed spending time with her family member, jigsaw puzzles, watching television, going to church and socializing with other residents. The resident indicated it was very important to have books, magazines, newspapers, keep up with the news, listen to music, do activities in groups, go outside when the weather was good and participate in religious services. During an interview with the Activity Director, on 1/23/26 at 1:34 p.m., she indicated she started working at the facility in November 2025. The facility had not had an activity assistant for the long term care part of the facility, but had one start work yesterday. The facility did have an activity assistant that worked on the two memory care units and when she had time she attempted to help the Activity Director on the long term care side of the facility. The Activity Director indicated she was required to attend meetings daily, from 9:00 a.m. to 10:00 a.m., and then had care plan meetings every Wednesday, from 10:00 a.m. to 1:00 p.m., it depended on how many care plan meetings were scheduled that day. The Activity Director indicated Resident B enjoyed going to bingo and had not reported to her that she would like to do other activities. The activity policy provided by the Director Of Nursing (DON) on 1/23/26 at 2:00 p.m., indicated the facility would provide an ongoing activity program to support residents in their choices. Activities were to promote self-esteem, pleasure, comfort, education, creativity, success, and independence. This citation relates to Intake 2713078. 3.1-33(a)

Based on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 11) Findings include: 1.The clinical record for Resident 11 was reviewed on 1/21/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus (chronic metabolic disorder characterized by high blood sugar). A care plan, dated 1/10/25, indicated Resident 11 had diabetes mellitus. The interventions included, but were not limited to, the staff were to administer the diabetic medications as ordered. A physician's order, dated 9/11/25, indicated Resident 11 was to receive 5 units of aspart insulin before meals. The insulin was not to be given if the resident's blood sugar was less than 100. The order was discontinued on 1/21/26. The January 2026 Medication Administration Record indicated on the following dates and shifts Resident 11 had received 5 units of aspart insulin when her blood sugar reading was less than 100: -On 1/8/26 in the morning, the resident's blood sugar reading was 94. The resident was administered 5 units of insulin. -On 1/13/26 in the morning, the resident's blood sugar reading was 92. The resident was administered 5 units of insulin. -On 1/17/26 in the morning, the resident's blood sugar reading was 89. The resident was administered 5 units of insulin. A physician's order, dated 11/19/25, indicated the staff were to administer 20 units of glargine insulin to Resident 11 in the mornings. The insulin was to be held if the resident's blood sugar was less than 110. The January 2026 Medication Administration Record indicated on the following dates and shifts Resident 11had received 20 units of glargine insulin when her blood sugar reading was less than 110: -On 1/8/26, the resident's blood sugar reading was 94. The resident was administered 20 units of glargine insulin. -On 1/9/26, the resident's blood sugar reading was 80. The resident was administered 20 units of glargine insulin. -On 1/13/26, the resident's blood sugar reading was 92. The resident was administered 20 units of glargine insulin. -On 1/16/26, the resident's blood sugar reading was 83. The resident was administered 20 units of glargine insulin. -On 1/17/26, the resident's blood sugar reading was 89. The resident was administered 20 units of glargine insulin. -On 1/20/26, the resident's blood sugar reading was 91. The resident was administered 20 units of glargine insulin. -On 1/21/26, the resident's blood sugar reading was 106. The resident was administered 20 units of glargine insulin. -On 1/22/26, the resident's blood sugar reading was 90. The resident was administered 20 units of glargine insulin. -On 1/25/26, the resident's blood sugar reading was 71. The resident was administered 20 units of glargine insulin. -On 1/26/26, the resident's blood sugar reading was 93. The resident was administered 20 units of glargine insulin.-On 1/27/26, the resident's blood sugar reading was 102. The resident was administered 20 units of glargine insulin. A physician's order, dated 1/21/26, indicated the staff was to administer 3 units of aspart insulin to Resident 11 before meals. If the resident's blood sugar was less than 110, the insulin was not to be given. The January 2026 Medication Administration Record indicated on the following dates and shifts Resident 11had received 3 units of aspart insulin before meals when the resident's blood sugar reading was less than 110: -On 1/25/26 in the morning, the resident's blood sugar reading was 71 and in the afternoon, the resident's blood sugar reading was 84. The resident was administered 3 units of insulin in the morning and in the afternoon. -On 1/26/26 in the morning, the resident's blood sugar reading was 93. The resident was administered 3 units of insulin. -On 1/27/26 in the morning, the resident's blood sugar reading was 102. The resident was administered 3 units of insulin. An interview was conducted with the Director of Nursing on 1/27/26 at 3:22 p.m. She indicated the staff had administered the resident's insulins when they should have been held, per the prescribed parameters as ordered by the physician. 2.The clinical record for Resident 11 was reviewed on 1/21/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, congested heart failure (chronic condition where the heart muscle weakens and can't pump enough oxygen-rich blood to meet the body's needs). A care plan, dated 1/22/25, indicated Resident 11 had swelling in her legs due to heart valve replacement, hypertension (high blood pressure), congestive heart failure and chronic kidney disease. The interventions included, but were not limited to, the staff were to monitor vital signs and notify medical provider of abnormalities and give medications as ordered. A physician's order, dated 9/23/25, indicated the staff were to administer 2 tablets of 20 milligrams of torsemide (water pill, used to treat excess fluid retention) daily to Resident 11. The medication was not to be given if the resident's systolic blood pressure (the top number in a blood pressure reading) was less than 100. The January 2026 MAR indicated Resident 11 had received 40 milligrams of torsemide every morning from 1/1/26 through 1/27/26. There were no blood pressures obtained prior to the administrations as ordered. An interview was conducted with the Director of Nursing on 1/27/26 at 3:22 p.m. She indicated she was unable to find blood pressure readings that had been obtained prior to the administration of the resident's 40 milligrams of torsemide medication. The order was not set up correctly in the electronic medication system in error. A medication administration policy was provided by the Executive Director on 1/23/26 at 2:54 p.m. It indicated, Policy.Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure staff maintained infection control by touching pill medications with their bare hands for 1 of 1 random observations of a medication administration. (Resident 53) Findings include:An observation was made of Qualified Medication Aide (QMA) 5 at a medication cart on 1/23/26 at 9:44 a.m. QMA 5 was observed to touching the medication drawers and multiple medication cards. The QMA pulled a medication card out of her medication cart and popped the resident's medication tablet into her bare hand. She placed the tablet into a medication cup full of other medications. The QMA indicated, at that time, the medication was for Resident 53. No hand washing or hand sanitizer was used by QMA 5, prior to popping the resident's medication into her hand or during the observation. An interview was conducted with the Nurse Consultant and the Director of Nursing (DON) on 1/23/26 at 2:00 p.m. The DON indicated staff should not touch medication tablets with their bare hands. The clinical record for Resident 53 was reviewed on 1/22/26 at 1:30 p.m. The residents diagnoses included, but were not limited to type II diabetes mellitus. A medication administration policy was provided by the Executive Director on 1/23/26 at 2:54 p.m. It indicated, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines:.14. Remove medication from source, taking care not to touch medication with bare hand. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure residents' rooms were homelike and in good repair for 2 of 4 resident rooms observed during an environmental tour. (Resident 10 and Resident 24) Findings include: 1.An observation was made of Resident 10's room on 1/21/26 at 11:22 a.m. The resident's closet door was observed to be broken. During an environmental tour, with Housekeeping Staff 1, Housekeeping Staff 2, and the Senior District Operations Manager on 1/28/26 at 11:51 a.m., Resident 10's room was observed. The sliding closet door was observed not attached inside the medal track causing the closet door to freely move out instead of glide back-n-forth in the track. Housekeeper Staff 1 indicated the closet door had been broken for a while. The Senior District Operations Manager indicated the medal track was bent and needed replaced. 2. An observation was made of Resident 24's room on 1/21/26 at 11:39 a.m. The bottom brown baseboard was observed pulled away from the wall under the heat and air unit. An interview was conducted with Resident 24 on 1/21/26 at 11:40 a.m. The resident indicated the baseboard had been like that for a long time. During an environmental tour, with Housekeeping Staff 1, Housekeeping Staff 2, and the Senior District Operations Manager on 1/28/26 at 11:51 a.m., Resident 24's room was observed. The bottom brown baseboard was observed pulled away from the wall under the heat and air unit. They indicated the maintenance department would address repairs that were needed in the resident rooms. The Facility Maintenance Guidelines and Procedure was provided by the Executive Director on 1/28/26 at 12:17 p.m. It indicated, It is our intent to provide a clean, comfortable environment. The maintenance of the facility will be conducted as follows:.Staff should place items they find in the normal course of their day in the TELS Work Order System when found as well as placing items in the system when residents make requests. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident, who was assessed by the facility as an elopement risk, did not exit the facility unsupervised, for 1 of 3 residents reviewed for elopement and elopement risk (Resident B). The resident was able to exit the secured memory care unit through a bathroom window without the knowledge of staff. The resident was found at a local gas station, located in a busy intersection, and later sent to a local hospital after involvement with local police and emergency medical services (EMS).The Immediate Jeopardy began on October 1, 2025, when a cognitively impaired resident with dementia exited the secured memory care unit through a bathroom window unsupervised into a potentially dangerous area, including a multiple lane, busy intersection, that the resident had to cross to get to the local gas station located approximately 0.3 miles away from the facility. The Executive Director, Director of Nursing, and the Corporate Nurse were notified of the Immediate Jeopardy on 10/6/25 at 4:27 p.m.Findings include:The clinical record for Resident B was reviewed on 10/6/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia with agitation and behavioral disturbances, sleep disorder, and diabetes. He was admitted to the facility's secured memory care unit on 8/7/25. An admission Minimum Data Set (MDS) assessment, completed 8/14/25, indicated Resident B had severely impaired cognition. He displayed wandering behaviors for one to three days during the assessment period. The wandering behaviors placed him at a significant risk for potential danger. An elopement risk assessment, dated 8/15/25, indicated Resident B had a history of elopement and/or attempted elopement while at home. He had a history of attempted leaving the facility without informing staff. He had verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. He had wandered with a goal-directed specific destination. His wandering behavior was likely to affect the safety and well-being of himself or others. He had been recently admitted or re-admitted (within the past 30 days) and was not accepting of the situation.A care plan, dated 8/15/25, indicated he was at risk for elopement from the facility related to attempts to leave the facility unattended and impaired safety awareness. The goal was for his safety to be maintained, and he would not leave the facility unattended. The interventions included distracting him from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Identify patterns of wandering and intervene as appropriate. Leave of absences with supervision. Place his picture in the elopement binder. Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Resident resided on a secured unit. A care plan, dated 8/26/25, indicated he had the potential to be verbally or physically aggressive related to dementia with agitation, with recent episodes observed. The goal was for him to have no new episodes of physical aggression toward peers. The interventions included administering medications as ordered, assessing and anticipating his needs, provide physical and verbal cues to alleviate anxiety; give positive feedback, assisting with verbalization of source of agitation, assisting to set goals formore pleasant behavior, encourage seeking out of staff member when agitated, and psychiatric/psychogeriatric consult as indicated.A care plan, dated 8/26/25, indicated he was at risk for sleep pattern disturbance. The resident had an order or had used sleep medication and had periods of staying awake at night due to being a truck driver in the past. The goal was for him to exhibit no sleep related behavioral symptoms, such as restlessness, irritability, lethargy, or disorientation. The interventions included administering sleep medications as ordered by the physician, assessing for adverse side effects, and assisting him in establishing a daily routine with periods of rest and activity. Also, to maintain an environment conducive to sleep (quiet, comfortable temperature, dimmed lights). A Behavioral Health Diagnostic Assessment, dated 9/2/25, indicated the reason for Resident B's referral for treatment was anxiety disorders, agitation, neurocognitive disorders, feeding/eating or sleep/wake disorders. The clinical assessment indicated Resident B was alert and conversational but not oriented. He was only oriented to person. He thought [NAME] was the president and stated he was in his older 20s when asked about his age. Resident B reported some anxiety. He can be physically aggressive with others on the Memory Care Unit. A General Note, dated 10/1/25 at 2:15 a.m., indicated at the start of the shift, at 10:00 p.m., Resident B was in his bedroom in bed sleeping. At around 2:15 a.m., during rounding, Resident B was awake in his bedroom with no noted anxiety at that time. Resident B walked out of his bedroom and into the hallway, and then went back into the bedroom and closed the door. At 4:15 a.m., writer (writer of the General Note) was notified by CNA (Certified Nurse Aide) that resident was not in the room. A search was initiated at that time, and a chair was in place under the window in the resident's bathroom and the window was open. At 4:15 a.m., the writer called code silver, and a search of the premises inside and outside was initiated. The Executive Director (ED), physician, and family were notified. The writer was notified that resident was at an acute care hospital at 4:45 a.m. The physician, ED, and family were notified.An SBAR (Situation, Background, Assessment, and Recommendation) Change of Condition note, dated 10/1/25 at 11:02 a.m., indicated Resident B had reported to the acute care hospital that he had fallen during the time he had left the building. An observation was conducted of the male memory care unit with the Maintenance Supervisor (MS) on 10/6/25 at 10:06 a.m. Resident B's room was observed with windows in the bed area and bathroom. The MS indicated the resident had moved a chair to the bathroom and climbed out of the bathroom window. The bathroom was observed with a wood block screwed inside the window. The MS indicated the wood block was placed after the resident had eloped out of the window. He indicated the two plastic pieces that were on the window, that were to prevent the window from opening all the way, were broken off. He believed it was the resident that night who had broken the two plastic pieces on the window but was unsure. He indicated he had put a wood block in other residents' bathroom windows prior to the incident but had not gotten to Resident B's bathroom window yet. All the resident rooms regardless of whether a resident resides in memory care have a wood block placed in the bedroom area windows for prevention of the windows from opening all the way. The male memory care unit ,since the incident, now had all the residents' bathroom windows with wood blocks applied as well. During an interview on 10/6/25 at 10:25 a.m., the ED indicated the male memory care unit was opened in July of 2025. She received a call from the facility staff that reported Resident B had eloped out the bathroom window. The resident was appropriately dressed in a hooded sweatshirt, pants, socks, and shoes. She was aware he did have a history of attempting to elope out of the doors but was not aware he could climb out of windows. During the silver alert, the facility staff had contacted hospitals, and they were able to find the resident at an acute care hospital. The ED drove to the hospital to speak with Resident B. He reported to her he moved a chair in the bathroom and climbed out the window. He had fallen climbing out of the window to the ground. The resident was observed with an abrasion on his arm. After he hit the ground, he couldn't recall what happened, but he stated, I ran the h*** out of there. He did end up at the gas station across the street from a local fast-food place. He had taken a candy bar and some gum from the gas station. The gas station staff had contacted the emergency medical services (EMS), and he was taken to an acute care hospital. The resident's cognitive baseline fluctuates; at times he was more cognitively intact than other times. The resident had reported the purpose of the elopement was that he needed to get to the bank. After the incident, the ED spoke to the resident's Power of Attorney (POA), and she reported the resident does get anxious about his money after a certain family member visits.An interview was conducted with Family Member (FM) 2 on 10/6/25 at 10:58 a.m. FM 2 indicated Resident B had a history of attempting to escape through windows. FM 2 had visited the facility, in the past, and had seen the bathroom window open. FM 2 had told a staff member that if Resident B realized the windows were opened, he would try to use the window to get out. FM 2 did not see any alarms or safety devices on the windows to keep them from opening. An interview was conducted with FM 3 on 10/6/25 at 12:33 p.m. FM 3 indicated she had seen the bathroom window open and expressed concern about Resident B eloping through the window. FM 3 had been told by the staff that there was nothing to worry about. FM 3 had informed the staff that Resident B would try to get out of the facility any way he could. FM 3 had told a staff member of the facility that Resident B would try to get out of the window. An interview was conducted with CNA 4 on 10/6/25 at 12:50 p.m. CNA 4 indicated she worked the 6:00 p.m. to 6:00 a.m. shift. She had worked the night of Resident B's elopement. She worked often on the memory care unit. Resident B had been pacing that night and appeared to be anxious. He normally would be sleeping. She had checked on him at 10:00 p.m., 12:00 a.m., and 2:00 a.m. At approximately 4:00 a.m.- 4:15 a.m., she had checked on the resident. The resident's bathroom door was locked. After opening the door, a chair was found in the bathroom with the window opened. Resident B was not in the bathroom. CNA 4 then alerted the nurse that Resident B was unable to be found. She had never opened nor seen the bathroom window open prior to the incident. CNA 4 didn't even know the residents' windows in the bathrooms were able to be opened.An interview was conducted with CNA 5, Unit Manager (UM) 6, Qualified Medication Aide (QMA) 7, and Licensed Practical Nurse (LPN) 8 on 10/6/25 at 2:08 p.m. They indicated Resident B was pleasant and easily redirected when he was agitated. The resident had been attempting to exit through the door for about 48-72 hours after he was admitted to the facility. He did adjust and had not been attempting since. The resident's family had attempted to care for him at home but had to admit him to the facility. He had become more aggressive towards the family. They have not observed the residents' windows open on the memory care unit nor do they open the residents' windows. QMA 7 indicated she had gone out to an appointment with Resident B, on the morning of 9/30/25, and he was not observed to be having any behaviors during that appointment and did not mind having to return back to the unit that day. An interview was conducted with LPN 8 on 10/6/25 at 2:55 p.m. She indicated she worked night shift approximately two to three times a month on the male memory care unit. LPN 8 had worked the night of 10/1/25, when Resident B eloped. Resident B can be agitated at times. He will voice about family stealing his money and needing to go to the bank. The resident did not appear to be anxious to her that night nor did she receive report he had been anxious that day. The resident was dressed that night but normally went to bed that way. If he was not sleeping, he normally would come into the dining room and talk with her at night. That night, he had walked in the hallway but had not come into the dining room to speak with her. From approximately 4:00 a.m. to 4:15 a.m., CNA 4 had reported Resident B was unable to be located. LPN 8 had gone into the resident's room and found a chair in the bathroom with the screen and window open. A silver alert was immediately called. LPN 8 had never observed the residents' bathroom windows opened by staff nor residents.An interview was conducted with the ED on 10/6/25 at 4:23 p.m. She indicated she had not had any conversations with Resident B's Power of Attorney (POA) regarding the elopement risk of the windows in the residents' bathrooms. The ED had spoken with the facility's admission staff member and case manager. They also had no conversations with the POA about the elopement risks involving the windows in the residents' bathrooms.On 10/6/25 at 4:01 p.m., an interview was conducted with the Memory Care Director (MCD). The MCD indicated she had spoken with Resident B's family when he was admitted to the facility. The family had informed the MCD that Resident B was an elopement risk but had not told her that Resident B had a history of trying to leave through windows. When Resident B was first admitted to the facility, he displayed exit seeking behaviors. The exit seeking behaviors had subsided after he had been at the facility for a while. Resident B could become agitated and was not always easily redirected. His cognition varied from day to day. The MCD indicated she believed the bathroom windows should have been locked and had not noticed they were not. FM 3 had informed the MCD of the family's concerns about the windows after Resident B had eloped on 10/1/25. The MCD had not seen any of the bathroom windows on the secured unit open. On 10/6/25 at 2:46 p.m., the Executive Director provided the current Elopement and Wandering Residents policy that indicated .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/ alarms to help avoid elopement . 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .The past noncompliance Immediate Jeopardy began on October 1, 2025. The immediate jeopardy was removed and the deficient practice corrected, on October 1, 2025, after the facility implemented a systemic plan that included the following actions: an audit of all residents was completed and elopement assessments were updated, education was given to all staff on elopement protocol, elopement drills were conducted on every shift, and all windows in the facility were audited to ensure safety blocks were in place. All identified windows missing safety blocks were installed. This citation is related to Intake 2633368 and Intake 2632780.3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy (feeding) tube received flushes per the physician's orders for 1 of 3 residents reviewed for feeding tubes. (Resident D)Findings include:The clinical record for Resident D was reviewed on 8/27/25 at 3:10 p.m. The diagnoses included, but were not limited to, muscle weakness, dysphagia, diabetes mellitus, and gastrostomy status. A Quarterly Minimum Data Set (MDS) assessment, dated 6/27/25, indicated Resident D had a feeding tube and received greater than 51% of their nutrition via the feeding tube. A care plan for tube feeding, initiated 4/14/25, indicated Resident D required tube feeding related to dysphagia. The interventions included, but were not limited to, see physician orders for current feeding orders and indicated Resident D was dependent with receiving tube feeding and water flushes. A current physician's order, dated 6/23/25, indicated the use of tube feeding to run at 65 milliliters (mLs) per hour and water flushes of 50 mL per hour. An observation was conducted of Resident D, on 8/27/25 at 1:50 p.m., with Registered Nurse (RN) 2. RN 2 pushed a button on the feeding pump to display the amount of water flushes Resident D was receiving. The pump was set to administer 60 mL per hour of water flushes and was confirmed by RN 2. An observation was conducted of Resident D, on 8/27/25 at 4:13 p.m., with Nurse 3. Nurse 3 pushed a button of the feeding pump to display the amount of water flushes Resident D was receiving. The pump was set to administer 60 mL per hour of water flushes and was confirmed by Nurse 3. A policy entitled Care and Treatment of Feeding Tubes, revised August 2024, was provided by the Director of Nursing on 8/27/25 at 5:00 p.m. The policy indicated feeding tubes would be utilized according to physician orders and direction for staff to provide care to the feeding tube that included, but were not limited to, frequency of and volume for flushing. This citation is related to Intake 2572707. 3.1-46(a)(2)

Based on interview and record review, the facility failed to ensure a resident was transported to appointments regarding a tunneled catheter removal for 1 of 3 residents reviewed for appointments. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/27/25 at 10:30 a.m. The diagnoses included, but were not limited to, anoxic brain damage (brain being deprived of oxygen), tracheostomy status ((surgically created hole in the neck that connects to the trachea (windpipe) to help a person breathe)), gastrostomy status (tube inserted through the abdomen and into the stomach), and osteomyelitis of vertebra (infection of the bone). A care plan, dated 4/15/25, indicated Resident B was on intravenous (IV) antibiotics related to an infection. The interventions included, but were not limited to, observing the IV dressing, changing the IV dressing and IV tubing as directed, monitor for signs and symptoms of infection, and monitor for signs of leaking at the IV side, edema at the IV insertion site, and/or any leaking of IV fluid out of the insertion site. A physician note, dated 4/29/25, indicated Resident B was scheduled for a tunneled catheter removal on 5/6/25 in the interventional radiology department at a local hospital. A progress note, dated 5/6/25 at 1:44 p.m., indicated Resident B's appointment was rescheduled due to a transportation issue. A progress note, dated 5/12/25 at 11:13 a.m., indicated Resident B's appointment was missed due to the transportation company arriving at the facility early. The transportation company left and never returned to take Resident B to his scheduled appointment. An interview was conducted with Registered Nurse (RN) 1 on 5/27/25 at 11:54 a.m. She indicated, on 5/6/25, she realized the transportation company didn't arrive at the facility to transport Resident B to his appointment and it was getting close to his appointment time. RN 1 contacted the transportation company, and they indicated Resident B was not on the list to be transported on 5/6/25. On 5/12/25, the transportation company arrived but it was around 11:00 a.m. and the appointment was for 1:00 p.m. RN 1 was under the impression Family Member 2 wanted to accompany Resident B to his appointments. Since Family Member 2 was not there, RN 1 instructed the transportation company to return later to pick up Resident B. The transportation company never returned to pick up Resident B for his appointment on 5/12/25. RN 1 indicated she did not call Family Member 2 to confirm if they were accompanying Resident B to his appointment. An interview was conducted with Family Member 2 on 5/27/25 at 11:39 a.m. She indicated Resident B had experienced missed appointments for the removal of his IV access on 5/6/25 and 5/12/25. On 5/12/25, she was told the transportation company arrived early and the facility staff didn't have Resident B go to the appointment because it was too early. So, the appointment was cancelled due to Family Member 2 not being there. Family Member 2 indicated she did not need to be there. Resident B was just to undergo the removal of his IV access. An appointment was scheduled, on 5/29/25, for Resident B's tunneled catheter removal. An interview conducted with the Director of Nursing (DON), on 5/27/25 at 2:22 p.m., indicated there was no facility policy regarding resident appointments. This citation is related to Complaint IN00459452. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with an intravenous (IV) access had orders for continued care for the IV access for 1 of 1 resident reviewed for IV access. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/27/25 at 10:30 a.m. The diagnoses included, but were not limited to, anoxic brain damage (brain being deprived of oxygen), tracheostomy status ((surgically created hole in the neck that connects to the trachea (windpipe) to help a person breathe)), gastrostomy status (tube inserted through the abdomen and into the stomach), and osteomyelitis of vertebra (infection of the bone). A physician order, dated 4/3/25, indicated the administration of Ertapenem Sodium Solution Reconstituted (broad spectrum antibiotic); administer one gram IV in the evening for an infection for six weeks. An IV care plan, dated 4/15/25, indicated Resident B was on IV antibiotics related to an infection. The interventions included, but were not limited to, observing the IV dressing, changing the IV dressing and IV tubing as directed, monitor for signs and symptoms of infection, and monitor for signs of leaking at the IV side, edema at the IV insertion site, and/or any leaking of IV fluid out of the insertion site. The April 2025 electronic medication administration record (EMAR) indicated Resident B's left chest single lumen PICC (peripherally inserted central catheter; form of IV access that can be used for an extended period) dressing was to be changed on a routine basis while in use. The order start date was 4/4/25 and discontinued on 5/2/25. The April 2025 EMAR indicated Resident B's left chest singe lumen PICC was to be observed every shift for signs and symptoms of infection. The order start date was 4/4/25 and discontinued on 5/2/25. A physician note, dated 4/29/25, indicated Resident B was scheduled for a tunneled catheter removal on 5/6/25 in the interventional radiology department at a local hospital. A progress note, dated 5/2/25, indicated Resident B's left chest singe lumen PICC was not a PICC. An appointment for the removal of the tunneled catheter line was scheduled for 5/6/25. The electronic health record indicated the following appointments were scheduled for Resident B's removal of the tunneled catheter, but the procedure was not able to be completed on 5/6/25 and 5/12/25. An appointment was scheduled for Resident B's tunneled catheter removal on 5/29/25. An observation was conducted of Resident B, on 5/27/25 at 11:25 a.m., with the Director of Nursing (DON). An IV access was still noted on Resident B's left chest. There was a dressing observed to the IV access with a written date of 5/21/25. The DON indicated the residents with an IV access should have monitoring and dressing changes conducted. There were no current orders reflective of the care and maintenance of the IV site to include any dressing changes, flushes to the IV access, and/or monitoring for any complications of the IV site. An interview conducted with the DON, on 5/27/25 at 2:24 p.m., indicated there was no documentation to reflect the dressing changes and/or monitoring of the IV access currently in the electronic health record for Resident B. A policy entitled Intravenous Therapy, undated, was provided by the DON on 5/27/25 at 2:22 p.m. The policy indicated the following, .12. A doctor's order is obtained before starting IV therapy . 13. IV sites are checked every four (4) hours or as per facility protocol and PRN [as needed] for signs and symptoms of infection or inflammation . 15. IV documentation is recorded in the nurses' notes and/or Medication Administration Record . 16. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medications and will discontinue as per the practitioner's order This citation is related to Complaint IN00459452. 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure a resident's call light was responded to in a timely manner, resulting in the resident experiencing anxiety, related to concerns regarding her health for 1 of 3 resident reviewed for staffing to meet resident needs. (Resident C) Findings include: In an interview with Resident C on 3-4-25 at 10:10 a.m., she indicated she has resided at the facility for about 6 years and typically was treated very well by staff and staff typically were very attentive to her, including with call light response. About two or so weeks ago, [I] had been sent to ER [emergency room ] for a nosebleed. After I got back here, around 4:00 a.m., my heart started thumping real hard and I turned on my call light to have the nurse come and check on me and get my vital signs. Not a soul showed up until after the day shift got here, somewhere around 7:00 a.m. It kind of scared me and my roommate. Who knows what could have happened to me? And it worries me that this type of thing could happen to someone else, too, that might be worse off than me. She indicated in the over five years she has been here, nothing like this has occurred before or since. She shared she had spoken to several people in management, including the new Director of Nursing (DON) who assured her things will be better. On 3-4-25 at 11:58 a.m., the Corporate Nurse provided a copy of a Grievance Form, dated 2-20-25, which indicated the Social Services Designee received a grievance from Resident C, on 2-20-25, regarding her call light not being responded to by facility staff, from when she activated it at 4:00 a.m., until 7:00 a.m., on 2-20-25. This concern was shared with the DON. The form documented the DON resolved the concern on 2-21-25, with an explanation provided of, Employees were written up after complete thorough investigation was done. In an interview with the DON on 3-4-25 at 12:15 p.m., she indicated she had spoken with Resident C on 2-20-25, about her call light not being answered for several hours. She indicated both Resident C and her roommate were both very alert and oriented and did not have a history of telling lies about the staff. I met with the nurse and aide that worked the night before [2-19-25 into 2-20-25]. Both of them said they didn't think her call light was on. The nurse wrote a statement on the write-up, but refused to sign it. I explained to both of them this type of thing is considered neglect and it is taken very seriously. They understand they are at the point where if anything else happens, they will be terminated. I decided not to terminate them, but to give them an opportunity for improvement. On 3-4-25 at 12:37 p.m., the DON provided copies of documents entitled, 3 Step Employee Memorandum, for Licensed Practical Nurse (LPN) 4 and Certified Nurse Aide (CNA) 5. The documents indicated, Describe the incident in detail .Failed to answer call light in a timely manner, and indicated this was a failure to perform assigned duties in an appropriate manner or at assigned times. In the section identified as Corrective Action To Be Taken (State corrective action you feel the employee may take to eliminate the problem.), it indicated for both employees, You must do purposely [sic] rounding on shift. All call lights must be answered in a timely manner. All assigned job duties must be completed on shift. Notify work colleague when taking scheduled break. LPN 4 handwrote a comment of, Resident's light was not on. Call light sounds on East Wing. East Wing nurse stated she did not see light. I also have two halls at night so am not on hall at all times. The signature line for LPN 4 was unsigned by LPN 4, but had a handwritten notation of, Refused to Sign. CNA 5's document did not have any employee comment, but in the employee signature area of the document, it indicated the counseling was conducted by phone. Both documents were signed by two facility supervisors. In an interview on 3-4-25 at 2:20 p.m., with the Corporate Nurse, she indicated education was conducted on responding to call lights with the nurse and aide at the time of their counseling. The remainder of the staff were receiving education on this topic from the Executive Director and the new DON on a one-on-one basis, to be able to set goals individually with each employee. She indicated the Executive Director and DON are about half-way through the employee list at this point and there will be an all-staff meeting on 3-6-25, which was planned prior to this survey, to address a number of issues, including but not limited to, responding to call lights in a timely manner. The clinical record of Resident C was reviewed on 3-3-25 at 3:38 p.m. Her diagnoses included, but were not limited to congestive heart failure, diabetes with neuropathy, morbid obesity and end stage renal with dialysis. Her most recent Minimum Data Set assessment, dated 12-30-24, indicated she was cognitively intact. This citation is related to Complaint IN00454054. 3.1-3(t)

Based on interview and record review, the facility failed to provide 1 of 3 residents, reviewed for transfers, a copy of the facility's bed hold policy prior to transferring to an area hospital. (Resident D) Findings include: The clinical record of Resident D was reviewed on 3-4-25 at 10:57 a.m. Her diagnoses included, but were not limited to, Wernicke's encephalopathy, CVA (cardiovascular accident or stroke) with left sided hemiparesis and hemiplegia, dysphagia (difficulty swallowing), gastrostomy (gastric feeding tube), and moderate protein-calorie malnutrition. A review of Resident D's progress notes indicated she had pulled out her gastric feeding tube, on 3-2-25, and was sent to an area hospital to have it replaced. A document, identified as a nursing home to hospital transfer form, was completed on 3-2-25 at 5:50 a.m. It indicated the reason for the transfer as Resident pulled out G-tube. The clinical record failed to have a copy of the bed hold policy in place and was unable to be provided by the facility prior to the exit of the survey. In an interview on 3-4-25 at 10:25 a.m., with Registered Nurse (RN) 3, she indicated when a resident was sent out to the emergency room , the nursing staff were to complete and send with the resident a copy of the bed hold policy and the state transfer paperwork. In an interview with the Corporate Nurse on 3-4-25 at 2:17 p.m., she indicated the facility does not have a specific policy regarding the use of the transfer-discharge paperwork, but follows the state and federal regulations and utilizes the state paperwork, including the bed hold documentation. We are to send that with the resident to the hospital and keep a copy for the chart. This citation is related to Complaint IN00454054. 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 3 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 1/21/25 at 1:00 p.m. The diagnoses included, but were not limited to, dementia. A Facility Reported Incident [FRI] was reported to the Indiana Department of Health, dated 12/30/24, indicating an incident had occurred, on 12/30/24, with Resident D. A brief description of the allegation indicated Resident D reported his wallet, credit card, and insurance card was taken. The follow up to the incident indicated Staff and resident interviews completed with no concerns. Credit card has been canceled and new [insurance] card ordered. Facility to replace wallet . The investigation to the reported incident was provided by the Administrator on 1/21/25 at 2:00 p.m. The investigation included resident interviews that were conducted during the investigation. The resident interview questions were the following: 1. Has staff, a resident, or anyone else here, abused you - this includes verbal, physical, or sexual abuse? If yes ask who the abuser was, what happened, when it occurred, where it happened, and how often .Did you tell staff? If yes, ask who the resident told. Report immediately to the administrator . 2. Have you seen any resident here being abused? If yes ask who the abuser was, what happened, when it occurred, where it happened, and how often .a. Did you tell staff? If yes, ask who the resident told. Report immediately to the administrator . The investigation did not include interviews that were conducted with the residents related to misappropriation of property. An interview was conducted with the Administrator on 1/21/25 at 3:08 p.m. She indicated the investigation for Resident D was completed. There were two allegations reported on 12/30/24. An allegation of abuse and an allegation of misappropriation of property. The staff that conducted interviews with the residents must have been asking only the abuse questions. An abuse policy was provided by the Executive Director on 1/21/25 at 11:40 a.m. It indicated the following, .Policy: 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 .V. Investigation of alleged abuse, neglect and exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation . 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . This citation is related to Complaint IN00451414. 3.1-28(d)

Based on interview and record review, the facility failed to ensure that a narcotic pain medication was placed in a controlled substance lock box upon being delivered to the facility and to ensure the oncoming and off going licensed personnel signed the controlled drug shift audit form when completing the controlled drug audit each shift for 1 of 3 residents reviewed for pain medications (Resident E). Findings include: The clinical record for Resident E was reviewed on 1/21/25 at 11:15 a.m. The diagnoses included, but were not limited to, diabetes and chronic non-pressure skin ulcers of the left leg. An Admission Minimum Data Set (MDS) assessment, completed 10/14/24, indicated she was cognitively intact and received scheduled pain medications. A care plan, last revised on 11/1/24, indicated Resident E was at risk for pain related to wounds on legs and toes and diabetes. The goal was for her to not have interruptions in normal activities due to pain. The interventions included, but were not limited to, administer analgesics (pain medication) as ordered by the physician. A physician's order, dated 1/14/25, indicated she was to receive fentanyl (narcotic pain medication) transdermal patch 25 micrograms (mcg) per hour. One patch was to be applied transdermal (on the skin) every three days. This order was discontinued on 1/16/25. A physician's order, dated 1/16/25, indicated she was to receive fentanyl transdermal patch 25 micrograms (mcg) per hour. One patch was to be applied transdermal every three days. An electronic medication administration record (EMAR) note, dated 1/15/25 at 12:56 p.m., indicated the fentanyl transdermal patch was not administered due to it being on order from the pharmacy. A Physician's Assistant Follow Up Visit note, dated 1/15/25, indicated resident E was evaluated for follow up of pain management. Fentanyl patches were not yet available from pharmacy, so she would continue the previous regimen until fentanyl patches are obtained. Resident E had no acute complaints at that time. Staff reported no other acute care concerns. Resident E appeared comfortable and in no acute distress. On 1/21/25 at 1:25 p.m., the Administrator provided the investigation file for Indiana State Reportable, dated 1/15/25, which indicated while counting narcotics during shift change, it was noted there were four fentanyl patches 25 mcg missing for one resident. The count was re-conducted with no change in the outcome. The Director of Nursing Services and the Administrator were notified of the missing medication. The investigation file contained a packing slip from the facility pharmacy, dated 1/14/25, which indicated that four fentanyl transdermal patches, 25 mcg, were sent to the facility from the pharmacy. During an interview on 1/21/25 at 1:50 p.m., the Administrator indicated Resident E's fentanyl patches, and the narcotic count sheet were missing. The fentanyl patches were left on the nursing station unattended. The facility was investigating to determine what happened to the fentanyl patches. The nurses' who had access to the medications when they were delivered had been drug tested with negative results. During an interview on 1/21/25 at 2:03 p.m., Pharmacy Technician 10 indicated that four fentanyl 25 mcg patches were sent to the facility and signed for by Registered Nurse (RN) 2. On 1/21/25 at 2:35 p.m., the [NAME] Hall narcotic book was observed with RN 3. The Emergency Kit and Controlled Drug- Shift Audit form for January 2025 was observed. There were no signatures present for the oncoming nurse, on 1/14/25 night shift, the oncoming nurse on 1/15/25 day shift, the oncoming nurse on 1/16/24 day shift, and 1/16/25 off going nurse on evening shift. During an interview on 1/21/25 at 2:35 p.m., RN 3 indicated the blanks on the Emergency Kit and Controlled Drug- Shift Audit form was because the staff had not signed the form. During an interview on 1/21/25 at 2:41 p.m., RN 2 indicated she had received the pharmacy delivery on the night shift of 1/14/25. The delivery was very large that night because there had been a new admission on the [NAME] Hall. RN 2 could not specifically recall if she had received Resident E's fentanyl patches due to the amount of medication she had received that night. RN 2 had left all the delivered medication on the nurses' station so that the other nurses could come pick up the medications for their halls. Since there were so many medications delivered for the [NAME] Hall, RN 2 had placed all the [NAME] Hall medications in a bag and taken them to the [NAME] Hall nurses' station. There had not been anyone at the [NAME] Hall nurses' station when she dropped off the bag of medications. RN 2 had told the [NAME] Hall nurse she put the medications that had been delivered at the [NAME] nurses' station when they passed in the hallway. RN 2 was not sure what happened to Resident E's fentanyl patches after she took them to the [NAME] Hall nurses' station. The controlled medications were counted between each shift. After the controlled medication count, the oncoming and off going nurse should sign the Emergency Kit and Controlled Drug Shift Audit form at the front the narcotic book. During an interview on 1/21/25 at 3:15 p.m., Unit Manager (UM) 4 indicated the facility staff had searched the facility thoroughly and had not been able to find Resident E's fentanyl patches. There had been a lot of medications delivered on the night shift, of 1/14/25, including multiple other narcotics. All the other narcotics were accounted for. UM 4 was unsure where the fentanyl patches could have gone. She questioned if they may have been thrown away because the fentanyl patches are normally delivered in a small plastic sleeve, which may have gotten stuck on something. UM 4 had educated the nursing staff about double checking and ensuring that all medications they sign for are present prior to signing the delivery forms. On 1/21/25 at 11:40 a.m., the Corporate Support Health Care Administrator provided the Narcotic Pain Patch Policy, last revised February 2023, which read .It is the policy of this facility to maintain records of all Narcotic patches at the time of receiving in the facility until destruction .Narcotic patches will be kept in a controlled substance lock box and reconciled at the end of each shift between the charge nurse responsible and the charge nurse taking responsibility of the medications . Both nurses will sign the shift change log verifying the count is accurate at the time of the reconciliation . This citation is related to Complaint IN00451414. 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview, and record review the facility failed to label refrigerated food with date opened, appropriately store frozen food, appropriately restrain facial hair of dietary staff with the use of a beard restraint, and store personal belongings away from drying rack of clean dishes. This had the potential to affect 67 of 74 residents in the facility. Findings include: A tour of the kitchen was conducted, on 12/16/24 on 10:20 a.m., with the Dietary Manager (DM). Inspection of the walk-in freezer revealed packaging of frozen corn dogs left open to air. The DM indicated that the packaging should not be open to air. Inspection of refrigerated foods revealed three bags of undated bags of lettuce, visible discoloration of lettuce was present in one of three bags. The DM indicated the date must have rubbed off the bags of lettuce and discarded them. [NAME] 2 had a full goatee and was not wearing a beard restraint while in the kitchen. A jacket was observed hanging on a chair adjacent to a drying rack of clean dishes. The DM indicated that the jacket belonged to one of the facility's cooks and it should not be there. On 12/17/24 at 11:40 a.m., the kitchen was entered for a second tour and [NAME] 2 was observed with a full goatee without a beard restraint. On 12/19/24 at 10:20 a.m., the kitchen was entered and [NAME] 2 was observed wearing a beard restraint covering his goatee. An interview was conducted with the DM, on 12/19/24 at 10:22 a.m., regarding the use of beard restraints. The DM indicated their policy states facial hair was to be a quarter of an inch to require the use of a beard restraint. A policy for Dietary Employee Personal Hygiene, dated 2022, was provided by the Director of Nursing on 12/19/24 at 10:38 a.m. The policy states, .Hair restraints . a. All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. b. Head coverings must be clean . A policy for Food Safety Requirements, dated 2024, was provided by the Director of Nursing on 12/19/24 at 10:38 a.m. The policy states, Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to have a functional call light in a resident's room and timely replace cove base at the base of a toilet for 2 of 7 residents observed for environment. (Resident 13 and 48) Findings include: 1. On 12/17/24 at 1:46 p.m., Resident 13's bathroom was observed. The elevated concrete base of the toilet was exposed and missing the cove base. Resident 13 indicated that it looked dirty and had been that way for a while. On 12/20/24 at 11:06 a.m., an environmental tour was conducted with the Maintenance Supervisor (MS). Resident 13's bathroom was observed, the elevated concrete toilet base was missing the cove base. During an interview on 12/20/24 at 11:45 a.m., the MS indicated the concrete base had been painted in November 2024 and then repainted again recently. Replacement of the cove base must have been missed. He did not believe there was a work order to replace the cove base. 51750 2. On 12/16/24 at 3:40 p.m. an observation of Resident 48's room revealed their call light was missing its button cover. An observation conducted on 12/17/24 at 2:35 p.m., revealed Resident 48's call light was still missing its button cover. An interview was conducted, on 12/18/24 at 1:57 p.m., with Certified Nurse Aide (CNA) 1. CNA 1 pushed Resident 48's call light and indicated the call light was broken and would be getting a new one. On 12/20/24 at 1:50 p.m. the [NAME] President of Risk and Regulatory (VPRR) indicated there was not a specific call light policy and it would fall under standards of care. On 12/20/24 at 1:50 p.m., the Executive Director provided the current Facility Maintenance Guidelines and Procedure which read, .Staff should place items they find in the normal course of their day in the TELS [sic] Work Order System when found as well as placing items in the system when residents make requests . 3.1-19(u)(1)

Based on interview and record review, the facility failed to ensure a medication was administered as ordered for 1 of 1 resident reviewed for dialysis. (Resident 71) Findings include: The clinical record for Resident 71 was reviewed on 12/20/24 at 2:00 p.m. The diagnoses included, but were not limited to, amputation of right leg and renal dialysis. A hospital discharge, dated 9/17/24, indicated the resident was to receive one tablet of 500/125 milligrams of amoxicillin clavulanate at bedtime in the evening after dialysis, and one tablet of 500 milligrams of amoxicillin one hour prior to appointment. A physician order, dated 12/6/24, indicated the resident was to receive four tablets of 500 milligrams of amoxicillin one hour prior to dialysis every Tuesday, Thursday, and Saturday. The December 2024 Medication Administration Record indicated the resident had received the 500 milligrams of amoxicillin one hour prior to dialysis every Tuesday, Thursday and Saturday. An interview was conducted with the Director of Nursing on 12/19/24 at 2:36 p.m. She indicated the resident had a recent hospitalization , and the staff activated the wrong amoxicillin order. The resident should be receiving one tablet of 500/125 milligrams of amoxicillin clavulanate at bedtime in the evening after dialysis. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's right to be treated with respect and dignity by a staff member who forcefully attempted to get a resident with a decreased ability to perform activities of daily living (ADLs) to perform her own incontinent care for 1 of 3 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 9/20/24 at 1:55 p.m. Her diagnoses included, but were not limited to, asthma, morbid obesity, and hypertensive urgency. A minimum data set assessment, dated 8/11/24, indicated Resident D was moderately cognitively impaired and was dependent on assistance for bathing/showering, dressing, and toileting. She required partial to moderate assistance with personal hygiene. An interview with Resident D was conducted on 9/20/24 at 2:27 p.m. She indicated, on 8/20/24, she required assistance with incontinent care and requested for two people to help her. When her nurse came in to assist, she grabbed her arm and placed a cold, wet towel in her hand and forcefully took her arm down to her pelvic area. She indicated the nurse said if her arm can reach down there then she can clean herself up and she didn't have any aliments with her arms. She indicated this interaction made her feel very upset, degraded, and humiliated. She indicated that she still feels sad about the incident and it was uncalled for. An interview with the Executive Director (ED) was conducted on 9/20/24 at 2:00 p.m. She indicated the incident was about a resident who needed assistance with incontinent care and stated she needed two people to assist her. According to her, she believed the physician's assistant and a certified nursing assistant were in the resident's room when the nurse came in to assist her. She indicated the nurse grabbed the resident's arm and guided her arm to her pelvic area to assist her with her rehabilitation efforts and for her to wipe herself. She indicated when she spoke with Resident D, she indicated the nurse was forceful. This citation is related to Complaint IN00442213. 3.1-3(a) 3.1-3(t)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 9/20/24 at 1:55 p.m. Her diagnoses included, but were not limited to, asthma, morbid obesity, and hypertensive urgency. A minimum data set assessment, dated 8/11/24, indicated Resident D was moderately cognitively impaired and was dependent on assistance for bathing/showering, dressing, and toileting. She required partial to moderate assistance with personal hygiene. An interview with Resident D was conducted on 9/20/24 at 2:27 p.m. She indicated, on 8/20/24, she required assistance with incontinent care and requested for two people to help her. When her nurse came in to assist, she grabbed her arm and placed a cold, wet towel in her hand and forcefully took her arm down to her pelvic area. She indicated the nurse said if her arm can reach down there then she can clean herself up and she didn't have any aliments with her arms. She indicated this interaction made her feel very upset, degraded, and humiliated. She indicated she still felt sad about the incident and it was uncalled for. An interview with the Executive Director (ED) was conducted on 9/20/24 at 2:00 p.m. She indicated the incident was about a resident who needed assistance with incontinent care and stated she needed two people to assist her. According to her, she believed the physician's assistant (PA) and a certified nursing assistant (CNA) were in the resident's room when the nurse came in to assist her. She indicated the nurse grabbed the resident's arm and guided her arm to her pelvic area to assist her with her rehabilitation efforts and for her to wipe herself. She indicated when she spoke with Resident D, she indicated the nurse was forceful. An incident report, dated 8/20/24, was received on 9/20/24 at 3:41 p.m. It indicated, on 8/20/24 at 1:30 p.m., a CNA stated another employee was utilizing inappropriate language and made contact with Resident D's arm. The immediate action taken was the initiation of an investigation and a full skin assessment was completed. Preventive measures taken indicated the investigation was initiated, social services notified to follow for signs and symptoms of psychosocial distress, and care plans were reviewed and updated. The follow-up, dated 8/26/24, indicated all staff was educated on abuse prohibition. All interview able residents were interviewed, psychosocial wellbeing was completed with no signs of distress, and care plans were reviewed and updated as needed. The investigation file for the incident was received on 9/20/24 at 10:03 a.m. from the ED. The file did not contain a statement from the PA even though she was a witness to the incident. It did not contain a written statement from Resident D. The ED indicated she had spoken with the resident but did not get her statement in writing. There was no statement from the CNA that reported the incident. An Abuse, Neglect and Exploitation policy was received on 9/19/24 at 11:08 a.m., from the Director of Nursing Services. The policy indicated, 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 .Investigation of Alleged Abuse, Neglect and Exploitation .an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Written procedures for investigations include .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation. This citation is related to Complaint IN00442213. 3.1-28(a) 3.1-28(d)

Based on interview and record review, the facility failed to identify individualized approaches of care for a resident with a diagnosis of dementia with agitation and to prevent a resident's distress for 1 of 3 residents reviewed for abuse. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/20/24 at 10:00 a.m. His diagnoses included, but were not limited to, dementia with moderate agitation, cerebral amyloid angiopathy (a condition that causes bleeding inside the brain and damages brain tissue leading to the loss of the ability to think), and reactive emotional distress. He was admitted to the facility, on 7/18/24, and moved to the locked memory unit, on 7/24/24, per a physician's note. A physician's order to give one 25 mg (milligrams) tablet of quetiapine (medication used to treat psychosis, schizophrenia, bipolar disorder and depression) as needed every 12 hours for delirium was placed on 7/18/24. A physician's assistant (PA) progress note, dated 7/19/24 at midnight, indicated Resident C was admitted to the facility following a recent hospitalization for placement to an extended care facility. Neurological testing revealed moderate dementia with agitation and reactive emotional distress as well as REM (rapid eye movement) behavior disorder (a sleep disorder that involves abnormal movements, behaviors, emotions, perceptions and dreams that occur while falling asleep, sleeping, between sleep stages or during arousal from sleep). He had increased behavioral disturbances at home with agitation and aggression which was noted on his outpatient psychiatry appointment on 6/4/24. On 7/23/24, the order for Resident C's 25 mg of quetiapine, as needed every 12 hours, was discontinued. The PA progress note, dated 7/24/24 at midnight, indicated the reason for the acute visit was per staff's request as Resident C exhibited increased anxiety and was moved to the locked memory care unit. The clinical record did not contain any behavior notes until 7/26/24. A behavior note, dated 7/26/24 at 2:26 p.m., indicated Resident C was seen in the hall walking completely naked. When he was approached, he was visibly upset and started to swing at staff with closed fists. Resident C's baseline care plan did not reference his behaviors (swinging closed fists at staff), nor did it contain interventions to the behaviors. The PA progress note, dated 7/30/24 at midnight, indicated Resident C was evaluated for intermittent behavior issues. Staff noted the resident was sometimes agitated and aggressive with staff and had displayed intermittent erratic behaviors throughout the day. He responded with some verbal antagonism to the instructions by staff and his aggression is concerning. No changes to his medication regime were attempted at the time but may consider the potential for an as needed medication for agitation/aggression if the behaviors persisted or worsened. On 8/2/24, a physician's order for 25 mg of quetiapine to be given at bedtime for depression and agitation was placed. The PA progress note, dated 8/2/24 at midnight, indicated per the family's request, Resident C's buspirone (used to treat anxiety) was discontinued, but resident will likely need another medication in its place to help manage mood/behaviors given continued breakthrough agitation and behavior issues per staff. On 8/11/24, Resident C's order for 25 mg of quetiapine at bedtime was discontinued. On 8/13/24, a physician's order was placed for Resident C. It indicated to give 25 mg of quetiapine every 12 hours as needed. The order was discontinued on 8/14/24. On 8/15/24, a physician's order was placed for Resident C to receive one 25 mg tablet of quetiapine at bedtime. The order was discontinued on 8/23/24. Resident C's care plan, dated 8/19/24, indicated he had a history of behaviors which included removing his cardiac monitor related to having dementia. The interventions included, but were not limited to, attempt interventions before the behavior begins, offer him something he liked as a diversion, and to speak to him in an unhurried, calm voice. The care plan did not indicate what he liked to be used as a diversion, nor did it indicate he was physically aggressive (swinging closed fists) or what made him agitated. A physician's progress note, effective date of 8/19/24 at midnight, indicated Patient has advanced dementia. He has associated psychotic symptoms with intermittent hallucinations. He also has episodes of agitation. There is also associated general anxiety and insomnia. A self-reported incident, dated 8/29/24, indicated at approximately 2:30 p.m., Resident C who had a severe cognitive deficit was in the common dining room on the reflections unit. Resident C was being re-directed from a behavior and made contact with Resident B's head with a closed hand. The residents were immediately separated. Resident C was placed on one-on-one observation until he was sent to the hospital for evaluation. Resident B was assessed, and no injuries were noted. An interview with QMA 3 (qualified medication assistant 3), conducted on 9/20/24 at 9:38 a.m., indicated she was the only staff member present when Resident C hit Resident B on 8/29/24. She indicated a group of female residents and Resident C (who is male) were in the common dining room talking and listening to music. She indicated she was tending to a resident just outside of the common dining room when she heard Resident C yell out SHHH really loud. She indicated the sound alerted her that something was wrong. She indicated she had told Resident C to come out of the dining room as to re-direct him and when she did Resident C banged his hand on table making a loud noise which startled the female residents. He proceeded to ask the female residents for their cups so he could throw it at QMA 3. QMA 3 indicated, Resident C had said something to the effect of 'someone give me something to throw at this b****'. She indicated he was all worked up and needed to call for help, so she had turned from Resident B (whom she had been assisting) and was just heading to the nursing office when she heard Resident B say 'OW, stop that! When she turned around, Resident C had grabbed both of Resident B's arms with his one hand and she saw him hit her. She stated, he hit her three times. She indicated she did not see the first hit but assumed that was why Resident B had yelled out ow. She did witness the second hit, and he had a closed fist and when he went to hit her, he drew his arm back to strike her and made contact. He hit her in the face/head. She indicated she ran over trying to get him to release her arms and that was when he hit her for the third time. She stated she finally got him off of her and told Resident B to go down the hallway and away from him. He then turned to the other ladies in the room, so she told them to get on other side of table. She wanted to let him focus on her so he wouldn't target the other residents. He was screaming and hollering. She managed to call for help and when help arrived, he was still physically aggressive. She indicated the loudness of the noise from them talking just triggered him. She knew this from a prior experience with Resident C. She indicated when he moved in, she was in Resident C's room talking to his wife when he did the shhh thing and his wife had stated he does that when things are too loud for him. Resident C's treatment administration record (TAR), for August 2024, indicated for behavior monitoring related to the use of psychotropic medications. There weren't any behaviors noted for the month nor were there any intervention attempts noted. An interview with the Director of Nursing Services (DNS) was conducted on 9/20/24 at 11:39 a.m. She indicated Resident C was seen by neurology at the Veterans Administration but did not know what/if any recommendations were indicated as his wife took him to those appointments. She indicated his care plan should have addressed his behaviors upon admission given he was admitted with dementia with agitation. A Behavioral Health Services policy was received on 9/20/24 at 11:53 a.m. It indicated, It is the policy of this facility to ensure all resident receive necessary behavioral health services to assist them in reaching and maintain their highest level of mental and psychosocial functioning .The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .The assessment and care plan will include goals that are person-centered and individualized .Staff will .obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health .Monitor the resident closely for expressions or indications of distress .Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record .Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident .The care plan shall .have interventions that are person-centered, evidence-based, trauma informed, and in accordance with professional standards of practice .be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition 3.1-37(a) 3.1-43(a)(2)

Based on interview and record review, the facility failed to ensure follow up to a resident that was unable to be located in the facility during the night for 1 of 4 residents reviewed for accidents. (Resident B) Findings include: The clinical record of Resident B was reviewed on 6/4/24 at 1:28 p.m. The diagnoses included, but were not limited to, hypertension, muscle weakness, alcohol abuse, and diabetes mellitus. A significant change minimum data set (MDS) assessment, dated 3/28/24, indicated Resident B was cognitively intact, utilized a wheelchair, received daily injections of insulin, administration of a diuretic, administration of a hypoglycemic medication, and administration of an opioid medication. A release of responsibility for therapeutic home visits form, dated for March, April, and May of 2024, indicated Resident B signed out of the facility on a leave of absence for 9 days in March, 7 days in April, and one day in May. There were no leave of absence forms for Resident B dated June of 2024. A progress note, dated 6/2/24 at 10:42 p.m., indicated Resident B left the facility and would not be redirected per policy or sign out that he was taking a leave of absence. A progress note, dated 6/2/24 at 11:37 p.m., indicated Resident B returned to the facility. A progress note, dated 6/3/24 at 10:30 p.m., indicated the following, . Resident B was not in his room when writer did rounds to check residents. Per CNA [certified nursing aide] resident was not here since Sunday [6/2/24]. Writer checked the sign in/out book and no sign out under the resident's name . There was no indication that staff knew of Resident B's whereabouts as to when he left the facility, if medications were retrieved for Resident B to take while he was out of the facility, and where Resident B was in case of any emergency. An interview conducted with Resident B, on 6/4/24 at 11:10 a.m., indicated he was in the process of moving to a different facility. He indicated he was allowed to have a certain number of days out of the year to utilize as a leave of absence. He would let the facility staff know when he was planning to take a leave of absence. He would sign in and out of the leave of absence book. He commented on how he left the facility last night but did not have any medications to take while he was on a leave of absence. He was planning to return to the facility sometime on 6/4/24. An interview conducted with the Director of Nursing (DON), on 6/4/24 at 11:29 a.m., indicated she was concerned when she read the progress note about staff not being able to find Resident B in his room. She was concerned about where he could be regarding his medications, care for himself, etc. Resident B does like to go on a leave of absence quite often and it's not uncommon for him to do so. An interview conducted with the DON, on 6/4/24 at 2:58 p.m., indicated the receptionist did see the resident leave the facility on 6/3/24 in the evening time. The receptionist did not let the staff know Resident B had left and she was educated about the policy and procedure for when a resident leaves the facility. A policy titled Therapeutic Leave, undated, was provided by the DON on 6/4/24 at 2:54 p.m. The policy indicated the following, .2. The facility will coordinate with the resident and/or representative the length of time the resident will be gone to ensure that adequate amounts and appropriate medication is ready for administration while on the leave .4. The facility will document in the medical record the resident's leave of absence and any education given to the resident and/or representative prior to the leave .6. If a resident has not returned from therapeutic leave as expected, the facility will attempt to contact the resident and resident representative and document attempts in the medical record 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and interventions were provided to prevent a cognitively impaired resident, who was assessed by the facility as an elopement risk, from exiting the facility unsupervised, for 1 of 1 resident reviewed for elopement (Resident B). The resident was able to exit the Alzheimer's Care Unit (ACU) and a facility exit door without the knowledge of staff. When the exit door alarmed, a staff member reset the alarm without checking outside the door for any resident. The resident was missing for more than 17 hours when found at a store 7 miles away and returned to the facility after being notified by local police. The Immediate Jeopardy began on June 13, 2020, when a cognitively impaired resident with dementia exited the Alzheimer's Care Unit and the facility unsupervised into a potentially dangerous area, including a four-lane moderately busy road and bus stop, and was missing for approximately 17 hours when he was found 7 miles from the facility. A staff member turned off the exit door alarm, approximately 30 seconds after Resident B exited the facility, but did not attempt to go outside and examine the perimeter to see what could have set off the alarm to the exit door. The Area Vice President and Executive Director (ED) were notified of the Immediate Jeopardy on 6/14/20 at 6:27 p.m. The Immediate Jeopardy was removed on 6/15/20, but 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: The clinical record for Resident B was reviewed on 6/14/20 at 3:39 p.m. The [DIAGNOSES REDACTED]. A Quarterly Interdisciplinary Resident Review, dated 1/30/20, indicated Resident B was cognitively impaired with impaired decision making skills that put him at risk for elopement. A care plan, revised 2/11/20, indicated the following, .I (Resident B) am at risk for elopement believing I need to get home. 4/25/20-Recently I have not been actively trying to leave and my roam alert has been discontinued .Interventions .Find something on the unit I would like to do to divert my attention from the door .Walk with me through the unit The resident resided on the Alzheimer's Care Unit which required a code to exit the door. A Quarterly Minimum Data Set (MDS) assessment, dated 4/7/20, noted a Brief Interview for Mental Status (BIMS) score of 8 that was indicative of moderate cognitive impairment. Resident B needed supervision with one staff person for transfers, walking, locomotion and eating along with extensive assistance with one staff person for toileting and personal hygiene. A news article, dated 6/14/20, indicated Resident B was missing from the facility since midnight. An incident report from the Indiana State Department of Health Survey Report System, dated 6/14/20 at 1:10 a.m., indicated the following, .(Name of Resident B) .Brief Description of Incident .On 6/14/20 at 0110 (1:10 a.m.), a Nurse Manager was notified by phone from a night shift nurse that while conducting a bed check for night time care, (Resident B's) whereabouts were unknown. The Nurse stated the facility had conducted a full internal search and the Nurse Manager, instructed to complete a full external search of the facility property .During the search and investigation, the facility identified on the security system that (Resident B) exited the facility through a side entrance/exit door that is not used by staff or visitors .(Resident B) was identified at 1150 (11:50 a.m.) On 6/14/20 at 2:30 p.m., an observation was made of the camera footage from the evening of 6/13/20. At 6:13 p.m., on 6/13/20, Resident B was identified as standing at the exit door just outside of the ACU. Resident B was pushing towards that exit door until he was able to push it open, at 6:14 p.m. Resident B proceeded to walk down the ramp while grasping the railing with his left hand and holding onto a shopping bag with his right hand. When Resident B exited from the camera, 30 seconds later, a staff member is identified, by the ED, as clearing the alarm from that exit door. There was no staff member observed exiting the building to determine what caused the door alarm to activate or check the perimeter. A form titled Daily Staffing Schedule, dated 6/13/20, indicated Registered Nurse (RN) 4 was working on the ACU with Certified Nurse Aide (CNA) 6 and CNA 8 on evening shift. An interview documented with CNA 8, dated 6/14/20, indicated the following, .I (CNA 8) didn't see him (Resident B) walking around like he usually does, but I saw him in the bed at about 2:30 p.m. The other aid (sic) was caring for those residents A written statement by RN 4, dated 6/14/20, indicated the following, .I (RN 4) gave (name of Resident B) his PM (evening) meds (medications) @ (at) 6pm. He was walking down the hall holding a Christmas shopping bag @ (at) this time. I was doing a bed check @ (at) 10:45 p.m. when I noticed (name of Resident B) was not in his room. I went to the TV room where he sits sometimes until he gets sleepy. When I didn't see him I asked the QMA (Qualified Medication Aide) if she had seen him and she said no. Then we started a room by room search and then expanded it to the rest of the building and around the outside of the building A written statement by QMA 10, dated 6/13/20, indicated the following, .came to ACU to work time about 10:45 p.m. doing charting on computer. (Name of RN 4) stated she should check on (name of Resident B). Walked with her (RN 4) but when we got to his (Resident B's) room he was nowhere to be found. Then started checking all rooms and bathrooms still couldn't find him (sic). We expanded our search to the other units and still couldn't locate him. I got flashlight started calling his name along creek (sic) and the woods on the back of property but couldn't locate resident Resident B was last seen by RN 4, on 6/13/20 at 6:00 p.m., for his evening medications. Resident B was realized to be missing 4 hours and 45 minutes later, on 6/13/20 at 10:45 p.m., during a bed check by RN 4 and QMA 10. A progress note, dated 6/14/20 at 11:45 a.m., indicated the following, .Notified by police that pt. (patient) has been found Another progress note, dated 6/14/20 at 1:03 p.m., indicated the following, .Head to toe assessment: Resident is alert and oriented to self and familiar faces. He is able to ambulate with a slow, steady gait. Breath sounds are clear. Bowel sounds present, resident had just eaten lunch. He was incontinent of bowel and bladder. He was showered. Overall, skin intact, lack of approx. (approximately) 2 x 2 blister on Left great toe and small 1x1 reddened areas to right 4th and 5th toe An interview conducted with the Director of Nursing (DON), on 6/14/20 at 4:17 p.m., indicated Resident B returned to the facility on [DATE] at 12:15 p.m. He was incontinent of bowel and bladder upon return to the facility. An interview conducted with the ED, on 6/14/20 at 2:10 p.m., indicated upon review of the camera footage it was determined Resident B exited the facility at 6:14 p.m. He was unsure how Resident B made it off of the ACU. Resident B was able to push the exit door, outside the ACU, until it disengaged and he opened the door to walk down the ramp towards the bus stop. Resident B's family indicated he loved riding the bus. An interview conducted with the ED, on 6/15/20 at 4:50 p.m., indicated when an exit door alarm sounds the expectations are for staff to go outside and check the perimeter to see if a resident is present. If a resident cannot be found then the staff are to conduct a head count to account for all residents in the facility. There was no policy for door alarms. A document titled Elopement Guideline, dated 1/28/19, indicated the following, .Elopement - When a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .Ongoing Review .All residents at risk of elopement are assessed quarterly and as needed .Door Alarms and Resident Protection Alarms .A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents .Only the Executive Director/or designee may authorize disabling the alarm system and is responsible for the method of monitoring for resident's safety and resetting the alarm .Environmental Guidelines .The LivingCenter will identify such environmental hazards such as entrances, stairwells, or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. The LivingCenter will implement interventions to minimize these risks and hazards as appropriate .Documentation should include: .Entries that are time specific to reflect the responsiveness and timeliness of actions taken to locate and assess the resident This Federal tag relates to Complaint IN 236. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received necessary care and services to attain or maintain their highest practicable level of physical well being (Resident B). The facility failed to recognize an admitting [DIAGNOSES REDACTED]. 1 of 3 residents reviewed for respiratory assessments. Findings include: The record of Resident B was reviewed on 1/25/2017 at 9:45 A.M. Resident B was admitted directly from an acute care hospital on [DATE]. [DIAGNOSES REDACTED].) Resident B's facility admitting [DIAGNOSES REDACTED]. A hospital Discharge Summary dated 12/13/16 and reviewed on 1/25/17 indicated: Discharge Diagnosis: [REDACTED].) Active Problems: Aspiration pneumonia of right lower lobe . Resident B's admitting physician orders did not contain any orders for respiratory assessment or treatment. An admission Clinical Health Status assessment dated [DATE] and reviewed on 1/25/17 did not indicate a [DIAGNOSES REDACTED]. There were no respiratory assessments or care plan goals or interventions for the problem of [MEDICAL CONDITION] from 12/13/16 until 12/18/16. A Progress Note dated 12/18/16 at 12:33 P.M., and reviewed on 1/25/17 indicated resideny (sic) noted to have some chest congestion .bilaterally scattered bronchi (coarse, rattling respiratory sounds) unable to speak verbally .118/66-70-22 (blood pressure, heart rate, respiratory rate) sat 95% (oxygen saturation) on room air resident unable to voice pain or discomfort call placed to .(doctor's office) order obtained to transfer resident out hospital (sic) daughter also notified and resident transferred to (acute care hospital) for evaluatin (sic) per stretcher. On 1/25/2017 at 12:45 P.M., the Director of Nursing indicated Resident B had been sent to the hospital at the resident's family's insistence. A hospital document titled Discharge Summaries Admission: 12/18/2016 -1/10/2017 (23 days) .Admission Diagnosis: [REDACTED]. Discharge Diagnosis: [REDACTED].S/[MEDICAL CONDITION](status [REDACTED].Hospital course: The patient is a (description of Resident B) .who presented to the ER (emergency room ) unresponsive from her ECF (extended care facility) . A Progress Note dated 1/10/2017 at 10:45 A.M., and reviewed on 1/25/17 indicated Resident returned around 10:45 a.m. transported via ambulance .[MEDICAL CONDITION] center of neck . A facility physician's progress note dated 1/23/2017 and reviewed on 1/25/17 indicated History of Present Illness: 70 yo (year old) back after a hospitalization for acute [MEDICAL CONDITION]; she is peg (feeding tube) [MEDICAL CONDITION] . During an interview on 1/25/2017 at 3:10 P.M., the Director of Nursing indicated the hospital discharge [DIAGNOSES REDACTED]. She also indicated she had no additional documentation of respiratory assessments, treatments, or interventions to provide. This Federal tag relates to Complaint IN 032. 3.1-37(a)

Based on record review and interview, the facility failed to ensure supervision and safety interventions were implemented to prevent the elopement of one of three residents known to be an elopement risk. (Resident #B) The Immediate Jeopardy began on 10/14/15 at 7:10: P.M., when Resident #B was admitted to the facility and was identified as a known elopement risk. The Executive Director, Director of Nursing Services, Area Vice President, and Executive Director in Training were notified of the Immediate Jeopardy at 4:45 P.M., on 10/16/15. The Immediate Jeopardy was removed on 10/20/15 at 3:30 P.M., when the facility educated staff on elopement policy and procedure, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility continued to provide reeducation and reassurance to residents and families regarding elopement. Findings include: On 10/16/15 at 10:27 A.M., the facility reported through the Indiana State Department of Health web based Survey Reporting System an initial report regarding the elopement of Resident #B, who was identified to be an elopement risk. The report indicated that on 10/15/15 at 11:45 P.M., Resident #B was identified as missing from the facility. The report indicated the Executive Director, Director of Nursing Services, and the Indianapolis Metropolitan Police were notified. A search was instituted, the resident's guardian (the Center for At Risk Elders) was contacted, and attempts were made to contact the resident's family. The record of Resident #B was reviewed on 10/16/15 at 12:00 P.M. Diagnoses, obtained from an Admission Record dated 10/14/15, included, but were not limited to, dementia with behavioral disturbance, Alzheimer's Disease, hypertension, angina, coronary artery disease, and chronic obstructive pulmonary disease. A timeline of events related to Resident #B was provided by the Director of Nursing Services on 10/19/15 at 10:45 A.M., and indicated by her to be an accurate accounting of the events related to the elopement of Resident #B. Information in that timeline was obtained through interviews conducted by facility executive staff. It included, but was not limited to: 10/14/15 7:15 P.M. .(Resident #B) arrived at (the facility) .Diagnosis (sic) listed: HTN, COPD, Depression with behavioral disturbance, SOB, chest pain. Per assessment (Resident #B) was at risk for elopement. Roam guard, (an electronic device intended to be worn by residents who are at risk for elopement; if the resident approaches an external door, a warning sounds and the door locks. If the resident exits an open door, a facility wide alarm sounds) per (Facility) Elopement Guideline, should have been placed on (Resident #B) at that time Per interview with (LPN #1) there was not a Roam Guard on the medication chart for the Rehab unit. When asked if she checked the other units medication chart she stated 'No.' When asked if she tried to contact anyone about where she could locate a Roam Guard, (LPN #1) stated. 'no.' 10/15/15 6:00 A.M. During verbal report from night shift nurse (LPN #1) was told by (RN #2) that due to confusion about wanting to see his wife, that the resident (Resident #B) should have a roam guard. (LPN #1) states she was on the unit until about 9:45 A.M. and was then relieved by (LPN #3), and during verbal report she told (LPN #3) that (Resident #B) should have a Roam Guard. When (LPN #1) was asked if she asked for a Roam Guard from the Unit Manager, DNS (Director of Nursing Services) or ED (Executive Director), all of which were present in the building (LPN #1) stated that she did not request the Roam Guard from any Department Manager. 10/15/15 2:00 P.M. .Stated she (CNA #4) never did see (Resident #B). That his bed was made and room appeared as though no one was occupying the room. (Resident #B's) name tag was on the outside door. 10/15/15 2:25 P.M. 'I (LPN #3) was standing at the treatment cart .(Resident #B) was standing at the doorway of his room .I told him I would be there in a few minutes to finish his paperwork .' When asked if she did go to the room to complete it, (LPN #3) stated, 'no I got moved to ACU.' 10/15/15 2:30 P.M. (LPN #5) Arrived to work, went to ACU to receive report from (LPN #3) .per (LPN #5) she (LPN #3) stated 'Everything was okay.' 10/15/15, between 2:00 P.M., and 4:00 P.M., from facility interviews with residents #J and #K: Both these residents were on the porch outside the Rehab unit and noted the resident walking across the parking lot. Both noted he did not exit the rehab unit door, but appeared as though he had exited the main door. Resident K stated 'I yelled at him .' but he did not answer .Both stated they never saw him again and both gentlemen stated they did not tell anyone about this . 10/15/15 3:00 P.M. (LPN #5) Did not administer (named medications) as ordered, when asked why he did not question the location of the resident, (LPN #5) stated, '(CNA #4) said he was gone out of the building with family.' Upon interview with both (CNA #4) and ((LPN #5), she (LPN #4) maintains she never made that statement and (LPN #5) acknowledges he may have misunderstood her. 'CNA #4) is at times difficult to understand due to English being her second language.' 10/15/15 11:30 P.M. He (LPN #5) stated that his Unit Manager had left him some paperwork that needed to be done and a part of that was the paperwork on (Resident #B), he stated it was at that time he questioned where the resident was and why he had not 'returned' to the facility, as he thought he heard (CNA #4) say he was out with family. 10/15/15 11:45 P.M. (LPN #5) Notified ED (Executive Director) That (Resident #B) was not in the facility. ED instructed (LPN #5) to initiate a search of the unit while ED awaited results. (LPN #5) returned to telephone and informed ED that resident was not on the unit. ED then instructed that he would be in the facility within 15 minutes and to initiate an ALL facility search. 10/16/15 12:00 A.M. ED arrived at facility and initiated an external premises search . 10/16/15 12:45 A.M. ED notified Indianapolis Metropolitan Police Department. (Officer) arrived at facility to take report. 10/16/15 12:52 A.M. Notified Area Vice President .in route to (addresses from admission records.) 10/16/15 2:15 A.M. (Officer) returned to facility, provided case number .stated he had discussed the report with his sergeant, and that a detective would be contact ED. (sic) The Executive Director (ED) and Area Vice President were interviewed on 10/16/15 at 3:00 P.M. The ED indicated Resident #B had eloped from the facility sometime on the afternoon of 10/15/15, and that he remained missing. The ED indicated that admission documentation indicated Resident #B had a [DIAGNOSES REDACTED]. The ED indicated both family and police had indicated Resident #B had an established pattern of disappearing and fraternizing with the homeless and street people of the Near East Side of Indianapolis, and he would typically be gone until his resources ran out. The ED indicated staff had not followed facility policy and procedure in not providing a Roam Guard device for a resident known to be an elopement risk, not maintaining awareness of his presence, and not promptly instituting a search and notifying management when he was first noted to be missing from the facility. In an interview on 10/20/15 at 9:30 A.M., with RN #2, indicated she reported for work on 10/14/15 at 10:00 P.M. and was given report on Resident #B by LPN #1. RN #2 indicated she was not advised Resident #B had a [DIAGNOSES REDACTED]. She indicated shortly after report Resident #B walked to the Rehab Unit door and stood there, but did not try to exit. She redirected him back to his room. She then reviewed Resident #B's record and noted a documented history of him running away from home. She indicated she thought Resident #B needed a Roam Guard, but there was not one available on the medication cart on her unit. She indicated she did not try to locate one elsewhere, and did not notify anyone of the need. She indicated that at shift change on the morning of 10/15/15 she gave report to LPN #1 and advised her she believed Resident #B needed a Roam Guard based on history and wandering behavior. She indicated she did not tell anyone else of her concerns. LPN #1 was interviewed on 10/19/15 at 5:30 P.M. She indicated that on the morning of 10/15/15 RN #2, who had worked the night shift, indicated during report that Resident #B needed a Roam Guard, but one was not available. LPN #1 indicated she did not attempt to locate a Roam Guard. She indicated when she left the facility at 9:45 A.M. she was relieved by LPN #3, and that she told LPN #3 that Resident #B needed a Roam Guard at that time. LPN #3 was interviewed on 10/19/15 at 5:20 P.M. She indicated she had worked with Resident #B on 10/15/15, including administering his morning medications, and passing his breakfast and lunch trays. She indicated the resident was pleasant and cooperative and very nice. She indicated Resident #B expressed no concerns or problems, and did not indicate he wanted to leave the facility. She indicated she saw him standing in his doorway observing the hall at 2:15 P.M., but that he did not leave his room. She indicated that was the last time she saw Resident #B. CNA #4 was interviewed on 10/20/15 at 2:15 P.M. She indicated she saw Resident #B in his room on the afternoon of 10/15/14, time uncertain, and that he was quiet, sitting on his bed, and did not to her knowledge leave his room. LPN #5 was interviewed on 10/20/15 at 2:00 P.M. He indicated that on 10/15/15 he arrived 30 minutes late for his afternoon shift, and that LPN #3, who he was following, had left the unit to work on another unit, and he did not get report from her. He indicated that when he went to the unit where she was working to get the unit keys, LPN #3 told him everything was ok and gave him no other information. LPN #5 indicated that Resident #B's name popped up (on the computer) for 5:00 P.M. medications, but that he did not look for Resident #B, because, in his words, other names popped up too, some were discharged . He indicated that when the night shift nurse, who came on at 10:00 P.M., began her daily census at around 11:30 P.M. was when he was first aware Resident #B was missing. He indicated at that time he notified the Executive Director and began a building search for Resident #B. An undated facility policy titled Elopement Guideline received from the Director of Nursing Services on 10/17/15 at 1:00 P.M. indicated: Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization . Initial Review: Upon admission, each resident is reviewed to establish elopement risk using the Clinical Status Form . The Immediate Jeopardy that began on 10/14/15 was removed on 10/20/15 at 3:30 P.M., when the facility educated staff on elopement policy and procedure, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility continued to provide reeducation and reassurance to residents and families regarding elopement. This Federal tag relates to Complaint IN 761. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident was adequately hydrated to prevent dehydration, resulting in a 4 day hospital admission, for 1 of 2 residents reviewed for dehydration. (Resident #30) Findings include: The clinical record for Resident #30 was reviewed on 1/14/13 at 11:00 a.m. The [DIAGNOSES REDACTED]. The 11/30/12 quarterly MDS (minimum data set) assessment indicated Resident #30 required extensive assistance of one person for eating. The 11/26/12 Nutrition Assessment indicated Resident #30 had the following dehydration risk factors: diuretic use, daily laxative use, and dementia. It also indicated the feeding ability of Resident #30 was total dependence and limited assistance. This assessment did not indicate Resident #30's estimated needs for fluid. During review of Resident #30's care plans, no care plan for dehydration potential could be found. The 1/8/13 nutrition assessment indicated Resident #30's estimated nutrient needs for fluid as "1580-1895 ml free fluids." During an interview with Unit Manager #6 on 1/16/13 at 12:40 p.m., she indicated the facility tracked the percentages of food and fluids consumed for residents. She indicated intake and output were not recorded for Resident #30. She also indicated, "We typically put residents on I's and O's (intake and output) if we see that they are not drinking or eating a whole lot, if they're on fluid restrictions. We didn't notice anything on (name of Resident #30)." Unit Manager #6 provided the "Resident Meals by Day Report" for Resident #30 on 1/16/13 at 3:25 p.m. She indicated the report combined food and fluid in its percentages. They were not tracked separately. Breakfast, lunch, dinner, and evening snack were accounted for in the report. It indicated the average meal intake percentages for the following days: 12/22/12 - 25% 12/23/12 - 16.7% 12/24/12 - 58.3% 12/25/12 - 25% (dinner was only meal included for this day) 12/26/12 - 50% 12/27/12 - 25% 12/28/12 - 25% 12/29/12 - 33.3% 12/30/12 - 66.7% 12/31/12 - 16.7% 1/1/13 - 50% (breakfast and lunch were only meals included for this day) During another interview with Unit Manager #6 on 1/16/13 at 3:45 p.m., she indicated the facility would know a resident was receiving adequate fluids if the "Resident Meals by Day Report" indicated meals above 50% and through skin assessments. She then stated, "I'm not sure," followed by, "If they're eating less than 25% of meals, they may not be receiving adequate fluids. We don't have a policy to monitor fluids." The progress notes indicated the following: 12/23/12, 10:39 p.m. - "...extra fluids encouraged & tolerated." 12/24/12, 4:36 a.m. - "Fluids encouraged." 12/24/12, 10:24 p.m. - "...extra fluids encouraged & tolerated." 12/25/12, 2:34 p.m. - "...continue to encourage extra fluids." 12/26/12, 7:17 a.m. - "Fluids encouraged." 12/26/12, 2:49 p.m. - "continue to encourage extra fluids." 12/26/12, 9:52 p.m. - "...extra fluids encouraged & tolerated." 12/27/12, 9:50 p.m. - "...extra fluids encouraged & tolerated." 12/28/12, 10:49 p.m. - "...fluids encouraged." 12/29/12 - Did not indicate fluids encouraged or tolerated 12/30/12 - Did not indicate fluids encouraged or tolerated 12/31/12 - Did not indicate fluids encouraged or tolerated The 1/1/13, 3:43 p.m. progress note indicated, "Change of Condition. Situation: appetite poor, and decrease fluid intake. Background: dx: infiltrates. Assessment: breath sounds congested appetite poor, res lethargic easily aroused. MD notified. v/s: 97.2, 94/70, 48 faint difficult to palpate (pulse), 20 (respirations) MD notified. Response: order for IV fluids. D51/2 normal saline @75ml hr give 2 liters. orders noted. family aware of new orders." The 1/1/13, 7:10 p.m. progress note indicated, "Resident unable to take po (by mouth) fluids or eat well. Unable to start IV fluids as ordered, due to res being dehydrated. VS T97.8, P78, R20, BP 127/46. Sats 97%. Alert and oriented with periods of lethargy. Resp easy and unlaboured. cracles and wheezes heard on all four lobes. Res transfer to (name of hospital) per (name of transport company). Family notified." The 1/2/13, 10:38 a.m. hospital progress note indicated the following: "...presenting to the (name of hospital) emergency department with complaints of sever (sic) fatigue, thirsty, and confusion, she lives at ECF (extended care facility) and claims that nobody was able to access her vein for IV trx (treatment). She is oriented at the time I saw her for T/P/P (time, place and person) and looked very dehydrated. She denies any cp (complaint of pain). Sob (shortness of breath), fever. chills. Ha (headache). LOC (level of consciousness), n (nausea), vomiting, she constantly asking for water. She was found to be hypotensive and was started on IV fluids. chest xray showed possible pneumonia and was started on [MEDICATION NAME]." The 1/1/13 9:08 p.m. hospital labwork for Resident #30 was provided by Consultant #8 at 3:05 p.m. on 1/16/13 who stated, "She was barely dehydrated." It indicated normal lab values and Resident #30's actual lab values as follows: Sodium - 142 (Normal: 134-143) Potassium - 4.8 (Normal: 3.5-4.9) Chloride - 107 (Normal: 98-109) BUN - 23 (Normal: 8-26) hemoglobin - 13.6 (Normal: 11.6-15.2) hematocrit - 40 (Normal: 34.4-45.6) The 1/4/13 hospital discharge summary indicated the following: "Discharge Diagnosis: [REDACTED]. Principle Problems: *Fatigue Active Problems: Anorexia Dehydration... Hospital Course and Physical Exam: ...admitted on [DATE] for Dehydration and [MEDICAL CONDITION]. In the process of her workup a UTI (urinary tract infection) was also found. The pt (patient) has been treated with IV hydration and ABx (antibiotics)...." During an interview with Consultant #8 on 1/16/13 at 1:23 p.m., she indicated, "She should absolutely have a dehydration care plan. Residents are assessed weekly and dehydration status should be part of that. We had a lot of upper respiratory going on and it got the best of a lot of people. We rely heavily on communication from CNAs (Certified Nursing Assistants) and nursing. We need them to tell us if someone needs more assistance with feeding." 3.1-46(b)

Based on record review and interview, the facility failed to ensure a resident (Resident B) received adequate supervision and the appropriate use of assistive devices (a physician ordered alarmed lap belt) to prevent an accident with injury (a fall from a wheelchair with a resultant hip fracture) for 1 of 3 residents reviewed for accidents in a sample of 3. Findings include: The record of Resident B was reviewed on 9/07/11 at 9:00 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident B was severely cognitively impaired, had physical and verbal behavioral problems directed towards others, and required staff assistance with activities of daily living, including extensive assistance with transfers and locomotion. Resident B's balance was noted to be not steady and requiring assistance for stabilization for all activities of transitions and walking. A physician's orders [REDACTED]." A "Pre-Restraint Evaluation" form for Resident B dated 3/03/11 was marked as "Yes" for concerns which included, but were not limited to: "Disoriented... In denial of physical limitations...Falls forward or back when walking...Unsteady on feet...Poor balance when walking...History of falls..." The Pre-Restraint Evaluation form also indicated on 4/11/11 "Resident continues to attempt to stand up unassisted poor safety awareness." A "Change of Condition" progress note entered by LPN #1 on 8/21/11 at 3:22 p.m. indicated "Situation: res (resident) was sitting in MDR (main dining room) in w/c (wheelchair) writer notified that res was on floor on L (left) side next to w/c at approx. (approximately) 2:45 p.m. Res stated wanted to get up and walk, and fell in (sic) floor..." A "Change of Condition" progress note entered by RN #9 on 8/22/11 at 00:25 a.m. indicated "Situation: F/U (follow up) fall resident C/O (complains of) left hip pain...Assessment...left lower extremity especially hip resident screamed and very guarding of this area... A "Change in Condition Report-Post Fall/Trauma" form completed by LPN #1 dated 8/21/11 at 3:00 p.m. indicated: "Resident's Name: (Name of Resident B)... On 8/21/2011 at 14:45, the following occurred: Falls: Transfer-Unassisted in Resident Dining Room...no apparent injury..." The "Change in Condition Report-Post Fall/Trauma" form has a 12 point "Physical Assessment" section which was left blank. The form also contained no resident statement or summary of assessment, causative factors, presence of restraints or assistive devices as required by facility policy. A document titled "Timeline for (Resident B) on 8/21/2011" prepared by the Director of Nursing Services (D.N.S.) included, but was not limited to: "2:30 pm (Resident B) was noted sitting in her w/c (wheelchair) in the MDR (main dining room)... 2:45 pm (Resident B) was noted on the floor in the MDR...she was put back in her chair and brought to the nurses station... 10:30 pm CNA approached resident and asked to take her to the bathroom...resident c/o (complained of) pain to CNA, then CNA brought her to the nurse at station and stated that resident was c/o of pain, pain medication given... 10:30 pm DNS was standing at the desk when the CNA notified the LPN that the resident was c/o of pain, the LPN then stated that resident had fallen earlier that day, RN on duty for night shift...immediately stated would (sic) help the CNA lie the resident down and assess the resident and call the DNS with update... 11:01 pm RN called DNS and informed her of the need for an X-ray, DNS instructed her to call MD for order... 11:18 pm LPN (LPN #1) documented her notification to MD regarding resident c/o left leg pain and inability to move with c/o pain... 8/22/2011 12:25 am RN on night shift called MD and obtained order for mobile x-ray... 1:14 am RN on night shift called MD and reported that (name of portable x-ray service) came to do x-ray but unable to obtain the x-ray due to resident guarding, MD gave new order to send to ER for x-ray of left hip and lower extremity... 2:00 am RN described the resident was...guarded as the transporters were getting her on the gurney... 6:05 am called hospital to check on status of resident, it was reported that resident was admitted for hip fracture..." On 8/25/11 Clinical Services Consultant #1 began a series of staff interviews in relation to Resident B's fall with injury of 8/21/11. Documentation of these interviews included, but was not limited to: "DNS spoke with (Resident B's guardian)...She told DNS that the surgery was Monday...pins were placed...Stated (Resident B) was in a lot of pain and disoriented. She also stated she was very disappointed and that this fall should not have happened as she was told by the staff that she fell in front of the nurse's station... (LPN #1) stated she heard (LPN #8) say 'oops, she's on the floor'...she did not hear an alarm sounding. She stated she heard (LPN #4) telling the staff she shouldn't move her since she was having pain. (LPN #1) had (CNA #7) and (CNA #3) pick (Resident B) up and put her in the wheelchair...I asked if they thought to lay her down to take a nap or lay her down to do a full assessment and she said no. She didn't know why she just didn't think about it... (CNA #7)...stated he was down the hall...when the nurse called for help. He helped pick (Resident B) up off the floor...he did not hear an alarm... (LPN #4) stated...someone came to the nurse's desk and said (Resident B) was on the floor...she asked (Resident B) if she could move her legs and could she turn over. (Resident B) responded 'I don't know' and then said something like 'honey something ain't right back there'. (LPN #4) stated she looked at (LPN #1) and asked her what she wanted to do about it...(LPN #4) stated her shift was almost over and (LPN #1's) was just starting so she turned to walked away. She stated she didn't hear (LPN #1) tell them to pick (Resident B) up but 2 aides did put her back in her chair. She stated she didn't hear an alarm sounding. (CNA #3)...stated... she heard someone say (Resident B) was on the floor...(CNA #3) asked (LPN #1) if she wanted her to get the Rosie (mobile VS (vital signs) machine) and (LPN #1) said 'no' or 'not yet'...(CNA #3) stated that (LPN #4) said that we need to leave her on the floor...(CNA #5) asked (Resident B) if she hit her head and she replied no but said her back was hurting and she rubbed her leg. (CNA #3) stated she heard (LPN #1) tell them to 'go ahead and get (Resident B) up...(CNA #3) stated (Resident B) had a frown on her face after they put her in the wheelchair...(CNA #3) asked (Resident B) if she was ok and (Resident B) stated, 'no my legs are hurting...(CNA #3) stated (LPN #1) was sitting within hearing range and thought she should have heard (Resident B) make that statement... (CNA #5)...asked those standing there if the alarm was working? No one stated they heard the alarm sounding...At 3:15p (CNA #5) saw (Resident B) sitting in front of the nurse's station leaning slightly off to her left side. She asked how (Resident B) was and (Resident B) replied, 'oh baby I'm hurting. The nurses were sitting at the station... (CNA #6) stated she was coming down the hall and (LPN #8) stated (Resident B) had fallen... (CNA #6) did not hear an alarm sounding. She saw the straps to the alarming Velcro seatbelt hanging down on each side of the wheelchair...(CNA #6) stated (Resident B) complained about pain in the right side of her back..." During an interview on 9/07/11 at 10:15 a.m. with the Administrator, Assistant Director of Nursing Services, and corporate Vice President present, the Director of Nursing Services indicated that Resident B was a known fall risk; that there was an order for [REDACTED]. on 8/21/11 with attendant hip fracture the seat belt was not on, and the alarm was not sounding. She also indicated that LPN #1's assessment following Resident B's fall was not thorough and was not adequately documented. A facility policy titled "Change in Condition Report-Post Fall Investigation Summary Guidelines for Completion" dated January 2011 indicated: Purpose: To assess individual condition after a fall occurs and to identify the reason and/ or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls. Procedure: If a resident falls...The licensed nurse shall initiate the Change of Condition-Post Fall Investigation Summary...Evaluate for causative factors including change in environment, presence of restraints or assistive devices...Summarize the significant assessment findings...and interventions that were in place at the time of the fall...Identify and (sic) new interventions that will be immediately implemented to reduce the potential for falls to reoccur..." This federal tag relates to complaint #IN 376. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a care plan was developed and implemented for 1 of 1 resident with a known risk for injury in the sample of 3 residents reviewed for care plans. (Resident B's open reduction, internal fixation of her right (arm) humerus fracture). Findings Include: 1. A facility document titled "Reporting Alleged Violations," dated March '07 received from the Administrator on 01/04/11 at 4:00 p.m., and indicated to be a current facility policy indicated: Policy: It is the policy of this facility to take appropriate steps to prevent the occurrence of...injuries of unknown source... Corrective Action...The DNS (Director of Nursing Services), or designee, initiates a care plan to reflect the resident's condition and measures to be taken to prevent recurrence..." A facility document titled "Care Plan," dated May 2001, received from the Administrator on 01/04/11 at 3:30 p.m. and identified as a current facility policy indicated: "Responsibility: The following individuals may have responsibility for completing the plan of care...RN...LPN/LVN... Purpose...identification of problems and developing solutions provides individualization and coordination of resident care... Policy: All residents must have a care plan...the interdisciplinary care plan is reviewed, revised, and updated quarterly and more frequently if warranted by a change in resident's condition..." 2. The record of Resident B was reviewed on 1/03/11 at 10:00 a.m. [DIAGNOSES REDACTED]. A "Facility Incident Reporting Form" faxed to the State Survey Agency on 12/02/10 indicated: "Incident Date: 12/1/2010 Resident Name: (name of Resident B) Brief Description of Incident: Resident was trying to scoot up in bed and in the process...she rolled out of bed to the floor, landing her on the right side of her body. Type of Injury/Injuries: Fracture to her right (arm) humerus. Immediate Action Taken: Resident...was sent to (name of acute care hospital)..where she was found to have fractured her right humerus." Resident B's record indicated she was readmitted to the facility on [DATE] following an open reduction, internal fixation (ORIF) of her right humerus fracture. Resident B's record contained no documentation of a care plan related to her fractured right humerus and subsequent ORIF, including but not limited to assessment of status of her arm, transfer techniques, weight bearing with the right arm, positioning while in bed, reporting of concerns or appropriate handling of the resident's arm. A Nurse Practitioner's progress note, dated 12/17/10 at 4:30 p.m., indicated "STAT (immediate) XR (x-ray) right upper extremity re: (related to) S/P (status [REDACTED]." An untimed Nurse Practitioner's progress note, dated 12/17/10, indicated "Send to emergency department...for evaluation due to S/P ORIF right humerus abnormal portable x-ray, increased pain and swelling." A Nurse Practitioner's "Follow Up Note" (untimed) indicated: "Imaging Results 12/17/2010, Humerus, 2VW (views) fixated fracture involving right distal humerus with mild displacement...treatment plan: [REDACTED]." During an interview on 01/03/11 at 2:00 p.m., with the Administrator and Director of Nursing Services (DNS) present, the Director of Nursing Services indicated that on 12/17/10 an Occupational Therapist had observed Resident B's right arm to be swollen. This was reported to the Nurse Practitioner, who assessed Resident B, ordered an x-ray, and subsequently sent Resident B to the hospital as noted above. During the interview on 01/03/11 at 2:00 p.m., with the Administrator and Director of Nursing Services present, the DNS indicated there was no care plan developed specific to care and safety precautions related to Resident B's right humerus fracture. 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure necessary care was implemented to protect a resident with a known risk for injury (Resident B's right humerus (arm) fracture on 12/01/10 and resulting open reduction, internal fixation) from further injury (a dislocation of Resident B's fractured right humerus) by not implementing an appropriate care plan and not instructing caregivers in proper care for 1 of 3 residents reviewed for quality of care. Findings include: The record of Resident B was reviewed on 1/03/11 at 10:00 a.m. [DIAGNOSES REDACTED]. A "Facility Incident Reporting Form" faxed to the State Survey Agency on 12/02/10 indicated: "Incident Date: 12/1/2010 Resident Name: (name of Resident B) Brief Description of Incident: Resident was trying to scoot up in bed and in the process...she rolled out of bed to the floor, landing her on the right side of her body. Type of Injury/Injuries: Fracture to her right humerus. Immediate Action Taken: Resident...was sent to (name of acute care hospital)..where she was found to have fractured her right humerus." Resident B's record indicated she was readmitted to the facility on [DATE] following an open reduction, internal fixation (ORIF) of her right humerus fracture. A Nurse Practitioner's progress note, dated 12/17/10 at 4:30 p.m., indicated "STAT (immediate) XR (x-ray) right upper extremity re: (related to) S/P (status [REDACTED]." An untimed Nurse Practitioner's progress note, dated 12/17/10, indicated "Send to emergency department...for evaluation due to S/P ORIF right humerus abnormal portable x-ray, increased pain and swelling." A Nurse Practitioner's "Follow Up Note" (untimed) indicated: "Imaging Results 12/17/2010, Humerus, 2VW (views) fixated fracture involving right distal humerus with mild displacement...treatment plan: [REDACTED]." During an interview on 01/03/11 at 2:00 p.m. with the Administrator and Director of Nursing Services (DNS) present, the DNS indicated that on 12/17/10 an Occupational Therapist had observed Resident B's right arm to be swollen. This was reported to the Nurse Practitioner, who assessed Resident B, ordered an x-ray, and subsequently sent Resident B to the hospital as noted above. At the time of this interview the Director of Nursing Services provided documentation which she indicated to be the complete record of the facility's investigation into the displacement of Resident B's fractured humerus, identified on 12/17/10. On 01/04/11 at 9:00 a.m., the Administrator provided an undated document headed "Regarding the education of staff caring for (Resident B)...All staff CNA's that have been rendering care for (Resident B) 12/2/2010 through 12/17/10 are as follows..." The list provided the names of 13 CNAs, for purposes of this report identified as CNAs 1 through 13 inclusive, and the names of 4 LPNs, identified as LPNs number 14 through 17, who may have provided the listed CNAs information concerning Resident B's care. The investigation documentation provided by the Director of Nursing Services as noted, and the balance of Resident B's record, contained no documentation of any interviews with the 13 identified CNAs or 4 LPNs specific to the staff's knowledge and practices of care, management or safety issues of Resident B's fractured right humerus, including but not limited to transfer techniques, weight bearing with the right arm, positioning while in bed, or appropriate handling of the resident's arm, assessments, or issues to be reported. During the interview on 01/03/11 at 2:00 p.m., with the Administrator and Director of Nursing Services present, the DNS indicated there was no care plan specific to care and safety precautions related to Resident B's right humerus fracture. The CNA Assignment Sheets for Resident B for the period beginning 12/03/10, when she returned from the hospital following the ORIF of her right humerus fracture, contained no instructions or information concerning proper care or precautions to be taken to protect Resident B from further injury to her right arm. A "History and Physical," dated 12/18/10, from the acute care hospital where Resident B was readmitted following the displacement of her right humerus fracture on 12/17/10 indicated: "Chief Complaint: Right arm pain. History of Present Illness...She had an open reduction/internal fixation done...on 12/02/10...She was returned to the extended care facility...She states she had continued pain and that the help in the extended care facility used the arm to move her as well, as she was sliding around in bed. She had no falls... Physical Exam...Extremities...She has gross deformity in varus at the distal 1/3 of her humerus Assessment...Right periprosthetic distal humerus fracture... Plan...plan on taking her to the O.R. tomorrow..." During the interview on 01/03/11 at 2:00 p.m., with the Administrator and Director of Nursing Services present, both indicated the source of Resident B's displaced fracture of 12/17/10 could not be determined with certainty. During an interview on 01/04/11 at 3:00 p.m., the D.N.S. again confirmed that Resident B had no care plan related to fracture care and that CNA assignment sheets had no instructions or information concerning appropriate care of the resident's recently fractured arm. This federal tag relates to complaint #IN 790. 3.1-37(a)