Every finding on record at Brickyard Healthcare - Churchman Care Center

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for a resident with a contracture for 1 of 1 resident's reviewed for mobility. (Resident 26) Finding includes: On 11/22/25 at 9:45 a.m., observed Resident 26 in her wheelchair. Resident 26 was self-propelling her wheelchair in the hall. Resident 26's left hand and wrist were observed to be bent toward the palm of the hand. On 11/22/25 at 11:00 a.m., the clinical record of Resident 26 was reviewed. The diagnoses included, but was not limited to, cerebral infarction and reduced mobility. The Annual Minimum Data Set assessment, dated 8/28/25, indicated Resident 26 had an impairment on one side of her upper extremity including her wrist and hand. An Occupational Therapy Note, dated 12/31/24, indicated Resident 26 stated she did not want to wear the 1/4 inch foam in her left hand due to increased pain. Resident was not a candidate to wear a Carrot (a devise used to position fingers away from the palm, reducing pressure, protecting skin and keeping hands dry) or palm protector due to severe contracture in left hand. The clinical record lacked a comprehensive person-centered care plan regarding an impairment or contracture to Resident 26's left hand. On 11/20/25 at 8:33 a.m., the Director of Nursing indicated Resident 26 should have had a care plan describing services required for the contracture on her left hand. The DON also indicated the resident had a history of refusing treatment to the contracture to her left hand. On 11/20/25 at 8:58 a.m., the Director of Nursing provided a policy and indicated it was the current policy being used by the facility. The policy titled Comprehensive Care Plans, undated and indicated it was the current policy being used by the facility. A review of the policy indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 3.1-35(a)

Based on interview and record review, the facility failed to thoroughly report all known information regarding an allegation of abuse at the time the allegation was reported to the state health department for 2 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include: During an interview on 2/10/25 at 8:04 a.m., Resident B indicated a few weeks ago, Resident C was in bed and waved Resident B into Resident C's room. Resident B walked into Resident C's room, pulled his pants down and exposed himself to Resident C. During an interview on 2/10/25 at 8:17 a.m., the Director of Nursing (DON) indicated, on 1/12/25, during evening shift she received a phone call from LPN 1 that Resident B was found in Resident C's room. Resident B had his pants down and was receiving oral sex from Resident C. The state health department reportable incident regarding Resident C performing oral sex on Resident B was reviewed, on 2/10/25 at 11:21 a.m. The incident indicated, on 1/12/25 at 8:10 a.m., both residents were found making inappropriate contact. The follow-up to the incident report, dated 1/17/25, indicated the investigation concluded that inappropriate touching occurred between both residents. During an interview on 2/10/25 at 11:08 a.m., CNA 1 indicated she walked into Resident C's room and Resident B was standing with his back toward the door and his pants were down. When he turned toward the door, she saw Resident C performing oral sex on Resident B. CNA 1 reported what she saw to LPN 1. On 2/10/25 at 11:11 a.m., the Administrator provided the Abuse, Neglect and Exploitation policy, revised 2/2023. The policy indicated allegations of abuse were reported to the state survey agency. This citation relates to Complaint IN00451109. 3.1-28(c)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a QMA (Qualified Medication Aide) for 1 of 1 residents reviewed for abuse. (Resident D, QMA 4) Findings include: During an interview on 11/21/24 at 12:07 p.m., RN 2 indicated Resident D was hitting QMA 4 when QMA 4 picked up a chair for protection. QMA 4 then moved towards Resident D with the chair and put the chair against his neck. RN 2 told QMA 4 to stop, RN 2 notified the Director of Nursing (DON) immediately. During an interview on 11/21/24 at 12:13 p.m., Licensed Practical Nurse (LPN) 3 indicated she observed Resident D become upset. Resident D had begun to yell out and was hitting the wall at that time. QMA 4 approached Resident D to take him to his room when Resident D punched QMA 4. QMA 4 backed up and grabbed a folded metal chair and physically placed it onto Resident D's upper chest just below his neck. LPN 3 yelled out to QMA 4 to stop and move away. LPN 3 then reported the incident to the DON immediately. LPN 3 indicated that all QMA 4 had to do was walk away from Resident D. LPN 3 indicated that QMA 4 had ample time to walk away, QMA 4 just wanted to show she was in control. LPN 3 indicated that QMA 4's actions stopped being self defense the minute she approached Resident D with the folded metal chair and pressed it against his upper torso and neck. During an interview on 11/21/24 at 12:45 p.m., the DON and Executive Director (ED) indicated that nursing staff reported that QMA 4 had abused Resident D while trying to remove Resident D from the nurse's station. Resident D was hitting the wall and yelling and QMA 4 made physical contact with Resident D with a folded metal chair. The DON and ED indicated that all staff knew Resident D and his behaviors. The DON and ED further indicated all staff knew the proper steps to deescalate Resident D. The DON indicated the proper solution was for QMA 4 to just walk away. At that time, the DON and ED provided the facility reportable incident, dated 11/20/24. The reportable incident indicated on 11/20/24 QMA 4 placed a folding chair against Resident D's chest after QMA 4 was struck by Resident D. The DON and ED also provided an interview with QMA 4 conducted by the facility on 11/20/24 at 8:15 a.m. QMA 4 indicated on 11/20/24, Resident D was hitting the wall and knocked over a bedside table. QMA 4 indicated that Resident D was behind the nurses station and QMA 4 was trying to get Resident D away from the nurse's station. Resident D had begun hitting and kicking. QMA 4 then grabbed a folded metal chair to block Resident D's hits and kicks. The clinical record for Resident D was reviewed on 11/21/24 at 1:33 p.m. The diagnoses included, but were not limited to, epilepsy, Bipolar Disorder, hypertension, intellectual disabilities, and dysphagia. The Annual MDS (Minimum Data Set) assessment, dated 9/23/24, indicated Resident D was rarely understood and had severe cognitive impairment. A Care Plan, revised 10/10/24, indicated Resident D had physical aggression towards staff, screaming/yelling out, and not allowing staff to put clothing up or other things off the floor. The interventions included, but were not limited to, allow resident time to calm down and reapproach. On 11/21/24 at 1:11 p.m., a policy titled Abuse, Neglect and Exploitation with a revision date of February 2023, and indicated it was the current policy used by facility. Review of a current policy, indicated the following: Abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse facilitated or enabled through the use of technology This deficient practice was corrected on 11/20/24 after the facility implemented a systemic plan of correction that included the following actions: all staff were educated on the abuse policy with ongoing monitoring and audits. This citation relates to Complaint IN00447653. 3.1-27(a)(1)

Based on interview and record review, the facility failed to have residents sign the appropriate consent or refusal forms for pneumococcal vaccinations upon admission for 4 of 5 residents reviewed for immunization records. (Resident 3, Resident 32, Resident 33, and Resident 44) Findings include: 1. On 10/16/24 at 10:45 a.m., Resident 3's clinical record was reviewed. Resident 3's diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe), chronic hepatitis C (a viral infection that affects the liver), and unspecified kidney injury. On 10/17/24 at 8:30 a.m., the DON (Director of Nursing), provided a copy of Resident 3's pneumococcal vaccine consent form. A review of the form indicated it was signed as verbal from POA [Power of Attorney] and was undated. 2. On 10/16/24 at 10:30 a.m., Resident 32's clinical record was reviewed. Resident 32's diagnoses included, but were not limited to, COPD, chronic kidney disease, and type 2 diabetes. On 10/17/24 at 8:30 a.m., the DON provided a copy of Resident 32's pneumococcal vaccine consent form. A review of the form indicated it was signed by the resident and was undated. 3. On 10/16/24 at 11:15 a.m., Resident 33's clinical record was reviewed. Resident 33's diagnoses included, but were not limited to, COPD, encephalopathy (a syndrome of brain dysfunction), and alcoholic liver disease. On 10/17/24 at 8:30 a.m., the DON provided a copy of Resident 33's pneumococcal consent form. A review of the form indicated it was signed by the DON for [Resident 33] and was dated 10/16/24. 4. On 10/16/24 at 11:00 a.m., Resident 44's clinical record was reviewed. Resident 44's diagnoses included, but were not limited to, chronic respiratory failure, tracheostomy status, and type 2 diabetes. On 10/17/24 at 8:30 a.m., the DON provided a copy of Resident 44's pneumococcal consent form. A review of the form indicated it was signed by two staff witnesses and was dated for 10/16/24. During an interview on 10/18/24 at 1:40 p.m., the RDCO (Regional Director of Clinical Operations) indicated that the forms should have been signed upon admission. The consent forms records were requested on 10/16/24 at the end of the first day of the survey and were provided on the morning of 10/17/24. All of the forms were dated for 10/16/24 or were undated, and the RDCO indicated that any undated areas on forms were also from 10/16/24. On 10/16/24 at 10:15 a.m., the DON provided an undated policy titled, Pneumococcal Vaccine (Series) and indicated it was the policy currently in use by the facility. A review of the policy indicated that each resident is to be assessed for pneumococcal immunizations upon admission and that a consent form shall be signed prior to the administration of the vaccine. 3.1-13(a)

Based on interview and record review, the facility failed to have residents sign the appropriate consent or refusal forms for Covid-19 (SARS-CoV-2) vaccinations upon admission for 4 of 5 residents reviewed for immunization records. (Resident 3, Resident 32, Resident 33, and Resident 44) Findings include: 1. On 10/16/24 at 10:45 a.m., Resident 3's clinical record was reviewed. Resident 3's diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe), chronic hepatitis C (a viral infection that affects the liver), and unspecified kidney injury. On 10/17/24 at 8:30 a.m., the DON (Director of Nursing), provided a copy of Resident 3's Covid-19 vaccine consent form. A review of the form indicated it was signed as verbal from POA [Power of Attorney] and was undated. 2. On 10/16/24 at 10:30 a.m., Resident 32's clinical record was reviewed. Resident 32's diagnoses included, but were not limited to, COPD, chronic kidney disease, and type 2 diabetes. On 10/17/24 at 8:30 a.m., the DON provided a copy of Resident 32's Covid-19 vaccine consent form. A review of the form indicated it was signed by the resident and was dated 10/16/24. 3. On 10/16/24 at 11:15 a.m., Resident 33's clinical record was reviewed. Resident 33's diagnoses included, but were not limited to, COPD, encephalopathy (a syndrome of brain dysfunction), and alcoholic liver disease. On 10/17/24 at 8:30 a.m., the DON provided a copy of Resident 33's Covid-19 consent form. A review of the form indicated it was signed by the DON for [Resident 33] and was dated 10/16/24. 4. On 10/16/24 at 11:00 a.m., Resident 44's clinical record was reviewed. Resident 44's diagnoses included, but were not limited to, chronic respiratory failure, tracheostomy status, and type 2 diabetes. On 10/17/24 at 8:30 a.m., the DON provided a copy of Resident 44's Covid-19 consent form. A review of the form indicated it was signed by two staff witnesses and was undated. During an interview on 10/18/24 at 1:40 p.m., the RDCO (Regional Director of Clinical Operations) indicated that the forms should have been signed upon admission. The consent forms records were requested on 10/16/24 at the end of the first day of the survey and were provided on the morning of 10/17/24. All of the forms were dated for 10/16/24 or were undated, and the RDCO indicated that any undated areas on forms were also from 10/16/24. On 10/16/24 at 10:15 a.m., the DON provided an undated policy titled, Covid-19 Vaccination and indicated it was the policy currently in use by the facility. A review of the policy indicated residents are to be offered immunizations for Covid-19 and that a consent form shall be signed prior to the administration of the vaccine.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 2 of 2 kitchen observations. Hair was not covered. (Dietary Manager) Findings include: On 10/16/24 from 9:08 a.m. to 10:00 a.m., observed the Dietary Manager in the kitchen food preparation area where food had been prepared for the morning meal and shipment of supplies were being put away. The Dietary Manager was observed to be lacking a hair net with hair measuring approximately one forth of an inch over the entire head. On 10/16/24 from 11:45 a.m. to 12:45 p.m., the Dietary Manager was observed in the kitchen assisting with food preparation for the noon meal. The Dietary Manager was observed to be lacking a hair net. During an interview on 10/16/24 at 12:45 p.m., the Dietary Manager indicated hair nets should be worn. During an interview on 10/17/24 at 2:58 p.m., the Regional Director for Clinical Operations indicated all kitchen staff preparing food should have been wearing hair nets. On 10/16/24 at 12:46 p.m., the Regional Director of Clinical Operations provided a copy of Food Safety requirement, dated 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, page 3 section 7.e . Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad, . On 10/17/24 at 2:00 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-24, effective November 13, 2004, indicated, (b)food employees shall wear hair restraints, such as hats, hair coverings or nets .that are designed and worn to effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure that written Notice of Transfer and Discharge was provided to the resident's representative and to the Office of the State Long-Term Ombudsman for 1 of 6 residents reviewed for written transfer and discharge notification. (Resident 31) Finding includes: On 10/17/24, at 2:00 p.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and type 2 diabetes. The face sheet indicated Resident 31 had a resident representative. The Annual Minimum Data Set (MDS) assessment, dated 8/22/24, indicated Resident 31 was cognitively intact. The clinical record's census tab indicated Resident 31 was transferred to the hospital emergency department on 8/5/24. The Notice of Transfer or Discharge document, dated 8/5/24, indicated Resident 31 was transferred to the hospital emergency department for a facility-initiated hospital transfer on 8/5/24. Resident 31 was provided a copy of the transfer document at the time of his transfer. On 10/21/24 at 1:45 p.m., the Administrator provided a copy of the facility's August 2024 monthly report submitted to the Office of the State Long-Term Ombudsman. The report indicated Resident 31 was transferred to the hospital on 8/5/24. The monthly report did not included a copy of Resident 31's Notice of Transfer and Discharge document. The monthly report lacked specific details for the transfer including the reason for transfer, bed hold policy, and appeal rights. The clinical record lacked documentation that the written Notice of Transfer and Discharge document was provided to the resident's representative and to the Office of the State Long-Term Ombudsman for the facility-initiated hospital transfer on 8/5/24. During an interview on 10/16/24 at 1:17 p.m., Resident 31 indicated he was transferred to the hospital this past August. During an interview on 10/18/24 at 8:43 a.m., the Director of Nursing Services (DNS) indicated Resident 31 was transferred to the hospital emergency department on 8/5/24. The facility lacked verification that the written Notice of Transfer and Discharge document was provided to the resident's representative and to the Office of the State Long-Term Ombudsman for the facility-initiated hospital transfer on 8/5/24. During an interview on 10/21/24 at 2:05 p.m., the Social Service Director indicated the Notice of Transfer and Discharge document was not included in the monthly report that was sent to the Ombudsman. The monthly report provided to the ombudsman only included the date and location of the transfer. On 10/21/24 at 9:12 a.m., the Regional Director of Clinical Operations provided a copy of the Transfer and Discharge (including AMA [Against Medical Advice]) policy, dated 2024, and indicated it was the current policy in use by the facility. A review of the policy indicated, .The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand .copies of notices for emergency transfers to the Ombudsman . 3.1-12(a)(6)(A)(iii)

Based on observation, interview, and record review, the facility failed to ensure a self medication administration assessment was completed for 1 of 1 residents randomly observed with medications left at bedside. Finding includes: During an observation on 10/16/24 at 9:38 a.m., Resident 30 was sitting up on the side of the bed. The following items were observed sitting on top of table in front of television: - One medication bottle of Simbrinza Ophthalmic Suspension 1-0.2%, for the treatment of glaucoma. - One medication bottle of Lantanoprost Solution 0.0005%, for the treatment of glaucoma. During an observation on 10/17/24 at 8:38 a.m., a small plastic medication cup with multiple unidentified tablets and capsules were observed sitting on the table in front of the television. During an interview at that time, Resident 30 indicated that he had to eat breakfast before he could take his medication, so the nurse left them for him. During an observation on 10/21/24 at 10:50 a.m., the following was observed sitting on top of refrigerator in Resident 30's room: - One medication bottle of Simbrinza Ophthalmic Suspension 1-0.2%, for the treatment of glaucoma. - One medication bottle of Lantanoprost Solution 0.0005%, for the treatment of glaucoma. On 10/21/24 at 11:03 a.m., Resident 30's clinical record was reviewed. The clinical record lacked a self-administration medication assessment. During an interview on 10/21/24 at 10:55 a.m., Qualified Medication Aide (QMA) 5 indicated medications should not be left in resident rooms. During interview on 10/21/24 at 11:30 a.m., the Director of Nursing indicated that it was not acceptable for staff to leave medication in resident rooms. The DON indicated Resident 30 did not have a medication self-administration assessment. On 10/21/24 at 11:30 a.m., the Director of Nursing provided a policy titled Medication Administration Policy, dated 2024, and indicated it was the policy currently in use for the facility. The policy indicated, 18. Observe resident consumption of medication. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to implement the comprehensive care plan for 1 of 2 residents reviewed for falls. (Resident 7) Finding includes: On 10/16/24 at 10:00 a.m., observed Resident 7's in bed. The bed was observed to be elevated (approximately 4 feet from the floor) and was not in the the lowest position. On 10/17/24 at 11:23 a.m., observed Resident 7's in bed. The bed was observed to be elevated (approximately 4 feet from the floor) and was not in the lowest position. On 10/21/24 at 8:45 a.m., observed Resident 7 in bed. The bed was observed to be elevated and was not in the lowest position. During an interview on 10/21/24 at 8:45 a.m., RN 4 indicated Resident 7's bed should always be in the lowest position. On 10/21/24 at 9:30 a.m., the clinical record for Resident 7 was reviewed. The diagnosis included, but was not limited to, dementia. The Annual Minimum Data Set assessment, dated 9/11/24, indicated Resident 7 required extensive assist with bed mobility and transfers. A Care plan, dated 2/20/23, indicated Resident 7 was at risk for falls. The interventions included, but were not limited to, keep bed in low position, dated 9/18/24. On 10/21/24 at 9:05 a.m., the Regional Director of Clinical Operations provided a policy titled Comprehensive Care Plans, dated 2024, a review of the policy indicated Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .3. The comprehensive care plan will describe, at minimum, the following . a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, .well being. 3.1-35(g)(2)

Based on interview and record review, the facility failed to document the drug dispositions for 1 of 3 closed record residents reviewed. (Resident 49) Finding includes: On 10/18/24 at 10:35 a.m., the clinical record of Resident 49 was reviewed. The diagnoses included, but were not limited to, paraplegia (paralysis of the legs and lower body), hepatitis C (a viral infection that affects the liver), and acquired absence of bilateral legs above the knee. A physician's order summary report of medications, dated for active orders as of 10/14/24, included, but were not limited to: - acidophilus probiotic blend 1 mcg (microgram) for probiotic - atorvastatin calcium 20 mg (milligram) for hyperlipidemia (high levels of fat in blood) - bacitracin ointment 500 unit/gm (gram) for wound care - benzocaine-menthol-zinc chloride gel 20-0.26-0.15 % for tooth pain - diazepam 5 mg for anxiety/seizures - docusate sodium 100 mg for constipation - ferrous sulfate 325 mg for iron supplementation - fluticasone propionate nasal suspension 93 mcg for nasal congestion - gabapentin 600 mg for pain - ibuprofen 400 mg for pain - Lidoderm patch 5 % for costochondritis (inflammation of the cartilage that connects your ribs to your breastbone) - linaclotide 145 mcg for irritable bowel syndrome - methadone hydrochloride 5 mg for substance abuse/pain - oxybutynin chloride extended release 5 mg for urinary incontinence - oxycodone hydrochloride 5 mg for spinal cord injury - oyster shell calcium 500 mg for supplement - sofosbuvir-Velpatasvir 400-100 mg for viral hepatitis C - trazodone hydrochloride 50 mg for depression - vitamin D3 1.25 mg for supplement A progress note, dated 10/14/24 at 5:47 p.m., indicated Resident 49 left the facility via bus and had been discharged with medication to home. Resident 49's record lacked documentation listing any name, type, or amount of medications that were sent home with the resident or resident's representative. During an interview on 10/18/24 at 10:50 a.m., the Regional Director of Clinical Operations (RDOC) indicated that the facility lacked documentation for drug dispositions for Resident 49. During an interview on 10/18/24 at 1:10 p.m., the RDOC indicated that the facility lacked a specific policy for drug dispositions. 3.1-25(s)

Based on observation, interview, and record review, the facility failed to ensure a medication cart was locked for 1 of 4 medication carts observed. (B Hall Medication Cart) Finding includes: On 10/16/24 from 9:25 a.m. until 9:40 a.m., observed an unlocked medication cart on the B hall. The cart was easily opened and no staff were visible in the area. The medication cart contained multiple resident's medications. The medications located inside the medication cart, included but was not limited to: - haloperidol 5 mg (milligram), a medication used to treat nervous, emotional and mental conditions. - metronidazol, a medication used to treat infections. - metoprolol 2.5 mg, a medication used to treat high blood pressure. - Eliquis 2.5 mg, a medication used to prevent blood clots from forming. During an interview on 10/16/24 at 9:45 a.m., the Medical Records Director indicated the medication cart should have been locked. On 10/17/24 at 10:53 a.m., the Regional Director of Clinical Services provided a policy titled Medication Storage, dated February, 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated .1. a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts .). 3.1-25(m)

Based on interview and record review, the facility failed to ensure residents were provided a two-step Mantoux skin test (tool used for screening for tuberculosis) upon admission for 3 of 5 residents reviewed for tuberculosis skin tests. (Resident 32, Resident 33, and Resident 44) Findings include: 1. On 10/16/24 at 10:30 a.m., Resident 32's clinical record was reviewed. Resident 32's diagnoses included, but were not limited to, COPD, chronic kidney disease, and type 2 diabetes. Resident 32's clinical record lacked any documentation of a first step or a second step Mantoux skin test upon admission. 2. On 10/16/24 at 11:15 a.m., Resident 33's clinical record was reviewed. Resident 33's diagnoses included, but were not limited to, COPD, encephalopathy (a syndrome of brain dysfunction), and alcoholic liver disease. Resident 33's clinical record lacked any documentation of a first step or a second step Mantoux skin test upon admission. 3. On 10/16/24 at 11:00 a.m., Resident 44's clinical record was reviewed. Resident 44's diagnoses included, but were not limited to, chronic respiratory failure, tracheostomy status, and type 2 diabetes. Resident 44's clinical record lacked any documentation of a first step or a second step Mantoux skin test upon admission. During an interview on 10/18/24 at 1:40 p.m., the RDCO (Regional Director of Clinical Operations) indicated that Mantoux skin tests should be given upon admission. On 10/21/24 at 1:30 p.m., the Administrator provided an undated policy titled, Resident Screening for Tuberculosis, and indicated it was the policy currently in use by the facility. A review of the policy indicated that the facility screens for tuberculosis in accordance with state requirements and tuberculin skin tests must be completed within three months prior to admission or upon admission. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure biohazard materials were stored behind a locked door for 1 of 1 biohazard rooms observed. (B Hall) Finding included: On 10/16/24 at 10:45 a.m., observed an unlocked biohazard room located on the B hall. No staff were present in the area. A sign posted on the door indicated caution biohazard materials, soiled utility, keep door locked. The door was unlocked and easily opened. Inside the room observed a large canister full of soiled linen. The room had a strong odor of urine. During an interview on 10/16/24 at 11:00 a.m., the Medical Records Director indicated the biohazard room should be locked. On 10/17/24 at 10:53 a.m., the Regional Director of Clinical Operations provided a copy of a policy titled Medical Waste, dated 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy: It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored, and transported as per Federal, State and local guidance and regulations. 3.1-19(f)

Based on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse by another resident for 1 of 3 residents reviewed. A male resident entered a female resident's room and exposed himself and masturbated. (Resident B, Resident C) Finding includes: During an interview on 1/31/24 at 8:29 a.m., Resident B indicated several weeks ago, on night shift, Resident C entered Resident B's room pulled out his (Resident C) penis and started to masturbate. Resident B got up off of her bed and left her room to get a nurse. During an interview on 1/31/24 at 9:30 a.m., the Administrator indicated on 12/2/23 at approximately 11:30 p.m., the Administrator was made aware that Resident C entered Resident B's room in his wheelchair, exposed himself, and started to masturbate in front of Resident B. Resident B immediately got up and pushed Resident C's wheelchair out of Resident B's room. Then Resident B left her room to get a nurse. During the investigation Resident C admitted to exposing himself and masturbating in Resident B's room. On 1/31/24 at 10:06 a.m., the Administrator provided a copy of a facility reportable incident report, dated 12/3/23, which indicated on 12/2/23 at 11:30 p.m., Resident C wheeled into Resident B's room and began touching himself inappropriately. Resident B left her room. Resident C apologized and was redirected to Resident C's room where privacy was established. Resident C remained on one-on-one supervision until his planned discharge. The clinical record for Resident B was reviewed on 1/31/24 at 9:04 a.m. The diagnoses included, but were not limited to, major depression, anxiety, and alcohol dependence. An Annual MDS (Minimum Data Set) assessment, dated 1/11/24, indicated Resident B was moderately cognitively impaired. The clinical record for Resident C was reviewed on 1/31/24 at 12:16 p.m. The diagnoses included, but were not limited to, schizoaffective disorder, malnutrition, and reduced mobility. An Admission MDS assessment, dated 11/1/23, indicated Resident C was cognitively intact. On 1/31/24 at 8:49 a.m. the Assistant Director of Nursing provided an undated copy of a facility policy, titled Abuse, Neglect and Exploitation, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to prevent abuse. The deficient practice was corrected on 12/3/23 after the facility implemented a systemic plan that included the following actions: the facility inserviced the staff on resident abuse, interviewed residents about abuse, and ongoing monitoring of resident behaviors, interventions, and social service follow-up. The Federal tag relates to Complaint IN00423163. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a Resident's Advanced Directive (code status) preference was documented accurately in the clinical record for 1 of 24 residents reviewed for Advanced Directives. (Resident 36) Finding includes: On 11/28/23 at 11:29 a.m., Resident 36's clinical record was reviewed. The Admission MDS (Minimum Data Set) assessment, dated 9/27/23, indicated Resident 36 was cognitively intact. The main screen tab portion of the electronic clinical record included an overview of Resident 36's vital information. A review of the tab indicated Resident 36's code status (decision regarding health care intervention) as full code (meaning a desire for all life sustaining measures to be implemented). The Physician Orders, dated 9/29/23 and with no end date noted, indicated Resident 36 was a full code. Resident 36's care plan indicated .Focus: I have an Advance Directive as evidenced by: DNR [Do Not Attempt Resuscitation], POST [Indiana Physician Orders for Scope of Treatment] form, date initiated: 9/11/23 and current through 12/25/23. Goal: Patient's wishes will be honored. Interventions: obtain Advance Directive with physician order and resident/responsible party signature . On 10/6/23, the POST form was completed, signed, and dated by Resident 36 and the attending Physician. A review of the document indicated the designated code status preference was Do Not Attempt Resuscitation/DNR. No other POST form was provided. The POST form, dated 10/6/23, was uploaded into Resident 36's electronic clinical record on 10/16/23. Resident 36's preferred DNR code status, as indicated by the care plan dated 9/11/23 and the POST form dated 10/6/23, was not accurately reflected in the electronic clinical record until 11/28/23. During an interview on 11/28/23 at 3:21 p.m., the Corporate Nursing Supervisor indicated that Resident 36's code status preference was DNR. The completed POST form, dated 10/6/23, had been uploaded into the clinical record on 10/16/23. However; the clinical record had not been updated to reflect Resident 36's DNR code status preference until 11/28/23. During an interview on 11/29/23 at 9:15 a.m., Resident 36 indicated some time ago the DNR code status paperwork was completed and provided to the facility. During an interview on 11/30/23 at 10:11 a.m., RN (Registered Nurse) 2 indicated the Resident's designated code status preference was listed on the main screen tab portion of the electronic clinical record. Staff retrieved the code status information for each resident from that portion of the resident's clinical record. On 11/28/23 at 3:44 p.m., the Director of Nursing Services provided a copy of the Resident's Rights Regarding Treatment and Advance Directives policy, dated 2023, and indicated it was the current policy in use by the facility. A review of the document indicated, .it is the policy of this facility to support and facilitate a resident's right to request, refuse and /or discontinue medical or surgical treatment and to formulate an advance directive. Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated .Should the resident have an advance directive, copies will be make and placed on the chart as well as communicated to the staff . 3.1-4(f)(4)(A)(ii)

Based on interview and record review, the facility failed to provide supervision to prevent an elopement for 1 of 3 residents reviewed for elopement. A resident diagnosed with schizoaffective disorder bipolar type and dementia, had a history of elopement and attempted to leave the facility 12 days prior, left the facility. The resident's whereabouts were unknown for 2 days when the resident was located by a bystander. The resident was confused and physically and verbally combative with EMS (Emergency Medical Services), had to be restrained and required inpatient psychiatric treatment. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 8/25/23 at approximately 4:30 p.m., when the facility failed to provide supervision to prevent an elopement. This resulted in a resident who left the facility without staff and the resident's whereabouts were unknown for 2 days. The [NAME] President and Director of Nursing were notified of the Immediate Jeopardy on 8/29/23 at 5:30 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on 8/26/23, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: During an interview on 8/29/23 at 8:38 a.m., the [NAME] President indicated Resident B left the facility, on 8/25/23 at 4:38 p.m. Resident B was located, on 8/27/23 at approximately 5:24 p.m. Resident B received a new debit card and got upset that he was not allowed to keep it per his guardian. The facility was notified by a bystander that Resident B was located. The facility sent 2 staff members to get Resident B, but once staff arrived to pick him up, Resident B refused to come back and became combative with the staff and started cursing. The police arrived, and Resident B was taken to a hospital. During an interview on 8/29/23 at 2:15 p.m., RN 1 (Registered Nurse) indicated she was Resident B's nurse when he left the facility. CNA 1 (Certified Nursing Aide) took Resident B's dinner tray to his room and when CNA 1 went back to collect the tray, Resident B was not in his room. CNA 1 noticed the tray had not been touched. RN 1 was notified that Resident B could not be located at approximately 9:30 p.m. RN 1 called 911 because the staff was not sure how long Resident B had been gone. RN 1 indicated she was told he was seen walking across the street, on 8/25/23 at approximately 4:38 p.m. During an interview on 8/29/23 at 2:32 p.m., CNA 1 indicated she delivered a meal tray to Resident B's room. Resident B was not in his room at that time. Just before CNA 1 delivered Resident B's meal tray, CNA 1 saw Resident B walking in the hall. When CNA 1 returned to Resident B's room to collect the meal tray she noticed the meal tray had not been touched and Resident B was not in his room. CNA 1 notified a QMA (Qualified Medication Aide) that CNA 1 was not able to locate Resident B. Then CNA 1 walked the halls of the inside of the facility but didn't see Resident B. CNA 1 thought since she reported this to the QMA, she did not need to do anything else, so CNA 1 went to provide other residents care. CNA 1 started charting when she finished providing care and realized she hadn't seen Resident B. CNA 1 went to check Resident B's room again and Resident B was not there. CNA 1 notified RN 1 that CNA 1 was unable to locate Resident B. CNA 1 indicated she watched the video footage from earlier in the day. Resident B was sitting outside on the front (unsecured) patio. Several staff members walked past him while he was outside unattended. When another resident turned his wheelchair away from Resident B, Resident B stood up and walked across the street. On 8/27/23, the staff were told from now on residents need to use the courtyard to sit outside not the front porch. The clinical record for Resident B was reviewed on 8/29/23 at 8:45 a.m. The diagnoses included, but were not limited to, schizoaffective disorder bipolar type, alcohol abuse, cocaine abuse, and cognitive communication deficit. A Quarterly MDS (Minimum Data Set) assessment, dated 7/18/23, indicated Resident B was cognitively intact and had moderate signs of depression. An Order Appointing Temporary Guardian, dated 12/7/22, indicated the welfare of Resident B required immediate action. Immediate and irreparable injury to Resident B could result before notice and a hearing could be held because of Resident B's need for immediate medical attention. Resident B lacked capacity to consent to such treatment. A Psychiatric Admission History and Physical, dated 5/1/23 at 9:52 p.m., indicated Resident B was admitted for paranoid and delusional thinking on an EDO (Emergency Detention Order). The EDO stated actively psychotic - continues to be paranoid and delusional, impulsive, agitated. He is labile, paranoid, and impulsive with poor insight and needed ongoing inpatient psychiatric care as he remained disorganized. Additionally, it was stated that there was reason to believe Resident B could harm himself or others. Resident B required locked restraints in the emergency room . A Nurse Practitioner note, dated 7/6/23, indicated Resident B expressed frustration over being at the facility. Resident B wanted to be transferred to a boarding house. Resident B had a lengthy inpatient psychiatric hospitalization for paranoid and delusional thinking. Resident B attempted suicide by overdose 3 times and set fire to a group home in April of 2023. A psychotherapy progress note, dated 7/24/23, indicated target symptoms and current severity (measured on a scale of 0-10; 0 indicated no symptoms and 10 indicated maximum severity). Anxiety 6/10, depression 7/10, withdrawal/isolation 5/10, hopelessness 6/10, paranoia 0/10, delusions 0/10, auditory hallucination 5/10. Plan: continue treatment plan created, on 6/15/23. A psychotherapy progress note, dated 8/7/23, indicated target symptoms and current severity. Anxiety 7/10 (more severe), depression 8/10 (more severe), withdrawal/isolation 6/10, paranoia 5/10, delusions 5/10, auditory hallucinations 7/10. Plan: continue treatment plan created, on 6/15/23. Each of these symptoms were more severe than the previous psychiatric progress note, dated 7/24/23. A progress note, dated 8/13/23 at 12:37 p.m., indicated Resident B was at the reception area and attempted to follow peers out the front door when redirected by receptionist. Resident B became agitated and started screaming at the receptionist. Resident B picked up a LOA (leave of absence) book and slammed it on counter and stated, why can't I leave. A progress note, dated 8/25/23 at 11:15 a.m., indicated writer informed (name of guardian service), in detail, regarding Resident B's financial issues with his debit card. Resident B received two additional debit cards and writer gave them to the Executive Director. Writer informed guardian service that Resident B was extremely frustrated and upset that he was unable to get a hold of his guardian to be able to spend his money on cigarettes, clothes, and other things that he would like. A progress note, dated 8/25/23 at 10:00 p.m., indicated it was reported to this nurse Resident B was missing. Staff did room to room search at this time. Was last seen in courtyard at approximately 5:00 p.m., wearing jeans and a black shirt. A progress note, dated 8/25/23 at 11:00 p.m., indicated writer called guardian services to report that Resident B left the facility and has not returned. Resident B was aware that he was unable to leave the facility without the guardians permission. A progress note, dated 8/27/23 at 5:39 p.m., indicated writer received call from a financial service located approximately 3 miles from the facility. Resident B went there to withdraw money from his account. Writer arranged transportation for Resident B to be brought back to the facility. A progress note, dated 8/27/23 at 5:49 p.m., indicated QMA 1 (Qualified Medication Aide) reported Resident B to be very combative at financial service location. 911 called and Resident B was transferred from financial service to a hospital. On 8/29/23 at 1:00 p.m., a hospital emergency department note, dated 8/27/23 at 6:21 p.m., was reviewed. The note indicated Resident B presented to the ED (emergency department) by EMS for confusion and agitation. Resident B was reported to have eloped from a facility as he has a known diagnosis of dementia. Resident B had reportedly been walking the street for the past several days and was found by a bystander who requested EMS. EMS found Resident B to be quite combative both verbally and physically. Resident B required restraints to the ambulance stretcher for Resident B's increased safety. On arrival to the ED, Resident B was yelling profanities at staff, and verbally and physically aggressive. Resident B was placed in four-point restraints for Resident B's and staff's safety. During an interview on 8/29/23 at 3:54 p.m., the DON (Director of Nursing) indicated Resident B should not have been outside on the front patio without supervision if he was an elopement risk. On 8/29/23 at 5:30 p.m., the DON provided a copy of an undated facility policy, titled Elopements and Wandering Residents, and indicated this was the current policy used by the facility. A review of the policy indicated this facility ensures that resident who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents. The past noncompliance Immediate Jeopardy began on 8/25/23. The Immediate Jeopardy was removed and the deficient practice corrected by 8/26/23 after the facility implemented a systemic plan that included the following actions: in-services related to procedures for elopements, leave of absences, care plans, and guardians. This Federal tag relates to Complaint IN00416202. 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse from a staff member related to a staff member pushing a resident to the floor after a verbal altercation, for 1 of 4 residents reviewed for abuse. A facility staff member failed to react and respond to a resident's behavior appropriately and professionally, resulting in the staff member purposefully pushing the resident to the ground. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 7/27/23 at approximately 8:00 p.m., when the facility failed to protect the resident's right to be free from physical abuse. The Administrator, Director of Nursing, the Regional Director of Clinical Operations, Area [NAME] President, and [NAME] President were notified of the Immediate Jeopardy, on 8/22/23 at 2:15 p.m. The Immediate Jeopardy was removed on 8/24/23 at 11:30 a.m., and the deficient practice corrected on 8/9/23, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: During an interview on 8/21/23 at 8:26 a.m., the Unit Manager indicated there was an abuse allegation made by Resident B against LPN 1 (Licensed Practical Nurse). The allegation was that LPN 1 pushed Resident B down. During an interview on 8/21/23 at 8:33 a.m., Resident B indicated a staff member was trying to come into her room and pushed her down to the floor. Resident B fell and hurt her left hip, but she didn't have to go to the hospital. Resident B couldn't remember the staff member's name. During an interview on 8/21/23 at 8:52 a.m., the Administrator indicated on 8/8/23, she was informed of an allegation that LPN 1 pushed Resident B. The Administrator immediately suspended LPN 1 and began an investigation. CNA 2 (Certified Nursing Aide) and CNA 3 heard LPN 1 tell LPN 2 that she pushed Resident B. CNA 1 was in Resident B's room with LPN 1 while they were looking for cigarettes. CNA 1 turned her head away from LPN 1 and Resident B. CNA 1 reported she saw Resident B fall face forward onto the bed. The Administrator terminated LPN 1 on 8/11/23, when the investigation was completed and the allegation was substantiated. During an interview on 8/21/23 at 9:17 a.m., CNA 2 indicated Resident B went into another resident's room and took a can of soda and some cigarettes while CNA 2 and CNA 3 were providing care to another resident. CNA 2 notified LPN 1. LPN 1 said she was going to get those f****** cigarettes. LPN 1 asked CNA 1 to go with her to Resident B's room. CNA 2 and CNA 3 heard LPN 1 tell LPN 2 that Resident B grabbed her shirt while LPN 1 was trying to search Resident B's room. LPN 1 said she wasn't going to let that big b***** do that to her, so LPN 1 pushed that b***** across the f****** floor and Resident B can pick herself up. Resident B told CNA 2 that LPN 1 pushed her hard and hurt her back. LPN 1 continued to work as Resident B's nurse for the rest of CNA 2's shift. CNA 2 did not report to the Administrator until the next day (7/28/23). During an interview on 8/21/23 at 9:38 a.m., CNA 1 indicated LPN 1 asked CNA 1 to go with her to Resident B's room. LPN 1 was going to look for cigarettes. When LPN 1 started looking in Resident B's closet, Resident B grabbed LPN 1's shirt. At that time, CNA 1 turned around to look behind Resident B's bed and when CNA 1 turned back around, Resident B was falling onto the bed. Resident B landed with her knees on the floor and face first onto bed. CNA 1 was going to help Resident B, but LPN 1 told CNA 1 to leave Resident B on the floor. Resident B was still on the floor when LPN 1 and CNA 1 walked out of the room and closed the door. Approximately 10 minutes later, CNA 1 heard LPN 1 say that b**** was probably still getting herself up off the floor. CNA 1 did not report this to a manager until the next day (7/28/23). During an interview on 8/22/23 at 8:16 a.m., CNA 3 indicated she had to write a statement. CNA 2 and CNA 3 wrote the statement together. CNA 3 did not see LPN 1 push Resident B. CNA 2 and CNA 3 finished providing care to another resident. When they were walking out of that resident's room, LPN 1 said Resident B had a hold of her, but LPN 1 got those f****** cigarettes. Then LPN 1 said Resident B was probably still getting herself off the ground. Resident B's door was closed so CNA 3 indicated she opened the door and saw Resident B getting up off the floor. Resident B's knees were on the floor and her arms were on the bed. CNA 3 didn't help Resident B get up because she was getting up on her own. At that time, Resident B said LPN 1 pushed her. Then CNA 2 and CNA 3 went outside with some residents and LPN 1 was outside bragging about pushing Resident B down. LPN 1 said that b**** grabbed a hold of her, so LPN 1 pushed her down and said don't f****** touch me b****. CNA 3 indicated she didn't report this to the Administrator because LPN 1 was telling LPN 2. CNA 2 and CNA 3 thought the nurse would report it. They should have been reported the incident immediately. Resident B said LPN 1 pushed her so hard she almost broke her back. During an interview on 8/22/23 at 8:30 a.m., LPN 2 indicated on 7/27/23, LPN 1 told LPN 2 that she had been jacked up by Resident B. Resident B pulled LPN 1 up by her shirt. Then LPN 1 grabbed LPN 2's shirt collar to show LPN 2 how Resident B grabbed her shirt. The clinical record for Resident B was reviewed on 8/21/23 at 12:51 p.m. The diagnoses included, but were not limited to, anxiety, depression, and schizophrenia. An Admission MDS (Minimum Data Set) assessment, dated 6/2/23, indicated Resident B was moderately cognitively impaired and was having hallucination and delusions. A witness statement, dated 7/28/23, indicated Resident B took soda and cigarettes from another resident. LPN 1 searched Resident B and then started looking in Resident B's closet. Resident B started hitting LPN 1 and CNA 1 started searching behind Resident B's bed. Resident B told LPN 1 the cigarettes belonged to her. Then CNA 1 saw Resident B fall face first into the bed. Resident B said LPN 1 hit her. Then CNA 1 and LPN 1 walked out of the room. LPN 1 closed the door. After that, CNA 1 heard LPN 1 tell another nurse what happened. A witness statement, dated 7/28/23, indicated CNA 2 heard LPN 1 say she was going to get those mother f****** cigarettes. CNA 1 told CNA 2 that Resident B grabbed LPN 1. CNA 1 turned to look for more cigarettes and then Resident B was flying across the room and face down on the bed. A few minutes later, LPN 1 was outside telling LPN 2. LPN 1 said she wasn't letting that b**** get her, so LPN 1 pushed Resident B's a** across the floor. During an interview on 8/21/23 at 1:02 p.m., the SSD (Social Service Director) indicated she didn't know very much information about the allegation that LPN 1 pushed Resident B because she didn't work that day. The SSD heard Resident B had another resident's cigarettes and that became a struggle. The SSD also heard that Resident B pushed LPN 1, so LPN 1 pushed Resident B. On 8/21/23 at 9:04 a.m., the Administrator provided a copy of an undated facility policy, titled Abuse, Neglect, and Exploitation, and indicated this was the current policy used by the facility. A review of the policy indicated the facility will prohibit and prevent abuse. The past noncompliance Immediate Jeopardy began on 7/27/23. The Immediate Jeopardy was removed and the deficient practice corrected by 8/9/23 after the facility implemented a systemic plan that included the following actions: in-services related to procedures for resident abuse, resident behaviors, and ongoing monitoring. This Federal tag relates to Complaint IN00415035. 3.1-27(a)(1)

Based on interview and record review, the facility failed to develop a behavioral health care plan that included person-centered interventions to reduce or prevent intrusive, physically violent, and verbally aggressive behaviors for 1 of 4 residents reviewed for behavioral health services. This deficient practice resulted in one resident being pulled out of bed and one resident being hit repetitively. (Resident C, Resident D, Resident E) Finding includes: During an interview on 8/21/23 at 10:22 a.m., LPN 3 (Licensed Practical Nurse) indicated Resident C was aggressive with staff and other residents. If someone looked at him, Resident C would yell or ball his fist. Resident C would get physical with other residents. Resident C was physically aggressive with Resident D. During an interview on 8/21/23 at 11:27 a.m., Administrator 2 indicated the police were called to the facility approximately 37 times, over a 4 month period, because of Resident C's behaviors. About a month ago, at the beginning of July, Resident C became physically aggressive with Resident D. Two days after he became aggressive with Resident D, Administrator 2 was notified by floor staff that Resident C was going into Resident D's room again and yelling he wanted Resident D dead. Administrator 2 went to Resident C's room and Resident C told Administrator 2 to get the f*** out of his room. Administrator 2 exited the room and Resident C came out of his room and stomped his feet and then charged at Administrator 2. The police had to take him down to the ground. Resident C was removed from the facility with police assistance and was taken to a hospital. During an interview on 8/21/23 at 3:03 p.m., the Regional Nurse indicated there were two separate incidents between Resident C and Resident E. The first incident was when Resident E was sitting in his wheelchair and Resident C walked up to Resident E and punched him. Resident E fell out of his wheelchair. Resident E complained of pain in his ribs and needed x-rays. The second incident was when Resident C and Resident E were both outside in the smoking area with staff present. Resident E punched Resident C and they got into a fight. Before staff could get to them Resident C was on top of Resident E punching him. During an interview on 8/22/23 at 11:16 a.m., CNA 2 (Certified Nurse Aide) indicated Resident E told her Resident C hit him so hard Resident C fell out of his wheelchair. Resident E told CNA 2 that he was scared to death. Resident E wanted to press charges. During an interview on 8/22/23 at 3:35 p.m., LPN 1 indicated there were so many incidents of resident to resident abuse in that facility and nothing was ever done. Resident C hit Resident E so hard he fell out of his wheelchair. LPN 1 wasn't on the unit the day Resident C dragged Resident D out of bed and on to the floor, but LPN 1 got in report that Resident D was sent to the hospital the day that happened. LPN 1 was Resident D's nurse the next day and LPN 1 sent Resident C to the hospital again. LPN 1 also got in report that Resident D had not eaten, drank anything, nor smoked a cigarette the entire day. Resident D also complained of pain and didn't want to be touched. LPN 1 knew Resident D had already been sent to the hospital the day he was attacked but Resident D was not acting himself. If Resident D didn't want to do anything else, he would have at least went to smoke a cigarette. There was definitely a change in condition in Resident D. Resident D's brother was not happy when LPN 1 called to notify him that Resident D was being sent to the hospital. Resident D's brother was not aware Resident D was dragged out of bed. It sounded like the facility gave the impression that Resident D was the aggressor. Resident C's room was directly across the hall from Resident D's room. During an interview on 8/23/23 at 9:12 a.m., RN 1 (Registered Nurse) indicated she was Resident E's nurse the day the Resident C walked up and punched Resident E. Resident E was sitting in his wheelchair and Resident C walked up and punched him. Resident E fell out of his wheelchair to the floor. Staff were able to intervene after Resident E was on the floor. Resident C continued to be aggressive toward Resident E and was difficult to redirect. Resident E complained of pain in his ribs, so the facility ordered x-rays for him. Resident E does complain of generalized pain but this time he specifically complaint of pain in his ribs. RN 1 was not sure what happened the second time Resident C and Resident E had a physical altercation. The clinical record for Resident C was reviewed on 8/21/23 at 10:42 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, intermittent explosive disorder, impulsiveness, and intellectual disability. A Quarterly MDS (Minimum Data Set) assessment, dated 6/26/23, indicated Resident C was cognitively intact. Resident C had hallucinations, verbal behavioral symptoms directed toward others, and wandered. A progress note, dated 4/19/23 at 4:10 p.m., indicated writer heard loud yelling coming from hallway. Writer went to see what was happening. Resident C observed yelling at Resident E and attempting to hit Resident E. Staff members noted standing between residents keeping them apart. Writer and the Administrator attempted to redirect Resident C, Resident C continued yelling that Resident E threatened Resident C's life and family, and Resident C was going to [NAME] Resident E. Writer and Administrator continued to redirect Resident C to his room on the other unit. Resident C then sat on his bed and continued to shout that he was going to [NAME] Resident E. A progress note, dated 4/20/23 at 8:06 a.m., indicated writer spoke with Resident C about his violent behavior towards Resident E. Writer educated resident that aggressive behaviors towards others would not be tolerated. Resident C agreed to not be violent towards staff or other residents. Writer also spoke with Resident C about his inappropriate sexual behaviors towards female staff. A therapy note, dated 4/24/23, indicated assessed Resident C's mental health and recent events. Discussed a recent altercation where he assaulted another resident. Patient reported the incident incorrectly and blamed the other resident, however when challenged by therapist, he admitted to assaulting the other resident. Target Symptoms and current severity on a scale of 0 (no symptoms) to 10 (maximum severity): anxiety 5/10, depression 5/10, withdrawal/isolation 0/10, panic 0/10, hopelessness 0/10, rumination (engaging in a repetitive negative thought process) 6/10, inappropriate behavior 0/10, agitation 6/10, verbal aggression 5/10, physical aggression 6/10, interpersonal problems 6/10, poor self-esteem 0/10, paranoia 0/10, delusions 7/10, auditory hallucinations 0/10, visual hallucinations 0/10, disorganized thinking 7/10, hypomania/mania 0/10, sleep disturbance 4/10, appetite disturbance 0/10, adjustment 2/10, pain exacerbation 0/10, somatization 0/10, tearful affect 0/10. Continue current plan created, on 3/29/23. A therapy note, dated 5/4/23, indicated Resident C reports that when he leaves his room other resident bother him. Resident C reported paranoia that he believes other residents are trying to get rid of him by the bubonic plague, a heart attack, or colon cancer. Target symptoms and current severity on a scale of 0 (no symptoms) to 10 (maximum severity): anxiety 5/10, depression 6/10, withdrawal/isolation 4/10, panic 0/10, hopelessness 0/10, rumination 6/10, inappropriate behaviors 0/10, agitation 3/10, verbal aggression 2/10, physical aggression 2/10, interpersonal problems 6/10, poor self-esteem 0/10, paranoia 6/10, delusions 7/10, auditory hallucinations 0/10, visual hallucinations 0/10, disorganized thinking 7/10, hypomania/mania 0/10, sleep disturbance 4/10, appetite disturbance 0/10, adjustment 4/10, pain exacerbation 0/10, somatization 0/10, tearful affect 0/10. Depression, withdrawal/isolation, paranoia, and adjustment symptoms were more severe compared to the severity scores, on 4/24/23. Continue treatment plan created, on 3/29/23. A progress note, dated 5/11/23 at 10:53 a.m., indicated during a supervised smoke break, Resident C was approached by Resident E and Resident E made contact to the right side of Resident C's face with a closed fist. Resident C then made contact to Resident E with a closed fist to his head and ribs. Resident C placed on 15-minute checks. A progress note, dated 5/11/23 at 12:20 p.m., indicated writer met with resident due to verbal aggression and homicidal behaviors towards another resident. Resident states that he was going to cut another residents head off and burn it. A progress note, dated 5/11/23 at 1:29 p.m., indicated writer spoke with Resident C's guardian. Writer informed guardian that due to Resident C's homicidal ideations today. Writer informed guardian that all documents were sent to the hospital and Resident C had been approved for hospitalization . A psychiatric evaluation, dated 5/12/23, indicated Resident C was admitted via power of attorney guardian for psychosis, schizoaffective disorder, intermittent explosive disorder, intellectual disability, mood affect disorder, anxiety disorder, impulsiveness, agitation, violent behaviors, Parkinson's, Alzheimer's, and dementia. Resident C had been physically aggressive and making homicidal statements towards other individuals. Resident C stated that he was going to cut their heads off and burn their heads. Resident C is in need of rapid emergent mental health stabilization due to the fact that he was a harm and danger to others. Past psychiatric history included, but was not limited to, inpatient hospitalization for mental health from 7/20/22 through 7/29/22, 10/19/22 through 10/28/22, and 2/28/23 through 3/16/23. Resident C failed outpatient treatment and has historical diagnoses of bipolar disorder, Alzheimer's dementia with signs and symptoms of verbal aggression, impulsivity, mania, with suicidal and homicidal ideations. A history and physical, dated 5/13/23, indicated Resident C presented with acute homicidal ideations, verbal aggression, impulsive behaviors, and mania. He had been verbally making homicidal statements toward others stating that he was going to cut their heads off and burn them. A therapy note, dated 5/25/23, indicated target symptoms and current severity from 0 (no symptoms) to 10 (maximum severity): anxiety 5/10, depression 6/10, withdrawal/isolation 4/10, panic 0/10, hopelessness 0/10, rumination 6/10, inappropriate behaviors 0/10, agitation 3/10, verbal aggression 2/10, physical aggression 2/10, interpersonal problems 6/10, poor self-esteem 0/10, paranoia 6/10, delusions 7/10, auditory hallucinations 0/10, visual hallucinations 0/10, disorganized thinking 7/10, hypomania/mania 0/10, sleep disturbance0/10, appetite disturbance 0/10, adjustment 4/10, pain exacerbation 0/10, somatization 0/10, tearful affect 0/10. Continue treatment plan created, on 3/29/23. A progress note, dated 6/22/23 at 9:30 a.m., indicated Resident C was actively engaging in auditory hallucinations. Resident C was verbally aggressive towards staff and other residents. Resident C was exhibiting signs of paranoid ideations as he stated, everyone is out to get me. Resident C continues to have outbursts as he engages in loud self-talk when no one else is around. A progress note, dated 6/24/23 at 2:19 a.m., indicated Resident C was asking staff and residents for cigarettes. Resident C grew angry when told no and that residents are not allowed to smoke at this time. Resident C began storming around facility yelling f*** you all and threatened another resident by telling her he was going to kill her and called her a b****. Police were discussing incident with Resident C. A progress note, dated 6/24/23 at 3:30 p.m., indicated Resident C was screaming at the nurses station for staff to give him cigarettes during non-smoking times. Resident C continues to act verbally aggressive to staff when reminded about scheduled smoking times screaming f*** you all. Police and emergency medical team were called. A progress note, dated 6/30/23 at 12:00 p.m., indicated writer met with Resident C due to Resident C being verbally aggressive, homicidal, and suicidal. Resident C threatened to kill the Executive Director and a CNA (Certified Nursing Aide). Resident C indicated why not he had nothing to live for. When asked if he had a plan resident indicated not right now, I will let you know. Writer will follow up. A progress note, dated 6/30/23 at 3:06 p.m., indicated writer spoke with caseworker regarding Resident C would be receiving a 30-day notice of discharge due to verbal and physical behaviors towards other residents and staff. Writer informed caseworker of the numerous times the police had been called on Resident C due to his threatening, verbally aggressive behaviors. A progress note, dated 7/2/23 at 10:57 p.m., indicated Resident C began being verbally aggressive and threatening when asked to lower his voice due to another resident using phone at A wing nurses station. Resident C stated he was going f*** up everybody here and he could go anyplace he wanted to go in this facility. Resident C would kill anyone trying to stop him. Resident C kept yelling he was a man, and he would be respected. Resident C finally calmed down and left the unit. Staff unable to redirect Resident C. A therapy note, dated 7/6/23, indicated processed the discharge paperwork that Resident C was served, on 7/3/23. Resident C became very belligerent when speaking about this situation and had to be redirected to lower his voice several times, which he was receptive to. Resident C does not plan to discharge from the facility willingly within 30 days and believes he was being wrongly asked to leave the premises. Resident C reported frustrations and complaint related to living in a communal environment. Resident C denied any auditory hallucinations and visual hallucinations and paranoia. Indicated target symptoms and current severity from 0 (no symptoms) to 10 (maximum severity): anxiety 6/10, depression 6/10, withdrawal/isolation 4/10, panic 0/10, hopelessness 0/10, rumination 6/10, inappropriate behaviors 6/10, agitation 6/10, verbal aggression 6/10, physical aggression 4/10, interpersonal problems 6/10, poor self-esteem 0/10, paranoia 6/10, delusions 7/10, auditory hallucinations 0/10, visual hallucinations 0/10, disorganized thinking 7/10, hypomania/mania 0/10, sleep disturbance 0/10, appetite disturbance 0/10, adjustment 4/10, pain exacerbation 0/10, somatization 0/10, tearful affect 0/10. Due to ongoing symptomology, therapist will create a new treatment plan at next encounter. A progress note, dated 7/7/23 at 6:32 a.m., indicated Resident C was walking down the hall when he was witnessed going into Resident D's room. Resident C grabbed Resident D and pulled him out of his bed and onto the floor. Resident D was crying, and staff told Resident C to go to his room. Nurse on B-wing called Executive Director and she was unable talk at that time. Nurse phoned other members of management for further instructions. The manager stated they wanted Resident C removed from the building. When the police arrived, they stated they could not arrest Resident C due to his mental state. The police said both Resident C and Resident D needed to go to the hospital. When the ambulance arrived, they assessed Resident D while on the floor and transferred Resident D from the floor to the stretcher. Resident C continued to come out into the hall and was yelling yeah he did it and he would do it again. Phoned the Director of Nursing, guardian, and doctor on call. Police called for another ambulance to come to transport Resident C to hospital. When the ambulance arrived Resident C continued to refuse. At that time management was working on getting someone to come and do one on one observation with Resident C. Resident C was yelling at one of the CNA's stating you're all just a bunch of 'b******* and h*** so why don't you come to my room and f*** me. This is the language Resident C continued to use and was offensive to everyone. Resident C continued to pace back and forth. Earlier that day, Resident C was outside and stated he was going to kill a m***********. Nurse sat with Resident C in hopes he would calm down. Resident C presented to be very angry and was shaking with closed fists. After Resident D was taken to hospital Resident C stayed in his room with the exception of one time he came to the nurse's station asking for snacks. A progress note, dated 7/7/23 at 11:04 a.m., indicated Resident C began aggressively threatening staff and being verbally abusive to residents and staff when asked to calm down. Resident C proceeded to curse and stated he didn't give a f***. Resident C indicated if he had his gun he would blow all of our heads off and cut all of our throats. Resident C proceeded to verbally yell out sexual threats stating to staff that she need to f*** him and go to his room and Resident C would pull her pants down if she act like she didn't know how to f*** him. Resident C proceeded to walk around yelling and was verbally abusive. A progress note, dated 7/9/23 at 7:12 p.m., indicated staff witnessed Resident C going into Resident D's room. Staff intervened and separated the two. The Administrator went to talk to Resident C about not going into Resident D's room. Resident C proceeded to scream at the Administrator to get out and Resident C was going to slit her throat if she didn't leave. Police and emergency medical service called. Police intervened when Resident C charged the Administrator with a closed fist. Police transported Resident C to the hospital. Hospital aware that we are not taking resident back to facility. The clinical record for Resident D was reviewed on 8/21/23 at 12:23 p.m. The diagnoses included, but were not limited to, hemiplegia following a stroke affecting right dominant side (was not able to move right arm, hand, nor right leg), depression, and bipolar disorder. Resident D was on hospice. A Quarterly MDS assessment, dated 5/3/23, indicated Resident D was not cognitively intact. A progress note, dated 7/8/23 at 8:08 p.m., indicated at this time the nurse from other unit stated to writer Resident C was witnessed going into Resident D's room and pulled Resident D from his bed onto the floor. After Resident C pulled Resident D to floor, Resident C was in hallway yelling he would do it again, Resident C cursed and called Resident D curse names. Management instructed nurse to call the police and have Resident C removed from the building. While comforting Resident C on the floor, this writer phoned police and ambulance. When police arrived, they stated they were not able to remove him from the building due to it being a private matter and there advice was to have both Resident C and Resident D sent to the hospital. Writer explained Resident C and Resident D were in their rooms waiting on ambulance to arrive so Resident D could be transported to the hospital. Writer assessed Resident D while waiting and did not find and injuries. Resident D was on the floor crying and attempts were made to console Resident D. When ambulance arrived, Resident D was then taken to the hospital. At this time resident on floor was crying and staff made attempts to console. Resident C stood in the doorway to his room and continued to yell and scream. Resident C was instructed to stay in room. Door was open and CNAs were in room with Resident C while he continued to curse and yell obscenities from his room. Resident C continued to threaten to strike Resident D again and also to strike staff. Police returned to facility and questioned why only Resident D was sent to the hospital. Writer explained management was attempting to provided one on one observation. The clinical record for Resident E was reviewed on 8/21/23 at 11:40 a.m. Diagnoses included, but were not limited to, dementia, age related cognitive decline, and schizophrenia. A Quarterly MDS assessment, dated 2/15/23, indicated Resident E was moderately cognitively impaired. A progress note, dated 4/19/23 at 4:32 p.m., indicated Resident E was sitting on his wheelchair in hallway. Resident C walked up and told Resident E that Resident C was done threatening Resident E and then hit him on his head. Resident E did not say anything to Resident C. Staff separated Resident C and Resident E. 15 minutes checks were implemented. A care plan, dated 3/24/23 and current through 7/10/23, indicated Resident C had mental health needs that would be adequately met at the skilled nursing facility related to diagnoses of schizoaffective disorder, bipolar disorder, anxiety, depression, and aggressive behaviors. The interventions included, to provide Resident C with opportunity to express mental health needs to staff and skilled nursing staff will provide routine opportunities to identify mental health needs of Resident C. During an interview on 8/21/23 at 1:02 p.m., the Social Service Director indicated Resident C threatened to kill the staff. The staff were scared of Resident C and would avoid him. On the day the police removed Resident C from the facility, the staff were very scared. Resident C's aggressive behavior had been happening at least twice weekly for a few weeks. Before that Resident C had threatening behavior. The staff should have monitored for verbally aggressive, physically aggressive behaviors, and paranoia. Resident C should have had a care plan that identified behaviors and included person-centered interventions to reduce or prevent his behaviors. On 8/21/23 at 4:35 p.m., the Administrator provided a copy of an undated facility policy, titled Behavioral Health Services, and indicated this was the current police used by the facility. A review of the policy indicated the facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed. Physician's orders for insulin were not followed. (Resident B) Findings include: On 5/31/23 at 11:00 a.m., the Interm DON indicated on 4/21/23 at 11:40 a.m., RN 1 had made a medication error . The Interim DON indicated RN 1 gave Resident B 60 units of Humalog (short acting insulin) instead of Lantus (slow acting insulin). After the administration of the incorrect insulin, Resident B was given some juice and Resident B indicated he was beginning to feel funny. Emergency services were called and a blood sugar (BS) was taken prior to transfer to hospital and it was 199. The clinical record for Resident B was reviewed on 5/31/23 at 1:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus, morbid obesity, and chronic respiratory failure. A review of Resident B's insulin orders, included, but were not limited to: - Glargine Solution (Lantus) Injection (insulin) 100 units subcutaneous two times a day, initiated 8/17/22. - Humalog Solution 100/ml inject per sliding scale, initiated 4/4/23. The After Care Summary from the hospital for Resident B indicated, it was noted to be a non emergency visit. Resident B was to remain in the emergency room for 4 hours to recheck his blood sugars. On 6/1/23 at 2:30 p.m., the Medication Administration Policy, undated, was reviewed. The Interim DON indicated this was the policy currently in use. The policy included, but was not limited to, to compare medication source with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time. The deficient practice was corrected by 4/24/23 after the facility implemented a systemic plan that included the following actions: nursing staff in-service regarding medication administration with sign-in sheets, verification of medication administration skills by written exam and demonstration, ongoing monitoring/auditing of insulin administration, and referral to the QAPI program for follow-up and continued monitoring. This Federal tag relates to complaint IN00408725. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive care plan was developed and implemented for 1 of 2 residents (Resident 29) reviewed for limited range of motion requiring the use of a splint and for 1 of 2 residents (Resident 34) reviewed for transmission-based precautions. Findings include: 1. On 11/2/22 at 10:55 a.m., observed Resident 29 resting in her bed after the nursing staff completed the resident's morning care. The nursing staff applied a splint onto Resident 29's right hand and wrist area. On 11/3/22 at 11:30 a.m., observed Resident 29 resting in her bed after the nursing staff completed the resident's morning care. The nursing staff had applied a splint onto Resident 29's right hand and wrist area. On 11/7/22 at 3:07 p.m., observed Resident 29 sitting in her electric wheelchair near the nurse's station. Resident 29 had a splint in place at the right and left hand and wrist areas. On 11/9/22 at 1:54 p.m. Resident 29's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/22, the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .resident requires total assist with transfer, bed mobility, toileting, dressing/grooming and bathing ADLs [activity of daily living] r/t [related to] complete [CONDITION(S)] due to C6 cervical spinal injury . On 11/7/22, the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/22, the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 9/17/22, indicated Resident 29 was cognitively intact and had limited range of motion of all extremities. The clinical record lacked a person-centered comprehensive care plan that addressed the bilateral splints for Resident 29's hand and wrist areas. During an interview on 11/2/22 at 11:00 a.m., Resident 29 indicated she had a C6 level of cervical spinal cord injury which resulted in [CONDITION(S)]. Resident 29 had worn splints for her right and left arm and wrist areas for years. The splints were to be put on in the morning and taken off at bedtime. During an interview on 11/7/22 at 4:11 p.m., the Corporate Compliance Director indicated Resident 29's clinical record lacked a comprehensive care plan that addressed Resident 29's bilateral splints for her hands and wrist areas. Resident 29 had utilized splints for both arms and wrist areas since 2016 and should have had splint care plans in place since that time. 2. On 11/2/22 at 11:15 a.m., observed Resident 34's room door to be closed. Observed a sign posted on the door which read Contact isolation. Next to the door was a plastic bin that contained PPE (personal protective equipment) supplies (gowns, gloves, and masks). On 11/3/22 at 10:56 a.m., observed Resident 34's room door to be closed. Observed a sign posted on the door which read Contact isolation. Next to the door was a plastic bin that contained PPE supplies. On 11/7/22 at 3:16 p.m., observed Resident 34's room door to be closed. Observed a sign posted on the door which read Contact isolation. Next to the door was a plastic bin that contained PPE supplies. On 11/3/22 at 11:00 a.m., Resident 34's clinical record was reviewed. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician orders, dated 8/30/22 with no end date noted, indicated Resident 34 was to be in contact isolation for [MEDICATION(S)] auris. The Quarterly MDS (Minimum Data Set) assessment, dated 9/12/22, indicated Resident 34 was cognitively intact. The clinical record lacked a person-centered comprehensive care plan that addressed the contact isolation for Resident 34. During an interview on 11/2/22 at 11:00 a.m., LPN (Licensed Practical Nurse) 2 indicated Resident 34 was in contact isolation due to [MEDICATION(S)] auris. Everyone who entered Resident 34's room was to wear a gown, gloves, and mask. During an interview on 11/2/22 at 11:22 a.m., Resident 34 indicated he had been in contact isolation for a while because of a yeast infection. During an interview on 11/7/22 at 10:30 a.m., CNA (Certified Nursing Assistant) 1 indicated Resident 34 was in isolation. During an interview on 11/7/22 at 10:49 a.m., the DNS (Director of Nursing Services) indicated Resident 34 was in isolation due to colonized [MEDICATION(S)] auris and would require long term isolation. Staff were to wear gowns, gloves and masks when providing personal care to Resident 34. A comprehensive [MEDICATION(S)] auris isolation care plan should have been developed and implemented when Resident 34 was diagnosed with the infection and subsequently placed into isolation on 8/30/22. On 11/7/22 at 11:30 a.m., the DNS provided a copy of the Comprehensive Care Plans policy, dated 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated, .to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs .care plan will be reviewed and revised by the interdisciplinary team . On 11/9/22 at 10:00 a.m., the CDC (Center for Disease Control and Prevention) guidance located at https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html, updated on 7/12/22, for [MEDICATION(S)] auris was reviewed. A review of the guidance indicated, .contact precautions or enhanced barrier precautions [infection control intervention designed to reduce transmission of multi-resistant organisms (MDROs)] in nursing homes .involve gown and glove use during high-contact resident care activities for residents known to be colonized .can last indefinitely due to the type of infection . 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was supervised when going outside at 11:07 p.m., which resulted in the resident having smoked unsupervised, having self propelled his wheel chair from the facility, being struck by a moving vehicle, and sustained multiple broken bones and internal injury that required surgical repair for 1 of 3 residents reviewed for accidents. (Resident B) The immediate jeopardy began on (MONTH) 13, 2019 when a resident was not supervised as indicated by Physician orders [REDACTED]. The Administrator and Director of Nursing were notified of the immediate jeopardy at 12:15 p.m. on (MONTH) 16, 2019. The immediate jeopardy was removed on (MONTH) 16, 2019, but the noncompliance remained at no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident B's clinical record was reviewed on 4/15/19 at 11:00 a.m. [DIAGNOSES REDACTED]. State of Indiana, County of Hamilton, Letter of Guardianship form indicated Resident B's father was court appointed as the guardian on (MONTH) 03, (YEAR). The significant change MDS (Minimum Data Set) assessment, dated 4/2/19, indicated Resident B was cognitively intact. Resident B was independently mobile by having self propelled a manual w/c (wheel chair). Resident B's physician's orders [REDACTED].resident may not go LOA (leave of absence) per guardian .resident only allowed to go LOA with approved escort from guardian . A smoking assessment, dated 1/15/19, indicated Resident B was a current smoker. The resident did not want to quit smoking. The resident understood the smoking policy, smoking times, and smoking place. Resident B's care plan, initiated on 1/21/19 and valid through 4/17/19, indicated resident was to be supervised when smoking. Resident B's care plan lacked documentation that indicated the resident was non-compliant with going outside unsupervised. An elopement assessment, dated 1/21/19, indicated Resident B was physically able to leave the facility on his own. The resident had no history of night wandering. The assessment lacked documentation of assessment for required supervision while outside as indicated by physician orders [REDACTED]. Resident B's Release of Responsibility for Leave of Absence sign in and out document indicated Resident B had last been signed out of the facility on 4/3/19 at 3:25 p.m. On 4/15/19 at 12:50 p.m., the BOM (Business Office Manager) provided the facility's surveillance video recording for 4/13/19. A review of the video recording indicated the following: -On 4/13/19 at 11:07 p.m., Resident B was observed to self propel his w/c out the front door of the facility. Resident B was wearing a dark colored jacket, ball cap, and pants. Resident B parked the w/c near the front door, lit and smoked a cigarette. No staff members were observed in the area. -On 4/13/19 at 11:10 p.m., Resident B was observed to self propel his w/c across the facility parking lot and then crossed a small grassy area near the road. Resident B had a small flash light that lit his way. No other lights were visible and no staff members were observed in the area. -On 4/13/19 at 11:11 p.m., Resident B was observed to self propel his w/c onto the road way. Resident B's w/c was on the right side near the edge of the road heading south on Perkins Street. Resident B was backing his w/c up as he traveled south on Perkins Street. No staff members were observed in the area. -On 4/13/19 at 11:12 p.m., Resident B was observed to longer be visible in the facility surveillance video. -On 4/13/19 from 11:12 p.m. to 11:44 p.m., ten vehicles were observed to travel south on Perkins Street. -On 4/13/19 at 11:44 p.m., the Beech Grove and Indianapolis police officers were observed to arrive and enter the facility. On 4/15/19 at 2:00 p.m., Perkins Street was observed to not have a side walk on either side of the street for pedestrians. On 4/16/19 at 10:38 a.m., Resident B's hospital report records were reviewed. The hospital records indicated Resident B was admitted to the hospital on [DATE]. He suffered injuries from a motor vehicle accident while he was on his w/c, away from the nursing facility. Resident B's injuries included, but were not limited to, fractured right thigh bone; fractured left thigh bone; fractured left lower leg bone; fractured right jaw; rib fractures and heart artery injury. The medical record indicated Resident B was transferred to another hospital setting for further evaluation and treatment. During an interview, on 4/16/19 at 3:48 p.m., CNA 3 indicated she worked on Resident B's hall on 4/13/19 and saw Resident B go outside of the facility, at 9:00 p.m., for a supervised smoke break. Resident B required supervision when smoking; was to be supervised when he went outside; and was to sign in and out in the log book when going outside. Resident B typically did not comply with supervision for smoking, going outside, or completing the sign in and out log book when leaving and returning to the facility. CNA 3 indicated residents and staff were aware of the supervision requirement. The front door was key coded for exiting the building; however, some residents were aware of the exit code. Individuals who wanted to enter the building after exiting must be let in in order to gain entry back into the facility. During an interview, on 4/15/19 at 4:04 p.m., LPN (Licensed Practical Nurse) 1 indicated Resident B participated in the facility resident smoke break at 7:00 p.m. and again at 9:00 p.m. Resident B was resting in bed at 10:00 p.m. She had last seen Resident B at 10:30 p.m. and had not known he had exited and left the facility until the police arrived. After 11:00 p.m., LPN 1 was alerted by the police that Resident B had left the building and had been struck by a moving vehicle Resident B had been transported, by ambulance, to the hospital due to multiple broken bones. LPN 1 indicated Resident B had informed the police he lived at the nursing facility. During an interview, on 4/15/19 at 3:45 p.m., the Security Guard, who worked the night of 4/13/19, indicated Resident B was in and out of the facility on four separate occasions during the evening on 4/13/19. The Security Guard indicated he was new to this position, it was his second day on the job, and that part of his tasks were to let individuals in and out of the facility as the exit doors were secured by a lock that needed a key code to unlock. At 11:00 p.m., Resident B exited the facility through the front door to smoke and he did not re-enter the facility. The police arrived at the facility, around 11:30 p.m., to inform the staff of the vehicle accident involving Resident B. During an interview, on 4/15/19 at 11:00 a.m., the DON (Director of Nursing) indicated Resident B was cognitively intact; ambulated by having self propelled a manual w/c; and was non-compliant with smoking rules and would leaving the facility without supervision, knowing he should have supervision. Based on the facility's investigation, Resident B was hit by a moving vehicle, on 4/13/19, and as a result suffered broken thighs, broken lower leg bones, and a small bleed of his aorta (heart artery). Resident B was scheduled for surgery due to his injuries sustained from the accident. During an interview, on 4/15/19 at 11:30 a.m., based on the facility's investigation, the ADM (Administrator) indicated Resident B exited the facility through the front door around 11:00 p.m. on 4/13/19. Resident B had self propelled his w/c onto the road; was struck by a moving vehicle, and transported to the hospital with multiple broken bones. During an interview, on 4/15/19 at 5:25 p.m., the ADM indicated the facility lacked a written policy regarding residents going outside; however, if a resident intended to leave the facility grounds, residents had been instructed to sign in and out. Resident B was not considered an elopement risk and was to have been supervised when smoking and when leaving the facility. During an interview, on 4/16/19 at 2:00 p.m., the DON indicated Resident B's care plan lacked documentation regarding non-compliance with supervision while the resident was outside of the facility. On 4/15/19 at 3:08 p.m., the facility Nurse Consultant provided an undated copy of the Golden Living Center Smoking Policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .residents are required to smoke during designated smoke times only with staff present .smoking is not permitted by doors . On 4/15/19 at 5:39 p.m., the ADM provided an undated copy of the Trinity Executive Services & Trinity Security, Inc, operating procedure document and indicated it was the current procedure in use by the facility. The ADM indicated the facility and security company had a contractual agreement for security services at the facility. A review of the document indicated, .control access of visitors and residents .ensure smokers are only smoking in designated smoking areas (at least 25 feet from building) . The immediate jeopardy that began on 4/13/19 was removed on 4/16/19, when the facility completed a facility wide audit to identify each resident who was not permitted to be outside without staff supervision. Each identified resident's plan of care was reviewed and updated as indicated to ensure staff supervision while outside. The facility implemented a book, positioned at the front desk, that indicated a list with picture of each resident who may not go outside without staff supervision. All security guards and all staff received education in regard to implemented use of the resident supervision book. The entrance key pad was reprogrammed so only staff can enter a code and open the door to exit outside. Signs were posted at the exit door requesting residents and families to seek out a staff member for assistance to exit outside. All residents who are cognitively intact received one-on-one education in regard to the corrected changes. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure safety precautions were utilized to prevent a resident from being hit by the meal tray hall cart which resulted in 2 fractures to the resident's left leg for 1 of 3 residents reviewed for injuries in a sample of 3 (Resident B). Findings include: Review on 1/22/19 at 9:30 a.m., of a Facility Reported Incident (FRI), dated 1/14/19, indicated Resident B reported to the Unit Manager, CNA 1 was passing hall trays and accidentally ran into him while he was asleep in his wheelchair. Review on 1/23/19 at 2:45 p.m., of a statement from CNA 1, dated 1/14/19, indicated she did not see the resident until it was too late and she thought she hit his chair. The resident did not complain of pain at that time and said he was alright. Review on 1/22/19 at 2:45 p.m., of an undated statement from CNA 2, indicated she yelled for CNA 1 to stop, but it was too late. CNA 1 asked the resident if he was ok and he said he was. Review, on 1/23/19 at 1:00 p.m., of a change of condition progress note, dated 1/15/19 at 11:36 a.m., indicated the resident reported the other day (could not remember the day) CNA 1, ran into Resident B while he was sleeping in his wheelchair and complained of pain in his left leg. The resident's leg was assessed and observed to have a hard area with some protruding noted around the knee of the left leg. An X-ray was ordered and Resident B was sent to the hospital for treatment. The record for Resident B was reviewed on 1/22/19 at 9:47 a.m. [DIAGNOSES REDACTED]. A Radiology Report, dated 1/15/19, indicated Resident B had an acute [MEDICAL CONDITION] mid tibia (lower leg bone) and proximal (just below the knee) fibula (lower leg bone). During an interview with the Director of Nursing (DON), on 1/22/19 at 2:45 p.m., she indicated the resident had not returned to the facility yet as he had surgery on his leg on 1/18/19. During an interview with CNA 2, on 1/22/19 at 3:34 p.m., she indicated she did not think the resident had been asleep in his chair. He was sitting in the hallway near the exit where residents wait to go out to smoke. CNA 2 reported she was standing on the right side of the cart and Resident B was on the left side of the cart and she did not see him until it was too late. Observation, on 1/23/19, of the area where the resident had been sitting was 2 resident rooms past the A-wing nurses station and clearly visible, without obstruction. Review of the staffing schedule, dated 1/10/19, provided by the DON, on 1/23/19 at 1:00 p.m., indicated CNA 1 and CNA 2 worked the same shift on that date. A CNA Job Specific Orientation checklist was provided by the Director of Clinical Education (DCE) on 1/23/19. A review of the checklist indicated orientation lacked documentation CNAs were provided training for moving the meal tray hall carts safely. This Federal tag relates to Complaint IN 436. 3.1-45(a)

1. Based on observation, record review, and interview, the facility failed to ensure a resident received supervision while smoking. This resulted in second degree [MEDICAL CONDITION] treatment in a hospital emergency room for 1 of 1 resident reviewed for smoking safely. (Resident 30) 2. Based on observation, record review, and interview, the facility failed to ensure a resident at risk for falls had her call light within reach as indicated by her plan of care for 1 of 4 residents reviewed for accidents. (Resident 7) 3. Based on observation, record review and interview, the facility failed to ensure three rooms containing hazardous materials were locked as indicated by facility policy for 16 self mobile cognitively impaired residents residing in the facility. Findings include: 1. Interview, on 5/30/18 at 3:05 p.m., Resident 30 indicated when he went out to the enclosed patio to smoke on 5/26/18 around 10:00 p.m. He had a lighter and 1/2 cigarette, which he had hidden from staff. He left his oxygen tank in the facility prior to going on the patio, but kept the oxygen tubing in his nose, It must have still had oxygen in it because it just blew up when I lit the cigarette. Observed areas on Resident 30's cheeks that were red and on the tip of his nose that were red and had a blackened appearing area. Resident 30 indicated the areas were very painful. The clinical record of Resident 30 was reviewed on 5/31/18 at 9:56 a.m. [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment, dated 5/19/18, indicated Resident 30 was independent in his ability to make decisions. A care plan, dated 12/21/15 and current through 8/27/18, indicated Resident 30 was at risk for smoking related injury due to smoking independently. Interventions included Provide smoking apron while smoking onsight. Safe Smoking Evaluations, dated 3/26/18 and 5/13/18, indicated Resident 30 desired to smoke, was able to physically hold the smoking device, remained alert during the course of smoking, acknowledged understanding of the policy related to storage of smoking materials, and was able to communicate he understood he could only smoke in designated smoking areas at designated times. Review, on 5/31/18 at 10:00 a.m., of a facility reported incident dated 5/27/18, indicated During morning med(ication) pass, RN (8) noticed that (Resident 30's) face was pink and that he had blisters on his cheeks, mouth and nose. (RN 8) asked (Resident 30) how he got those injuries and (Resident 30) reported to her that last night he went outside to smoke at 9 p.m. unsupervised, and burned himself. Resident also states that after he burned himself, he went straight to his room without notifying the nurses or anyone that he had burned himself .Action Taken .(medical doctor) notified. Res(ident) was offered ER (emergency room ) for assessment .resident also gave up the smoking materials he had hidden to the nurse. Review, on 5/31/18 at 2:00 p.m., of an emergency room evaluation, dated 5/27/18, at 3:53 p.m., indicated, Coming from ECF (extended care facility) .2 [MEDICAL CONDITION] on bilateral facial cheeks and around mouth .burns and blistering of bilateral cheeks and nares (nostrils) .burning and swelling of nasal passages . Interview, on 5/30/18 at 11:47 a.m., RN 3 who was responsible for Resident 30's care during the evening of 5/26/18, indicated she would not have been able to observe residents going out the unlocked door to the enclosed patio unless she happened to be sitting in the nurses' station. Interview, on 06/04/18 at 11:00 a.m., Resident 13 indicated he had seen Resident 30 go out on the patio on 5/26/18 around 10:00 p.m. Resident 30 had left his oxygen tank inside the facility, but the oxygen tubing was still in his nose. Resident 13 saw a big flash .he (Resident 30) got burned on his face .said he (Resident 30) would tell the nurse but he (Resident 30) never did that night. Interview, on 5/31 at 2:40 p.m., the Director of Nursing (DON) indicated the patio door was left unlocked at all times prior to Resident 30's accident, on 5/26/18, so residents could sit outside independently in the secure courtyard. Now it is kept locked. On 5/28/18 at 2:35 p.m., the DON provided a policy, dated 12/27/17, titled Golden Living Center Smoking Rules, and indicated it was policy currently used by the facility. The policy indicated, 1. You must smoke only during designated times which are posted by the courtyard 2. You may only smoke in courtyard with staff present . 4. You must allow the facility to lock up all smoking materials including cigarettes/lighters and they will only be given out during smoke times .5. Smoking any other time or place on the facility grounds is strictly prohibited Smoking times: 9:30 am, 11 am, 1:30 pm, 3:30 pm, 6 pm . 2. The clinical record of Resident 7 was reviewed on 5/31/18 at 9:50 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 3/9/18, indicated Resident 7 was severely impaired in her ability to make decisions and needed extensive assistance for transferring, walking and toileting. An assessment, dated 3/9/18, indicated Resident 7 was at risk for falls. A care plan, dated 4/19/16 and current through 6/20/18, indicated Resident 7 was at risk for falls. Interventions included, Call light .in easy reach. A care plan, dated 4/29/16 and current through 6/20/18, indicated Resident 7 had a physical functioning deficit related to: Self care impairment. Has [MEDICAL CONDITION]. Interventions included, Call light within reach. On 5/30/18 at 9:15 a.m., Resident 7 was observed sitting in her wheelchair at the foot of her bed. Her call light was pinned to her pillow at the head of her bed, out of her reach. On 6/1/18 at 3:24 p.m., the Director of Nursing (DON) indicated Resident 7 still used her call light sometimes. On 6/4/18 at 10:38 a.m., Resident 7 was observed sitting in her wheelchair at the foot of her bed. Her call light was observed hanging on the wall next to her bed, out of her reach. On 6/4/18 at 2:00 p.m., the DON provided a policy dated 4/25/18, titled Falls Management Guideline, and indicated it was the policy currently used by the facility. The policy indicated, Residents at risk for falls are care planned with individualized interventions. 3. During initial tour, on 5/29/18 at 10:30 a.m., the following was observed: A. A sign on the door near the A wing nurses station. The sign indicated Soiled Utility; caution biohazard material; keep door locked. The door was unlocked and easily opened. Inside the room were 2 large red biohazard containers with red biohazard bags. During an interview, on 5/29/18 at 10:40 a.m., Certified Nursing Assistant 1 indicated, the door should be locked. B. A sign on the door next to the time clock. The sign indicated Janitor Closet; keep door locked. The door was unlocked and easily opened. The room contained: 1. Three 1 quart bottles of Lime off #410/Acid Cleaner and descaler. A Review, on 5/29/18, of the manufacturer's label indicated keep out of reach. Minimum Safety Data Sheet (MSDS) dated 5/5/15, indicated Physical Hazards: CORROSIVE. Health hazards: Causes skin corrosion, causes serious eye damage. 2. One 1 quart bottle of CBC plus; toilet bowl cleaner. A review, on 5/29/19 at 1:30 p.m, of manufacturer's label indicated keep out of reach. MSDS dated 4/15/15, indicated Physical Hazards: CORROSIVE; Health hazards: Causes skin corrosion, causes serious eye damage. 3. One 1 quart bottle of Clorox Commercial Solutions Clorox Urine Remover for Stain and Odor. Review on 5/29/18 at 1:30 p.m., of the manufacturer's label indicated keep out of reach. MSDS dated (undated), indicated First Aid Measures: Ingestion: Drink a glassful of water. Call poison control center or doctor immediately. 4. One 1 pound 11 ounces tub of Clorox Healthcare Bleach Germicidal Wipes. Review on 5/29/18 at 1:30 p.m., manufacturer's label indicated keep out of reach. MSDS dated 1/5/15, indicated eye contact: Hold eye open and rinse slowly and gently with water for 15 - 20 minutes. Skin contact: Rinse skin with plenty of water. If irritation persists, call a doctor. Inhalation: move to fresh air. If breathing problems develop, call a doctor. Ingestion: Drink a glassful of water. Call a doctor or poison control center During an interview, on 5/29/18 at 10:55 a.m., Certified Nursing Assistant 2 indicated the door should be locked at all times. C. On the B wing, a door next to the nurses station, had a sign on it. The sign indicated Soiled Utility; caution biohazard material. The door was easily opened. The room contained two 1 quart bottles of CBC plus; toilet bowl cleaner. Review on 5/29/18 at 1:30 p.m., manufacturer's label indicated keep out of reach. MSDS dated 4/15/15, indicated Physical Hazards: CORROSIVE; Health hazards: Causes skin corrosion, causes serious eye damage. On 5/29/18, the DON provided census documentation which indicated 16 residents in the facility are independently mobile and cognitively impaired. On 5/30/18 at 8:32 a.m., the Director Of Nursing provided a policy titled Supplies and Equipment dated 5/24/18, and indicated it was the current policy being used by the facility. The policy indicated Process: .Hazardous (chemicals, sharp items, etc.) supplies will be secured in locked storage areas. 3.1-45 (a)(1)

Based on record review and interview, the facility failed to ensure staff followed physician's orders for pain medications which likely caused respiratory arrest due to CNS (central nerves system) depressants for 1 of 3 residents reviewed for pain medications in a sample of 3 (Resident #B, RN #1, LPN #2, LPN#3, and LPN #4). Findings include: The record for Resident #B was reviewed on [DATE] at 10:00 A.M. [DIAGNOSES REDACTED]. Resident #B was admitted to the facility on [DATE] and discharged on [DATE]. Recapitulation of the physician's orders for [DATE], indicated the resident was prescribed: -[MEDICATION NAME] (pain medication) - 2 milligrams (mg/dosage) by mouth PRN (as needed) every 6 hours - [MEDICATION NAME] - 4 mg by mouth PRN every 6 hours. (FDA Boxed Warning: Drug is a potent Schedule II opioid agonist with highest abuse potential and risk of causing respiratory depression. Alcohol, other opioids, and CNS depressants potentiate respiratory depressant effects, increasing risk of potentially fatal respiratory depression) -Ambien - 5 mg by mouth at bedtime (sedative-hypnotic to treat [MEDICAL CONDITION]. Depresses CNS-central nervous system) -[MEDICATION NAME] - 10 mg by mouth every day at bedtime (muscle relaxant - other CNS depressants can cause increased CNS depression and increased [MEDICATION NAME] effect) -[MEDICATION NAME] - ([MEDICATION NAME]-pain medication) [MEDICATION NAME] Patch (placed on skin) 75 mcg (micrograms) every 72 hours ([MEDICATION NAME] are Schedule II opioid agonist with highest potential for abuse and risk of fatal overdose due to respiratory depression. [MEDICATION NAME] levels peak between 24 and 72 hours of treatment; serious or life-threatening hyperventilation may arise during initial [MEDICATION NAME] application period) Resident #B's "Controlled Medication Accountability" (receipt/record/disposition) narcotics sheet dated [DATE] was reviewed on [DATE] at 4:15 P.M., and indicated the following: [MEDICATION NAME] ([MEDICATION NAME] - 2 mg) Take one tablet (2 mg) by mouth every 6 hours as needed for moderate pain; Take two (2) tablets (4 mg) by mouth every 6 hours as needed for severe pain. Doses administered as follows: [DATE] at 12 A.M., 1 tablet (2 mg) administered by RN #1 [DATE] at 3 A.M., 2 tablets (4 mg) administered by RN #1 [DATE] at 6 A.M., 1 tablet (2 mg) administered by RN #1 [DATE] at 9 A.M., 2 tablets (4 mg) administered by LPN #2 [DATE] at 12 Noon, 1 tablet (2 mg) administered by LPN #2 [DATE] at 4 P.M., 2 tablets (4 mg) administered by LPN #3 [DATE] at 10 P.M., 2 tablets (4 mg) administered by LPN #3 [DATE] at 12 A.M., 1 tablet (2 mg) administered by LPN #4 Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] mg was administered on [DATE] at 12 A.M., [MEDICATION NAME] 10 mg administered on [DATE] at 2100 (9 P.M.) and a new [MEDICATION NAME] Patch - 75 mcg placed on the resident on [DATE] at 9:00 A.M. A nurses note dated [DATE] at 1:40 A.M., indicated the resident rated her pain at ,[DATE] on the pain scale of (,[DATE] = 0 being no pain and 10 being the worst pain) and then went back to sleep. A nurses note dated [DATE] at 4:26 A.M., indicated the resident was unresponsive to verbal or physical stimuli at 3:50 A.M., was pale in color and could not find a pulse. CPR (cardiopulmonary resuscitation) was initiated and 911 was called. The resident was transported to the hospital by ambulance. EMT's (emergency medical technician) report dated [DATE], indicated the resident was negative for brachial and radial pulses but positive for a femoral pulse and heart sounds. Her pupils were dilated at 7 mm (millimeters) and the facility staff was assisting resident with ventilations. The resident was transported to the hospital. Review of the hospital notes indicated the resident was seen in the ED (emergency department) on [DATE] at 4:20 A.M. Assessment of the resident indicated she was unresponsive with [MEDICAL CONDITION] place. She also had received 2 mg of [MEDICATION NAME], 5 mg of Ambien, and had a [MEDICATION NAME] on at the time of admission. The resident received [MEDICATION NAME] 0.8 mg (drug used for the management of overdoses) while in the emergency room with no improvement in mental status and admitted to the ICU (intensive care unit). Review of the hospital discharge summary dated [DATE] indicated, "[MEDICAL CONDITIONS] due to respiratory arrest: appears to be a severe event ... arrest likely due to primary respiratory event likely due to CNS depressants ..." During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 9:50 A.M., she indicated there was an order for [REDACTED]. A current facility policy dated ,[DATE] and titled "Medication Administration - General Guidelines" and provided by the ADON on [DATE] at 4:30 P.M., indicated: "Policy: Medications are administered as prescribed in accordance with good nursing principles and practices ... Procedures: ... 4) Five Rights - ... right dose and right time, are applied for each medication being administered. ... B. Administration: ... 2) Medications are administered in accordance with written orders of the prescriber ..." This Federal tag relates to Complaint IN 061. 3XXX,[DATE](c)(2)

Based on record review and interview, the facility failed to ensure a resident's Foley (urinary) catheter was cared for in a manner to prevent urinary tract infections for 1 of 2 residents reviewed with Foley catheters in a total sample of 3. (Resident 'A') The facility failed to to assess the resident related to intake and urinary output, failed to assess the resident's urine for color, clarity, and odor, failed to provide catheter care, and attempted Foley catheter irrigation without a physician's orders [REDACTED]. Findings include: A current policy entitled "Indwelling Catheter Justification/Decision Diagram" provided by the DON (Director of Nursing ) on 10/21/2010 at 3:30 p.m., included but was not limited to the following: "....New Admission/Re-Admission of resident with Indwelling Catheter...Complete Rap (Resident Assessment Protocol) Note/Summary Statement The Rap Note/Summary Statement is to be complete and must include the following information: Type of Catheter, Approximate length of time that catheter had been present, Clinical conditions/underlying factors present that make the indwelling catheter unavoidable, [DIAGNOSES REDACTED]." The record for Resident 'A' was reviewed on 10/18/2010 at 3:15 p.m. [DIAGNOSES REDACTED]. History and Physical from a hospital admission on 2/19/2010, included, but was not limited to, the following: "...Past Medical History: Significant for urosepsis...." An Admission MDS (Minimum Data Set) assessment dated [DATE], included, but was not limited to, the following: "...severely impaired cognitive skills for daily decision making, bed mobility requires total dependence and two persons, functional limitation in range of motion included the arm (including shoulder or elbow), Hand (including wrist or fingers), Leg (including hip or knee) and Foot (including ankle or toes) limitation on both sides with full loss...RAP Assessment for ADL - Functional / Rehabilitation Potential...Resident had a TBI ([MEDICAL CONDITION]) and is a quad (quadriplegic) completely dependent on staff for all care. Does not communicate...He has beginning contractures in his hands and uses splints...." An Admission MDS (Minimum Data Set) assessment dated [DATE], included but was not limited to, the following: "...incontinent of bowel and bladder .... " The corresponding Resident Assessment Protocol (RAP) triggered for Urinary Incontinence and Indwelling Catheter. RAP additional notes included Resident has had a TBI ([MEDICAL CONDITION]) and does not respond, he is totally incontinent of bowel and bladder. His skin is intact. Do not expect him to improve and he is not a candidate for retraining or schedule due to his condition. There was no care plan related to the resident ' s Foley catheter provided for this time period. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], included but was not limited to the following: "...severely impaired cognitive skills for daily decision making, bed mobility requires total dependence and two persons, functional limitation in range of motion included the arm (including shoulder or elbow), Hand (including wrist or fingers), Leg (including hip or knee) and Foot (including ankle or toes) limitation on both sides with full loss...." A Discharge Summary from hospitalized from [DATE] through 7/11/2010, included but was not limited to the following: "...Discharge Diagnoses: [REDACTED]. 2. Urinary tract infection secondary to Pseudomonas and [DIAGNOSES REDACTED]....History of Present Illness:...significant history of multiple recurrent bouts of [MEDICAL CONDITION] secondary to wound infection related to sacral decubitus and/or urinary tract infections. He was readmitted on transfer from extended-care facility due to recurrent [MEDICAL CONDITION].Hospital Course: The patient was admitted to the Intensive Care Unit. He was again found to be septicemic with positive blood cultures for Pseudomonas in the blood and [DIAGNOSES REDACTED] in the urine. His [MEDICAL CONDITION] has resolved with fluids and stress steroids....Addendum Dictated 7/11/2010: no active [MEDICAL CONDITION] infection/pneumonia at present...." Resident 'A' was readmitted to the facility on [DATE]. A readmission "Clinical Health Status" dated 7/11/2010 at 1:30 p.m., included, but was not limited to, the following: "...Skin Conditions....Skin Concern #4, Date first observed: 7/11/2010, anchored Foley 16 X 10 (16 French X 10 cc balloon)...." "Progress Notes," Type: General, dated 7/23/2010 at 08:06 (8:06 a.m.), included, but were not limited to, the following: "...Foley cath (catheter) care provided at this time. Drainage noted around cath tubing, attempted to change Foley cath. Upon deflating and removing cath, large amount of blood noted from penis opening. Penis cleaned and assessed for tears and abrasion. No trauma noted. Bleeding continues. Ambulance called to transport res to (hospital name) for eval (evaluation)...." "Progress Notes", Type: Change of Condition, dated 7/23/2010 at 08:47 (8:47 a.m.), included, "Situation: Res presented with elevated temp (temperature) and frank bleeding, Background: Hx (history) of frank bleeding and elevated temps, Assessment: Temp 103.9 (AX) (axilla), lg (large) amounts of blood from penis, Response: Transferred to (hospital name) per ambulance, family/MD (medical doctor) notified." "Emergency Physician Patient Care Record" dated 7/23/2010, included but was not limited to the following: "...Foley catheter was pulled out and bleeding from urethra...Clinical Impression: 1.[MEDICAL CONDITION], 2. Traumatic catheter pull with hematuria, 3. UTI (urinary tract infection)...." "Final Report Admission H & P (History and Physical) Note" dated 7/23/2010, included but was not limited to the following: "...(Resident's name)...was sent from his ECF (extended care facility) residence for fever, [MEDICAL CONDITION] and blood in his urine (Foley was somehow pulled out)....Impression and Plan:[MEDICAL CONDITION]ly multiple sources...pseudomonas UTI (urinary tract infection)...Foley replaced today (was pulled out) had gross hematuria, getting CBI (continuos bladder irrigation) until clears, if does not improve involve GU ([MEDICAL CONDITION]) consult...." "Final Discharge Summary" dated 7/29/2010, included but was not limited to the following: "Discharge Diagnoses: [REDACTED]. 2. Hematuria secondary to trauma, resolved...." During an interview with LPN #1 on 10/21/2010 at 2:44 p.m. (with Executive Director #2 present intermittently), she recounted the events of 7/23/2010. She indicated the resident was running a temperature of 103 degrees and had been sent out frequently. She indicated there was a "dark color in the rubber tubing part of the catheter." She indicated she attempted to "irrigate the catheter and couldn't," so (she) removed catheter after she deflated the balloon with a syringe (different from the syringe used to attempt to irrigate the Foley). She indicated she removed 3-5cc with a 10 cc syringe and upon deflating the balloon, the Foley "shot out" and blood began to come out from his penis. She indicated there was a constant trickle (blood) till the EMT's arrived. LPN #1 indicated there was very little urine in the (Foley) bag. She indicated the outputs were documented on the flowsheet or on the MAR (Medication Administration Record) or CNA (Certified Nursing Assistant) will put in computer if a Input and Output ordered. Documentation failed to indicate physician order [REDACTED]." "Progress Notes" dated from 7/20/2010 through 7/23/2010 did not include documentation related to Foley catheter care and/or the color, clarity and amount of urine. Treatment Record for July 2010 indicated "Catheter care q shift, Order Date: 6/22/2010, Every shift. The Treatment Record for July 2010, indicated there was no catheter care provided for each shift for 7/21, 7/22 and 7/23/2010. "Intake and Output Summary" for July 2010, provided by the DON on 10/21/2010 at 3:30 p.m. stopped as of 7/20/2010. The DON indicated there was no further documentation related to Intake and Output for July 2010. This federal tag relates to Complaint IN 824. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure a resident whose respiratory condition was deteriorating was assessed timely after a physician ordered the resident sent to the hospital for evaluation and treatment. The resident was not assessed between 6:34 p.m. and 8:45 p.m., when the ambulance arrived to transport the resident. The deficient practice resulted in a delayed request for emergency transport and medical intervention. The resident required assistance with ventilation in the ambulance and immediate intubation in the emergency room . The facility also failed to ensure a resident with a Foley catheter and with a history of urinary tract infections was monitored for changes in output and color and clarity of urine. The deficient practice affected 1 of 3 residents reviewed related to assessment in a sample of 3. (Resident 'A') Findings include: The clinical record for Resident 'A' was reviewed on 10/18/2010 at 3:15 p.m. [DIAGNOSES REDACTED]. A. "Progress Notes" included but were not limited to the following: 2/26/2010, 09:45 (9:45 a.m.) "b/p (blood pressure) 140/70 p (pulse) 72 r (respirations) 18 t (temperature) 97.8 O2 (oxygen) sats (saturation) 94% on 2L (liters) O2 (oxygen). Bilateral expiratory wheezes pre and post neb (nebulizer) treatments, no coughing noted, no change in O2 sats based on nebs...Gtube checked for placement prior to each use, residual zero this shift. HOB (head of bed) elevated at least 30 degrees at all times to prevent aspiration of [MEDICAL CONDITION] content. 2/26/2010, 14:02 (2:02) "temp up at 12 noon, 100.3. Tylenol [MEDICATION NAME] 20 ml (milliliters) given per g tube...." 2/26/2010, 18:34 (6:34 p.m.) "resident seem getting more congested and temperature is now 103.2. Even past Tylenol at 4pm. Doctor Office notified with new order to send resident to (hospital name) ER (emergency room ) for evaluation and treatment. resident mother (name) notified, states 'OK and to send him to (hospital name).' Awaiting for ambulance." 2/26/2010, 22:30 (10:30 p.m.) (sic) "Resident temperature remain 103.2 even past Tylenol dose an hour ago, increasing congestion, audiadible (SIC) congestion O2 (oxygen) SAT (saturation) 90% at 3LTS (liters) of O2. Skin hot to touch and moist. Pulse 100/per min. Ambulance here to transport to (hospital name). Mother aware." 2/26/2010, 22:58 (10:58 p.m.) "Resident transported to hosp (hospital) at 2050 (8:50 p.m.) by (name of ambulance service)." Ambulance report indicated an arrival time of 2045 (8:45 p.m.), enroute time 2055 (8:55 p.m.) and ER arrival time of 2106 (9:06 p.m.). Narrative included, but was not limited to the following: "...Pt (patient) with low O2 sats...Nurse stated pt has O2 sat 91%. Pt on O2 2lpm (liters per minute) via NC (nasal cannula). Pt pale, warm diaphoretic. O2 sat 85%, pulse 176, BP (blood pressure) on scene 128/90. Enroute VS (vital signs) taken (increased) No further BP taken due to bagging pt. BVM (bivalve mask) at 15lpm...Rales upper lobes, diminished lower...." No further "Progress Notes" were provided by the DON (Director of Nursing) as requested on 10/21/2010 at 3:45 p.m. to indicate from 6:34 p.m. to 8:45 p.m. any additional assessments were performed or attempts made to call 911 due to deteriorating condition. During an interview with the DON and Administrator on 10/21/2010 at 3:45 p.m., the DON indicated there was no policy for length of time to wait for transport. If resident needs 911 (emergency response), it is called. Both DON and Administrator indicated they were not familiar with the ambulance service used. They attempted to obtain information regarding when the ambulance service received the call, but no further information was provided. B. Resident A's Discharge Summary from hospitalized from [DATE] through 7/11/2010, included but was not limited to the following: "...Discharge Diagnoses: [REDACTED]. 2. Urinary tract infection secondary to Pseudomonas and [DIAGNOSES REDACTED]....History of Present Illness:...significant history of multiple recurrent bouts of [MEDICAL CONDITION] secondary to wound infection related to sacral decubitus and/or urinary tract infections. He was readmitted on transfer from extended-care facility due to recurrent [MEDICAL CONDITION].Hospital Course: The patient was admitted to the Intensive Care Unit. He was again found to be septicemic with positive blood cultures for Pseudomonas in the blood and [DIAGNOSES REDACTED] in the urine. His [MEDICAL CONDITION] has resolved with fluids and stress steroids....Addendum Dictated 7/11/2010: no active [MEDICAL CONDITION] infection/pneumonia at present...." Resident 'A' was readmitted to the facility on [DATE]. During an interview with LPN #1 on 10/21/2010 at 2:44 p.m. (with Executive Director #2 present intermittently), she recounted the events of 7/23/2010. She indicated the resident was running a temperature of 103 degrees and had been sent out frequently. She indicated there was a "dark color in the rubber tubing part of the catheter." She indicated she attempted to "irrigate the catheter and couldn't," so (she) removed catheter after she deflated the balloon with a syringe (different from the syringe used to attempt to irrigate the Foley). She indicated she removed 3-5cc with a 10 cc syringe and upon deflating the balloon, the Foley "shot out" and blood began to come out from his penis. She indicated there was a constant trickle (blood) till the EMT's arrived. LPN #1 indicated there was very little urine in the (Foley) bag. She stated the outputs were documented on the flowsheet or on the MAR (Medication Administration Record), or the CNA (Certified Nursing Assistant) will put the amounts in computer if on Input and Output. Review of "All Active Orders for July 2010" included but was not limited to the following: "...Catheter care q (every) shift - Every shift Every day Order Date: 6/22/2010...." "Progress Notes" dated from 7/20/2010 through 7/23/2010 did not include documentation related to Foley catheter care and/or the color, clarity and amount of urine. A Treatment Record for July 2010 indicated "Catheter care q shift, Order Date: 6/22/2010, Every shift. The Treatment Record for July 2010, indicated there was no catheter care provided for each shift for 7/21, 7/22 and 7/23/2010. An "Intake and Output Summary" for July 2010, provided by the DON on 10/21/2010 at 3:30 p.m. stopped as of 7/20/2010. The DON indicated there was no further documentation related to Intake and Output for July 2010. This federal tag relates to Complaint IN 824. 3.1-31(a)

Based on record review and interview, the facility failed to ensure a resident with a gastrostomy tube was provided care to minimize the risk of aspiration pneumonia for 1 of 2 residents reviewed with a history of aspiration pneumonia in a total sample 3 with gastrostomy tubes. (Resident 'A') The facility failed to administer tube feedings, water flushes, and [MEDICAL CONDITION] medications as ordered. The facility failed to monitor [MEDICAL CONDITION] residual in accordance with facility policy. The deficient practice resulted in the resident's being hospitalized twice for aspiration pneumonia The second hospitalization resulted in intubation, and subsequently a tracheotomy when the resident could not be weaned from the ventilator. Findings include: A current policy entitled "Administration of Enteral Feeding: [MEDICATION NAME]/Gravity Drip, Protocols" provided by the DON (Director of Nursing ) on 10/21/2010 at 3:30 p.m., included but was not limited to the following: "Administration of Enteral Feeding: [MEDICATION NAME]/Gravity Drip, Protocols:...Verifications of feeding tube placement will be done each time before the administratio of feeding formula, modifications or free water flushes, and/or at least one time per shift....Step 9...evaluate color, and amount of residual-[MEDICAL CONDITION] secretions...." The record for Resident 'A' was reviewed on 10/18/2010 at 3:15 p.m. [DIAGNOSES REDACTED]. Resident 'A' was admitted to facility on 2/16/2010 at 1:57 p.m. Review of a "Medication Record" dated "2/1/2010 - 2/28/2010, included but was not limited to the following: [MEDICATION NAME] 1.5 to run at 50 ml (milliliters)/hr (hr) X 22 hrs until eval (evaluation) by dietary daily, which was changed with a physician's orders [REDACTED]. Off 4 hours for ADL's and Therapy with no times designated and no initials for the dates, 2/17 or 2/18/10. H2O (water) flush 180cc q (every) 4 hours timed at 12M, 4A, 8A, 12N, 4P, & 8P (midnight, 4:00 a.m., 8:00 a.m., noon, 4:00 p.m., and 8:00 p.m.) and had initials for 2/18/10 at 12M, 4A, 8A, and 12N. There were no water flushes given on 2/16 and 2/17/2010. [MEDICATION NAME] 5mg/5ml sol (solution) (promotes [MEDICAL CONDITION] emptying) 10mg gastrostomy Tube every eight hours for diseases of the esophagus timed at 6:00 a.m., 2:00 p.m., and 10:00 p.m. There were initials for 2/16 at 6:00 a.m. (The resident was admitted to the facility on [DATE] at 1:57 p.m.) From 2/16/2010 at 1:57 p.m. to 2/18/210 at 2:13 p.m., the resident should have received 5 doses of the medication but only received 1 dose. Resident 'A' was sent to theER on [DATE] at 2:13 p.m. History and Physical from hospitalized from [DATE] to 2/24/2010, dated 2/19/2010, included but was not limited to the following: "...admitting [DIAGNOSES REDACTED].Abdomen: positive bowel sounds in all 4 quadrants, distended, [DEVICE] with brown discharge....The patient is going to be admitted under the care ...with working [DIAGNOSES REDACTED]..1. Aspiration pneumonia, 5. Dysphagia, gastrostomy tube: Hold the feedings today. He had 180 ml residual....8. Reflux disease...." Resident 'A' was readmitted to the facility on [DATE] at 4:15 p.m. Review of a "Medication Record" dated "2/1/2010 - 2/28/2010, included but was not limited to the following: Glucerna 1.2 at 90cc/hr for 20 hours timed at Day, Eveni (Evening) and Night. Off 4 hours for ADL's and Therapy with no designated times. [MEDICATION NAME] HCL gastrostomy Tube Dose: 10ml = 10mg, every eight hours timed at 1300 (1:00 p.m.), 0500 (5:00 a.m.) and 2100 (9:00 p.m.). Out of 6 opportunities for administration, only four doses were given. Two doses were missed: the 2/24, 2100, and the 2/26/10, 0500 dose. Water for Irrigation, sterile (Sterile Water for Irrigation) Dose: 150cc Every four hours, Irrigate [MEDICAL CONDITION] tube with 150cc water q 4 hours timed at 0400 (4:00 a.m.), 0800 (8:00 a.m.), 1200 (Noon), 1600 (4:00 p.m.), 2000 (10:00 p.m.) and 0000 (Midnight). Out of 14 opportunities for administration, only 6 were documented as administered. All February 2010 documentation for Resident 'A' was found and provided on 10/21/2010 by the DON (Director of Nursing) at 9:30 a.m. During interview at this time, the DON indicated this was all available documentation for care provided in February 2010. There were no interim careplans initiated upon admission on 2/16/2010 related to the resident's gastrostomy tube and history of aspiration. During an interview with the DON on 10/21/2010 at 1:10 p.m., she indicated, "Therapy would let nursing know when they were planning on PT (Physical Therapy) or OT (Occupational Therapy). Each discipline was spaced out as the resident could not tolerate both closely together. Therapy states because he was a tube ([DEVICE]) he was done during lunch about 1 p.m. Off until they completed. It lasted approx (approximately) 11/2 hrs (hours). A few times it was longer. Therapy informed nursing at start and end of till ADL's done around therapy schedule." She also indicated there was no documentation indicating the actual times the feeding was off and on as ordered. The following nurses notes indicated residual checks were performed: Review of a handwritten Nurses Notes dated 2/17/2010 10:00 p.m., when tube feeding rate was increased from 50cc/hr to 90cc/hr, "no residual was indicated." Review of a handwritten Nurses Notes dated 2/18/2010, 6:00 a.m. indicated "[DEVICE] patent, flushes without diff (difficulty) - no residual noted - placement checked prior to use of [DEVICE]." Review of a computer generated Nurses Notes dated 2/18/2010, 6:33 a.m. indicated "G tube patent, checked for placement prior to use, zero residual." There was no documentation of residual checks being preformed on 2/16/2010 after admission, on 2/17/2010, night shift and day shift or on 2/18/2010, day shift prior to the resident being transported to the ER. The following computer generated nurses notes dated 2/24/2010 through 2/26/2010 indicated irrigation or "flushes well": 2/24/2010, 22:34 (10:34 p.m.) "Res (Resident) readmitted to the facility, ...at 4:15 p.m....[DEVICE] patent and flushes freely. Placement checked via ausculation. HOB elevated more than 30 degrees. Glucerna infusing per pump @ 90ml/hr...." 2/25/2010, 06:37 (6:37 a.m.) " ...HOB elevated to 30 degrees, [DEVICE] patent, flushes well, no residual noted, placement checked prior to each use. 2/26/2010, 02:27 (2:27 a.m.) "...HOB elevated to 30 degrees....[DEVICE] with Glucerna infusing at 90 ml's/hr, res tolerating feeding without difficulty. [DEVICE] patent, flushes well, no residual, placement checked prior to each use...." 2/26/2010, 09:45 (9:45 a.m.) "b/p (blood pressure) 140/70 p (pulse) 72 r (respirations) 18 t (temperature) 97.8 O2 (oxygen) sats (saturation) 94% on 2L (liters) O2 (oxygen). Bilateral expiratory wheezes pre and post neb (nebulizer) treatments, no coughing noted, no change in O2 sats based on nebs...Gtube checked for placement prior to each use, residual zero this shift. HOB (head of bed) elevated at least 30 degrees at all times to prevent aspiration of [MEDICAL CONDITION] content. 2/26/2010, 14:02 (2:02) "temp up at 12 noon, 100.3. Tylenol [MEDICATION NAME] 20 ml (milliliters) given per g tube...." 2/26/2010, 18:34 (6:34 p.m.) "resident seem getting more congested and temperature is now 103.2. Even past Tylenol at 4pm. Doctor Office notified with new order to send resident to (hospital name) ER (emergency room ) for evaluation and treatment. resident mother (name) notified, states 'OK and to send him to (hospital name).' Awaiting for ambulance." 2/26/2010, 22:30 (10:30 p.m.) (sic) "Resident temperature remain 103.2 even past Tylenol dose an hour ago, increasing congestion, audiadible (SIC) congestion O2 (oxygen) SAT (saturation) 90% at 3LTS (liters) of O2. Skin hot to touch and moist. Pulse 100/per min. Ambulance here to transport to (hospital name). Mother aware." 2/26/2010, 22:58 (10:58 p.m.) "Resident transported to hosp (hospital) at 2050 (8:50 p.m.) by (name of ambulance service)." Ambulance report indicated an arrival time of 2/26/10 at 2045 (8:45 p.m.), enroute time 2055 (8:55 p.m.) and ER arrival time of 2106 (9:06 p.m.). Narrative included, but was not limited to the following: "...Pt (patient) with low O2 sats...Nurse stated pt has O2 sat 91%. Pt on O2 2lpm (liters per minute) via NC (nasal cannula). Pt pale, warm diaphoretic. O2 sat 85%, pulse 176, BP (blood pressure) on scene 128/90. Enroute VS (vital signs) taken (increased) No further BP taken due to bagging pt. BVM (bivalve mask) at 15lpm...Rales upper lobes, diminished lower...." Review of the "Emergency Physician Patient Care Record" dated 2/26/2010, 2100 (9:00 p.m.) included, but was not limited to, the following: " pt intubated on arrival secondary (to) resp (respiratory) insufficiency, suctioning ...intubation yielded copious amounts secretions ...tube feeds...Clinical Impression: 1. Resp Failure, 2. Aspiration Pneumonia...." Review of the "Final Report Discharge Summary" from the hospital dated 3/11/2010, included, but was not limited to, the following: " Discharge Diagnoses: [REDACTED]. Acute hypoxic [MEDICAL CONDITION], resolved.... 4. Recurrent aspiration pneumonia....Procedure: 1. Chest x-ray 2/25/2010 showed persistent low lung volumes, obscuration of the left hemidiaphragm which may represent atelectasis or infiltrate...3. Chest computerized tomography 3/4/2010, Interval development of relatively severe bibasilar airspace consolidation compatible with pneumonia...5. Chest x-ray 3/9/2010 showed exchange of the endotracheal tube for a [MEDICAL CONDITION]. 6. Order [MEDICATION NAME] fluoroscopy procedure showed successful conversion of the previous gastrostomy tube to a 22 french MIC gastrojejunostomy tube....History of Presenting Complaint:...Patient was transferred from the Extended Care Facility due to respiratory difficulty. He was noted to have fever up to 103 degrees Fahrenheit at the Extended Care Facility associated with severe dyspnea. Chest x-ray at the outside facility showed right lower lobe infiltrate. Patient was started on antibiotics for pneumonia, but on the day of presentation, he was found to be pale, warm, diaphoretic with dyspnea. At the Emergency Department, febrile, [MEDICAL CONDITION], tachypneic with respiration difficulties and was intubated on arrival. Copious amounts of tube feeds were suctioned from his airways. He has a [DEVICE] for feeding and an indwelling Foley catheter chronically...Hospital Course: 1. [MEDICAL CONDITION]: Patient presented with signs and symptoms suggestive of [MEDICAL CONDITION], probably secondary to aspiration pneumonia. Patient was fluid-resuscitated in the Emergency Department....2. Acute Hypoxic [MEDICAL CONDITION] due to Aspiration Pneumonia: Patient was on ventilator support throughout admission.... " Resident 'A' was transferred from the hospital to an acute care facility on 3/11/2010. Review of History and Physical from Acute Care facility dated 3/11/2010, included but was not limited to the following: "...History of Present Illness: ...Patient had been originally admitted from an extended care facility due to respiratory distress. Patient was found to have a right lower lobe infiltrate. He was found to have [MEDICAL CONDITION] secondary to aspiration pneumonia was fluid resuscitated and started on antibiotics....He required intubation and was unable to be weaned and therefore underwent [MEDICAL CONDITION] placement on 3/9/2010....Peg Conversion to gastrojejunostomy 3/10/2010.... This federal tag relates to Complaint IN 824. 3.1-44(a)(2)