Every finding on record at Brickyard Healthcare - Muncie Care Center

Based on observation, interview, and record review the facility failed to develop and implement individualized care plan interventions to support and protect cognitively impaired residents involved in a relationship. (Resident B and Resident C) Findings include:On 8/25/26 at 9:20 a.m., Resident B and Resident C were observed sitting in the dining room, in their wheelchairs, drinking from coffee cups. On 8/25/26 at 11:50 a.m., Resident C and Resident B were sitting in their wheelchairs at a table in the dining room. On 8/26/26 at 12:52 p.m., Resident B and Resident C were sitting in their wheelchairs at a table in the dining room talking to each other. Review of a facility reported incident indicated, on 8/20/26, Residents B and C were observed to be engaged in what appeared to be a consensual intimate act. The facility's investigation file was provided by the Administrator on 8/25/26 at 10:51 a.m. and contained a statement from CNA 7, dated 8/20/26. The statement indicated, while CNA 7 was conducting rounds and assisting residents to the bathroom after lunch, she knocked and then entered Resident C's room to check on him. Upon entering, she observed Resident B sitting on the side of Resident C's bed while Resident C was lying down. Resident C's pants and incontinence brief were pulled down. Resident B was leaning toward Resident C's pelvic area and appeared to be performing oral sex on Resident B. When the residents noticed the CNA's presence, Resident B appeared startled and Resident C pulled up his brief and pants. She assisted Resident C with getting properly dressed. During an interview, on 8/25/26 at 11:13 a.m., CNA 7 indicated, on 8/20/26 at around 1:30 p.m., towards the end of her shift, she walked past Resident C's room and saw his privacy curtain partially open. She observed Resident C's legs and Resident B leaning over him. She entered his room and observed Resident C lying in bed with his pants and incontinence brief pulled just past his hips. Resident B was sitting on the side of the bed leaning over and performing oral sex on Resident C. Resident C's roommate was in the room in his bed sleeping. Resident B's and Resident C's cognition fluctuated. They had a similar relationship to a school relationship in that they held hands and were around each other a lot. The staff tried to redirect her from going into his room and they kept them separated. During an interview, on 8/25/26 at 11:37 a.m., CNA 10 indicated CNA 7 asked for assistance on 8/20/26. She entered Resident C's room and Resident C's pants were pulled up and Resident B was sitting sideways on Resident C's bed. She assisted Resident B up from the bed and took her to the dining room. Resident C could be nice, but at times, he was aggressive and rude. He was rude to Resident B at times and made her cry. Resident B was very Godly and had indicated to do what a man says to keep him happy. Resident C thought that Resident B was his wife. Resident B had a picture of her husband in her room and brought the picture to the dining room and Resident C would get angry about the picture. They could be together in their rooms, but staff just keep an eye on them. Resident B would sit in Resident C's recliner and Resident B would lay in bed. CNA 10 had not observed anything sexual before between them but had seen them kiss. Resident C was incontinent and Resident B was incontinent at times. The residents were allowed to have a relationship/friendship, as family ok'd it, but nothing sexual. Staff were to keep an eye on the residents when they were together or in their rooms. During an interview, on 8/25/26 at 12:10 p.m., Resident B indicated she was unable to identify the name of the facility, what month or year it was, and could not name who the president of the United States was. She identified Resident C as her boyfriend and they talked about getting married but he cussed too much for her and she had been praying for him. She and Resident C mostly dated and they didn't do sex too much. She didn't let him do whatever he wanted to her, as she was not that kind of person. During an interview, on 8/25/26 at 12:59 p.m., Resident C's family member indicated they had a care plan meeting with the facility. Resident B and C would get mad when asked to leave each other's room. The family member was okay with Resident B and Resident C sharing a room and felt that it would keep him from going to other resident's room thinking that the rooms were Resident B's, which she felt caused his last fall. The family included Resident B when they visited Resident C. They were aware that they sat together, and one of them laid in bed while the other sat in the recliner. They were aware of the facility talking with both of them about risks and safety related to a sexual relationship. Resident C had confusion and dementia. He thought he was in a hotel or trapped in a movie theatre. During an interview, on 8/25/26 at 1:32 p.m., Resident C indicated he was unable to identify what the name of the facility was, who the president of the United States was, or what year it was. He identified Resident B as his girlfriend, and indicated they had a friendship, not a sexual relationship. He indicated that he did not live at the facility and the facility was a university. He indicated that the men who worked at the facility, also attended school at the facility and golfed. Resident C indicated he was [AGE] years old and was able to voice the month and date he was born. During an interview, on 8/25/26 at 2:10 p.m., the Memory Care Director indicated Resident B and Resident C had a friendship, and she asked them both frequently if everything was okay with them. Resident C could identify Resident B in a crowd and knew her by name. Resident C had occasional verbal aggression with staff during care which was expected with cognitive impairment. His Brief Interview for Mental Status (BIMS) score fluctuated between 4 and 7 (sever cognitive impairment) depending on the day, the words he recalled, and the timeline. Resident B knew who Resident C was, sought him out, and knew his name. She had occasional verbal aggression with staff. Her BIMS score was an 8 (moderate cognitive impairment). Capacity to consent was whether or not the residents had the understanding, consequences and understood the consequences and could explain it, who their significant other was, recognize and explain the associated risks. The BIMS score did not always affect the capacity to consent, and it was a good guideline but not always about the here and now. Their relationship was primarily holding hands and the occasional kiss. They hung out in each other's rooms, and sat at meals and activities together. The Memory Care Director felt they both had the capacity to consent to a sexual relationship and they understood the risks. During an interview, on 8/26/26 at 10:07 a.m., the Administrator, with the Nurse Consultant and the Memory Care Director present, indicated the interdisciplinary team were going to meet and talk about Resident B and C's relationship and would try to come up with a solution. During a follow up interview, on 8/26/26 at 10:40 a.m., CNA 7 indicated interventions were keeping an eye on Resident B and Resident C. Interventions regarding their relationship were found in the Kardex (summary tool that connects resident's care plans directly to daily task lists for staff) on Point Click Care (PCC) (electronic health records). On 8/26/26 at 11:21 a.m. the Memory Care Director indicated there was not a super detailed care plan needed prior to 8/20/26 for Resident B's and C's relationship because the residents were just hand holding. She would typically update the care plan when the relationship progressed. The facility would then work through privacy factors and honor and respect the residents' wishes. At this time, the facility was working through the investigation and then they would come to a final determination. During a follow up interview, on 8/26/26 at 12:52 p.m., the Memory Care Director indicated the capacity to consent assessment that was completed in April for Resident B and C was due to another couple that had kissed and the facility completed the consents preemptively. During a follow up interview, on 8/26/26 at 12:57 p.m., CNA 10 indicated interventions included separating the residents if they were found in each other's rooms and redirecting them. Interventions were found on the Kardex in the electronic health record. During an interview, on 8/26/26 at 1:08 p.m., CNA 8 indicated interventions for Resident B and Resident C were keeping them in the dining room, because they wouldn't do anything sexual down there. She did not know where to find care plan interventions and someone would tell her what the interventions were. Resident B's clinical record was reviewed on 8/25/26 at 9:29 a.m. Diagnoses included colostomy status and vascular dementia, unspecified severity, with other behavioral disturbance. An 8/7/26, quarterly, Minimum Data Set (MDS) assessment indicated she had moderate cognitive impairment. No behaviors were exhibited. She had a colostomy and was frequently incontinent of urine. A current, 3/29/26, care plan indicated she had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, and impaired decision making. Interventions included asking yes/no questions in order to determine her needs (3/29/26), communicating with her/family/caregivers regarding her capabilities and needs (3/29/26), and related to communication; using her preferred name, identifying yourself at each interaction, facing her when speaking and making eye contact, reducing any distractions (turning off the TV, radio, closing the door etc.), she understood consistent, simple, directive sentences, and providing her with necessary cues such as stopping and returning if agitated (revised 5/13/26). A current, 4/21/26, care plan indicated she expressed that she wished to be involved in a personal relationship with a male peer. Her goal was that her privacy was to be honored (revised 5/15/26). Interventions included, due to cognitive status, staff would observe for any assistance needed regarding the relationship (4/21/26) and encouraging her to alert staff if any questions or support was needed regarding the relationship or ending the relationship, if needed (4/21/26). Her clinical record lacked an individualized care plan related to intimate sexual expression and activity. A 4/21/26 capacity to consent assessment indicated the following:She was able to explain what engaging in sexual activity meant.She had the ability to avoid exploitation (Trading sexual favors for money, cigarettes etc.).She had the ability to say yes or no to sexual activity at any time.She understood that she could change her mind about engaging in sexual activity at any time.She had the ability to identify who she was having a relationship with (For example, she believed that she was in a relationship with her spouse, but the other person was not actually her spouse).Her sexual behaviors were not consistent with her formal held beliefs.She understood that sexual activity could have physical, emotional, and health consequences. Her clinical record lacked an assessment of capacity to consent between 4/21/26 and 8/20/26. A social service note, dated 8/20/26 at 2:57 p.m., indicated she was spoken to regarding staff concerns of possible inappropriate contact with another resident. She denied any inappropriate contact. Resident C's clinical record was reviewed on 8/25/26 at 10:38 a.m. Diagnoses included generalized anxiety disorder, major depressive disorder, recurrent, moderate, restlessness and agitation, and vascular dementia, severe, with agitation. A 7/13/26, significant change, MDS assessment indicated he had severe cognitive impairment. No behaviors were exhibited. He was frequently incontinent of both bowel and bladder. A current, 10/22/25, care plan indicated he had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, and impaired decision making. Interventions included asking yes/no questions in order to determine the his needs (10/22/25), communicating with the him/family/caregivers regarding his capabilities and needs (10/22/25), related to communication; using his preferred name, identifying yourself at each interaction, facing him when speaking and making eye contact, reducing any distractions (turning off the TV, radio, closing the door, etc.), he understood consistent, simple, directive sentences, providing him with necessary cues stopping and returning if agitated (revised 11/5/25), engaging him in simple, structured activities that avoided overly demanding tasks, he preferred reading the newspaper, listening to country music, keeping up with the news (10/22/25), presenting him with just one thought, idea, question or command at a time (10/22/25), and providing a program of activities that accommodated his abilities (10/22/25). A current, 4/21/26, care plan indicated he expressed that he wished to be involved in a personal relationship with female peer. His goal was that his privacy was to be honored (revised 7/16/26). Interventions included due to cognitive status, staff would observe for any assistance needed regarding the relationship (4/21/26) and encouraging him to alert staff if any questions or support was needed regarding the relationship or ending the relationship, if needed (4/21/26). His clinical record lacked an individualized care plan related to sexual expression and activity. A 4/21/26 capacity to consent assessment indicated the following: He was able to explain what engaging in sexual activity meant.He had the ability to avoid exploitation (Trading sexual favors for money, cigarettes etc.).He had the ability to say yes or no to sexual activity at any time.He understood that he could change his mind about engaging in sexual activity at any time.He had the ability to identify who he was having a relationship with. (For example, he believed he was in a relationship with his spouse, but the other person was not actually his spouse.) His sexual behaviors were not consistent with his formal held beliefs.He understood that sexual activity could have physical, emotional, and health consequences. His clinical record lacked an assessment of capacity to consent between 4/21/26 and 8/20/26. A social service note, dated 8/21/26 at 1:15 p.m., indicated social services and the Administrator spoke with a family member regarding the progression of Resident C's relationship with a female peer. Family had already been previously informed of the relationship with no concerns, however, due to the progression of the relationship, family was notified. The family member expressed no concerns regarding the relationship and felt it was good for Resident C. The family member expressed that they wanted nothing done any differently regarding the relationship, as it made Resident C happy and helped improve his life. The family member further expressed that if the opportunity presented itself for the two of them to share a room, they would also be open to that as they felt it would be beneficial. An undated current facility policy, titled Care Plan Revisions Upon Status Change, provided by the Administrator on 8/26/26 at 1:29 p.m., indicated the following: .Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change.b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. the team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with new or modified interventions. This citation relates to Intake 3172907. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure door alarms and resident safety device alarms were responded to in a timely manner to prevent an elopement. (Resident B) This deficient practice was corrected on 5/17/26, prior to the start of the survey, and was therefore past noncompliance. Findings include: Resident B's clinical record was reviewed on 6/10/26 at 9:46 a.m. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, unspecified focal traumatic brain injury with loss of consciousness status unknown, subsequent encounter, other obsessive-compulsive disorder, generalized anxiety disorder, major depressive disorder, recurrent, moderate, and unspecified dementia, mild, with anxiety. A quarterly Minimum Data Set assessment, dated 4/27/26, indicated he was moderately cognitively impaired and did not exhibit behaviors.A current care plan, dated 5/15/24, indicated Resident B exit-sought after attending C-wing activities, asking how to get out, and if staff would let him out. Interventions included offering him a snack (5/15/24), reassuring him that it was for his safety (5/15/24), redirecting him in a calm, supportive manner (5/15/24), redirecting him when agitation occurred by guiding him towards activities and other items of interest (10/7/25).A current care plan, dated 7/1/24, indicated he became agitated at times when told he could not leave the building, he exit sought, and had increased anxiety about leaving. Interventions included talking to him in a calm and supportive manner (7/1/24).A current care plan, dated 6/17/25, indicated he was an at-risk/wanderer for elopement due to impaired safety awareness. Interventions included assessing fall risk (6/17/25), identifying pattern of wandering (purposeful, aimless, or escapist), and intervening as appropriate (6/17/25), and providing structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes (6/17/25).A quarterly Elopement Evaluation, dated 10/31/25, indicated he was at risk for elopement.Nurses' notes indicated the following:On 4/8/26 at 2:59 p.m., he was exit-seeking. Interventions included were offering snacks and distracting him with activities. On 5/3/26 at 4:41 p.m., he was exit-seeking. Interventions included redirecting him and offering activities.On 5/8/26 at 9:53 p.m., he was in front of the nurse's station attempting to remove his Wanderguard. He became agitated and talked loudly.On 5/9/26 at 9:45 p.m., he yelled at staff because he couldn't leave, used the counter to stand up, and attempted to hit staff at the nurse's station. He continued to yell about leaving and was unable to be redirected. Interventions included redirection, distraction, and offering hydration/nutrition.On 5/11/26 at 6:10 p.m., he was hitting, kicking, and yelling at staff. He was annoyed with the Wanderguard on his wrist. Interventions included giving him food and fluids.On 5/17/26 at 7:40 p.m., a CNA observed him outside on the service driveway. Two nurses immediately went outside and brought him back in. The temperature outside was 84 degrees. He wore jeans, T-shirt, and shoes. He was calm and showed no signs of distress. He was redirected and brought back into the building. A skin assessment and an elopement assessment were completed. He was placed on 15-minute checks and moved to the secured unit.The facility investigation binder for Resident B's 5/17/26 elopement was provided by the Administrator on 6/10/26 at 10:09 a.m. and included the following:The timeline for 5/17/26 indicated at 3:30 p.m. Resident B was in his wheelchair, self-propelling on C-wing. At 3:45 p.m., the pastoral group exited the front doors, and Resident F assisted the group by keeping the door open and entering in the bypass code. At 3:50 p.m., CNA 25 notified Supervisor 15, while completing rounds on the memory care unit. CNA 7 indicated she saw a resident outside on the service drive. Staff immediately responded. At 3:52 p.m., Resident B was assessed, found with no injury or distress. He was redirected and placed on the memory care unit.In a typed and signed statement, dated 5/19/26, Resident F indicated he assisted the church group out of the facility by continuing to press the handicap button to keep the door open. The group was slow moving, so the alarm continued to go off. He admitted that he had previously witnessed staff inputting the bypass code, he memorized it, but did not realize it was the code to turn off the alarm and he had no intention to put anyone at risk. While he held the door open, his back was turned and did not see Resident B exit the facility and did not have a full view of the walkway and who were exiting the facility. Resident F confirmed that CNA 25 responded to the alarm and looked outside. In a typed and signed statement, dated 5/19/26, CNA 25 indicated the front door alarm was sounding around 3:30 - 3:40. She observed Resident F at the front door, opening the door for the pastoral group, and noted he knew the bypass code. She immediately looked at the front area and did not observe any residents outside. She notified Supervisor 15 that the alarm was sounding.In a typed and signed statement, dated 5/19/26, Supervisor 15 indicated she was completing rounds on the secured unit and received a call from CNA 25 indicating the alarms were sounding, but did not see anyone in the immediate area after her brief search. During that time, CNA 7 had looked out the window and noticed a resident was on the service road self-propelling towards the back parking lot.In a typed and signed statement, dated 5/19/26, CNA 7 indicated at approximately 3:40 to 3:50, while she was in a resident's room she noticed a resident outside and believed it was Resident B and immediately notified her supervisor.During an interview, on 6/10/26 at 11:22 a.m., CNA 7 indicated that she entered a resident's room on the secured unit and a resident followed behind her. Something out of the corner of her eye caught her attention outside and she noticed a man in a wheelchair on the service drive who appeared to be struggling to move. The resident following behind her indicated who the man was (Resident B) and that he was her old friend. CNA 7 went out to the hallway where Supervisor 15 and RN 21 were standing and asked them if that was Resident B outdoors. Supervisor 15 indicated that it was Resident B and immediately went outside to retrieve him.During an interview, on 6/10/26 at 11:57 a.m., Supervisor 15 indicated she was completing rounds on the secured unit when CNA 25 called her at approximately 3:52 p.m. and indicated the front door/Wanderguard alarm was sounding. At that same time, CNA 7 came out of a resident's room and indicated she thought Resident B was outside on the service drive in his wheelchair. Supervisor 15 and RN 21 exited the building to retrieve Resident B. When they approached Resident B, he indicated he was so thankful for them finding him.During an interview, on 6/10/26 at 12:10 p.m., RN 21 indicated she was walking down the hall, and CNA 7 indicated that she was looking out the window and asked if that was Resident B she saw outside on the service road right before you get to the pond. RN 21 and Supervisior 15 went outside to retrieve Resident B, when they approached him, he indicated that he was so glad to see them but didn't indicate where he was going. Resident B was previously moved from the secured unit due to behaviors related to a female resident and Resident B. RN 21 did not hear the alarms sounding due to being on the secured unit. She believed Resident B exited from the front doors. Resident B frequently asked how do I get out of here, and said I want to get out of here. He was definitely an elopement risk. That particular day, there were a lot of resident's families visiting and he followed somebody out of the building. She believed someone held the door open for him.During an interview, on 6/10/26 at 1:57 p.m., CNA 25 indicated she entered the facility from the back door after taking a break. The front door alarm was sounding. As she approached the front doors there were family members coming in, passing her in the hall. Resident F was sitting near the keypad, and he turned off the alarm. There were no other staff present. She walked outside and looked but did not see any residents. She called Supervisor 15 to report the alarm sounding as per procedure. As she reported to Supervisor 15, Supervisor 15 indicated that Resident B was noted to be outside. The alarm would sound if a resident with a Wanderguard activates it or if the door was held open.On 6/10/26 at 1:23 p.m., website www.timeanddate.com was reviewed for past weather for 5/17/26. According to the website at 2:53 p.m., the temperature was 84 degrees Fahrenheit and at 3:53 p.m. the temperature in [NAME] was 85 degrees Fahrenheit.On 6/10/26 at 3:04 p.m., the Administrator measured the distance from the facility's front doors to the service road where Resident B was noticed by CNA 7 using a measuring wheel. The distance measured 828 feet. The walkway included a sidewalk with a slight decline to the facility parking lot, from the facility parking lot to the service road on [NAME]-Mar Drive was concrete with potholes and asphalt filled potholes, and the service road was concrete.During an interview, on 6/10/26 at 3:18 p.m., the Maintenance Assistant, with the Director of Maintenance and Administrator present, indicated if the front door was held open for 30 seconds the alarm would sound. The Director of Maintenance indicated if a Wanderguard was within 10 feet of the sensor that was located in the ceiling the doors would automatically lock and no one would be able to get in or out of the facility. Once the code was entered into the keypad for the Wanderguard system, the resident could exit the facility.During an interview, on 6/11/26 at 9:04 a.m., CNA 17 indicated if the door or the Wanderguard alarms were sounding they would complete a resident count and see why the alarm was sounding.During an interview, on 6/11/26 at 9:17 a.m., Resident B propelled himself in the hallway. His wheelchair was equipped with long handled brakes and anti-rollback wheel devices. He self-propelled by using hands and his right foot as he kept his left leg elevated off the floor. He was unable to indicate what facility he was at nor what city he was in. He believed he had a girlfriend but was unable to remember her name. He indicated that he was unable to remember whether or not he exited the facility by himself or if he had previously had a worn a Wanderguard device. During an interview, on 6/11/26 at 9:35 a.m. CNA 9 indicated Resident B was polite and could get mad easily but was redirectable. He did not try to exit seek but he liked to follow people down the hall.During an interview, on 6/11/26 at 12:20 p.m., CNA 32 indicated, on 5/17/26, Resident B had been at the nurses station, asking to leave the facility as he often did but was redirectable. The nurse and the other aide working the Rehab/Hospice unit was taking care of another resident. CNA 32 was getting residents up for supper. She heard the alarm sounding from the Wanderguard system located just outside the Rehab/Hospice unit and she believed someone turned it off, but she did not know who. After caring for a resident, she stepped out of the room and noticed Supervisor 15 and RN 21 running past the door outside. Prior to Resident B being found outside, the residents who smoked were going in and out of the facility on their own and knew what the code was to get out, there was one resident who wandered from C-wing to the Rehab/Hospice unit and activated the Wanderguard alarm system. Staff would shut it off assuming it was either the residents who smoked or the wandering resident. The code to the keypad was posted on the side of the keypad box.During an interview 6/11/26 at 12:44 p.m., CNA 36 indicated she saw Resident B left the Rehab/Hospice unit and activated the Wanderguard alarm and the nurse shut off the alarm. She was on C-wing and heard the front door/Wanderguard alarm sound and went to see why the alarm was sounding. Family entered and exited the facility and Resident F sat at the keypad and shut off the alarm. He told her that he randomly picked numbers on the keypad but she believed he knew the code. Once the alarm stopped sounding, they didn't go to the door to see why the alarm had been sounding, they assumed a staff member shut it off. There were residents that have special privileges of knowing the codes to the doors, exiting and entering the facility. She was not sure who was allowed to have the code. There was a resident who was recently discharged who knew the code and shared the code with other residents.During an interview, on 6/11/26 at 1:32 p.m., LPN 45 indicated on 5/17/26 she had heard that a resident had exited the facility while she was in a room assisting a resident. Between the visitors and the resident that smoked she heard the alarm go off a lot that day. She had not responded to the alarms but believed there were other staff who had. There were a few residents who knew the code to exit the building and a lot of those residents smoked.An undated current facility policy, titled Elopements and Wandering Residents, provided by the Administrator, on 6/11/26 at 2:36 p.m., indicated the following: .Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.This deficient practice was corrected by 5/17/26 after the facility implemented a systemic plan that included the following actions: the facility assessed exit doors, exterior gates, and the perimeter; changed exit codes and bypass codes, posted signage at exit doors, provided in-servicing education to staff on elopement, wandering residents and restricting code access to staff only, completed resident elopement and Wanderguard audits, and conducted ongoing elopement drills.This citation related to Intake 3018354.410 Indiana Administrative Code 16.2-3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to protect a resident's right to be free from abuse by failing to provide supervision to ensure a cognitively impaired resident who wandered (Resident B) was free from resident-to-resident physical abuse by a resident known to be aggressive towards others (Resident C) for 1 of 3 residents reviewed for abuse. The deficient practice was corrected on 1/26/26, prior to the start of survey, and was therefore past noncompliance. Findings include: Review of an Incident Report sent to the Indiana Department of Health indicated the following:On 1/18/26 at 6:53 p.m., Resident B and Resident C were in the dining room, following mealtime. Staff were assisting other residents to their rooms when they were alerted by yelling coming from the dining room. Resident B was on the ground and Resident C was kicking him. Resident C had a laceration to the lip and hematoma to the right side of the forehead. Action Taken, added 1/18/26, indicated both residents were immediately separated, the nurse called 911, and a head-to-toe assessment was completed on Resident B. Resident B complained of generalized pain and family requested an emergency room evaluation. Resident C remained aggressive, attempting to hit and kick staff and refused an assessment. The provider was notified and an order was received to send Resident C to the emergency room for a psychiatric evaluation. The residents' representatives were notified.Preventative Measures, added 1/28/26, indicated an investigation was initiated. Follow up, added 1/23/26, indicated an investigation was completed. Both residents were sent to the Emergency Department post-incident. Resident C returned to the facility with increased monitoring while asleep and one-on-one monitoring while awake until his discharge to a psychiatric facility on 1/19/26. Resident C remained out of the facility. Psychosocial follow up to be completed upon his return. Resident B returned to the facility and continued increased monitoring per usual. Psychosocial follow-ups were completed on Resident B with no signs or symptoms of psychosocial distress. Both resident care plans were reviewed and updated. Resident C's clinical record was reviewed on 1/27/26 at 11:18 a.m. Diagnoses included moderate vascular dementia with agitation, severe dementia in other diseases classified elsewhere with agitation, anxiety, and unspecified mood affective disorder.Current orders included the following: brexpiprazole (atypical antipsychotic) 4 mg by mouth once daily (1/17/26), quetiapine fumurate (antipsychotic) 25 mg by mouth at bedtime (1/16/26), and citalopram (antidepressant) 10 mg PO once daily (11/19/25), and hydroxyzine hydrochloride (anxiety) 10 mg by mouth every six hours as needed (11/18/25).A 11/12/25, admission Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. Other behavioral symptoms occurred one to three days during the assessment period. No mobility devices were required. Resident C required partial assistance from staff for bathing, dressing, transfers, and walking.A current care plan, dated 11/7/25, indicated the resident is/has the potential to be aggressive related to dementia, ineffective coping skills, and poor impulse control. The resident can have behaviors of arguing with other residents, verbal aggression towards his son, yelling at others, talking about others standing by his door, name calling, obsession with another resident coming too close to his door, and physically aggressive when he feels others are somewhere they should not be. Interventions include: One-on-one supervision while the resident is awake and 15 minute checks while he is asleep (1/18/26); When the resident becomes agitated: Intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive- staff walk calmly away and approach later (11/7/25), Intervene as necessary to protect the rights and safety of others. Divert attention. Remove the resident from the situation and take the resident to an alternate location as needed (11/12/25).Review of Resident C's progress notes indicated the following:A progress note, dated 1/16/26 at 12:14 p.m., indicated the resident was seen by the psychiatric provider. The resident was very paranoid and aggressive. Medication changes were made. On 1/18/26 at 7:32 a.m., Resident C became agitated when he thought the resident across the hall was in his room, when he was not. Interventions attempted: Both residents were redirected. The interventions were effective after cursing each other.On 1/18/26 at 9:35 a.m., Resident C was calm and engaging in activities. He was still concerned about the male resident going into his room. The resident kept getting up and looking down the hall to see where the male resident was at. Resident C was reassured that no one was going into his room. He was encouraged to participate with activities, coffee, and devotion. Exercise and snacks were given. The resident remained worried that a particular resident was going to go into his room. On 1/18/26 at 9:12 p.m., LPN 3 was in another room when she heard a commotion in the hallway. LPN 3 stepped into the hallway and observed Resident C down the hallway, kicking and stomping a male resident who was on the floor in a fetal position with his hands over his head. LPN 3 separated the residents, and Resident C began swinging and coming at LPN 3 and other staff. On 1/19/26 at 7:56 a.m., Resident C returned to the facility at approximately 11:00 p.m. The resident was placed on 15-minute checks at the time per protocol. The resident settled in and went to sleep shortly after his arrival from the hospital.On 1/19/26 at 11:41 a.m., the Interdisciplinary Team met and determined the resident should be sent for a psychiatric stay related to his recent aggressive behaviors. The provider and resident representative were notified and agreed with the plan of care. A referral was in progress.On 1/19/26 at 12:18 p.m., Resident C continued to get up during meals and activities to make sure his door was closed. He yelled down the hall when the door was not closed. The resident was assured no one was going in his room. He was redirected to activities and offered snacks and fluids. This was effective for short periods of time.Review of Resident C's monitoring indicated the resident was on 15-minute checks when he returned from the hospital early morning on 1/19/26 while sleeping and one-on-one monitoring while awake until he was discharged to the Psychiatric facility on 1/19/26.On 1/19/26 at 3:45 p.m., the resident was transported to the psychiatric facility. Resident C remained out of the facility during the survey. Resident B's clinical record was reviewed on 1/27/26 at 11:53 a.m. Diagnoses included severe vascular dementia with agitation, major depressive disorder, difficulty in walking, and other lower back pain.Current orders included the following: risperidone (antipsychotic) 2 mg by mouth at bedtime (11/12/25), tramadol hydrochloride (pain) 50 mg by mouth every six hours (1/7/26), sertraline hydrochloride (antidepressant) 50 mg by mouth once daily (11/25/25), gabapentin (pain) 300 mg by mouth three times daily (1/23/26), and lidocaine pain relief 4 % patch to the lower back topically in the morning (1/20/26). Monitor for side effects and report to the physician: antidepressant- agitation (11/11/25). Behavior monitoring for vascular dementia with agitation every shift for behavior monitoring (11/11/25). A 1/20/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. Resident B exhibited other behavioral symptoms not directed towards others one to three days of the assessment period. He exhibited wandering behavior one to three days of the assessment period. The resident required a walker for mobility. He required substantial assistance from staff for dressing, sit-to-stand, and transfers. The resident was dependent on staff assistance for toileting, bathing, and personal hygiene. Resident B required supervision for walking. He had one fall with no injury since the prior assessment. The resident did not have any skin concerns.Resident B's care plans indicated the following: A problem of wandering and elopement risk related to wandering aimlessly and exit seeking in the afternoon/evening due to sundowning. The resident wandered around the unit at night and into other residents' rooms (10/22/25). Interventions included: Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The resident preferred the newspaper, snacks, and country/rock music (10/22/25).A problem of physical aggression related to mild neurocognitive disorder due to a known physiological condition with behavioral disturbance, anger, dementia and poor impulse control. The resident has a history of harm to others (10/24/25). Interventions included: Analyze times of day, places, circumstances, triggers, and what de-escalates the behavior and document (10/24/25), When the resident becomes agitated: Intervene before agitation escalates (10/24/25).A problem of verbal aggression related to dementia, ineffective coping skills, and poor impulse control (10/24/25). Interventions included: When the resident becomes agitated, intervene before agitation escalates and guide away from the source of distress (10/24/25).A problem of behaviors such as putting himself on the floor and getting up by himself, wandering around the unit, getting mad at others, cursing staff, putting staff in the corner, packing items that belong to him and others, and throwing items at staff (10/28/25). Interventions included: The resident remains on 15-minute checks (1/18/26).Review of Resident B's progress notes indicated the following:A progress note, dated 1/6/26 at 6:00 p.m., indicated Resident B was wandering and out of other residents' rooms. The resident was encouraged to stay out of other residents' rooms and offered fluids and snacks. The intervention was effective.On 1/9/26 at 5:47 p.m., Resident B was wandering up and down the hall. The resident was offered to use the restroom, snacks, and something to drink. The intervention was ineffective. The resident went to his room on his own.On 1/14/26 at 2:27 a.m., the resident continued on 15-minute checks.On 1/14/26 at 2:42 a.m., Resident B was getting in and out of bed wandering the hall and wandered into another resident's room to urinate. The attempted intervention was food and drinks. It was not effective. The DON, supervisor, and family were notified.On 1/17/26 at 8:11 p.m., the resident continued with 15-minute checks and no adverse effects were noted from medication changes.On 1/18/26 at 8:51 a.m., Resident B and the resident across the hallway had a cursing match. Resident B grabbed the rail outside the other resident's when the resident across the hall became agitated that Resident B was close to his room. The intervention attempted was redirection of both residents. The effectiveness of the intervention included: No contact was made from either resident. On 1/18/26 at 8:42 p.m., the nurse was passing medications and heard a commotion from several rooms up. Upon investigation, Resident B was on the floor lying in a fetal position with his arms over his head and another resident was kicking him. A skin assessment, pain assessment, and neurological assessments were completed. Resident B had a hematoma to his right forehead, an abrasion to the left side of his face, and red areas on his back. His pain was rated five out of ten. The neurological assessment was within normal limits. The resident was transferred to the hospital for evaluation, with notifications completed.A progress note, dated 1/19/26 at 8:05 a.m., indicated the resident returned to the facility at approximately 12:00 a.m. Monitoring was continued.On 1/19/26 at 5:40 p.m., Resident B tried to wander behind the nurse station, he was yelling and getting in the CNA's face. He stated his food was behind the desk. The resident was redirected to the dining room and given his tray and fluids. Interventions were effective. On 1/20/26 at 9:52 a.m., Resident B was spoken to about the previous event, but the resident could not remember any event. He was participating in activities in the dining room. He was calm, cooperative, and pleasant during the interview. The resident did not report nor show any signs of distress. On 1/20/26 at 3:47 p.m., Resident B was wandering more than usual in and out of rooms including the room across the hallway. He was bossy with staff, telling them what to do and how to do it. The interventions included food and snacks. The interventions were ineffective as the resident kept wandering in and out of rooms. No notifications were listed.On 1/23/26 at 9:30 a.m., the Interdisciplinary Team met to discuss the resident's behavior related to restlessness and agitation. The resident was followed by social services and interventions were effective after a period of time. The psychiatric provider was notified of the behaviors. Gabapentin was increased to 300 mg by mouth three times daily. The plan of care was continued at this time. On 1/23/26 at 10:53 a.m., the resident continued on 15-minute checks.On 1/26/26 at 4:00 p.m., Resident B wandered in and out of other residents' rooms looking for his tools. The resident was redirected to his room and offered fluids and snacks. Staff assisted the resident and plugged in his phone. The resident watched television. Interventions were effective. On 1/27/26 at 3:52 p.m., the Interdisciplinary Team met to review Resident B's behaviors as well as interventions. Care plans were reviewed and updated. The psychiatric provider was notified with no new orders. Monitoring of behaviors continued at this time. The resident continued to be easily redirected. Review of Resident B's 15-minute checks included 15-minute checks in place from 1/1/26 through 1/27/26. Review of the facility investigation of an altercation between Resident B and Resident C, on 1/18/26 at 6:53 p.m., included the following information:The facility reported incident to the Indiana Department of HealthFace Sheet, assessment, pertinent progress notes, and diagnoses of Resident BFace Sheet, pertinent progress, notes, and diagnoses of Resident CCognitive assessments for both residents.Emergency Department progress notes for both residents.Imaging reports from the Emergency Department for Resident BSkin assessments for 17 residents dated 1/23/26Adult Protection Notice dated 1/18/26 at 9:28 p.m.Police report Written statements from LPN 3 and QMA 4Inservice sign in for all staff and policies dated 1/18/26 titled abuse, neglect, exploitation, de-escalation, and non-pharmacological interventionsThe investigation was consistent with the information reported to the Indiana Department of Health.During an observation on 1/27/26 at 12:33 p.m., on the secured memory care unit, Resident B's and Resident C's rooms were directly across the hallway from each other. During an observation on 1/27/26 at 12:54 p.m., Resident B was in the dining room seated at a table with another male resident working on a puzzle during a scheduled activity. Activity Assistant 10 was present in the dining room. Resident B was dressed, non-skid footwear in place, and Resident B was seated in a standard chair with his rollator beside him. No skin impairments were present during the observation. No concerns of aggression were observed. During an observation on 1/27/26 at 4:07 p.m., Resident B walked out of his room and towards the dining room. A staff member followed close behind him. The resident walked to the dining room table and sat down next to Activity Assistant 10. Six other residents were in the dining room at that time and interacting with Activity Assistant 10 during the observation. No concerns of aggression were observed.Interviews indicated the following:During an interview on 1/27/26 at 3:43p.m., LPN 9 indicated she was familiar with both Resident B and Resident C. Resident B was a wanderer and sometimes wandered in and out of other residents' rooms. Resident B got upset at times if things were not done his way. Resident B was known to be verbally aggressive with other residents. Resident B was typically easy to redirect. Staff redirect him from wandering or situations with other residents by offering him snacks, toileting, and activities. Resident B liked bingo, coloring, and watching television in his room. Resident C was known to be aggressive, obsessive, and anxious that someone was going to go into his room while he was in the dining room. Resident C was known to be aggressive with residents and staff since he arrived at the facility. Sometimes Resident C was difficult to redirect. Resident C liked to color, watch movies in the dining room, and any food, coffee, and chocolate milk. At times, they must give him space and then reapproach Resident C. Resident B and Resident C's rooms were directly across from each other on the memory care unit. Approximately half of the residents on the unit wandered. The activities programming on the memory care unit typically ended at 4:00 p.m. On 1/27/26 at 4:10 p.m., CNA 12 indicated the evening shift typically had one nurse and two CNAs scheduled on the memory care unit. It was difficult in the evenings, with behaviors and wandering, to adequately redirect the residents. Due to behaviors on the unit on 1/26/26, she was finishing yesterday's showers. During a telephone interview on 1/27/26 at 6:32 p.m., QMA 4 indicated she was working on 1/18/26, the night of the altercation on the memory care unit, when an altercation between Resident B and Resident C took place around approximately 7:00 p.m. QMA 4 was in another resident's room with CNA 5 when LPN 3 yelled out for assistance. LPN 3 had just left the room she was in along with CNA 5 and QMA 4. CNA 14 had stepped off the memory care unit. CNA 5 was on the memory care unit to assist in place of CNA 14. When QMA 4 stepped out to the hallway, LPN 3 was trying to separate Resident C from Resident B. Resident B was on the floor in the hallway, on his right side, and near the dining room. Resident C was standing up and stomping on Resident B's left side rib area. Resident C was very persistent. The residents were separated. Resident B was taken to his room by LPN 3 while Resident C was monitored by QMA 4. Unit Manager 6 came to the memory care unit to assist after the residents were separated. Resident C did not like any residents near his room. Resident C was known to yell and be aggressive towards Resident B as their rooms were close. Resident C had been able to be redirected prior to this time. During a telephone interview on 1/27/26 at 7:10 p.m., CNA 5 indicated she was in the memory care unit assisting in another resident's room the evening of 1/18/26 along with LPN 3 when they heard Resident C cursing from the room they were in. LPN 3 immediately went out into the hallway. After CNA 5 assisted the other resident on the toilet, CNA 5 heard LPN 3 yelling stop. CNA 5 went to the hallway and LPN 3 was separating Resident C from Resident B. CNA 5 observed Resident B on the floor in the hallway near the dining room while Resident C kicked Resident B in the head and ribs. Resident B grabbed his rib area and had blood on his lip. CNA 5 reported the altercation Unit Manager 6, who indicated she was calling the DON simultaneously. CNA 5 returned to her scheduled unit. When she left, Resident C was trying to hit the staff who were with him and the nurse was with Resident B. During a telephone interview on 1/28/26 at 9:39 a.m., LPN 3 indicated she was in another resident's room on the memory care unit, along with QMA 4 and CNA 5, on 1/18/26 at approximately 7:00 p.m. when they heard a commotion. LPN 3 stepped out into the hallway and Resident B was on the ground in a fetal position with his hands over his head. Resident C was cursing, kicking, and stomping on Resident B's back, sides, and head. The beginning of the altercation was unwitnessed. It occurred in the hallway near the dining room. The residents were separated and QMA 4 toileted, and remained with, Resident C while LPN 3 remained with Resident B and completed his head-to-toe assessment. Resident B was alert but unable to describe what happened. The resident had pain in the rib area, red marks on the left side of his face, and a red mark on his forehead. The police were notified. Both residents were sent out to the Emergency Department for evaluation. Resident C was known to need intervention because he was obsessive about accusing Resident B of going into his room. Around breakfast time on 1/18/26, Resident B walked down the hallway and placed his hand on the rail in the hallway near Resident C's room with LPN 3 close to Resident B. Resident C got upset with Resident B and yelled for Resident B to get out of Resident C's room. Resident C was redirected and assured Resident B was not in his room and Resident B continued to the dining room for breakfast along with LPN 3. No new interventions were implemented prior to the altercation that happened later that evening. Resident B remained on the 15-minute checks that were already in place.During a telephone interview, on 1/28/26 at 10:17 a.m., Unit Manager 6 indicated she was at the facility in the evening on 1/18/26. Unit Manager 6 was called to the memory care unit by a CNA due to a resident-to-resident altercation between Resident B and Resident C. LPN 3 reported that Resident C was kicking and stomping on Resident B. Simultaneously, she immediately called the DON, who was the contact for the Administrator while he was away. Unit Manager 6 made the aides and LPN 3 aware she made the report to the DON, the physician, and notified staff to write statements and place them under the DON's door. Staff did not report any staffing concerns to her. They had mentioned increased behaviors since the facility had a change in the memory care unit structure. This had been discussed with the DON and Administrator. To help with the behaviors/congestion, they had been taking some of the residents out of the memory care unit at times, for other activities, to help.On 1/28/26 at 1:03 p.m., Resident B was seated in a chair at the edge of the dining room and stated his name. He indicated he felt safe with the residents and staff at the facility. On 1/28/26 at 2:34 p.m., the DON indicated Unit Manager 6 notified her of the resident-to-resident altercation between Resident B and Resident C, sometime after 6:00 p.m. on 1/18/26. The DON indicated she also reported it to the Corporate Nurse Consultant. Resident C was abusive to Resident D by stomping and hitting him. The facility should have prevented the resident-to-resident abuse. On 1/28/26 at 3:17 p.m., the Administrator indicated the facility had knowledge of agitation between Resident B and Resident C earlier in the day on 1/18/26, prior to the resident-to-resident abuse when Resident C stomped and kicked Resident B.On 1/28/26 at 4:21 p.m., the DON indicated the Interdisciplinary Team were reviewing the behaviors and checking to ensure effectiveness of the interventions that are in place. They also reached out to update the psychiatric providers. The Ad-hoc (Quality Assurance Performance Improvement) was put in place on 1/23/26 which included the log for monitoring behavior interventions. All staff were in-serviced on abuse, non-pharmacological behavior interventions, and de-escalation which began on 1/18/26 and was completed on 1/22/26.A current facility policy, revised 2025, titled Abuse, Neglect and Exploitation, provided by the Administrator on 1/27/26 at 3:38 p.m., indicated the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing writing policies and procedures that prohibit and prevent abuse. III. Prevention of Abuse. B. Identifying correcting and intervening in situations in which abuse. is more likely to occur with. staff on each shift in sufficient numbers to meet the needs of the resident and assure the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.D. The identification, on going assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict. The deficient practice was corrected by 1/26/26, after the facility implemented a systemic plan that included a thorough investigation, facility in-services regarding abuse, neglect, exploitation, de-escalation, and non-pharmacological behavior interventions. An Ad Hoc (Quality Assurance Performance Improvement Plan) for resident behaviors, dated 1/23/26, indicated progress notes for all residents for the last 7 days were reviewed with no concerns identified on 1/23/26. Education was completed with IDT on daily review of progress notes to include SBARs, behavior documentation, and completion of an IDT follow-up note. The DON or designee completed on-going monitoring to review documentation for intervention effectiveness and IDT follow-up documentation. Audits were completed on 1/26/26 and 1/27/26.This citation relates to Intake 2721115.3.1-27(a)(1)

Based on record review and interview, the facility failed to offer and educate residents regarding Pneumococcal vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 48) Finding includes: Resident 48's clinical record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and dependence on supplemental oxygen. An admission Minimum Data Set (MDS) assessment, dated 2/3/25, indicated the resident was cognitively intact. Specialized services included continuous oxygen therapy. Review of the resident's vaccinations included the following: The resident had a historical administration of Pneumovax (pneumococcal) 23 on 3/5/20, prior to admission to the facility. A Pneumococcal Vaccine Consent Form, dated 7/7/23, indicated the resident was provided education and declined administration. The clinical record lacked additional offerings of the Pneumococcal vaccine since 2023. During an interview on 5/1/25 at 11:37 a.m., the Infection Preventionist indicated residents who refused the Pneumococcal vaccines on admission were not offered the vaccines again when they were eligible to receive the next doses per CDC guidance. During an interview on 5/1/25 at 2:58 p.m., the DON indicated the Pneumococcal vaccines should have been offered/administered following the CDC guidance. A current facility policy, undated, titled General Immunization/Vaccination, provided by the DON on 5/1/25 at 2:57 p.m., indicated the following: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases . Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against infectious diseases in accordance with national standards of practice. 2. Immunizations will follow current CDC guidance and scheduling based on the specific vaccinations. 3. Residents, staff, and volunteer workers will be offered immunizations against infectious diseases as per current federal, state and local guidance 3.1-18(b)(5)

Based on observation, interview, and record review, the facility failed to provide catheter care in a manner to reduce the risk of contamination for 1 of 1 resident reviewed for catheter services (Resident 46). Findings include: During an observation on 5/2/25 at 2:08 p.m., CNA 14 performed ABHR (alcohol based hang rub) prior to entry the resident's room. A PPE (personal protective equipment) cart was located just inside the door. CNA 14 donned gloves but no gown. She bent down and emptied resident 46's catheter bag into a plastic graduated cylinder. She emptied the cylinder in the toilet, then removed her gloves and donned a new set, which she pulled from the pocket of her scrubs. No hand hygiene was performed. She then filled two plastic buckets with soap and water, placed washcloths into them and placed the buckets on the resident's bed. The CNA then assisted the resident to stand at his walker, placing her gloved hands on his left arm and shirt, as well as the walker, resulting in contaminated gloves. Using her contaminated gloved hands, she pulled down his pants, removed his brief, and put the soiled brief into a trash can, touching the trash bag. With the same soiled gloves, the CNA obtained several washcloths and one bucket and wiped the resident's genitalia and the catheter tubing. Using the same gloved hands she obtained a second and third wash cloth and repeated the process. She obtained two clean washcloths and dried the resident's genitalia and catheter tubing. Using the same gloves, the CNA obtained a clean brief that was on his bed, placed the brief on him, pulled up his pants, touched the privacy curtain, and began placing the soiled washcloths in a trash bag. She took off her contaminated gloves and washed her hands in the sink. During an interview following the observation, CNA 14 indicated she was unsure if she needed to perform hand hygiene after taking off soiled gloves. Gowns should be worn in an EBP (enhanced barrier precaution) room, but she forgot to don one. Resident 46's clinical record was reviewed on 4/29/25 at 2:43 p.m. Current diagnoses included malignant neoplasm of the prostate, benign prostatic hyperpiesia with urinary tract symptoms, history of urinary tract infections (UTI), and schizophrenia. Resident 46 had current physician's orders for the following: change 18 french catheter monthly and as needed (3/21/25), change Foley catheter bag weekly and as needed (2/17/25), Foley catheter care every shift and as needed (8/8/23), flush catheter with 50 cc of saline daily at bed time (8/10/23), and observe for signs and symptoms of UTI-leaking, burning with urination, increased frequency of urination, cloudy urine, flank pain, fever or abdominal cramps every shift. Notify doctor if signs or symptoms are observed (8/8/23). Sign outside resident's room. Gown and gloves for all interactions with resident. Used for residents with MDRO (multi-drug resistant organism) or have a high risk of MDRO acquisition (Residents with wounds or indwelling medical devices). Used for high activity interactions with resident. Face shields should be used for any task that have high potential for splash or spray (4/6/24). A 3/19/25, quarterly, Minimum Date Set (MDS) assessment, indicated the resident had an indwelling catheter and required substantial assistance for toileting. The resident had a current, 9/4/24, care plan problem/need regarding the use of an indwelling catheter. An approach for this need was to provide catheter care each shift (5/12/22). The goal for this need was for the resident to be free of complications related to the use of a catheter (revised 9/4/24). The resident was observed in common areas with a catheter bag attached to his wheelchair during the following dates and times: 4/28/25 at 10:27 a.m., 4/29/25 at 9:56 a.m., and on 5/1/25 at 10:16 a.m. and 11:32 a.m. During an interview with the IP (Infection Preventionist) on 5/2/25 at 2:44 p.m., she indicated during catheter care for a resident on EBP, supplies should be gathered in the room, hand hygiene should be performed, a gown donned, with gloves and potentially a mask if the task might incur splash. If gloves were soiled, they should be removed. Hand hygiene should be done if hands were soiled. Then a new pair of gloves should be donned and if necessary, all other PPE. PPE should be donned during high-contact care activities. A current, undated, facility policy titled, Catheter Care, provided by the IP on 5/2/25 at 3:49 p.m. indicated .Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care 15. Using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap) 3.1-41(a)(1)

Based on record review and interview, the facility failed to follow Registered Dietician recommendations and notify the physician for a resident experiencing significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 42) Finding includes: Resident 42's clinical record was reviewed on 4/30/25 at 2:58 p.m. Diagnoses included essential hypertension, morbid severe obesity due to excess calories, and type 2 diabetes mellitus. An overweight/obesity care plan, initiated on 8/5/21, indicated the resident received a carbohydrate controlled regular textured diet, experienced 5.7 percent (%) weight loss in 30 days, and weight loss in 180 days. Interventions included the following: Diet as ordered (8/5/21) and monitor meal intakes (8/5/21). A current care plan, initiated on 12/28/24, indicated the resident had behaviors and would refuse to be weighed. A current order, initiated 2/28/25, indicated a regular texture consistent carbohydrate diet. Resident 42's meal consumption, for the last 30 days was reviewed and indicated the resident typically ate 76-100 % of her meals, occasionally 51- 75 % of meals, and rarely 0-25 % of meals. Resident 42's weight record was reviewed and indicated the following: 291.6 pounds (lbs) on 10/22/24, 283.6 lbs on 11/5/24, 281.6 lbs on 1/20/25, 281.4 lbs on 2/1/25, 265.4 lbs on 3/2/25, and 256.8 lbs on 4/27/25. A 3/5/25, quarterly, Minimum Data Set (MDS) assessment, indicated Resident 42 was cognitively intact, required set up assistance from staff for eating, and was on a physician prescribed weight-loss regimen. Resident 42 weighed 266 lbs. on 3/2/25. A 3/12/25, Interdisciplinary team (IDT) Nutrition At Risk (NAR) note indicated Resident 42 weighed 265.4 lbs on 3/2/25 and had experienced a significant weight loss in 30 days, the previous weight was 281.4 lbs on 2/1/25. The recommendation was to discontinue the carbohydrate control portion of the diet to improve intake, continue to evaluate for weight changes, and update the care plan as appropriate. A 3/21/25, IDT NAR note indicated Resident 42 weighed 265.4 lbs on 3/2/25 and 281.4 lbs on 2/1/25. The recommendation was to discontinue the carbohydrate control portion of the diet to improve intake, continue to evaluate for weight changes, and update the care plan as appropriate. A 3/26/25, IDT NAR note indicated Resident 42 weighed 265.4 lbs on 3/2/25 and 281.4 lbs on 2/1/25. The recommendation was to discontinue the carbohydrate control portion of the diet to improve intake, continue to evaluate for weight changes, and update the care plan as appropriate. A 4/3/25, IDT NAR note indicated Resident 42 weighed 265.4 lbs on 3/2/25 and 281.4 lbs on 2/1/25. The recommendation was to discontinue the carbohydrate control portion of the diet to improve intake, continue to evaluate for weight changes, and update the care plan as appropriate. A 4/28/25, IDT NAR note indicated Resident 42 weighed 246.8 lbs on 4/27/25 and previous weights were 265.4 lbs on 3/2/25 and 281.4 lbs on 2/1/25. The resident experienced a significant weight loss of 7% in 30 days. The recommendation was to discontinue the carbohydrate control portion of the diet to improve intake, continue to evaluate for weight changes, and update the care plan as appropriate. Review of the Registered Dietitian Reports from 2/3/25- 3/26/25 indicated Resident 42 was not reviewed. The clinical record lacked documentation indicating the physician was notified of the significant weight loss. The clinical record lacked an order to change the resident's diet or that the physician declined the recommendation to change the resident's diet. During an interview, on 5/2/25 at 10:07 a.m., CNA 16 indicated Resident 42 usually consumed 75-100% of her meals and did not require feeding assistance. During an interview, on 5/2/25 at 12:11 p.m., the Director of Nursing (DON) indicated she received electronic mail (e-mails) from the Registered Dietitian. The Registered Dietitian Report had recommendations for each resident reviewed. The DON was not aware the IDT NAR notes in the resident electronic medical record (eMar)recommended a change in Resident 42's diet as she went off the e-mailed report. Resident 42 was not in the Registered Dietitian Report e-mail. During an interview, 5/2/25 at 1:56 p.m., the DON indicated the physician should have been notified when the resident experienced significant weight loss. The IDT NAR notes should've included documentation indicating the physician notification. The Registered Dietitian completed the IDT NAR notes in the residents' clinical records. The NAR program was not effective if the recommendations were not communicated and the physician was not notified. A facility policy, dated 2023, titled, Nutritional Management, provided by the DON on 5/2/25 at 2:31 p.m., indicated the following: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition .Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates .Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: Diet liberalization unless the resident's medical condition warrants a therapeutic diet . Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include .The physician will be notified of: Significant changes in weight, intake, or nutritional status . 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to check placement and prevent contamination during site care for 1 of 2 residents reviewed for feeding tubes. (Resident 36) Finding includes: Resident 36's clinical record was reviewed on 4/30/25 at 8:27 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke), oropharyngeal phase dysphagia (difficulty swallowing), and unspecified protein-calorie malnutrition. Current orders included check placement of tube prior to medication administration, flush feeding tube with 80 milliliters (ml) of water every shift, and place a split drain sponge with antibiotic ointment for feeding tube maintenance every shift. A 2/13/25, annual, Minimum Data Set assessment indicated Resident 36 had severe cognitive impairment. The resident required moderate assistance with eating. He was dependent on staff for assistance with all other activities of daily living. Nutritional approaches included a mechanically altered diet and a feeding tube. A discontinued care plan, resolved on 4/2/25, indicated the resident received supplemental tube feedings due to inadequate food and beverage intake related to a stroke with right hemiparesis, dysphagia, and malnutrition. Interventions included the following: provide care to the feeding tube site as ordered, water flushes as ordered, report concerns to the physician as needed, and check tube placement every feeding. During a feeding tube site care observation on 4/30/25 at 9:53 a.m., LPN 9 performed hand hygiene and donned a gown and gloves prior to entering the resident's room. She placed the tube feeding site care supplies on a foldable chair at the bedside. The chair, where she placed the supplies, lacked a barrier. She used her gloved hands and released the bottom of the abdominal binder that covered the feeding tube site. Without hand hygiene or checking placement, the feeding tube was opened with the same gloved hands and a syringe without the plunger was connected to the feeding tube. The feeding tube was flushed with water via gravity and closed with her contaminated gloved hands. The resident's old split drain sponge was removed. There was scant drainage noted on the old dressing. Without completing hand hygiene and a change of gloves, the bottle of normal saline wound wash was picked up from the chair and sprayed onto a clean gauze. Prior to spraying the saline, the gauze was opened with the same dirty gloves. The feeding tube site had minimal redness. The site was cleansed from the insertion site moving in an outward motion. LPN 9 used her contaminated gloved hands to open the resident's dresser drawer, and picked up a tube of zinc oxide cream in her right hand. She returned to the resident's bedside without hand hygiene and a change of gloves, placed the zinc oxide cream on the foldable chair, removed a packet of antibiotic ointment from her pocket, opened the antibiotic ointment, and squeezed the antibiotic ointment onto her right gloved index finger. She used her index finger and applied the antibiotic ointment to the reddened feeding tube insertion site and then applied a new split drain sponge to the site. The abdominal binder was put back in place over the feeding tube. During an interview, on 4/30/25 at 10:22 a.m., LPN 9 indicated during the above feeding tube site care observation, she should have checked placement of the feeding tube prior to flushing the resident's feeding tube. She would have typically performed hand hygiene and changed her gloves after removing the old dressing and prior to cleansing the resident's feeding tube site, but she did not this time. Hand hygiene and a change of gloves should have been completed after touching the resident's drawer, the items in the drawer, and prior to application of the resident's antibiotic ointment to the feeding tube site. The lack of proper infection control practices placed the resident at risk for infection. During an interview on 4/30/25 at 11:40 p.m., the DON indicated staff were required to verify placement of a feeding tube prior to flushing, administration of medication, and administration of feedings. Hand hygiene and glove changes were required after touching potentially contaminated surfaces during feeding tube site care. A lack of proper hand hygiene placed the resident at risk for infection. A current facility policy, undated, titled Verifying Placement of Feeding Tube, provided by the DON on 4/30/25 at 1:29 p.m., indicated the following: Policy: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube. Policy Explanation and Compliance Guidelines: 1. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified A current facility policy, undated, titled Gastrostomy Site Care, provided by the DON on 4/30/25 at 1:29 p.m., indicated the following: It is the policy of this facility to perform gastrostomy site care as ordered and per current standards of practice. Policy Explanation and Compliance Guidelines: . 8. Set up supplies using clean technique using over bed table covered with towel or disposable barrier. 9. Wash hands and don gloves. 10. Apply any other PPE [personal protective equipment] as needed to protect staff from any exposure to infectious material and to comply with any isolation precautions ordered. 11. Maintain clean technique. 12. Remove old dressing if applicable and discard in appropriate container. 13. Wash hands and don gloves. 14.gently clean the area around the tube and continue in an outward circular fashion . 18. Apply dressing as ordered 3.1-44(a)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to follow physician orders regarding oxygen flow rate and humidity for 1 of 2 residents reviewed for oxygen. (Resident 48) Finding includes: Random observations of Resident 48 indicated the following: During an observation on 4/28/25 at 2:57 p.m., Resident 48 was in her bed asleep with oxygen on via nasal cannula at five liters per minute. The humidity bottle attached to the oxygen concentrator was empty and dated 4/24. During an interview with the resident, she indicated she wore oxygen continuous at four liters per minute. She was unable to get out of bed and did not adjust the oxygen flow rate. On 4/29/25 at 9:00 a.m., the resident was asleep in bed with the oxygen on via nasal cannula at five liters per minute. The humidity bottle attached to the oxygen concentrator was empty and dated 4/24. Resident 48's clinical record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (low oxygen), chronic respiratory failure with hypercapnia (high carbon dioxide levels), and dependence on supplemental oxygen. A current order, dated 2/3/25, included oxygen at four liters per minute via nasal cannula. Physician notification was required if oxygen saturations were below 90 percent. A current order, dated 2/6/25, included a humidification bottle change once weekly, on Thursday, and as needed for humidity every shift. A 2/3/25, admission, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident was dependent on staff assistance for toileting, bathing, dressing, and personal hygiene. She required substantial assistance for transfers. Specialized services included continuous oxygen therapy. A current care plan, dated 3/13/23, indicated the resident had a potential for alteration in her respiratory status related to chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia and hypercapnia. Interventions included administer oxygen as needed per physician order (3/13/23) and monitor oxygen flow rate and response (3/13/23). A Nurse's note, dated 4/14/25 at 5:38 p.m., indicated Resident 48 complained of breathing discomfort and restlessness. The oxygen saturation level was 87 percent. The oxygen was increased to five liters per minute via nasal cannula and an as needed inhaler was administered. The nurse remained with the resident for ten minutes. After 10 minutes, the resident's oxygen saturation was 92 percent and the resident verbalized she felt better. The nurse planned to report the information to the next shift. The clinical record lacked a physician notification of the resident's change in respiratory status when the oxygen flow rate was changed to five liters per minute. During an observation on 4/29/25 at 4:04 p.m., Resident 48 was in bed watching television with her oxygen on via nasal cannula at five liters per minute. The humidity bottle attached to the oxygen concentrator was empty and dated 4/24. The oxygen concentrator was turned around backwards and positioned in a manner that the flow rate was difficult to read. During an interview on 4/29/25 at 4:22 p.m., LPN 7 indicated Resident 48 was cooperative with care. The resident did not get up on her own and had not been known to change her own oxygen flow rate. On 4/29/25 at 4:29 p.m., LPN 7 was in Resident 48's room and indicated the resident's oxygen flow rate was set on five liters per minute with an empty humidity canister dated 4/24. The resident's oxygen flow rate was ordered at four liters per minute. Oxygen flow rate should have been followed per physician orders. The oxygen humidification should have been changed as needed to prevent a lack of humidification. She had not received any information in report regarding a change in the resident's respiratory status. The residents oxygen saturation was 94 percent. LPN 7 was unable to find any information in the resident's clinical record where the physician was notified when the oxygen flow rate was changed to five liters per minute on 4/16/25. On 4/29/25 at 4:47 p.m., the DON indicated residents' oxygen flow rates should have been administered according to the physician's orders. The physician should have been notified when a resident required oxygen at five liters per minute when the order indicated to administer oxygen at four liters per minute. Humidity should have been changed as needed to prevent an empty oxygen humidification bottle. On 4/30/25 at 9:34 a.m., CNA 8 indicated she was familiar with the resident and never knew the resident nor her family to change the oxygen flow rate. A current facility policy, undated, titled Oxygen Administration, provided by the DON on 4/30/25 at 9:47 a.m., indicated the following: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control . 9. The equipment needed for oxygen administration will depend on the type of delivery system ordered . Types of delivery systems include: a. Nasal Cannula - Oxygen is administered through plastic cannulas in the nostrils. Effective for low oxygen concentrations less than 40 %. Requires humidification at flow rates greater than 4 liters/minute . 12. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to provide individualized interventions for dementia services to reduce or eliminate the need for psychoactive medications for 1 of 4 residents reviewed for dementia care. (Resident 29) Findings include: Resident 29's clinical record was reviewed on 4/29/25 at 2:56 p.m. Current diagnoses included dementia with agitation, diabetes mellitus, insomnia, major depressive disorder, generalized anxiety disorder, and delusional disorder. Current physician's orders included the following psychoactive medications: Risperdal 0.5 mg (an anti-psychotic medication) - one tablet- two times daily for delusional disorder (4/29/25), buspirone HCL 10 mg (an anti-anxiety medication)- one tablet-three times daily for anxiety (3/3/25), Klonopin 0.5 mg (an anti-anxiety medication)- one tablet daily at bedtime (3/5/25), Zoloft 125 mg (an anti-depressant medication)- one tablet daily for depression (10/25/2024), and Remeron 7.5 mg (an anti-depressant used as an appetite stimulant). A 3/20/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, did not have hallucinations or delusions during the assessment period, displayed both verbal and psychical aggressive behaviors and rejected care visit one to three days of the assessment period, received anti-psychotic medication, antidepressant medication, and anti-anxiety medication during the assessment period. A 4/29/25 Psychiatry Progress Note indicated the visit was initiated due to increased anxiety and/or increased aggression. The resident had a failed GDR (gradual dose reduction) of Risperdal due to being aggressive towards another resident. The resident did not display delusions or hallucinations. A review of Resident 29's behavior notes from 12/1/24 through 5/1/25 (approximately five months) indicated the following: December 2024: The resident had eight (8) documented behavioral events this month. Two documented events were medical events. Four events were resistance to care. Five of the six non-medical behaviors the resident calmed with non-chemical interventions. A 12/31/24 at 4:03 p.m., note indicated the resident had been unclothed in the hall and staff had tried to dress her. The resident fought during attempts to clothe her. A 12/31/24 at 12:36 p.m., note indicated the resident became upset with her surroundings in the dining area and threw chocolate milk. She became calm when removed from the situation and allowed to rest. A 12/28/24 at 11:31 p.m , late entry note indicated, the resident slapped and scratched when being assisted to change her cloths for bed. Non-chemical intervention were successful and the resident went to bed. A 12/23/24 at 10:59 p.m., note indicated the resident could not remember how to swallow. A 12/23/24 at 10:51 p.m., note indicated the resident was having difficulty remembering how to swallow. A 12/6/24 at 8:31 p.m., note indicated the resident resisted care and spit and pulled the staff's hair. The staff left her alone and she became calm. A 12/6/24 at 4:26 p.m., note indicated the resident resisted toileting and changing. Non-chemical interventions were effective to calm the resident. A 12/6/24 at 7:28 a.m., note indicated the resident took other residents food and threw and orange juice. The resident was calmed when given extra food and taken to a different dining area. January 2025: The resident had one documented event of resisting personal care this one. The one event was successfully managed by non-chemical interventions. A 1/15/25 at 1:07 p.m., note indicated the resident became upset and yelled and hit at staff during peri-care. Non-chemical intervention were successful and the resident was calmed. February 2025: The resident had four (4) documented behavioral events this month. Three of 4 events were successfully managed by non-chemical interventions. A 2/25/25 at 6:05 a.m., note indicated the resident got out of bed and crawled on the floor. The resident had been in bed prior to the event. The resident was assisted to her wheelchair and she became calm. A 2/20/25 at 12:29 p.m., note indicated the resident grabbed another resident's hair while they were both in the dining room. Redirection and non chemical interventions were effective in calming the resident. Laboratory tests were ordered. A 2/20/25 at 10:16 a.m., note indicated the resident attempted to stab an activity staff member with a colored pencil and also hit and bit at staff. The resident had taken the colored pencils from the activity table and became angry when staff tried to take them away. Non-chemical interventions suck as coffee and snacks were effective to calm the resident. The record did not indicate if the staff members attempted to trade items or snacks for the colored pencils the resident had taken. A 2/12/25 at 5:10 a.m., note indicated the CNA was performing early morning care and bent to fix the resident's sock and the resident kicked her. The record lacked any indication why morning care needed to occur at 5:00 a.m. All attempts to calm the resident were unsuccessful. March 2025: The resident had two (2) documented behavioral events this month. Two of two events were successfully managed with non-chemical interventions. A 3/30/25 at 11:06 a.m., note indicated the resident grabbed the CNA and hit at her as the CNA attempted to dress her for the day. Non-chemical interventions were successful and the resident was dressed for the day. A 3/12/25 at 10:53 a.m., note indicated the resident grabbed the activity assistant and told her to sit down. Non-chemical interventions were successful in calming the resident. April 2025: The resident had six (6) documented behavioral events this month. One time she was startled and lashed out. Four (4) of 6 events the resisted care, three of which events she had been sleeping before the staff woke her to provide care. Five of six events were successfully managed with non-chemical interventions. A 4/28/25 at 10:58 a.m., note indicated was startled by activity staff and swatted them in the face. Non chemical interventions were successful to calm the resident. A 4/27/25 at 5:54 a.m., note indicated the resident resisted early morning care hitting and slapping. The resident had been asleep when staff awoke her for care. The staff redirected and switch care givers without success. The record lacked documentation of the reasoning the resident had to be woke from sleep in order to provide care. A 4/26/25 at 9:40 a.m., late entry note indicated the resident had been asleep in bed and was woke by staff for morning care. The resident resisted care and hit, grabbed and slapped at staff. When left alone and provided a different care giver at a later time the resident was co-operative. The record lacked documentation of the reasoning the resident had to be woke from sleep in order to provide care. A 4/26/25 at 7:23 a.m., note indicate the resident was asleep in bed when the staff awoke her for morning care. The resident hit, bit and kicked to resist care. Non-chemical interventions were somewhat effective. The record lacked documentation of the reasoning the resident had to be woke from sleep in order to provide care. A 4/19/25 at 11:12 a.m., late entry, note indicated the resident had been seated in her chair when staff approached her for care. She resisted care hitting and slapping. The staff redirected the resident and were eventually able to provide care. A 4/15/25 at 3:14 p.m., note indicated the resident was tearing up BINGO cards at an activity. She was offered drinks and snacks which were effective in redirecting her behavior. A 4/4/25 at 12:23 p.m., note indicated the resident was eating lunch and a CNA tried to assist her she cursed the CNA and hit her. Non-chemical interventions were successful to calm the resident. Review of SBAR (Situation, Background, Assessment and Recommendation)- Change of Condition notes from the 12/1/24 to 5/1/25 contained three behavioral events: A 1/26/25 at 11:12 a.m., SBAR note indicated, Resident attempted to stand without assistance and fell on her face. A 3/10/25 at 5:44 p.m., SBAR note indicated Two residents [names] both going to the dining room around 1650 hour and both made physical contact with each other. A 4/25/25 at 10:30 a.m., SBAR note indicated resident was in the activity room. propelled self to other side of table. smacked another resident's hand and pulled her hair. resident states resident was running her mouth. Following pharmacy recommendations for GDRs (gradual dose reductions of psychoactive medications on 3/15/25, the Nurse Practitioner refused recommendations indicating the resident was still having significant behaviors and anxiety. The resident had four documented behaviors in February and two in March 2025. Non-chemical interventions were documented as successful for the majority of the behavioral events. Although behavioral concerns were listed as the reason for maintaining current levels of psychoactive medications, approaches to behavioral care plans were not updated now resolved including, but not limited to, the following: The resident had a care plan problem regarding yelling at staff, attempting to exit, claiming someone is trying to kill me, throwing food, stating she would burn the place down (5/25/22). There were no new approaches were added since 4/25/23 nor had this problem been identified as resolved. The resident had a care plan problem regarding laying clothes all over the room (6/1/22). There were no new approaches since 6/1/22 nor had this problem been identified as resolved. The resident had a care plan problem regarding racial comments, not wanting others near me, making fun of others (6/3/22). There were no new approaches since 6/3/22 nor had this problem been identified as resolved. The resident had a care plan problem regarding agitation, yelling, running her walker into others, become upset with others, tearfulness, and suicidal comments (5/2/22). There were no new approaches to this problem since 8/29/23 nor had this problem been identified as resolved. The resident had a care plan problem of believing there was a horse in the hallway (3/29/24). There have been no new approaches to this problem since 3/29/24. The resident had a care plan problem regarding believing her clothing was poisoned (5/17/24). There have been no new approaches since 5/17/24. The resident had a care plan problem regarding calling staff fat a####, saying she worked here, knocking staffs glasses off during care, being combative (5/22/24). There were no new approaches to this problem since 5/22/24 nor had this problem been identified as resolved. The resident had a care plan problem regarding the refusal of care, refusing medication, believing care will cause her to get hurt (6/17/24). There were no new approached to this problem since 6/26/24 nor had this problem been identified as resolved. The residents record lacked an assessment for possible triggers to behaviors and personalized updated approaches to behavioral and dementia care plans. During an interview on 5/2/25 at 2:57 p.m., CNA 10 indicated Resident 29 had behaviors of being resistant to care. She did not have see or hear things that were not there. She liked it when staff talked to her and had a conversation. She could be easily redirected with pop and movies. Sometimes switching care givers helped. She did at times strike out at others out of the blue. Mostly dementia behavior. During an interview on 5/2/25 at 2:59 p.m., QMA 11 indicated Resident 29 had random behaviors. She occasionally had behaviors you didn't see coming. She did resist care. She did not see or hear things. She was not tearful. She liked movies, food, drinks. She did at time resist care. Snacks and switching care givers helped when she resisted. She had dementia behaviors. During an interview on 5/2/25 at 3:01 p.m. Agency CNA 12 indicated she was familiar with Resident 29. The resident resisted care. She did not see or hear things. She was not tearful. Staff needed to walk away and re-approach if she was resisting. During an interview on 5/2/25 at 3:03 p.m., LPN 13 indicated the resident did have behaviors. She resisted care. She was overwhelmed in large groups. If staff removed her from stimulating environments it helped. She likes treats and pop. During an interview on 5/2/25 at 12:22 p.m., the Administrator, DON, and Dementia Unit Manager indicated the facility would attempt to provide information about personalized dementia care provided to Resident 29 in order to reduce dementia related behaviors and reduce the need for psychoactive medications. A current, undated, facility policy titled, Dementia Care, provided by the Administrator on 5/2/25 at 2:25 p.m., indicated : Care and services will be person centered and reflect each resident's individual goals .Individualized non-pharmacological approaches to care will be utilized . 3.1-37(a)

Based on record review and interview, the facility failed to ensure shift to shift narcotic reconciliation was completed for 5 of 6 carts reviewed for medication storage. (C Unit 2 hall cart, C Unit 1 hall cart, Advanced Acute Care Unit cart (AACU), Acute Care Unit (ACU) short hall cart, ACU long hall cart) Finding includes: 1. During a medication storage observation of the C Unit 1 hall cart, accompanied by LPN 3 on 5/1/25 at 11:41 a.m., the Controlled Drugs- Count Record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In April 2025- 4/4/25 on evening shift, 4/18/25 on evening shift, 4/20/25 on day and night shifts. During an interview, at the time of the observation, LPN 3 indicated the narcotic count sheet was to be completed at the beginning of every shift. The medication count needed to be completed before the two nurses signed the form verifying the count was correct. 2. During a review of the C Unit 2 hall cart Controlled Drugs- Count Record, provided by Medical Records on 5/1/25 at 12:50 p.m., the following dates lacked signatures for shift to shift reconciliation of controlled medications: In February 2025- 2/2/25 on night shift, 2/6/25 on night shift, 2/7/25 on evening and night shifts, 2/20/25 on night shifts, 2/21/25 on day shift. 2/28/25 on evening and night shift. In March 2025- 3/1/25 on night shift, 3/2/25 on night shift, 3/8/25 on night shift, 3/12/25 on evening shift, 3/14/25 on evening shift, 3/15/25 on night shift, 3/16/25 on evening and night shifts, 3/25/25 on night shift. In April 2025- 4/9/25 on evening shift, 4/14/25 on evening shift. 3. During a review of the AACU hall cart Controlled Drugs- Count Record, provided by Medical Records on 5/1/25 at 12:50 p.m., the following dates lacked signatures for shift to shift reconciliation of controlled medications: In January 2025- 1/4/25 on evening shift, 1/5/25 on evening shift, 1/11/25 on evening shift, 1/12/25 on evening and night shifts, 1/14/25 on day shift, 1/16/25 on evening and night shifts, 1/17/25 on evening and night shifts, 1/18/25 on evening shift, 1/19/25 on evening shift, 1/20/25 on day and evening shift, 1/21/25 on day shift, 1/25/25 on day, evening, and night shifts, 1/26/25 on day, evening, and night shifts, 1/28/25 on evening shift, 1/29/25 on evening shift, 1/30/25 on evening shift. In February 2025- 2/1/25 on day and evening shifts, 2/2/25 on day and night shifts, 2/4/25 on evening and night shifts, 2/8/25 on evening shift, 2/9/25 on evening shift, 2/13/25 on day and evening shifts, 2/14/25 on evening and night shifts, 2/15/25 on evening shift, 2/16/25 on day and evening shifts, 2/22/25 on evening shift, 2/23/25 on evening shift, 2/24/25 on evening shift, 2/27/25 on evening shift. In March 2025- 3/1/25 on night shift, 3/2/25 on night shift, 3/3/25 on night shift, 3/4/25 on night shift, 3/5/25 on night shift. 4. During a review of the ACU short hall cart Controlled Drugs- Count Record, provided by Medical Records on 5/1/25 at 12:50 p.m., the following dates lacked signatures for shift to shift reconciliation of controlled medications: In January 2025- 1/3/25 on night shift, 1/8/25 on night shift, 1/9/25 on night shift, 1/17/25 on night shift, 1/24/25 on night shift, 1/25/25 on night shift, 1/26/25 on night shift. In February 2025- 2/2/25 on evening shift, 2/13/25 on night shift, 2/16/25 on night shift, 2/28/25 on evening shift. In March 2025- 3/1/25 on day and evening shifts, 3/2/25 on day shift, 3/9/25 on evening shift, 3/15/25 on night shift, 3/29/25 on day shift, 3/30/25 on night shift. In April 2025- 4/4/25 on night shift, 4/27/25 on night shift. 5. During a review of the ACU long hall cart Controlled Drugs- Count Record, provided by Medical Records on 5/1/25 at 12:50 p.m., the following dates lacked signatures for shift to shift reconciliation of controlled medications: In January 2025- 1/4/25 on day shift, 1/8/25 on night shift, 1/26/25 on day, evening, and night shifts. In February 2025- 2/13/25 on night shift, 2/16/25 on night shift, 2/22/25 on day shift, 2/24/25 on day shift. In March 2025- 3/1/25 on day and evening shifts, 3/2/25 on day shift, 3/11/25 on evening shift, 3/15/25 on night shift, 3/17/25 on evening shift, 3/29/25 on day shift. In April 2025- 4/19/25 on day shift, 4/24/25 on evening shift, 4/26/25 on day shift, 4/17/25 on day and night shifts. During an interview, on 5/2/25 on 2:25 p.m., the Director of Nursing (DON) indicated the expectation for staff was to complete a narcotic count at the start of each shift and exchange of keys. The two nurses sign the log to confirm the count was completed and correct. This process prevents drug diversion. A facility policy, dated 2025, titled, Controlled Substance Administration & Accountability, provided by the DON on 5/2/25 at 11:00 a.m., indicated the following: It is the policy of this facility to promote safe, high quality patient cares, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways: . All controlled substances obtained from a non-automatic medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided .The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient information .Inventory Verification .For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift . 3.1- 25(b)(3)

Based on observation and interview, the facility failed to ensure insulin was dated after opening and discarded when expired for 1 of 3 medication carts reviewed. (ACU Medcart) Finding includes: During an observation on [DATE] at 10:48 a.m., the ACU Medcart was reviewed with LPN 13. A Lantus Subcutaneous Solution 100 unit/ml (insulin glargine) vial for resident 59 was opened and dated [DATE] and a HumaLOG Injection Solution 100 unit/ml (insulin lispro) vial was opened and undated. A Dulaglutide Subcutaneous Solution (to treat diabetes) Pen-injector 4.5 mg/0.5 ml for resident 12 was opened and undated. An Insulin NPH (neutral protamine [NAME] insulin) Suspension Pen-injector 100 unit/ml for resident 18 was opened and unlabeled. LPN 13 indicated insulin expired 30 days after opening and the pens and vials should have been labeled appropriately and the expired items thrown away. On [DATE] at 9:25 a.m. manufacturer recommendations for the Lantus, retrieved from https://products.sanofi.us/lantus/lantus.html indicated in-use (opened) vials may be stored at room temperature or refrigerated for 28 days. On [DATE] at 9:28 a.m., manufacturer recommendations for Humalog, retrieved from /https://pi.lilly.com/us/humalog-vial-ifu.pdf indicated store opened vials in the refrigerator or at room temperature up to 86 F (30 C) for up to 28 days. A current, undated facility policy, titled Insulin Pen, provided by the DON on [DATE] at 12:00 p.m. indicated, .2. Insulin Pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used;a new pen must be ordered from the pharmacy .9. Insulin pens should be dispose of after 28 days or according to manufacturer's recommendation 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

Based on interview and record review, the facility failed to ensure bed hold policies were provided to the resident and/or responsible parties at the time of the hospital transfer for 2 of 3 residents reviewed for hospitalization. (Residents 48 and 60) Findings include: 1. During an interview on 4/28/25 at 2:57 p.m., Resident 48 indicated she was hospitalized a couple months ago for about a week and did not receive any paperwork regarding a bed hold. Resident 48's record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic respiratory failure, congestive heart failure, chronic obstructive pulmonary disease (COPD), centrilobular emphysema, asthma, and pneumonia. A progress note, dated 1/26/25 at 4:38 p.m., indicated the resident was sent to the hospital for difficulty breathing. A progress note, dated 1/31/25 at 6:40 p.m. indicated the resident returned from the hospital. The clinical record lacked indication of bed hold notification or policy was provided to the resident or representative. 2. During an interview with Resident 60 on 4/28/25 at 1:44 p.m., he indicated he was hospitalized last month with pneumonia. He did not receive paperwork or notification of the bed hold or the facility's policy regarding bed holds. Resident 60's record was reviewed on 5/1/25 at 11:19 a.m. Diagnoses included, heart failure, end stage renal disease, chronic obstructive pulmonary disease, and pneumonia. A progress note dated 3/12/25 at 10:18 p.m. indicated the resident was transferred to the hospital. A progress note dated 3/18/25 at 10:52 p.m. indicated the resident returned to the facility at 6:00 p.m. The clinical record lacked indication of bed hold notification or the bed hold policy was given to the resident or representative. During an interview with the DON on 5/1/25 at 3:39 p.m., a copy of the facility bed hold policy and Notice of Transfer/Discharge was provided. The DON could not provide evidence of who these forms were given to, as they were typically sent with the ambulance staff when the resident was transferred. During an interview with the DON on 5/1/25 at 4:32 p.m., she indicated the facility was unable to find bed hold notifications in either resident's clinical record. A current undated policy titled, Notice of Bed Hold Policy, obtained from the DON on 5/1/25 at 3:39 p.m., indicated the following: .Our facility is required by state and federal law to inform you of our bed hold policy 3.1-12(a)(25) 3.1-12(a)(26)

Based on record review and interview, the facility failed to ensure the designated resident health care representative signed medical consent forms for 1 of 1 resident reviewed for health care representation. (Resident 256) Finding includes: Resident 256's clinical record was reviewed on 4/30/25 at 10:59 a.m. Diagnoses included schizoaffective disorder, bipolar disorder, and other cirrhosis of the liver. The admitted was 4/25/25. A 5/20/24 court document titled, Order Appointing Health Care Representative, indicated Resident 256 had been declared legally incompetent and appointed a legal health care representative. The health care representative was not related to Resident 256 and had full authority to make health care decisions. A 4/25/25 alert note indicated Resident 256's daughter told staff she was not the resident's health care representative. A voice mail message was left for the legal health care representative. A 4/26/25 mental health consent form was signed by Resident 256's daughter. A 4/26/25 psychotropic medications informed consent form was signed by Resident 256's daughter. A 4/26/25 Indiana Physician Order for Scope of Treatment (POST) form was signed by Resident 256's daughter, which declared the resident was to receive all life saving measures. A 4/28/25 social services general note indicated the facility tried to contact the court appointed health care representative and was informed he was on vacation through 5/5/25. A 5/2/25 social services general note indicated the facility spoke with the legal representative's appointed contact person for the court appointed health care representative and was given verbal approval to send the resident to the emergency room as necessary. During an interview, on 5/2/25 at 11:14 a.m., the Administrator indicated he was aware Resident 256 had a legal health care representative and had sent the facility Admission Contract by electronic mail (e-mail). The health care representative was on vacation and had not signed the contract yet. During an interview, on 5/2/25 at 11:46 a.m., the Social Services Director (SSD) indicated she was aware Resident 256 had a legal health care representative, but he was on vacation and could not be reached. The facility contacted the daughter, since she was listed as an emergency contact and the consents needed signed promptly. The SSD had not sent these consents to the health care representative by e-mail. The SSD had recently spoken with the legal representative's appointed contact person to get verbal permission to send the resident out for evaluation. During an interview, on 5/2/25 at 2:44 p.m., the Administrator indicated the facility had made attempts to contact the health care representative. Resident 256's daughter was asked to sign the consent forms while waiting for the health care representative to return from vacation. No additional information was provided by the facility prior to exit on 5/2/25.

Based on record review and interview, the facility failed to provide notifications of hospitalization to the Long-Term Care Ombudsman for 1 of 3 residents reviewed for hospitalizations. (Resident 60) Finding includes: During an interview with Resident 60 on 4/28/25 at 1:44 p.m., he indicated he was hospitalized last month with pneumonia. Resident 60's record was reviewed on 5/1/25 at 11:19 a.m. Diagnoses included heart failure, end stage renal disease (kidney failure), dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and pneumonia. A progress note dated 3/12/25 at 10:18 p.m. indicated the resident was sent to the hospital by ambulance. A nurse's note dated 3/18/25 at 10:32 p.m. indicated the resident returned to the facility via ambulance at 6:00 p.m. During an interview with the SSD on 5/1/25 at 3:52 p.m., she indicated Ombudsman notifications for transfers and discharges had not been sent out for March 2025 and were usually sent within the first week of the next month. She was in charge of sending Ombudsman notifications. Resident 60 was hospitalized on [DATE] and the Ombudsman should have been notified. During an interview with the DON on 5/2/25 at 9:06 a.m., she indicated the facility did not have a policy regarding Ombudsman notification. A undated document titled, Indiana Long Term-Term Care Ombudsman Program, provided by the DON on 5/2/25 at 9:06 a.m. included the following: Report the following to both the State LTC Ombudsman (SLTCO) and your local LTC Ombudsman Representative: Acute Emergency Transfer When a resident is transferred on an emergency basis to an acute care facility and expected to return, the SLTCO must be notified. Information from facilities regarding emergency transfers should be provided in a monthly list to the SLTCO, which should include resident's names, dates of transfer, facilities to which residents were transferred, and reasons for the transfers A table in the document indicated when a resident experiences a transfer or discharge to a hospital, notice to the Ombudsman is required when practicable, and can be via a monthly list. 3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to notify the physician of elevated blood pressures for 1 of 5 residents reviewed for unnecessary medications. (Resident 39) Finding includes: Resident 39's record was reviewed on 4/29/25 at 2:21 p.m. Diagnoses included malignant neoplasm of frontal lobe, malignant neoplasm of parietal lobe, and essential (primary) hypertension. Current physician orders included, Aldactone (blood pressure medication) tablet 50 milligram (mg) one tablet by mouth one time a day, hydrochlorothiazide (blood pressure medication) 50 mg tablet by mouth in the morning, amlodipine besylate (blood pressure medication) 10 mg tablet give one tablet by mouth one time a day, and clonidine (blood pressure medication) 0.3 mg tablet give one tablet by mouth two times a day. An alert note dated 1/25/25 at 9:27 a.m. indicated the resident was admitted to the hospital for a stroke. Review of blood pressure readings from 4/1/25 through 5/1/25 indicated the following: 4/1/25 8:47 p.m. 200/90 mmHg (millimeters of mercury), 4/2/25 7:53 p.m. 200/101 mmHg, 4/9/25 8:48 p.m. 189/100 mmHg, 4/12/25 7:51 a.m. 176/107 mmHg, 4/13/25 7:11 a.m. 190/96 mmHg, 4/13/25 11:10 a.m. 190/96 mmHg, 4/29/25 2:20 a.m. 222/138 mmHg, 4/30/25 3:07 a.m. 198/102 mmHg, and 5/1/25 2:42 a.m. 195/100 mmHg. The resident's clinical record lacked physician notification for these elevated blood pressures. During an interview with LPN 15 on 5/1/25 at 3:32 p.m., she indicated there was not a standard protocol for notifying the physician of abnormally high blood pressure. If she had obtained an abnormal blood pressure, the physician would have been notified immediately. During an interview with LPN 17 on 5/2/25 at 1:55 p.m., she indicated the physician was working to stabilize the resident's blood pressure and noted recent changes in his medication. The resident was scheduled to see the physician again on 5/7/25 for a follow up. Although there was not an order, staff let the physician know about the resident's blood pressure every week. Blood pressures for the resident during her shifts were 140s/80s and she would have called for blood pressure over 140. During an interview with the DON on 5/2/25 at 2:57 p.m., she indicated there was no standing protocol for physician notification regarding abnormal vital signs unless directly ordered by the physician. The DON indicated the physician should have been notified of blood pressures outside the resident's baseline. A current, undated facility policy titled, Notification of Changes, provided by the DON on 5/2/25 at 12:03 p.m. included the following: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification Definitions: Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before) .Circumstances requiring notification include: .b. Potential to require physician intervention .3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute Condition. iii. Exacerbation of a chronic condition 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to provide education regarding and failed to offer COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 48) Finding includes: Resident 48's clinical record was reviewed on 4/29/25 at 2:37 p.m. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and dependence on supplemental oxygen. An admission Minimum Data Set (MDS) assessment, dated 2/3/25, indicated the resident was cognitively intact. A COVID-19 Vaccine Consent/Declination Form, dated 9/13/23, indicated the resident was provided education and declined administration. The declination indicated the following information, I understand that I can change my mind at any time and accept the COVID-19 vaccination at a later time and will receive current education at that time. The clinical record lacked any other offerings of the COVID-19 vaccine since 2023. During an interview on 5/1/25 at 11:37 a.m., the Infection Preventionist indicated residents who refused the COVID-19 vaccines on admission were not offered the vaccines again when they were eligible to receive the next doses per CDC guidance. During an interview on 5/1/25 at 2:58 p.m., the DON indicated the COVID-19 vaccines should have been offered/administered following the CDC guidance. A current facility policy, undated, titled General Immunization/Vaccination, provided by the DON on 5/1/25 at 2:57 p.m., indicated the following: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases . Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against infectious diseases in accordance with national standards of practice. 2. Immunizations will follow current CDC guidance and scheduling based on the specific vaccinations. 3. Residents, staff, and volunteer workers will be offered immunizations against infectious diseases as per current federal, state and local guidance 3.1-18(b)(5)

Based on record review and interview, the facility failed to follow physician ordered parameters for medication administration related to a blood pressure medication for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: Resident B's closed clinical record was reviewed on 2/5/25 at 9:55 a.m. Diagnoses included heart failure, hypertension, constipation, dementia, and schizoaffective disorder. She was transferred to an emergency department and discharged from the facility on 12/28/25. A signed physician's order, dated 10/15/24, indicated to give metoprolol succinate extended release (to treat high blood pressure) 25 mg (milligram), 1/2 tablet (12.5 mg) in the evening to treat heart failure. The order indicated to hold the medication for a systolic blood pressure (SBP) below 100 and heart rate (HR) less than 60 beats per minute (BPM). On 12/22/24 at 8:00 p.m., the resident's SBP was 110 and her HR was 62 BPM. The resident's electronic medication administration record for December 2024, indicated the medication was held. The record lacked indication of the reason the medication was not administered. A signed physician's order, dated 10/11/24, indicated to give hydralazine hydrochloride (to treat high blood pressure) 100 mg, one tablet every eight hours for hypertension. Order indicated to hold medication for a SBP below 110 and/or a HR below 60 beats per minute. A review of the residents electronic medication administration record for December 2024, included the following: a. On 12/10/24 at 1:00 p.m., the resident's SBP was 102. The clinical record indicated the medication was administered to the resident. The record lacked indication of the medication being held. b. On 12/16/24 at 1:00 p.m., the resident's SBP was 92, the clinical record indicated the medication was administered to the resident. The record lacked indication of the medication being held. c. On 12/19/24 at 1:00 p.m., the resident's SBP was 105, the clinical record indicated the medication was administered to the resident. The record lacked indication of the medication being held. d. On 12/22/24 at 9:00 p.m., the resident's SBP was 110, the clinical record indicated the medication was held and not administered. The record lacked indication of reason for the medication being held. During an interview on 2/6/25 at 2:15 p.m., the DON indicated the medication should have been held or administered per physician order when within or outside of ordered parameters. A current facility policy, dated 2024, titled, Medication Administration, provided by the DON on 2/6/25 at 2:50 p.m., included the following: Policy Explanation and Compliance Guidelines: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside of the physician's prescribed parameters. This citation relates to Complaints IN00451394 and IN00451774. 3.1-37(a)

Based on interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a currently certified Infection Preventionist for 2 of the 5 days of the survey, or prior since 2/5/24. This deficient practice had potential to affect 98 of 98 residents in the facility. Findings include: During an interview on 7/8/24 at 10:35 a.m., the Administrator indicated RN 12 was the Infection Preventionist. A review of the facility's Infection Control Surveillance Binder was completed on 7/12/24 at 10:43 a.m., and documentation indicated the information was completed by the ADON. During an interview on 7/12/24 at 11:45 a.m., the ADON indicated she was the infection preventionist and had been in that roll since January 2024. During an interview 7/12/24 at 12:46 p.m., the Administrator indicated the ADON had been acting Infection Preventionist for the facility. RN 12 had been promoted about two months ago and had not completed her certification as yet. RN 13, who had Infection Preventionist certification, worked at the facility part-time and was to train and consult for the Infection Control Program. A review of a Centers for Disease Control and Prevention Completion for Nursing Home Infection Preventionist Training Course certificate for the ADON, provided by the Administrator on 7/12/24 at 12:42 p.m., indicated the course was completed on 7/10/24. During a telephone interview on 7/12/24 at 1:57 p.m., RN 13 indicated she had not worked as the Infection Preventionist or consulted for the ADON since 2/5/24. She had trained the ADON regarding surveillance issues and how to map infections, how to identify clusters of infections and how to respond, as well as antibiotic stewardship and how to identify and document criteria. She currently worked part-time at the facility and had no involvement with the infection control program. A current facility policy, dated 3/21/23 and titled, Infection Prevention RN Job Description, provided by the DON on 7/12/24 at 1:50 p.m., included the following: .Qualifications .Must also meet state requirements for relevant licensure or certifications Completed specialized training in infection prevention and control through accredited continuing education Cross reference F880. Cross reference F881.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program per facility policy. This had the potential to affect 98 or 98 residents residing in the facility. Findings include: A review of the facilities Infection Control Surveillance Binder was completed on 7/12/24 at 10:43 a.m., for the months of May and June 2024, and included the following: For June 2024, the binder contained an Infection Control Report completed by the ADON. It indicated the facility had 19 infections and 19 residents received antibiotics. The binder lacked documentation of resident names and infection types, or supporting documentation of treatment's provided or criteria for determining treatment. For May 2024, the binder contained an Infection Control Report completed by the ADON. It indicated the facility had 18 infections and 18 residents received antibiotics. The binder included 14 Revised McGeer Criteria for Infection Surveillance Checklist forms and three lab or xray results. The checklists lacked documentation regarding symptoms, criteria, or type of infection, or if the criteria for antibiotic treatment was met or not met. During an interview on 7/12/24 at 11:45 a.m., the ADON indicated she was the facility's infection preventionist. The surveillance binder was her record for infection surveillance. The facility's unit managers were to complete the Revised McGeer Criteria for Infection Surveillance Checklist forms when an infection was suspected. These were to be forwarded to her for the monthly report generation. She had not completed the forms herself or reviewed them. She had not received any forms during the month of June. She had not followed up with the unit managers and had not confirmed appropriateness for antibiotic usage. Her responsibility was solely to complete the monthly report. A current, undated facility policy titled Antibiotic Stewardship Program, provided by the DON on 7/12/24 at 12:10 p.m., indicated the following: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use Policy Explanation and Compliance Guidelines: .2. a. Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms 4. The program includes antibiotic use protocols and a system to monitor antibiotic use

Based on observation, interview, and record review, the facility failed to implement and utilize infection prevention and control practices related to contact isolation, enhanced barrier precautions (EBP), and diagnostic testing for 3 of 5 residents reviewed for infection control. (Resident's B, C, and 99) 1.During an observation on 7/10/24 at 11:04 a.m., Resident B's door had an EBP sign on the left side of the door and a contact isolation sign was on the right side of the resident's door. The personal protective equipment canister was just inside the resident's room beside the bathroom door. The contact isolation sign indicated everyone must clean their hands, put on a gown, and put on gloves before entering the room. During an observation on 7/10/24 at 11:32 a.m., LPN 8 performed hand hygiene and put on gloves as she entered the resident's contact isolation room. She walked to the resident's left side of the bed and her clothing brushed up against the bed linens with her unprotected clothing. Then she went around the foot of the bed and used a graduated measuring container to empty the resident's over full expanded urinary drainage bag. An isolation gown was not worn by LPN 8 throughout the observation. During an interview on 7/10/24 at 11:35 a.m., LPN 8 indicated the resident was in contact isolation and she had not worn a gown when she was in his room emptying the urinary drainage bag. During an interview on 7/12/24 at 10:37 a.m., CNA 9 indicated contact isolation was posted on a sign outside the residents' doors when it was required. A gown and gloves should have been worn for care in contact isolation rooms. Resident B's clinical record was reviewed on 7/9/24 at 3:04 p.m. Diagnoses included, paraplegia, obstructive and reflux uropathy, malignant neoplasm of the bladder, and Methicillin-resistant Staphylococcus aureus (MRSA - bacteria resistant to treatment) infection. A current physician order, dated 7/3/24, included Bactrim (antibiotic) Double Strength (DS) - give 1 tablet by mouth twice daily related to a MRSA infection for 10 days. A current physician order, dated 4/8/24, included gown and gloves for all interactions with the resident every shift. A quarterly Minimum Data Set (MDS) assessment, dated 6/5/24, indicated the resident was cognitively intact. He was dependent on staff assistance for toileting and transfers and used a wheelchair for mobility. He required a urostomy and had frequent bowel incontinence. 2. During an interview at the time of observation on 7/10/24 from 11:18 a.m. to 11:23 a.m., LPN 8 was in the Resident C's EBP room at bedside with gloves on and no gown during the observation. She leaned in towards and against the resident's bed mattress with her scrubs directly against the resident's linens as she disconnected the old urinary drainage bag in her right hand and held the new drainage bag tubing in her left hand. LPN 8 reconnected the new urinary drainage bag to the suprapubic catheter. During an interview on 7/10/24 at 11:35 a.m., LPN 8 indicated the resident was in EBP and she had not worn a gown when she was in his room emptying the urinary drainage bag. Resident C's clinical record was reviewed on 7/9/24 at 3:14 p.m. Diagnoses included obstructive and reflux uropathy and urine retention. A current physician order, dated 4/29/24, included gown and gloves for all interactions with the resident every shift for enhanced precautions. A quarterly MDS assessment, dated 5/3/24, indicated the resident was cognitively intact. The resident was dependent on staff assistance for toileting, lower body dressing, bathing, and transfers. He had an indwelling catheter and was always incontinent of bowel. 3. During an interview on 7/9/24 at 12:15 p.m., Resident 99 was in her room and indicated she was currently suffering from very loose stools, perhaps from antibiotic use. The loose stools impacted her ability to participate in therapy. Resident 99's clinical record was reviewed on 7/9/24 at 4:00 p.m. Diagnoses included the following: unspecified open wound of right foot, subsequent encounter, constipation, and need for assistance with personalized care. A current physician order, dated 7/3/24, included vancomycin hydrochloride (antibiotic used to treat serious infections) administer 10 milliliters (ml) intravenously every 12 hours. A current physician order, dated 7/8/24, included check stool for Clostridium difficile (C. diff- a bacteria that causes an infection of the colon) one time for loose stools. The clinical record lacked any current, completed, or discontinued contact isolation orders from the date loose stools were reported through 7/11/24. An admission Minimum Data Set assessment, dated 6/12/24, indicated the resident was cognitively intact. She required moderate to maximal assistance for toileting, dressing, personal hygiene, and mobility. The resident had occasional urinary incontinence and frequent bowel incontinence. She had a surgical wound and received antibiotic during the assessment period. The clinical record lacked care plans for contact isolation or potential for C. diff. A Nurse's Note, dated 7/7/24 at 1:36 p.m., indicated a bowel movement had not been documented for 3 days, but the resident had experienced loose stools. A Nurse's Note, dated 7/8/24 at 7:20 p.m., indicated the resident voiced concerns related to diarrhea the past few days. Physician orders were received for a stool sample for C. diff and an order for anti-diarrhea medication. Review of the lab results report, dated 7/9/24, indicated the specimen was not collected for C. diff. The nurse was notified. The clinical record lacked indication another specimen was collected, nor the provider notified, that the order was not completed. During an observation on 7/9/24 at 4:15 p.m., the resident's door was closed and had an enhanced barrier precaution (EBP) sign noted on the left side of the door. During an observation on 7/10/24 at 9:44 a.m., the resident's door was closed and had an enhanced barrier precaution sign noted on the left side of the door. During an interview at the time of observation on 7/10/24 at 11:02 a.m., an EBP sign remained on the left of the resident's door. The resident exited her room in her wheelchair and indicated she was headed down to therapy. She was wearing her normal clothing. During an interview, QMA 6 indicated Resident 99 was not in her room. The door was labeled as EBP and lacked indication of any other type of isolation. The clinical record lacked any other isolation orders, active or discontinued, since the resident's ordered stool sample for C. diff testing. A resident with loose stools should have been placed immediately in contact isolation while awaiting the results of the C. diff stool specimen. He was unable to find or provide stool sample laboratory results. During an interview on 7/10/24 at 11:35 a.m., LPN 8 indicated a gown and gloves were required in contact isolation and EBPs. Failure to use a gown in contact isolation and EBPs put other residents at risk for infection because bacteria could have been carried from her clothing into other residents' rooms. During an interview on 7/11/24 at 3:58 p.m., the ADON indicated any resident suspicious for C. diff with loose stools and awaiting results from a C. diff stool sample should have been placed on contact isolation. The contact isolation should not have been removed unless the test result came back negative. Staff should have been educated on the contact isolation and the importance of washing their hands. They did not have any residents in contact isolation for C. diff precautions in the facility. During an interview on 7/11/24 at 5:07 p.m., LPN 7 indicated the resident's clinical record lacked C. diff stool sample results because the specimen was not collected. It should have been collected as ordered. The clinical record lacked indication why the specimen was not obtained. There was no indication of physician notification of the inability to obtain the ordered stool specimen. The resident was not restricted to her room because EBPs were ordered, rather than contact isolation. The resident was at an increased risk for C. diff due to her intravenous antibiotics. Services should have been provided in her room to prevent the potential spread of an infection to other residents. During an interview on 7/11/24 at 5:12 p.m., the ADON indicated the resident should have been placed in contact isolation when she was symptomatic with loose stools and the stool specimen was ordered. The ADON was the Infection Preventionist and should have caught the error, but she had not recognized the the resident was not in contact isolation, nor the stool specimen not collected, due to additional responsibilities. During an interview on 7/12/24 at 10:37 a.m., CNA 9 indicated she was responsible for the care of the residents on C- 3 Unit on this date. She had not received information/education regarding any residents on contact isolation for C. diff on her unit. It was posted outside the residents' doors when contact isolation was required. Resident 99's door remained with an EBP sign to the left of the door. The resident was not in contact isolation. During an interview on 7/12/24 at 12:10 p.m., the DON indicated staff were required to wear a gown and gloves upon entering the contact isolation rooms. Staff were required to wear a gown and gloves in EBPs for manipulation of a urinary catheter drainage bag. Three or more loose stools in a day, foul odors, and abdominal cramping were signs of potential C. diff. Residents on intravenous vancomycin were at higher risk for C. diff. She had to look at the entire clinical picture to determine if a resident should have been placed in contact isolation with the above mentioned symptoms of C. diff. During an interview on 7/12/24 at 2:25 p.m., the Administrator indicated the facility followed the Center for Disease Control (CDC) and Indiana Department of Health guidelines regarding infection control practices. During an observation on 7/12/24 at 2:30 p.m., the resident was not in her room. A contact isolation sign was hung to the left of the door, along with the EBP sign. An unknown staff member indicated the resident had gone to the activity room. During an observation on 7/12/24 at 2:33 p.m., Resident 99 was in the activity room in a group activity. Resident 99 had cards in her hand and was in the process of playing a card game where cards were exchanged with the other players. During an interview on 7/12/24 at 2:35 p.m., Resident 99 indicated she last had several loose watery stools on 7/11/24. She had not been educated or encouraged to remain in her room. She was unaware the facility had not received the C. diff stool specimen results. A current facility policy, undated, titled Provision of Physician Ordered Services, provided by the DON on 7/12/24 at 2:43 p.m., indicated the following: .Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Policy Explanation and Compliance Guidelines: 1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders . 2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity . 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record . A current facility policy, undated, titled Enhanced Barrier Precautions, provided by the DON on 7/12/24 at 1:50 p.m., indicated the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Policy Explanation and Compliance Guidelines: .3. Implementation of Enhanced Barrier Precautions: .b. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: .g. Device care or use: central lines, urinary catheters . 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk A current facility policy, undated, titled Isolation Precautions, provided by the DON on 7/12/24 at 1:50 p.m., indicated the following: Policy: It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. This policy specifies the different types of precautions, including when and how isolation should be used for a resident . Policy Explanation and Compliance Guidelines: .2. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission . 10. The Infection Preventionist will serve as a consultant to facility staff on infectious diseases and the implementation of isolation precautions 3.1-18(a)(2) 3.1-18(b)(2)

Based on interviews and record review, the facility failed to report to the Administrator or designee allegations of abuse for 1 of 3 allegations of abuse reviewed (CNA 6 to Resident D). This failure to report the allegation immediately resulted in CNA 6's abuse of a cognitively impaired resident later in the day. Findings include: During an interview with LPN 19, on 8/2/23 at 4:39 p.m., she indicated CNA 7 had reported to her Resident D was grabbed roughly by CNA 6 during her shower on 7/29/23. LPN 19 was in the process of handling other things and was passing medication at the time CNA 7 reported this to her (between 8:00 a.m. and 9:00 a.m.). She did not report the allegation to the Administrator or their designee. An Incident Submission email confirmed an incident report was submitted to the Indiana Department of Health on 8/3/23 at 2:51 p.m. The actual or identified date and time of the incident was 7/31/23 at 1:39 p.m. The report indicated the following: The description added, on 8/3/23, indicated during another investigation, CNA 7 reported that Resident D alleged CNA 6 was rough during her shower and verbalized CNA 6 held her wrist and pushed her into the shower chair. Resident D was moderately cognitively impaired. During an interview with the DON, on 8/3/23 at 2:10 p.m., she indicated she thought they had 24 hours to report abuse and had always reported abuse within 24 hours to the State Agency. The information in the reportable related to staff to resident abuse was what she was told during interviews and they were still completing interviews. The housekeeper was not interviewed until on Monday 7/31/23. The allegation of abuse for Resident D, they were not aware of until Monday 7/31/23. They had investigated the allegation with Resident D along with the allegation of abuse for Resident B and was located in the investigation in the binder, it was not reported to the State Agency. LPN 19 was suspended for not reporting the allegation of abuse to Resident D, she knew about the allegation in the morning but she was busy with other things. Review of the current IDOH Long-Term Care Abuse and Incident Reporting Policy, effective 12/8/22 and retrieved from https://www.in.gov/health/files/IDOH-LTC-Abuse-and-Incident-Reporting-policy_policy-SIGNED.pdf indicated the following: .Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or other health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property .Immediately means as soon as possible, in the absence of a shorter state time frame requirement, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse .All allegations of staff to resident abuse must be reported. Staff may receive allegations from any source, including other staff, residents, family members, or other health care providers. Also, each occurrence must be reported. If staff are aware of or witnessed any abuse that occurs, it must be reported Cross reference F600 and F609. This Federal tag relates to complaint IN00414267. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 4 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely these deficient practices would lead to chronic or recurrent fear and anxiety. Findings include: During the initial tour of the AACU (Advanced Alzheimer's Care Unit) accompanied by LPN 27, on 8/2/23 at 9:45 a.m., Resident B was observed lying in her bed. LPN 27 indicated Resident B liked to take morning naps and wandered the unit in the afternoon. During an interview with LPN 27, on 8/2/23 at 11:28 a.m., she indicated Resident B was not aggressive but did have a tongue on her. It was typical to find her in someone else's room. On 8/2/23 at 2:13 p.m., Resident B was observed ambulating independently in the hallway. On 8/3/23 at 11:01 a.m., Resident B was observed sitting in a dining room chair at a table, with another resident across the table from her. Resident B's clinical record was reviewed on 8/2/23 at 1:47 p.m. Diagnoses included hallucinations, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, delusional disorders, cognitive communication deficit, Alzheimer's disease with early onset, major depressive disorder, recurrent, in remission, anxiety disorder due to known physiological condition and psychotic disorder with hallucinations due to known physiological condition. Her current medications included buspirone (anxiety) 5 mg (milligram), donepezil (memory loss) 10 mg daily, sertraline (depression) 75 mg daily and divalproex sodium (mood disorder) 125 mg twice daily. A quarterly MDS (Minimum Data Set), dated 7/13/23, indicated she was severely cognitively impaired. She had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days during the assessment period. She wandered four to six days during the assessment period. She required extensive assistance of one staff member for bed mobility, transfers, walking in room/corridor, locomotion on/off unit, dressing, toilet use and personal hygiene. She had a current care plan problem of sometimes having behaviors that included wandering in the halls with no pants on, wandering into others rooms and laying in their bed and looking for her dad (3/2/23). Her interventions included staff would redirect her to her own bed as needed (3/3/23) and allow her time to fully wake up before redirecting her out of another resident's bed (7/30/23). She had a current care plan for a history of trauma that affected her negatively due to growing up in poverty and another stressful event that occurred in her life since being in the nursing facility. The triggers that have the potential to re-traumatize her included staff not talking to me in a slow calm manner (7/31/23). Her interventions included encourage her to be as independent as possible (7/31/23), her triggers were staff talking to her in a hurried tone (7/31/23), respect her personal space (7/31/23), staff would assist her with recovery and help avoid re-traumatization (7/31/23) and staff would know what her triggers were (7/31/23). A change of condition note, dated 7/29/23 at 1:09 p.m., indicated she had hit her head during a possible fall incident. She had a small bump on the top of the right side of her head and she reported she had neck pain with range of motion. She was sent to the ER (emergency room ). The ER physician progress note, dated 7/29/23 at 1:21 p.m., indicated she was being seen for complaint of neck pain. Her history of present illness included she was [AGE] years old with a history of dementia and was assaulted at the nursing home. She stated she was at the of the bed, when an aide came in and threw her on the ground. She denied any loss of consciousness but that she hit the back of her head. She appeared at baseline mentally. She denied any chest pain, shortness of breath, stomach pain or back pain. Reportedly, there was a fell ow staff member that witnessed her being thrown on the ground. She had no external signs of trauma. Her vitals were within normal limits. She complained of a headache. A CT (Computerized Tomography) scan of her head and cervical spine were ordered and were unremarkable. A nurses note, dated 7/29/23 at 4:45 p.m., indicated Resident B's brother was notified of her being transported to the ER and of the staff member allegedly getting rough with her. A nurses note, dated 7/31/23 at 11:40 a.m., indicated a skin assessment was completed. There was bruising to her right upper extremity, her right hand (6 cm x 5.8 cm), and her left wrist (6.5 cm x 5.2 cm). The bruises were purple in color. She denied any pain or discomfort and stated that she bumped into things all day. A nurses note, dated 8/2/23 at 9:59 a.m., indicated a follow up call was made to Resident B's brother regarding the incident that occurred with a CNA. He was informed the CNA was no longer employed at the facility as she failed to follow the resident care and treatment protocol which resulted in a negative outcome. During an interview with Housekeeper 12, with the Assistant [NAME] President of Operations present, on 8/2/23 at 2:48 p.m., she indicated when she was in the AACU dining room, she could see Resident B laying on the floor in another resident's room. She observed CNA 6 pick the top of Resident B's head up and slam her head onto the floor while Resident B laid on the floor. Housekeeper 12 just stood there stunned. She told her co-worker what happened, and later told her boss. During an interview with CNA 7, on 8/2/23 at 3:18 p.m., she indicated she and CNA 6 were taking a male resident to his room to lay him down after lunch. Resident B was in the male resident's bed when they walked into his room. CNA 6 walked over to Resident B and began shaking her arm aggressively to get her out of his bed. Resident B screamed Stop it! multiple times. CNA 6 then picked Resident B up by her left arm and left leg and lifted her off the bed (approximately waist high). Resident B kicked CNA 6 pretty hard and knocked CNA 6's glasses off her face and a piercing from her nose. CNA 6 then dropped Resident B on the floor. Resident B landed on her bottom and hit her head on the foot board of the bed. She felt CNA 6 intentionally dropped Resident B to the floor. She yelled at CNA 6 to leave the room and yelled at Housekeeper 12, who was standing in the dining room, to go get a nurse. Resident B yelled Yeah, bit--h get out of here! CNA 6 took a step out of the room and then stepped back into the room with her fist clenched like she was going to hurt Resident B. She left the room. LPN 23 entered the room to check on Resident B. CNA 6 then came back into the room with Housekeeper 12 and QMA 8 to look for her nose ring. CNA 6 indicated she wouldn't touch Resident B the rest of the day. Later, CNA 6 asked CNA 7 if she believed that she meant to hurt Resident B, and CNA 7 told her that she could had handled the situation better than she had. Earlier, Resident D had indicated to her that CNA 6 grabbed her by her wrists and slammed her down onto the shower chair and it hurt. CNA 6 was sent home around 2:00 p.m. During an interview with LPN 23, on 8/2/23 at 4:11 p.m., she indicated QMA 8 came to her while she was on the ACU (Alzheimer's Care Unit). She told her CNA 6 was crying from having her glasses and nose piercing ripped off of her face and that she was so pis--d off that the situation had gotten to that point. CNA 6 had gone in to the male resident's room and Resident B was in his bed, so she picked Resident B up in a cradle position to sit her up on the side of the bed. Resident B was kicking at her, so she lowered her to the ground. CNA 6 requested to go outside for a smoke break but wanted to get her nose ring from the room first. When LPN 23 entered the male resident's room, Resident B was standing up and did not appear in any distress. Housekeeper 12, CNA 7, and QMA 8 were in the room looking for CNA 6's nose piercing and it was located within a minute or two. CNA 6 indicated she needed to go to the other unit to have her friend help her put her nose piercing in and she would not touch Resident B the rest of the day if that's what she had to do. LPN 23 and CNA 7 walked Resident B to her room. CNA 7 indicated to LPN 23 she wanted to talk to her privately about what really happened. CNA 7 was visibly upset and indicated to her CNA 6 was roughly shaking Resident B to wake her up and to get her out of the male resident's bed. CNA 6 picked Resident B up by her one arm and one leg and dropped her and that she was rough with another resident earlier but had reported it to LPN 19 already. While they were talking privately, CNA 6 entered the room crying. She indicated she was sorry this had happened. LPN 23 indicated she worked with CNA 6 the previous weekend for the last four hours of CNA 6's sixteen hour shift. LPN 23 felt CNA 6 was kind of hateful and disrespectful to the residents in the way she spoke to them. She yelled at them rather than talking to them. She had an attitude towards the residents. There was a male resident who tried to follow her into a female resident's room,and rather than redirecting him calmly, CNA 6 said to the male resident You can't come in here, this is a female resident's room and I have to change her! LPN 23 indicated she didn't think too much of it and thought CNA 6 was just over-stimulated or irritated. LPN 23 went to report what was told to her by CNA 7 to LPN 19, who had worked at the facility longer than she had. As she walked to the break room to talk with LPN 19, CNA 7, Housekeeper 12, and a Laundry Aide were talking in the hall. Housekeeper 12 informed her CNA 6 shoved Resident B's head on the ground. LPN 23 spoke with LPN 19, and went back to the unit to assess Resident B. Resident B told LPN 23 she was shoved to the ground. She was pushed on her chest and hit her head. LPN 19 walked CNA 6 out of the building. During an interview with LPN 19, on 8/2/23 at 4:39 p.m., she indicated she was on lunch break when LPN 23 came to get her and indicated there was a mess in AACU. CNA 6 was already outside. CNA 7 reported she had witnessed CNA 6 roughly try to get Resident B up. Resident B started fighting CNA 6 and knocked out her nose ring and knocked her glasses off of her face, and CNA 6 just dropped Resident B on the floor. LPN 19 felt CNA 6 should had left Resident B where she was and let her go back to sleep. CNA 7 had reported to her that Resident D was grabbed by CNA 6 during her shower. LPN 19 was in the process of handling other things and was passing medication at the time CNA 7 reported this to her (between 8:00 a.m. and 9:00 a.m.). She called the DON and sent Resident B to the hospital because she complained of neck pain. When CNA 6 came back in from smoking she indicated this was [NAME]--t and she didn't do anything, she was just trying to get Resident B up out of bed and she started kicking and fighting and she went to the ground. During a phone interview with CNA 6, on 8/3/23 at 9:36 a.m., she indicated Resident B was laying in another resident's bed. She woke her up by tapping on her shoulder and removed the blanket and informed her she was in the wrong room. Resident B didn't want to get up, but she needed to take care of the resident of the bed she was in. She assisted her to sit up and moved her to the head of the bed by putting her arm under Resident B's shoulder blades and thigh. She did not pick her up. Resident B was upset and confused, and thought she was in the correct room. She assisted her to stand up from the bed. Resident B was upset, and she hit her (the CNA's) glasses off her face and her facial piercing from her nose. As Resident B walked, the CNA lowered her to the ground. She did not drop her. After the resident was on the ground, CNA 7 had asked her to leave the room. She felt it was because the resident needed another person to assist her. She did not believe she touched Resident B while she was on the floor. She left the room. She was in pain due to her piercing was ripped out of her face. It was a tense situation, she was not mad at Resident B. Resident D had repeated verbalizations, such as can she go to her room when she was already in her room. During her shower, she tried to stand up and she would tap her on the shoulder to cue her and told her that the tile was slippery. She felt that she managed her stress well and when she felt stressed out, she asked to take a 15 minute break. During an interview with QMA 8, on 8/3/23 at 2:31 p.m., she indicated she was sitting at the desk charting. CNA 6 walked down the hall crying, and indicated she tried to get Resident B out of a male resident's bed, and Resident B ripped her nose ring out of her nose and knocked her glasses off her face. QMA 8 reported to LPN 23 what CNA 6 told her. She went back to the male resident's room with CNA 6 to find CNA 6's nose ring and then CNA 6 left the unit. Resident B was [NAME] and smart-mouthed, but she had never seen her be aggressive. CNA 7 reported to her, about 30 minutes prior to the incident with Resident B, that Resident D tried to stand up during the shower and CNA 6 shoved her back into the shower chair. A current facility policy, titled Abuse, Neglect and Exploitation, copyrighted 2023 and provided by the DON, on 8/2/23 at 2:45 p.m., indicated the following: Policy: It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse The deficient practice was corrected by August 1, 2023, prior to the start of the survey, and was therefore past noncompliance. The facility had completed resident assessments, staff and resident interviews, and education related to abuse. This Federal tag relates to complaint IN00414267. 3.1-27(a)(1)

Based on interview and record review, the facility failed to prevent the physical abuse of a cognitively impaired resident (Resident G) by a staff member (CNA [Certified Nursing Aide] 17). The facility also failed to prevent sexually inappropriate behaviors when a cognitively intact resident (Resident F) touched a severely cognitively impaired resident (Resident E) inappropriately. Using the reasonable person concept, it is likely these deficient practices would lead to chronic or recurrent fear and anxiety. The deficient practice was corrected by February 15, 2023, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, audits, and education related to abuse. Findings include: 1. Review of a facility reportable, dated 2/14/2023, indicated the ED (Executive Director) was escorting a terminated employee from the facility. The terminated employee became vocal and stated whoever punched [Resident G] in the face needed to be next. The facility had previously investigated a bruise under the resident's right eye, and determined it was from a previous fall. Once the allegation was made by the terminated employee the facility re-opened an investigation. The clinical record for Resident G was reviewed on 2/24/2023 at 2:30 p.m Diagnoses included, type 2 diabetes, encephalopathy, anxiety disorder, hypertension, vascular dementia with behaviors and chronic pain. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 2/15/2023, indicated the resident was severely cognitively impaired. Review of a care plan, dated 8/30/2022, indicated I sometimes have behaviors which include Rejection of care such as yelling and being combative with care. Interventions included, but were not limited to, please tell me what you are going to do before you begin; Speak to me unhurriedly and in a calm voice. Review of a risk management report, dated 1/27/2023, indicated staff noted a purple bruise to the resident's right eye right measuring 4.8 centimeters (cm) long x 2.4 cm wide. Staff noted the bruise was observed on 1/27/2023 at 6:00 a.m., when the day shift began. In a written statement, dated 2/15/2023, Employee 18 indicated CNA 4 and CNA 17 had provided care to the resident, and when they exited the room CNA 17 indicated the resident had elbowed her in the private area. A written statement by the DON (Director of Nursing) indicated on 2/15/2023, CNA 17 was notified of suspension, pending investigation. CNA 17 had indicated the resident sustained a fall a few days prior, and then he had the bruise. CNA 17 indicated the resident was combative at times, but care was always completed with two staff members and it wasn't that bad. A written statement, dated 2/15/2023, by the ED and DON, indicated CNA 4 was re- interviewed regarding any incident on 1/25/2023. During the interview, CNA 4 stated She did it. She hit him. I am sorry I haven't said anything sooner, but I was afraid that I would lose my job. CNA 4 and CNA 17 had been providing care to the resident. CNA 4 was holding the resident's hands and CNA 17 was standing behind the resident. The resident's hand slipped from CNA 4 and the resident's elbow hit CNA 17 in the private area. From behind the resident, CNA 17 swung out and hit the resident in the eye. CNA 4 indicated they were shocked and it happened so quickly. During an interview, on 2/27/2023 at 11:13 a.m., CNA 4 indicated on 1/25/2023 while providing care for Resident G with CNA 17,the following had occurred: Dinner had just finished between 5:00 and 5:30 p.m. Usually they got people ready for bed, changed them, toileted them. She (CNA 17) asked for help with Resident G. CNA 4 was holding his hands and at first, the resident was ok. When CNA 17 started to pull the resident's pants down, he had started to shake. He had then pulled his hands free and hit her. CNA 4 didn't see where, but knew he had hit her. She was standing behind him, and just shot out and hit him on his face with a closed hand. When CNA 4 asked her why she did that, she said I am sorry he just hit me in my (slang term for female private area). CNA 4 was shocked and did not know how to react, so he just stayed away from her. He didn't tell anyone. He realized now he should have told someone. When the ED and DON asked him the previous week what had happened, he told them what had actually happened. He had never seen CNA 17 do anything like that before. She was one of the kinder aides, so he was really shocked. During the survey, the facility attempted to contact CNA 17 for an interview, but were unsuccessful. 2. The clinical record for Resident E was reviewed on, 2/24/2023 at 1:47 p.m Diagnoses included, dementia, anxiety, visual hallucinations, and delusional disorder. Review of the most recent admission Minimum Data Set (MDS) assessment, dated 2/2/2023, indicated the resident was severely cognitively impaired. The resident was admitted to the facility's memory care secured unit on 1/27/2023. Resident behaviors included wandering four to six days out of the assessment period. A current care plan, dated 1/27/2023, indicated I have a diagnosis of Alzheimer's or related dementia. Due to cognitive loss, diminished decision making capabilities and safety and security issues, placement in the secure Alzheimer's Care unit with programs designed for this population is needed as evidenced by: dx [diagnosis] of dementia. Review of a facility reportable incident, dated 2/7/2023, indicated on 2/6/2023 at 9:30 a.m., Housekeeper 2 observed Resident F with his hands down the back of Resident E's pants. The residents were in Resident E's room. The clinical record for Resident F was reviewed on 2/24/2023 at 2:00 p.m. Diagnoses included, end stage renal disease with dependence on renal dialysis, obstructive sleep apnea, depressive disorder, vascular dementia, anxiety, and sexual dysfunction. Review of the most recent quarterly MDS, dated [DATE], indicated the resident was cognitively intact. Behaviors included, but were not limited to the following: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)- occurred one to three days during the assessment period. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)-occurred one to three days during the assessment period. A current care plan, dated 4/1/2022, indicated I sometimes have behaviors which include kissing other residents, holding others [sic] resident's hands; inappropriate touching Dx: other sexual dysfunction not due to a sustance o [sic] know [sic] physiological condition. Review of a Psychiatry Progress Note, dated 12/29/2022, indicated there were no sexually in appropriate behaviors during the visit. The gradual dose reduction for Paxil was declined since there had been a decrease in sexually inappropriate behaviors since receiving Paxil (antidepressant/antianxiety) 20 mg once a day. Review of a Psychiatry Progress Note, dated 1/19/2023 indicated the resident was being seen for psychiatric follow up and medication management for dementia, depression, mood disorder, and sexual inappropriate behaviors. The noted indicated the resident had multiple noted behaviors of inappropriate gestures and touching of staff and other residents, but was stable. An order for Depo-Provera (hormone-suppressant) 150 mg/ml weekly-on Monday after dialysis and to monitor closely as written at this visit. Review of a Psychiatry Progress Note, dated 2/2/2023 indicated the resident was being seen for acute increased sexually inappropriate behaviors towards staff and other residents. The resident had a new order for Depo-Provera 150 mg/ml intramuscular suspension one a day on Fridays. One dose had been administered at the time of the visit. The order was changed to Mondays after dialysis on 2/2/2023. During an interview, on 2/24/2023 at 2:24 p.m., Housekeeper 2 indicated on 2/6/2023 she had entered Resident F's room, and observed him with his hands down the back of Resident E's pants. The housekeeper reported Resident E did not seem to know what was happening. She just looked at me dumbfounded. It was like she was saying 'I don't know what to do'. She didn't seem to be on board with it. During an interview, on 2/24/2023 at 3:17 p.m., the DON indicated Resident F was no longer on the secured unit. He had been placed there because of his confusion and exit-seeking behaviors. After the incident, the resident was reassessed and moved off the unit. Resident E was new to the facility, and wandered in and out of other residents' rooms. During an interview, on 2/27/2023 at 10:28 a.m., the DON indicated Resident F had a history of sexually inappropriate behaviors and had not moved from the secured unit due to his fluctuations in his cognitive state and exit-seeking behaviors. The facility felt he was safe to move off the unit, after the incident, because his BIMS (cognitive assessment) was 15 out of 15. During an interview, on 2/27/2023 at 1:32 p.m., QMA (Qualified Medication Aide) 8 indicated she had never had any experience with Resident F's behaviors. But, she knew he could be head strong and had heard about his sexually inappropriate behaviors. During an interview, on 2/27/2023 at 1:25 p.m. LPN 7 indicated Resident F was made a care in pairs (two-person ) because he would fondle the staff during care. Review of a current, undated facility policy, titled Abuse, Neglect and Exploitation was provided by the Assistant Director of Nursing on 2/24/2023 at 10:19 a.m. The policy indicated the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Definitions: . 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 and certain resident to resident altercations. Abuse also includes the deprivation by any individual including 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 including abuse facilitated or enabled through use of technology .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm This Federal tag relates to complaints IN00401123 and IN00401809. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent and provide adequate assessment of a fall for 1 of 4 residents reviewed for accidents (Resident B) This deficient practice resulted in Resident B sustaining a fracture of the left ankle. Findings include: The clinical record for Resident B was reviewed on 10/5/2021 at 9:38 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], hypertension, left eye [CONDITION(S)], chronic pain syndrome and depression. The last documented weight of the resident was on 7/25/2021 at 307 pounds. An Admission Minimum Data Set (MDS) assessment, dated 6/24/201, indicated the resident was severely cognitively impaired. The resident required extensive assistance of 2 persons for bed mobility, transfers, locomotion, toilet use, dressing, eating, personal hygiene. The resident was non- ambulatory; impaired upper and lower extremities both sides and had no history of falls prior to admission. Review of a CNA assignment sheet, dated 8/5/2021, indicated Resident B was a fall risk and required total assistance for transfers with a mechanical lift. Review of a fall care plan indicated the resident was at risk for falls. Interventions were as follows: 1.) Assess for pain initiated 6/21/201, last revised 9/22/2021. 2.) Gait belt with transfers initiated 6/21/2021, last revised 9/22/2021. 3.) Keep environment free of clutter initiated 6/21/2021, last revised 9/22/201. An admission fall risk assessment, dated 6/18/2021 and a current fall risk assessment, dated 9/13/2021, indicated the resident was at risk for falls. A nursing progress note, dated 9/13/2021 at 11:45 a.m., indicated a Certified Nursing Assistant (CNA) reported the resident was on the floor in her room next to her bed. The note indicated the resident was assessed for pain and injury and found to have full range of motion. The resident complained of pain in the right knee and was assisted back to bed by several staff members using a mechanical lift. A nursing progress note, dated 9/14/2021 at 2:41 p.m., indicated the resident's husband requested the resident be sent to the emergency room for evaluation. The physician and the Director of Nursing (DON) were made aware. The medical record lacked any documentation for the reason the husband wanted the resident sent to the hospital for evaluation. The clinical record lacked any documentation of altered mental status. A Post Fall Evaluation, dated 9/13/2021 at 4:21 p.m., indicated the fall was unwitnessed; the reason for the fall was not evident; there were no changes in mental status, behaviors or mobility status. A Fall Follow Up, dated 9/13/2021 at 4:21 p.m., indicated the resident fell out of bed. An abrasion was listed as an injury with no location or measurement documented. The follow up documented the resident was up on side of bed when staff walked in and resident was transferred to the emergency room the next day. Review of a written statement of an interview with the resident by the DON, dated 9/13/2021 at 11:30 a.m., indicated the resident stated she was on the side of the bed sitting, then she was falling to the floor. Review of a written Interdisciplinary Team (IDT) note, dated 9/14/2021 at 9:00 a.m., indicated the resident was sitting on the side of the bed and fell . The resident complained of knee pain that improved once she was back in bed. The CNA was educated on not leaving the resident on the side of the bed unattended. The resident was to be referred to therapy for safety on side of bed. Review of the Emergency Department Physician Progress Note, dated 9/14/2021 at 3:31 p.m., indicated the resident presented to the emergency room with altered mental status and was unable to provide history. The note indicated per the husband and nursing home the resident had been verbal, conversant and followed commands at baseline. The husband indicated during the night of 9/13/2021, the resident became non-verbal and unable to tract conversations or follow commands. The initial assessment concluded the resident was non-verbal and not at baseline. The left ankle and left finger were deformed and bruised. The resident's recorded emergency room weight was 283.7 pounds. Review of imaging on 9/14/2021 at 6:24 p.m., indicated left ankle dislocation with medial malleolar and fibular fractures. The resident was also found to have left middle finger subluxation. A closed reduction under sedation was performed in the emergency department. Review of the Inpatient Orthopedic Staff Progress Note, dated 9/21/2021 at 8:55 a.m., indicated the resident had been admitted to the hospital ICU for metabolic [CONDITION(S)]. She is now waking up from her moribund state and is answering questions intermittently and complaining of some right leg is [sic] well as right hip and left ankle pain. Review of a x-ray of the right femur, dated 9/21/2021 at 11:48 a.m., indicated a communicated impact fracture of the distal femur. Review of the hospital inpatient clinical records on 10/5/2021 at 9:40 a.m., lacked any documentation of falls or accidents. During an observation on 10/5/2021 at 3:26 p.m., the Maintenance Director put a resident bed in high position and measured the height from top of mattress to the floor at 36 inches. During an interview on on 10/5/2021 at 10:54 a.m., the Therapy Director indicated Resident B was discharged from physical therapy on 8/11/2021 with a recommendation of mechanical lift use for transfers. The Therapy Director indicated the resident would have needed assistance to get to the side of the bed and would not have been able to sit on the side of the bed without assistance. During an interview on 10/5/2021 at 11:03 a.m., PT 1 indicated Resident B had needed max assistance of 1-2 persons to sit on the side of the bed. The resident would need to have the bed in the low position, feet on the floor and hands on the bed with at least standby guard assistance to maintain a sitting position on the side of the bed. PT 1 indicated the resident had been able to follow commands and was usually compliant with therapy unless she became emotional, but could be redirected to participate. During an interview on 10/5/2021 at 12:05 p m., Unit Manager 3 indicated on 9/13/2021 she had been called to Resident B's room by CNA 4 and was told the resident had been sitting on the side of the bed and fell . The Unit Manager indicated she did not know how the resident had been able to sit on the side of the bed. She indicated the resident always kept her bed in the high position so she could look out of the windows in her room. She indicated CNA 4 had witnessed to fall but had been unable to intervene and the resident had fallen on the CNA's foot. The Unit Manager indicated the resident had [CONDITION(S)] and her joints were deformed and had not look any different than usual. During her post fall assessment she did not see any bruising. The resident complained of right knee pain but had normal range of motion. No x-rays were ordered. On 9/14/2021 the resident was sent to the hospital for evaluation because she was not herself mentally. The resident could normally follow commands and make her needs known. The alteration in mental status was not documented in the clinical record. During an interview on 10/5/2021 at 1:04 p.m., CNA 4 indicated on 9/13/2021 she was assisting the roommate of Resident B. She indicated she left the room to get some water and when she returned she observed Resident B in the process of swinging her legs over the side of the bed to sit up and then fell on to the floor. She indicated and demonstrated the resident fell on her knees and hit her head on the wall. She indicated she had never seen the resident attempt to sit up on her own. I was shocked. CNA 4 indicated she thought there might have been up to 10 people in the room to help get the resident off the floor and back into bed by using a mechanical lift. During an interview on 10/5/2021 at 2:53 p.m., the DON indicated the fall care plan for Resident B had not been updated with current interventions. The DON indicated she did not think Resident B had ever transferred with a gait belt. During an interview on 10/6/2021 at 11:03 a.m., LPN 5 indicated she knew Resident B and had never known her to attempt to sit on the side of the bed unassisted. During an interview on 10/6/2021 at 11:04 a.m., CNA 6 indicated she had provided care to Resident B often. I took care of her all the time. She indicated the resident was unable to get up on the side of her bed by herself. The resident required 2-3 people to turn her in the bed. The resident would freak out when staff sat her up to feed her. Review of a current undated policy, titled Accidents and Supervision, indicated the following: . Policy Explanation and Compliance Guidelines: . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of aspersion: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. This policy was provided on 10/5/2021 at 2:04 p.m. by the DON. This Federal tag relates to Complaint IN 228. 3.45-(a)(2)

Based on interview and record review, the facility failed to ensure monitoring for a resident's suprapubic catheter for 1 of 3 residents reviewed for urinary infections (Resident E). This deficient practice resulted in Resident E being admitted to the hospital for [CONDITION(S)] and a UTI (Urinary Track Infection). Findings include: Resident E's clinical record was reviewed on 9/14/21 at 10:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His medications and orders included, but were not limited to, [MEDICATION(S)] (decrease [MEDICATION(S)] levels) solution 30 cubic centimeter (cc) daily, [MEDICATION(S)] (bladder relaxant) 5 (mg) milligram daily, tamsulosin (treat urinary retention) 0.4 mg daily, change catheter bag and leg bag on the first and the 15th on night shift, cleanse suprapubic site with normal saline, pat dry, apply drain sponge every day shift, leg bag in a.m. and switch to catheter bag in p.m. every morning and at bedtime for catheter maintenance, document output via catheter every shift. His discontinued orders included, but was not limited to, flush suprapubic catheter with 60 milliliters (ml) of normal saline one time due to pain and bladder spasms one time only related to obstructive and reflux [CONDITION(S)] on 3/10/21, change suprapubic catheter due to sluggishness one time only for sluggishness on 3/10/21 and suprapubic catheter with 16 french Foley to be changed monthly at urology office revised on 3/1/21. A modified quarterly Minimum Data Set (MDS), dated [DATE], indicated he was cognitively intact. He required extensive assistance of two staff members for bed mobility, dressing and personal hygiene. He required limited assistance of two staff member for toileting. He had and indwelling catheter (including suprapubic catheter and nephrostomy tube). He had an external catheter. He was always incontinent of bladder. He had a [CONDITION(S)] (MDRO). His care plans included, but were not limited to, the following: a. Urinary Tract Infection, potential due to: history of chronic urinary tract infections and suprapubic catheter. His goal was the urinary tract infection would resolve without complication. His interventions included, chronic/recurring urinary tract infection managed without complications, encourage fluids unless contraindicated, observe and report signs and symptoms of Urinary Tract Infection (UTI): changes in color, odor or consistency or urine, dysuria, frequency, fever, pain, provide suprapubic catheter care every shift and as needed, secure catheter and tubing appropriately. b. Urinary Tract Infection, potential or actual due to: Urinary Tract Infection (UTI), supra-pubic catheter. His goal was the urinary tract infection will resolve without complication. Interventions included, labs as ordered, medications as ordered and urology consult as needed. c. Disorder of the urea cycle metabolism, unspecified. His goal was he would remain free from complications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A consultation/clinical referral, dated 4/21/21, indicated the resident's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no new orders with stop dates noted and the date and time of next appointment was in six months. An office visit report, dated 4/16/21, indicated in the notes section suprapubic, Extracorporeal Shock Wave Lithotripsy (ESWL) with stent - stable remove stent in one week. History of Transurethral Resection of the Prostate (TURP) - has foley changed at nursing home. The clinical record lacked indication the catheter bag and tubing had been changed since the April appointment with the urologist. A Situation, Background, Assessment, Response (SBAR) change of condition note, dated 8/14/21 at 6:30 p.m., indicated the resident was unable to stand, complained of dizziness, he felt weak, he was alert and speaking to staff. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . His blood pressure was 72/50, his heart rate was 48 on initial assessment, he was encouraged to drink more fluids, the next blood pressure was 85/50 and a heart rate of 51. The medical doctor and DON was notified. The resident would be sent to the emergency room . A nurses note, dated 8/15/21 at 1:53 a.m., indicated he was admitted to the hospital for [CONDITION(S)], UTI and pneumonia. An Adult Protective Service Report Integrated Care Management from a local hospital, dated 8/17/21, indicated the Resident E arrived to the emergency department in very poor condition. He had an old suprapubic catheter which had been there for an unknown period of time and his clothing was soaked in urine. Per his history and physical he was diagnosed with [MEDICATION(S)] with a likely source of the suprapubic catheter, poor management by Extended Care Facility (ECF) staff. An Emergency Department Progress Note (ED), dated 8/14/21, indicated, but was not limited to, Computed Tomography (CT) of abdomen evidence of [MEDICATION(S)]. Given patient's systolic blood pressure was 80, White Blood Count (WBC) was high at 14, [CONDITION(S)] was low at 129 with [MEDICATION(S)]. Plan to admit for [CONDITION(S)], UTI, [CONDITION(S)] and dehydration. During an interview with the DON, on 9/14/21 at 1:30 p.m., she indicated he had the suprapubic catheter for a couple years, the facility was changing it some during the COVID pandemic and it was normally changed at the urologist office. During COVID they changed it once a month at the facility. They did preventative cleansing around the cite of the suprapubic catheter. During a telephone interview with RN 75, on 9/15/21 at 12:36 p.m., she indicated she was not aware when the resident's suprapubic catheter was changed last, she worked weekends and she thought it was changed during the week. When the resident was sent to the hospital he was dizzy, his blood pressure was low, he was stable and was talking to her. The CNA had indicated he looked pale and they had just cleaned him up. His catheter was not leaking at that time. The resident was clean when he left the facility and she would not let a resident leave the facility with urine on them. During an interview with the Certified Medical Assistant (CMA) at the urologist office, on 9/15/21 at 1:48 p.m., she indicated the resident was last seen on 4/21/21, normally they only needed to see patients once every six months or once a year if they lived in a nursing home or an assisted living. The suprapubic catheters were normally changed in the nursing facilities if they were able. The urologist notes had indicated the catheter was changed at the facility. The facilities were to call for notes/questions and to schedule the 6 month appointment. In April the suprapubic catheter was changed as a courtesy, because he had abdominal pain and he was pulling at his genital area. A current facility policy, titled Suprapubic Catheterization, provided by the Administrator on 9/14/21 at 1:34 p.m. indicated the following: Policy: Suprapubic catheters will be changed in accordance with current standards of practice to minimize risk for bacterial contamination or failed insertions. Policy Explanation and Compliance Guidelines: 1. The care and maintenance of suprapubic catheters shall be in accordance with physician orders. The orders shall specify the type and size of catheter, and frequency of catheter changes . 3. Suprapubic catheters shall be changed in this facility only after the stoma tract has healed (usually about four weeks), and the surgeon (or physician if catheter is chronic) has approved the catheter changes in this facility This Federal tag relates to Complaint IN 054. 3.1-47(a)(3)

Based on record review and interview, the facility failed to develop and implement immediate interventions to prevent further falls for 2 of 3 residents reviewed for falls (Residents B and E) and failed to notify the physician of abnormal findings of a physical assessment following a resident's fall for 1 of 3 residents reviewed for falls (Resident B). This deficient practice resulted in Resident B sustaining a subdural hematoma and being placed on palliative care. Findings include: Review of Resident B's closed clinical record was completed on 2/17/21 at 12:27 p.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A 7/23/20 significant change Minimum Data Set (MDS) assessment indicated she had both short and long term memory problems, and her daily decision skills were moderately impaired. She required extensive assistance with bed mobility, transfers, walking in the corridor, toileting, and personal hygiene. She required limited assistance walking in her room. She was not steady during transitions and walking and required staff assistance to stabilize. She did not use an ambulatory aide. She had no fall history. She had a 3/31/20 care plan problem of physical functioning related to self care impairment, [MEDICAL CONDITION] disorder, and [MEDICAL CONDITION]. Interventions included, but were not limited to, call bell within reach, staff to assist with bed mobility, staff to assist with eating, staff to assist with toileting, and staff to assist with transfers. She had a 4/1/20 care plan problem of little or no awareness of safety, or boundaries related to other's personal space. She needed help to remain in a living environment that met and supported her need to safely wander due to not always being aware if areas were okay for her to be in. Interventions included, but were not limited to, have some of my personal belongings in my room and memory box, I may become confused and frightened by the alarm that sounds when I try to leave my living space; please comfort me by turning off the alarm and offer to take a walk with me to the family room, garden, or kitchen for a snack, in the afternoon it is harder for me to remain satisfied in my secured living environment. It may help if you keep me involved in activities such as (left blank). She had a 4/8/20 care plan problem of risk for falls related to diabetes, [MEDICAL CONDITION], dementia, and general decline. Interventions included, but were not limited to, (7/24/20) bright colored walker tape, (4/8/20) foot wear to prevent slipping, (4/8/20) environment well lit and free of clutter, and (7/31/20, initiated on 8/4/20) low bed with mat at bedside. A 6/26/20 progress note indicated she was sent to an inpatient geriatric psychiatric facility for treatment. A 7/17/20 progress note indicated she returned to the facility via ambulance. She was walking per her usual without difficulties. A 7/17/20 admission assessment indicated she could not ambulate or transfer independently, nor could she ambulate or transfer with limited assistance. She had a fall risk assessment score of 11; a score above 10 deemed the resident at risk for falls. She was disoriented at all times and incontinent/ambulatory. She required an assistive device. A 7/23/20 progress note indicated at 7:59 p.m., she fell in the hallway as she was walking with another resident. She was next to the resident dining room door when she fell in the doorway, facing down the hall toward the ACU unit. She sustained a small cut above her right eye and a bloody nose. Her right eye appeared to be starting to swell and darken. Her neurological assessment (neuro check) and range of motion (ROM) appeared to be within normal parameters for the resident. A new physician's orders [REDACTED]. An additional note indicated her fall had actually occurred at 7:15 p.m. There was no indication in the clinical record an intervention was immediately implemented to prevent further falls, nor was the care plan updated. A 7/24/20 at 5:07 a.m. progress note indicated the area around her right eye was starting to bruise. Her blood pressure was 128/74. A 7/24/20 progress note indicated she had been up for breakfast, then requested to lay down after the meal. Her blood pressure was 116/45. The physician was not notified of the lower blood pressure. Review of a 7/24/20 Interdisciplinary (IDT) note indicated they had met to discuss the resident's 7/23/20 fall. The resident had been ambulating in the hall when she fell . She was noted to have a small laceration above her right eye. The intervention was bright colored tape to her walker. A 7/24/20 at 9:02 p.m. progress note indicated she had a blackened right eye with a small 1 centimeter (cm) laceration above the same right eye. She had been ambulating with her walker as normal a lot of the rest of the shift. Her blood pressure was 120/62. On 7/30/20 at 10:45 p.m., a CNA heard a noise in Resident B's room, entered the room, and observed her lying on the floor next to her bed on her left side. The resident would frequently get up out of bed at night. She had a new 1.0 cm long x 0.1 cm wide laceration to the side of her left eye and a 4.0 cm long x 0.1 cm wide skin tear to her left elbow. Steri strips were applied to the laceration near her left eye and to her left elbow. Her blood pressure was 120/68. There was no indication in the clinical record an intervention was immediately implemented to prevent further falls, no was the care plan updated. A 7/31/20 at 9:12 a.m. progress note, signed by LPN 13, indicated she was .resting in bed. Resp. easy. No sign of distress noted. Dressing to left hand intact. No drainage noted. Range of motion within normal limits (sic) No signs of pain or discomfort A 7/31/20 at 3:20 p.m. note, signed by LPN 22, indicated she was .resting in bed. Resp. easy. No sign of distress noted. Dressing to left hand intact. No drainage noted. Range of motion within normal limits (sic) No signs of pain or discomfort Review of a neuro check document, started 7/30/20 at 10:45 p.m., indicated the 7/31/20 assessment for the 2:00 p.m. -10:00 p.m. shift blood pressure was 109/73 and her oxygen saturation was illegible. A 7/31/20 10:00 p.m. - 6:00 a.m. assessment indicated her blood pressure was 105/68, she had no speech, was lethargic, and no documentation for her pupil reaction. Review of a 7/31/20 at 4:00 p.m. progress note (late entry made 8/4/20 at 11:18 a.m.) indicated the IDT team met to discuss the resident's 7/30/20 fall. She was found on the floor in her room by a CNA after hearing a noise from her room. She had a laceration to the side of her left eye, as well as skin tear on her left elbow. The intervention was a low bed with a mat at bedside. A 7/31/20 at 6:30 p.m. progress note (late entry made 7/31/20 at 11:59 p.m.) indicated a CNA informed the nurse Resident B had been non-responsive since she began her shift at 2:00 p.m. Upon assessment, the resident was non-responsive and her blood pressure was 105/68. The physician gave an order to send her to the emergency department if her family agreed. She was transported to the hospital via ambulance. Review of a 7/31/20 Emergency Department note indicated the resident had a significant subdural hematoma with midline shift. She also had a left hip contusion/hematoma and patchy groundglass opacities of the right lung. Review of a 7/31/20 neurosurgery consult indicated Resident B had right sided facial trauma, yellow in color with deeper purple spots and laceration repairs on the eyebrow. She would not open her eyes, but was breathing on her own. She would react as if in pain to her right arm, but would not move it. After discussing options with her family, it was decided she would be provided palliative care and no surgery would be performed. Review of an 8/3/20 written statement from CNA 18 indicated she noted Resident B to be sleeping at around 2:00 p.m. She continued to sleep until around 4:00 - 4:15 p.m., when CNA 18 tried to awaken the resident for supper. She observed the resident with white spots in the back of her throat and her breathing was labored and she was gasping for breath. She notified LPN 22, who went in to check on the resident. At 6:00 p.m., when LPN 37 came on duty, CNA 18 notified her the resident was not doing well. Review of an 8/3/20 written statement from CNA 24 indicated she had cared for Resident B on 7/31/20. The resident did not get out of bed all day, but did move her mouth and tongue during oral care. She stirred a little, but did not open her eyes or speak. Review of an undated written statement from LPN 13 indicated she had completed an assessment on the resident at 7:30 a.m. and had checked on her at 11:00 a.m., when she responded to her name. Review of notes from an undated phone interview with LPN 22 indicated at 4:00 p.m., a CNA had told her Resident 20 wasn't looking well. She took her vital signs; the resident sounded gurgly and improved when she elevated the head of her bed. Resident 20 had opened her eyes and looked at her. At 5:45 p.m., she put the vitals on the neuro check sheet. During an interview, on 2/18/21 at 11:18 a.m., LPN 14 indicated falls were documented in the clinical record. Care plans were not updated by the nurses; the IDT completed the care plan. If an intervention was put into place by the nurse, it would be documented in the notes, and then IDT would review it. During an interview, on 2/18/21 at 1:49 p.m., the DON indicated interventions were put into place after the resident falls, such as bright colored tape on her walker. The intervention would have been discussed on the phone with the DON when she was notified of the fall and put on the CNA assignment sheets. The interventions were probably not documented in clinical record until the IDT reviewed it, and they did not keep copies of the CNA sheets. The IDT notes were put in the clinical record after the meeting took place. The facility had concluded, after their investigation, the resident had not been unresponsive when LPN 22 assessed her. The physician should be notified if a resident has lower than normal blood pressures. LPN 22 should have probably noted the assessment in the clinical record, but not necessarily. 2. On 2/17/21 at 1:15 p.m. Resident E was observed sitting in her room near the entrance to her door in her wheelchair, she had on non skid socks. She had an abrasion to the end of her nose. A staff member gave her her stuffed dog and locked her wheels to her chair at the entrance to her room. On 2/18/21 at 9:34 a.m., Resident E was observed in her wheelchair sitting on the Advanced Alzheimer's Care Unit (AACU) indoor porch, she had non skid socks on. Resident E's clinical record was reviewed, on 2/17/21 at 12:38 p.m. [DIAGNOSES REDACTED]. Her current orders included, but were not limited to, [MEDICATION NAME] (blood pressure) 10 milligram (mg) daily, klonopin (anti-anxiety) disintegrating 0.125 mg three times daily, memantine (cognition) 10 mg twice daily, [MEDICATION NAME] (anti-depressant) 100 mg daily, Physical Therapy to evaluate and treat related to falls and gate weakness, dated 1/24/20, STAT (now)/call 1. 2-view x-ray of right hip 2. Right two view x-ray to hand and wrist, Diagnosis: [REDACTED]. May also include electrical stimulation, dated 1/22/21. A modified quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident was severely cognitively impaired. She required extensive assistance with bed mobility, dressing and toilet use. She required limited assistance with transfers, walk in room or corridor. She required supervision with locomotion on the unit. She used a walker. She was occasionally incontinent of bladder and always continent of bowel. She had not had any prior falls. A fall risk assessment, dated 10/12/20, indicated the resident was at risk for falls. A nurses note, dated 10/15/20 at 3:00 a.m. indicated the resident's call light was engaged. A CNA responded to the call light and the resident was sitting on the floor in front of toilet on her buttocks with her legs extended in front of her. She denied pain. Her range of motion was within normal limits. There were no internal/external rotation of extremities. Vital signs were obtained and the resident was assisted up and into bed. She had urinated on the floor and had slipped. She had regular socks on at time of fall. Neurological checks implemented due to unwitnessed fall. She was a poor historian, she stated it was too far. The fall follow up paperwork, provided by the ADON, indicated the intervention for the fall on 10/15/20 was the floor was cleaned and took the resident to the toilet at 2:00 a.m. bed check. The clinical record lacked a care plan intervention for the resident's fall on 10/15/20. A nurses note, dated 10/16/20 at 5:57 a.m., indicated the resident continued on fall follow up monitoring and bruises were noted on the resident's right forearm and tailbone. A Situation, Background, Assessment and Recommendation (SBAR) - change of condition note, dated 10/16/20 at 9:46 p.m., indicated the resident was found on the floor in room [ROOM NUMBER]. She was in the room with several other residents who had claimed she had fallen. The resident's vitals and range of motion were normal for her. The resident's klonopin was held for one week and the resident started on [MEDICATION NAME] (antibiotic) 1 gram (gm) for three days. The fall follow up paperwork, provided by the ADON, indicated the intervention for the fall on 10/16/20 was a medication change. The clinical record lacked a care plan intervention for the fall on 10/16/20. A nurses note, dated 10/17/20 at 7:36 p.m., indicated the resident was found on the floor by a CNA. The resident tried to transfer herself, lost her balance and fell at the end of her bed, no injuries were seen, the resident complained of pain to her right side mid back area. Unit manager and doctor were notified. A new order for Tylenol (pain reliever) 650 mg to be given every six hours as needed (PRN) for pain. The resident was placed on neurological and 15 minute checks. Neurological checks and vital signs were within normal limits. A SBAR - change of condition note, dated 10/17/20 7:37 p.m., indicated the resident was found on the floor by a CNA at the end of her bed. The resident tried to self transfer and lost her balance. She had a history of [REDACTED]. The resident's neurological and vital signs were within normal limits, no injuries were visible. The resident complained of mid back pain to her right side. Her vital signs and neurological checks were within normal limits, she was assisted up and into chair, physician and unit manager was notified. The resident was placed on follow up for fall with neurological checks for 72 hours and 15 minute checks until confusion subsided. The fall follow up paperwork, provided by the ADON, indicated the intervention for the fall on 10/17/20 was UTI treatment and emergency room (ER) visit for a rib fracture. The clinical record lacked a care plan intervention for the fall on 10/17/20. A nurses note, dated 10/18/20 at 2:41 a.m., indicated the resident was in increasingly more pain from the prior day fall. She had a large bruise on her right side, approximately 5 inches long by 1/2 inch wide, that was not present earlier. Resident rated her pain 8/10 and wished to go to the hospital. A nurses note, dated 10/18/20 at 11:15 a.m., indicated a report was received from the hospital and the resident was admitted for a fracture to her fibula (lower leg bone). A Final Report for a Computed Tomography (CAT) Scan (CT) chest with intravenous (IV) contrast, CT abdomen and pelvis with IV contrast from the hospital, dated 10/18/20 at 5:22 a.m., indicated the indications for the exam were a fall, right rib pain from a fall on 10/17/20 at 7:30 p.m. Impression of the CT scan of the chest indicated: 1. Findings suggestive of flexion/distraction injury of the upper [MEDICATION NAME] spine. Severe compression deformity of the T4 which is unchanged from chest radiograph completed on 3/2/20, but there were acute appearing nondisplaced posterior spinous process fractures of T3 and T4. 2. Acute minimally displaced right lateral ninth and tenth fractures in the setting of multiple bilateral chronic deformities. A Final Report for a Magnetic Resonance Imaging (MRI) [MEDICATION NAME] spine without contrast from the hospital, dated 10/18/20 at 7:47 a.m., indicated the indications for the exam were T3/T4 fractures, recent fall and right rib pain. Impression of the MRI indicated: 1. Acute fractures of the T3 and T4 spinous processes with small amount of adjacent marrow [MEDICAL CONDITION] signal and paraspinal [MEDICAL CONDITION]. 2. Chronic appearing compression deformities of the T1 to T4 vertebral bodies. An Interdisplinary Team (IDT) note, dated 10/19/20 at 2:59 p.m., indicated the resident's fall that occurred on 10/16/20 was discussed. Resident was found in another room on the floor. Witnesses stated that she fell down. She stated that she lost her balance. No injuries were noted during the assessment. Intervention was a medication changed. An IDT note, dated 10/19/20 at 3:08 p.m., indicated the resident's fall that occurred on 10/17/20 was discussed. The resident had recent fall on 10/16/20 and again on 10/17/20. Resident was found on the floor in her room, she had attempted to transfer herself from the wheelchair and lost her balance. Assessment was completed by the nurse. No injuries were noted. Vital signs were within normal limits. Neurological checks were initiated. Interventions was a treatment for [REDACTED]. A SBAR change of condition note, dated 10/30/20 at 2:15 a.m. indicated the resident was noted sitting upright on her buttocks on the floor at 2:15 a.m. at the 15 minute check time, she had been sitting in her recliner at 2:00 a.m. The resident's foot rest was in an upright position, she was not wearing shoes, only nonskid socks. Her television and lights were on per the resident's request and she had been awake since the beginning of the shift. She had been toileted at approximately 12:15 a.m. with incontinence care provided. The resident denied and there was no evidence of her hitting her head, she was assisted to stand with a gait belt and two assist, she requested to use the bathroom, staff gave her the walker and she ambulated with stand by assistance of staff. The was no change in weight bearing or range of motion, no new apparent injuries noted, superficial abrasion to her backside from previous fall, the resident sustained [REDACTED]. The resident was forgetful with confusion noted, she was able to demonstrate call light use without difficulties, there were no complaints or sign or symptoms of pain and her call light was within easy reach, 15 minute checks continued. The resident had a [DIAGNOSES REDACTED]. The fall follow up paperwork, provided by the ADON, indicated the intervention for the fall on 10/30/20 was to replace recliner with one without a foot rest. The clinical record lacked a care plan intervention for the resident's fall on 10/30/20. A SBAR change of condition note, dated 11/5/20 at 6:15 a.m., indicated the resident was sitting on her buttocks in front of her recliner with her bilateral lower extremities out in front of her, a blanket that resident had over her while resting in the recliner prior to fall was under her buttocks and her bilateral lower extremities, her shoes were on, footrest on the recliner was down. The resident stated, I don't know what happened, a head to toe assessment was completed, no apparent injuries were noted, she denied and there was no evidence of her hitting her head. She was assisted to stand with a gait belt and two assist, staff provided her with her walker and she ambulated without change in range of motion, weight bearing or gait. The resident requested to get back into her recliner. There were no signs, symptoms or complaints of pain, her call light was within reach and 15 minute checks continued. The resident had a history of [REDACTED]. The fall follow up paperwork, provided by the ADON, indicated the intervention for the fall on 11/5/20 was dycem (non slip mat) in her recliner. The clinical record lacked a care plan intervention for the resident's fall on 11/5/20. A SBAR change of condition note, dated 11/25/20 at 9:57 p.m., indicated the resident was found lying on the floor on her back in her room, she had sneakers on both feet, the floor was dry and clutter free. The resident had dementia. The clinical record lacked a care plan intervention for the resident's fall on 11/25/20. Her current focused care plan, initiated on 7/7/20, indicated she was at risk for falls related to: dementia with behavioral disturbance, anxiety , muscle weakness and unsteadiness on feet. Her goal was no fall related injuries. Interventions were call light or personal items available and in easy reach initiated on 7/07/20. Footwear to prevent slipping, initiated on 7/7/20. Toilet resident after meals, initiated on 10/29/20. Open drapes/blinds during the day, initiated on 11/17/20 and revised on 11/24/20. Bright tape on walker, initiated on 11/23/20. During an interview, on 2/18/21 at 11:57 a.m., the DON indicated with the Administrator present, she thought Resident E had fibula fracture because that was the report they received from the hospital and didn't know until she came back from the hospital that it was not a fractured fibula, they were having trouble receiving the paperwork from the hospital. On 2/18/21 at 3:06 p.m. LPN 59 indicated they tried to keep Resident E within sight or in her recliner in her room. She would get up by herself and she needed lots of reminders to sit. On 2/18/21 at 3:54 p.m., the DON indicated that some of the interventions would not stay on the care plan, when she moved to the Alzheimer's Care Unit (ACU), the resident would move only one time so those types of care plans, would indicate they were resolved on the care plan. Review of a current facility policy, titled Falls Management Guideline, dated 4/25/18 and provided by the DON on 2/18/21 at 9:56 a.m., indicated the following: .Following a resident's fall .The licensed nurse assesses the resident for injuries .Appropriate interventions are implemented .Care Plan is updated .Residents at risk are care planned with individualized interventions This Federal Tag relates to Complaint IN 080. 3.1-45(a)

Based on observation, interview and record review, the facility failed to notify the physician or change the wound treatment to prevent the development and/or worsening of a pressure ulcer for 2 of 4 residents reviewed skin wounds (Resident C and E). This deficient practice resulted in debridement (using chemicals or instruments to remove dead tissue from an area), osteo[DIAGNOSES REDACTED] and removal of the resident's coccyx. (Resident C). Findings include: 1. The closed clinical record for Resident C was reviewed on [DATE] at 9:26 a.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had one unstageable pressure ulcer on admission. She had a pressure reducing device for the wheelchair and bed. The resident was a two-person assistance for bed mobility, transfer, dressing and hygiene. An admission assessment, dated [DATE], indicated the resident had a left buttock wound that measured 0.8 cm x 0.4 cm x 0.1 cm. The area was open with active red drainage. The Braden scale (for predicting pressure ulcer risk) indicated the resident had a score of 18, which indicated she was at risk for developing a pressure ulcer. A current health care plan, dated [DATE], indicated problem for pressure ulcer actual or at risk due to actual pressure ulcer. Interventions included, but were not limited to, nutritional support and weekly wound assessments. A wound evaluation flow sheet, dated [DATE], indicated Resident C had an unstageable pressure ulcer that measured 0.8 cm x 0.4 cm and 0.1 cm. The wound had a scant amount of red drainage with both necrotic (dead tissue) and [MEDICATION NAME] tissue. A physicians order, dated [DATE], indicated to cleanse the left buttocks with normal saline, pat dry and apply Santyl (enzymatic [MEDICATION NAME] ointment) to the wound and cover with a moist to dry gauze. The wound was then covered with Allevyn foam dressing and to be changed daily. A nutritional assessment, dated [DATE], indicated the resident had a pressure area and was receiving Pro-Stat (liquid protein) 30 mL three times daily. A nutritional care plan was initiated. No additional nutrition assessments or notes were provided. A Braden assessment, dated [DATE], indicated a score of 18. A computerized tomography (CT) scan, dated [DATE], indicated the resident underwent [REDACTED]. A physician visit, dated [DATE], indicated decubitis ulcer of buttock, unstageable. The physical examination of the skin indicated general inspection, warm and dry. The assessment indicated the wound was chronic and stable. A physician visit, dated [DATE], indicated decubitis ulcer of buttock, unstageable. The physical examination of the skin indicated general inspection, warm and dry. A review of the Wound Evaluation Flow Sheet, indicated the following measurements for the coccyx pressure ulcer: a. [DATE], 0.8 cm x 0.4 cm x 0.1 cm b. [DATE], 1.6 cm x 2.3 cm x 0.1 cm c. [DATE], 1.6 cm x 2.3 cm x 0.1 cm d. [DATE], 2.6 cm x 4.8 cm x 0.1 cm e. [DATE], 3.0 cm x 4.8 cm x 0.1 cm f. [DATE], 3.2 cm x 4.8 cm x 0.1 cm g. [DATE], 3.1 cm x 4.8 cm x 0.2 cm h. [DATE], 3.1 cm x 4.8 cm x 0.2 cm i. [DATE], 3.1 cm x 4.8 cm x 0.2 cm j. [DATE], 3.2 cm x 4.8 cm x 6.3 cm k. [DATE], 3.9 cm x 4.8 cm x 6.5 cm l. [DATE], 4.5 cm x 4.8 cm x 6.8 cm m. [DATE], 5.0 cm x 4.8 cm x 6.8 cm n. [DATE], 5.0 cm x 4.8 cm x 6.8 cm o. [DATE], 5.0 cm x 4.9 cm x 6.8 cm p. [DATE], 5.1 cm x 5.0 cm x 6.5 cm On [DATE], the resident had a positive laboratory report for Clostridioides difficile (bacterium that causes diarrhea and [MEDICAL CONDITION]). On [DATE], a physicians order indicated to give FIRVANQ ([MEDICATION NAME] oral, an antibiotic) from [DATE] through [DATE] for the treatment of [REDACTED]. On [DATE] at 3:14 p.m., an Situation, Background, Assessment, Recommendation (SBAR) indicated the resident had a decline in condition. The resident was not responding per normal self. The physician was contacted and the resident was sent to the emergency department. A discharge MDS assessment, dated [DATE], indicated the resident had a pressure ulcer that she was admitted with. On [DATE] at 10:19 p.m., the facility was notified the resident was admitted to the hospital [MEDICAL CONDITION]. Review of hospital records began on [DATE] at 11:40 a.m. An emergency room report, dated [DATE] at 6:37 p.m., indicated a nurse went in to perform bowel care and a wound on the buttock was identified. The physician came to the bedside and indicated the wound was a stage 4 pressure wound. An admission history and physical, dated [DATE], indicated the resident had a critically high white blood cell count greater than 40,000 (normal usually between 4,000 and 11,000) k/cumm (cubic millimeter). A preoperative report, dated [DATE], indicted the resident had a stage 4 pressure ulcer to the presacral area. Excisional debridement of the skin, epidermis, dermis, muscle, fascia and bone were completed. The coccyx bone was then exposed and appeared infected which resulted in a coccygectomy (surgical procedure in which the coccyx is removed.) A wound care note, dated [DATE], indicated the stage 4 wound was surgically debrided on [DATE]. The wound measured 6.0 cm x 9.0 cm x 4.5 cm. A tunnel at 3:00 o'clock measured 10 cm and at 5:00 o'clock, measured 7.5 cm. The wound had 360 degrees of undermining. Negative-pressure wound therapy was applied at 150 mmHg (millimeter of mercury). A wound care note, dated [DATE], indicated the wound measured 6.0 cm x 9.0 cm x 4.5 cm with undermining from 10:00 o'clock to 6:00 o'clock. A tunnel at 3:00 o'clock measured 11.5 cm and at 5:00 o'clock, measured 6.2 cm. The wound had 360 degrees of undermining. Negative-pressure wound therapy was applied at 150 mmHg. A wound care note, dated [DATE], indicated the wound had a small amount of slough (dead tissue) and a large amount of red, beefy tissue. The tunneling areas were resolved, but undermining was present from 9:00 o'clock to 4:00 o'clock. Negative-pressure wound therapy continued at 150 mmHg. A final report, dated [DATE], indicated the following: Incision and drainage with removal of the coccyx on [DATE] Negative-pressure wound therapy placed [DATE] Naso-Gastric (NG) tube placed [DATE] Left Internal Jugular (IJ) line placed [DATE], dislodged [DATE] and an [MEDICATION NAME] radiology IJ line placed on [DATE] Percutaneous Endoscopic Gastrostomy (PEG) placed [DATE]. A discharge summary, dated [DATE], indicated the discharge [DIAGNOSES REDACTED]. The noted indicated .patient initially presented to the ED from a skilled nursing facility because of lethargy and altered mental status. On examination, the patient was found to have a large destructive sacral necrotic wound for which she underwent immediate debridement .under operations and procedures .repeat debridement .wound vac. The resident continued to decline clinically and her overall prognosis was poor. Palliative care was consulted and she was transitioned to hospice care on [DATE]. A discharge summary, dated [DATE], indicated the resident was kept comfortable but deceased on [DATE]. 2. During an observation on [DATE] at 9:38 a.m., Resident E was in bed, on his right side. LPN 3 moistened two gauze pads with normal saline and swabbed the inside of the wound, under the undermining. The resident moaned in distress. LPN 3 indicated the resident got Tylenol three times daily for pain. The wound was then packed with clean gauze and covered with a dressing. The clinical record for Resident E was reviewed on [DATE] at 1:50 p.m. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was at risk for developing pressure ulcer, but had none on admission. The resident was a two-person assistance for bed mobility, transfer, dressing and hygiene and was receiving hospice care. A current health care plan, dated [DATE], indicated the resident was at had a pressure ulcer to the coccyx. Interventions included, but were not limited to, notify physician of worsening conditions and weekly wound assessments. A second health care plan, dated [DATE], indicated the resident had a self care impairment. Interventions included, but were not limited to, transfer assistance with two persons, bed, dressing and hygiene assistance with one person. A nutritional assessment, dated [DATE], indicated the resident was underweight with an average meal intake of 25%-75%. He was currently receiving [MEDICATION NAME] (dietary supplement) 120 mL twice daily. He had no pressure areas noted on admission. A weekly skin assessment, dated [DATE], indicated his skin was intact. A Braden assessment, dated [DATE], indicated a score of 14, moderate risk of developing a pressure ulcer. A progress note, dated [DATE], indicated to discontinue Resinol (skin protectant) and start Sureprep (barrier film on peri-wound skin) and cover with Allevyn foam dressing every shift. A weekly skin assessment, dated [DATE], indicated he had a pre-existing condition. No additional information was documented. A wound evaluation flow sheet, dated [DATE], indicated Resident E had a wound that measured 4.0 cm x 4.0 cm. The wound bed contained slough. No wound stage was noted. On [DATE], the order was changed to apply [MEDICATION NAME] (antiseptic) to wound bed and cover. On [DATE], the resident received Bactrim DS (antibiotic), give 1 tablet by mouth two times a day for [MEDICAL CONDITION] through [DATE]. On [DATE], the order was changed to apply Santyl to the wound bed and cover with a moist gauze and dry dressing. On [DATE], the order was changed to cleanse the coccyx with normal saline, apply moist gauze to the undermining area and cover with a foam dressing. The dressing was to be changed twice daily. A review of the Wound Evaluation Flow Sheet, indicated the following measurements for the coccyx pressure ulcer: A. [DATE], 4.0 x 4.0; the wound bed contained slough and no wound stage was noted. B. [DATE], 4.0 x 4.0; the wound bed contained slough and no wound stage was noted. C. [DATE], 4.0 x 4.8 x 1.5 cm; the wound had undermining of 2 cm and no wound stage was noted. D. [DATE], 4.5 x 4.5 x 1.2 cm; the wound had undermining of 1 cm and no wound stage was noted. E. [DATE], 4.0 cm x 4.2 cm x 1.0 cm with 1 cm of undermining. The wound was noted as a stage 3 wound. F. [DATE], 4.0 x 4.5 x 3.0 cm; undermining is noted with no depth. On [DATE], a progress note indicated a change in condition. The residents left hip was noted to be hot and red. The resident had a temperature of 103.0 degrees. A new order, dated [DATE], indicated to give [MEDICATION NAME] (broad-spectrum antibiotic) Inject 1 gram intramuscularly one time only related to a bacterial infection for three days. The order was changed to give Bactrim DS by mouth, daily for 14 days. During an interview on [DATE] at 12:12 p.m., the DON indicated Resident C was not sent out for any debridement, but on [DATE], all the slough came off the bottom and that was when the wound was deeper. She indicated Santyl was the only treatment they had been using for the wound. No SBAR or physician notification was done on [DATE]. She was currently the facilities wound nurse, but the nurses' usually did the initial assessment. She had some education to do with some of the staff related to wound documentation. On [DATE] at 10:40 a.m., the Nurse Practitioner indicated they did send Resident C for a surgical consult because the CT scan came back abnormal on [DATE]. The resident was seen by the surgeon in (MONTH) and he did not recommend any surgery. She indicated the surgeon only mentioned a possible hernia, but no mention of a pressure wound. During an interview with the DON and nurse consultant on [DATE] at 1:20 p.m., they indicated the Registered Dietician only saw both Resident C and E on their initial nutritional assessment. They could not find any progress notes or additional information related to any changes or adjustments made. A current facility policy, dated [DATE], titled, Skin Integrity Guideline, which was provided by the DON on [DATE] at 12:45 p.m., indicated the following: Purpose: To provide a comprehensive approach for monitoring skin conditions. General Guideline: Patients/Residents will be assessed or observed for risk of skin breakdown: .The facility develops a routine schedule to review patients/residents with wounds or at risk . DNS or designee will be responsible to implement and monitor the skin integrity program Wound status is monitored on a weekly basis. .Nursing notified dietary of any patient/resident admitted with pressure .Documentation completed by .Registered Dietician .new pressure ulcer and surgical wounds and continues monthly for non-healing Stage II or greater This Federal tag relates to Complaints IN 780 and IN 992. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)

Based on observation, interview and record review, the facility failed to ensure a severely cognitively impaired resident, who was at risk for elopement, received the supervision to prevent elopement from the memory care locked unit. This failure resulted in the resident being without supervision and exposed to hazardous conditions for 1 of 4 residents reviewed for elopement. (Resident C) The immediate jeopardy began on 9/18/2018 when a severely cognitively impaired resident was left unsupervised at a doctor appointment where he left the doctor office and was found across the street in a hotel. The Administrator was notified of the immediate jeopardy on 10/1/2018 at 2:08 PM. The immediate jeopardy was removed and the deficient practice was corrected, on 9/26/2018 prior to the start of the survey and was therefore Past Noncompliance Findings include: The clinical record for Resident C was reviewed on 9/28/2018 at 11:30 AM. [DIAGNOSES REDACTED]. Review of Significant Change Minimum Data Set (MDS), dated [DATE], indicated the resident was found to be severely cognitively impaired with poor decision making. The resident also required limited physical assistance of one for ambulation and the use of a walker/cane. Review of an Admission Assessment, dated 8/9/2018, indicated the resident was at risk for elopement. Review of a Quarterly Interdisciplinary Resident Review assessment, dated 9/6/2018, indicated the resident was at risk for elopement. Review of the clinical record indicated the following: a. On 8/31/2018 the resident eloped from a birthday party in the main dining room. A progress note, dated 8/31/2018 at 5:28 PM, indicated after the party the resident got up and headed for the front door. Staff noticed and immediately went after him. The resident did exit the facility and staff stayed with him while he walked the parking lot. The police were notified and in route, however the resident became tired and agreed to go back into the facility. b. On 9/18/2018 the resident was left at a doctor appointment unsupervised. The resident was picked up by the ambulance service at approximately 2:43 PM from the facility and taken to the doctor appointment. The facility received a call from family at 3:20 PM stating resident was missing. The resident was found across the street from the doctor's office in a hotel and was returned to facility at 4:53 PM. Review of a nursing progress note, dated 9/24/2018 at 1:15 PM, indicated the resident was on 15 minute checks due to a previous elopement. The resident had been observed attempting to use the code to open the door to the locked unit. Review of a nursing progress note, dated 9/25/2018 at 3:00 AM, indicated the resident remained on 15 minute checks and had been standing at the double doors and stated he was ready to go home. Review of a nursing progress note, dated 9/25/2018 at 12:57 PM, indicated the resident remained on 15 minute checks. Review of the police report from the local police department indicated at approximately 9:52 PM on 9/25/2018, an officer was dispatched to investigate a report of an elderly man walking alone. The police were called by citizen who indicated she had picked up the resident and had driven him to a couple of addresses and stated the male did not know where he lived and seemed confused. The citizen then took the resident to a gas station and called the police. The officer's report indicated he saw the resident walking approximately 1.9 miles from the facility and the resident was soaking wet from the rain. Residence was established when the resident removed papers from his back pocket with the name and address of the facility. The officer called the facility to confirm the man was indeed a resident. The officer returned the resident to the facility at approximately 10:21 PM. Review of a nursing progress note, dated 9/25/2018 at 11:27 PM, indicated the resident was returned to the facility by the police in handcuffs. The resident returned to the facility with the following new visible injuries: a skin tear to the left forearm measuring 1.7 cm x 1.7 cm. A dark purple bruise to the left tricep measuring 2.2 cm x 2.2 cm. A dark purple bruise to the wrist measuring 0.8 cm x 1.5 cm. A dark purple bruise to the posterior right elbow measuring 0.8 cm 2.1 cm. A dark purple bruise to the posterior right wrist measuring 1.5 cm x 2.2 cm. A dark purple area to the 4th knuckle on the right hand measuring 2.2 cm x 2.4 cm. A slight discoloration to the back of the head. Review of an post elopement event, dated 9/25/2018, indicated the resident had impaired memory, was confused and had dementia. The resident's predisposition situation factors included wandering, ambulating without assistance and exhibiting behaviors. The resident was returned to the facility by the police while in handcuffs. The resident had multiple bruises to his bilateral arms, wrist, knuckles and a skin tear to the left forearm. Review of the facility investigation indicated the resident was last seen by staff at approximately 8:30 PM on 9/25/2018 and was returned to the facility at approximately 10:21 PM. The resident was unaccounted for and without supervision for approximately 1 hour and 51 minutes. During an interview on 9/28/2018 at 4:35 PM, the Unit Manager indicated the facility was unable to determine exactly how the resident was able to exit the locked unit and the facility without being seen while on a locked memory care unit, 15 minute checks and the front doors to the facility locked requiring a key code to exit. During an interview on 9/28/2018 at 5:12 PM, LPN 2 indicated she was on duty the evening of 9/25/2018. She did not know how the resident was able to leave the unit and the facility without being seen. She was passing medications at approximately 8:30 PM and saw the resident go into his room. She stated no 15 minute checks were done after the resident went to his room and 15 minute checks needed to be done until they were discontinued. An observation of the area where the resident was found by the citizen on 9/28/2018 at 6:00 PM., indicated the resident would have walked from the facility through a busy four way stop and across a four lane state highway to reach the location where the resident was found by the concerned citizen. Parts of this area had uneven pavement, pot holes, poor lighting, water drainage ditches and several areas of construction. The past noncompliance Immediate Jeopardy began on 9/18/2018. The Immediate Jeopardy was removed and the deficient practice corrected by 9/26/2018 after the facility implemented a systemic plan that included the following actions: staff education on elopement; staff education on one to one monitoring and staff education on 15 minute checks. This Federal tag relates to Complaint IN 263. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents were free from accidents and hazards by failure to properly supervise dementia residents who resided in a locked unit of the facility. This deficient practice resulted in a head injury with 12 sutures for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: The clinical record for Resident (C) was reviewed on 9/29/14 at 12:30 p.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident (C) was severely cognitively impaired. During observation on 9/29/14 at 10:45 a.m., Resident (C) had a large healing wound on the forehead. A Progress Note dated 9/19/14 at 11:15 a.m., indicated the nurse was called outside to the courtyard. A resident was observed on the sidewalk in a prone position, holding his head. A moderate amount of sanguineous (blood) drainage was observed. Following the assessment, the wound measured 5 cm x 0.5 cm. The physician was notified and the resident was sent to the emergency room . Resident (C) returned to the facility with 12 sutures on his head Review of the Fall Investigation Report dated 9/19/14, indicated the Art Therapy Director had taken the resident outside with a visiting dog and photographer. She escorted the dog and photographer back into the lock unit and forgot to go back outside and bring Resident (C) inside. The investigation report indicated "(name of staff member) stated she left him outside alone about 20-25 min." The Fall Investigation Report also contained a written statement from LPN #2 stating "I went out to him. I was the first one out there. (name of resident) was the only one out there." During an interview on 9/29/14 at 11:30 a.m., the Dementia Unit Manager indicated Resident (C) was out in the courtyard when he fell and staff was with him. She indicated the resident was sent to the hospital where he received 12 sutures in his forehead. During an interview on 9/29/14 at 11:45 a.m., the Art Therapy Director indicated she went outside with the resident, a visiting dog and photographer. She indicated she went back inside to let the dog and photographer off the locked unit and left Resident (C) outside alone. She indicated lunch was getting ready to be served and a CNA found the resident outside. During an interview on 9/29/14 at 12:10 p.m., CNA #3 indicated a family member came up to her and told her a resident was on the sidewalk outside. She then went and got LPN #2 to help her. During an interview on 9/29/14 at 12:15 p.m., LPN #2 stated the CNA sent someone to get her to help the resident. She indicated the resident was alert but had moderate bleeding. During an interview on 9/30/14 at 9:55 a.m., CNA #6 indicated residents were often left out in the courtyard unattended. During an interview on 9/30/14 at 11:15 a.m., the Dementia Unit Director indicated the Art Therapy Director was assisting people off the unit and the resident was left outside and fell on the cement. He indicated it was an unusual occurrence and was not sure why it was not reported to the State. He indicated staff were not allowed to leave residents outside unattended. The current care plan dated 8/20/14, indicated Resident (C) had identified problems related to falls, history of falls, pain and osteoporosis. Approaches to the problem included, but were not limited to, routinely remind resident to ask for assistance when wanting to transfer and assess that wheel chair is of appropriate size; assess need to have wheelchair locked/unlocked for safety and anti-tippers. Review of a summary report of a meeting dated 9/22/14 titled "Strategies to reduce and prevent falls" which was provided by the Administrator on 9/30/14 at 9:00 a.m., indicated the following: "STRATEGIES TO REDUCE AND/OR PREVENT FALLS ...Consistent staff, proper supervision... ...Know what 13% fall benchmark means in your facility (How many residents with falls can you have at your facility and still stay under the benchmark? Know where you are in terms of the benchmark... ...Prepare ahead for...there are staff members available to monitor during these times of reduced coverage."... This Federal tag relates to Complaint IN 844. 3.1-45(a)(2)

Based on clinical record review and interview, the facility failed to ensure 2 of 3 residents (Resident #C and #E) reviewed for [MEDICAL CONDITION] care and services had complete orders for [MEDICAL CONDITION] care resulting in a build up of secretions requiring the need for hospital evaluation and treatment for one of the residents.(Resident #C). Findings include: 1.) The clinical record for Resident # C was reviewed on 11/18/13 at 1:45 p.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident was unable to take food orally and had a gastrostomy tube for nutritional feedings. A nursing note entry, dated 11/1/13 at 4:30 p.m., indicated Resident #C was admitted to the facility with a rectal tube, foley catheter, gastrostomy tube, and gallbladder drain in place. The note indicated "resident sometimes opens eyes to physical stimuli; otherwise is unresponsive..." admission orders Oxygen at 21% [MEDICAL CONDITION] with humidifier. [MEDICAL CONDITION] a #9 Porter Trach." The orders also indicated the resident was to have an [MEDICATION NAME] (a inhalation medication given to help improve respirations) nebulizer treatment every 8 hours related to acute and chronic [MEDICAL CONDITION]. The admission orders [REDACTED]'s inner cannula was to be cleansed and/or changed, or any information about the possible need to suction the inner cannula to prevent secretion build up and decreased patency of the airway. A nursing note entry, dated 11/3/13 at 10:59 p.m., indicated "...Trach midline and patent. [MEDICAL CONDITION] provided with deep tracheal suctioning, site care per sterile technique...." A nursing note entry, dated 11/4/13 at 1:22 a.m., indicated "...trach midline with no redness or drainage. secretions noted clear and yellow...." A nursing note entry, dated 11/4/13 at 3:32 p.m., indicated "Trach care provided... Inner cannula suctioned for increased secretions... Drsg (dressing) changed...." A nursing note entry, dated 11/6/13 at 10:22 a.m., indicated "...trach care done..." The note did not indicate what was included in [MEDICAL CONDITION] provided. These were the only documentation [MEDICAL CONDITION] services noted from 11/1/13 through 11/6/13. A nursing note entry, dated 11/7/13 at 11:19 a.m., indicated "Received clarification [MEDICAL CONDITION] orders.... Change #9 [MEDICAL CONDITION] once a day..." The clinical record lacked any information related to the inner cannula being changed until 11/8/13. A nursing note entry, dated 11/9/13 at 11:02 a.m., indicated "[MEDICAL CONDITION] done this shift, moderate sputum yellowish/greenish noted, inner cannula changed as ordered...." A nursing note entry, dated 11/10/13 at 3:32 a.m., indicated "res with thick yellow/tan secretions suctioned with large amounts of secretions obtained res diaphoretic... [MEDICAL CONDITION] completed with inner cannula changed." A nursing note entry, dated 11/10/13 at 4:24 a.m., indicated "MD notified of change in resident received new order to send to (initials of hospital) to be evaluated and treated...." The clinical record indicated the resident returned to the facility on the same date and had pleural effusions. The record indicated the physician was not going to put the resident on an antibiotic at that time. A new order was obtained following the resident's readmission, dated 11/10/13 at 8:07 a.m., that indicated "Assess for secretions every four hours for possible suctioning and humidified oxygen every 4 hours as needed [MEDICAL CONDITION] to acute and chronic [MEDICAL CONDITION]." RN #7 (Unit Manager for Resident #C's unit) was interviewed on 11/19/13 at 9:30 a.m. Additional information was requested related to the lack [MEDICAL CONDITION] orders and services provided. RN #7 reviewed the resident's computerized chart and hard chart and indicated the facility only had admission orders [REDACTED]. She was unable to find any [MEDICAL CONDITION] orders other than the ones obtained on 11/7/13 and 11/10/13 noted previously. RN #4 (also identified as the Nurse Clinical Educator) was interviewed on 11/19/13 at 9:40 a.m. When queried regarding basic orders needed for [MEDICAL CONDITION] care, she indicated she would expect orders for site care, suctioning as needed, cannula size, cannula cleaning and/or changing information in addition to any oxygen orders. 2. The clinical record for Resident #E was reviewed on 11/18/13 at 12:19 p.m. [DIAGNOSES REDACTED]. The clinical record lacked an order for [REDACTED]. During an interview with Medical Records #2 on 11/20/13 at 8:10 a.m., additional information was requested related to suctioning orders for Resident #E. During an interview with the acting Director of Nursing and LPN #3 on 11/20/13 at 2:10 p.m., they indicated Resident #E had no order for [MEDICAL CONDITION] suctioning. 3. The undated policy for "[MEDICAL CONDITION] Care" was provided by Nurse Clinical Educator on 11/19/13 at 12:10 p.m. The policy indicated: "...Purpose: To provide adequate [MEDICAL CONDITION] site care: Maintain a patent airway, to facilitate the therapeutic exchange of gases. Prevent the transmission of pathogenic microorganisms thus decreasing nosocomial infections. Policy: Stoma care for [MEDICAL CONDITION] should be done every shift and PRN (as needed) unless otherwise ordered. Assessment: General guidelines for assessment may include, but not limited to: ...Observe characteristics of secretions increase/decrease, thick/thin, color, blood tinged...Observe for signs or symptoms of respiratory distress...." 4. The undated policy for "[MEDICAL CONDITION] Suctioning" was provided by Nurse Clinical Educator on 11/19/13 at 12:10 p.m. The policy indicated: "Responsible: The following individuals may have responsibility for [MEDICAL CONDITION] suctioning, consistent with state specific professional licensing requirements. Only licensed nurse per MD (Doctor of Medicine) orders. Purpose: To provide adequate [MEDICAL CONDITION] suctioning: Maintain a patent airway, to facilitate the therapeutic exchange of gases... Policy: [MEDICAL CONDITION] suctioning should be done PRN (as needed). Assessment: General guidelines for assessment may include, but are not limited to: ... Observe characteristics of secretions increase/decrease, thick/thin, color, blood tinged...Observe for signs or symptoms of respiratory distress...." This Federal tag relates to Complaint IN 385. 3.1-47(a)(5) 3.1-47(a)(4)

Based on clinical record review and interview, the facility failed to ensure 2 of 3 residents (Resident #C and #E) reviewed for [MEDICAL CONDITION] care and services had complete orders for [MEDICAL CONDITION] care resulting in a build up of secretions requiring the need for hospital evaluation and treatment for one of the residents.(Resident #C). Findings include: 1.) The clinical record for Resident #C was reviewed on 11/18/13 at 1:45 p.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident was unable to take food orally and had a gastrostomy tube for nutritional feedings. A nursing note entry, dated 11/1/13 at 4:30 p.m., indicated Resident #C was admitted to the facility with a rectal tube, foley catheter, gastrostomy tube, and gallbladder drain in place. The note indicated "resident sometimes opens eyes to physical stimuli; otherwise is unresponsive..." admission orders Oxygen at 21% [MEDICAL CONDITION] with humidifier. [MEDICAL CONDITION] a #9 Porter Trach." The orders also indicated the resident was to have an [MEDICATION NAME] (a inhalation medication given to help improve respirations) nebulizer treatment every 8 hours related to acute and chronic [MEDICAL CONDITION]. The admission orders [REDACTED]'s inner cannula was to be cleansed and/or changed, or any information about the possible need to suction the inner cannula to prevent secretion build up and decreased patency of the airway. A nursing note entry, dated 11/3/13 at 10:59 p.m., indicated "...Trach midline and patent. [MEDICAL CONDITION] provided with deep tracheal suctioning, site care per sterile technique...." A nursing note entry, dated 11/4/13 at 1:22 a.m., indicated "...trach midline with no redness or drainage. secretions noted clear and yellow...." A nursing note entry, dated 11/4/13 at 3:32 p.m., indicated "Trach care provided... Inner cannula suctioned for increased secretions... Drsg (dressing changed)...." A nursing note entry, dated 11/6/13 at 10:22 a.m., indicated "...trach care done..." The noted did not indicate was included in [MEDICAL CONDITION] provided. These were the only documentation [MEDICAL CONDITION] services noted from 11/1/13 through 11/6/13. A nursing note entry, dated 11/7/13 at 11:19 a.m., indicated "Received clarification [MEDICAL CONDITION] orders.... Change #9 [MEDICAL CONDITION] once a day..." The clinical record lacked any information related to the inner cannula being changed until 11/8/13. A nursing note entry, dated 11/9/13 at 11:02 a.m., indicated "[MEDICAL CONDITION] done this shift, moderate sputum yellowish/greenish noted, inner cannula changed as ordered...." A nursing note entry, dated 11/10/13 at 3:32 a.m., indicated "res with thick yellow/tan secretions suctioned with large amounts of secretions obtained res diaphoretic... [MEDICAL CONDITION] completed with inner cannula changed." A nursing note entry, dated 11/10/13 at 4:24 a.m., indicated "MD notified of change in resident received new order to send to (initials of hospital) to be evaluated and treated...." The clinical record indicated the resident returned to the facility on the same date and had pleural effusions. The record indicated the physician was not going to put the resident on an antibiotic at that time. A new order was obtained following the resident's readmission, dated 11/10/13 at 8:07 a.m., that indicated "Assess for secretions every four hours for possible suctioning and humidified oxygen every 4 hours as needed [MEDICAL CONDITION] to acute and chronic [MEDICAL CONDITION]." RN #7 (Unit Manager for Resident #C's unit) was interviewed on 11/19/13 at 9:30 a.m. Additional information was requested related to the lack [MEDICAL CONDITION] orders and services provided. RN #7 reviewed the resident's computerized chart and hard chart and indicated the facility only had admission orders [REDACTED]. She was unable to find any [MEDICAL CONDITION] orders other than the ones obtained on 11/7/13 and 11/10/13 noted above. RN #4 (also identified as the Nurse Clinical Educator) was interviewed on 11/19/13 at 9:40 a.m. When queried regarding basic orders needed for [MEDICAL CONDITION] care, she indicated she would expect orders for site care, suctioning as needed, cannula size, cannula cleaning and/or changing information in addition to any oxygen orders. 2. The clinical record for Resident #E was reviewed on 11/18/13 at 12:19 p.m. [DIAGNOSES REDACTED]. The clinical record lacked an order for [REDACTED]. During an interview with Medical Records #2 on 11/20/13 at 8:10 a.m., additional information was requested related to suctioning orders for Resident #E. During an interview with the acting Director of Nursing and LPN #3 on 11/20/13 at 2:10 p.m., they indicated Resident #E had no order for [MEDICAL CONDITION] suctioning. 3. The undated policy for "[MEDICAL CONDITION] Care" was provided by Nurse Clinical Educator on 11/19/13 at 12:10 p.m. The policy indicated: "...Purpose: To provide adequate [MEDICAL CONDITION] site care: Maintain a patent airway, to facilitate the therapeutic exchange of gases. Prevent the transmission of pathogenic microorganisms thus decreasing nosocomial infections. Policy: Stoma care for [MEDICAL CONDITION] should be done every shift and PRN (as needed) unless otherwise ordered. Assessment: General guidelines for assessment may include, but not limited to: ...Observe characteristics of secretions increase/decrease, thick/thin, color, blood tinged...Observe for signs or symptoms of respiratory distress...." 4. The undated policy for "[MEDICAL CONDITION] Suctioning" was provided by Nurse Clinical Educator on 11/19/13 at 12:10 p.m. The policy indicated: "Responsible: The following individuals may have responsibility for [MEDICAL CONDITION] suctioning, consistent with state specific professional licensing requirements. Only licensed nurse per MD (Doctor of Medicine) orders. Purpose: To provide adequate [MEDICAL CONDITION] suctioning: Maintain a patent airway, to facilitate the therapeutic exchange of gases... Policy: [MEDICAL CONDITION] suctioning should be done PRN (as needed). Assessment: General guidelines for assessment may include, but are not limited to: ... Observe characteristics of secretions increase/decrease, thick/thin, color, blood tinged...Observe for signs or symptoms of respiratory distress.... 3.1-47(a)(5) 3.1-47(a)(4)