Every finding on record at Brickyard Healthcare - Richmond Care Center

Based on observation, interview and record review, the facility failed to ensure fluids were available and within reach and failed to ensure call lights were within reach for 3 of 3 residents reviewed for accommodation of needs (Resident 41, Resident 10 and Resident 5). Findings include:1. During an observation and interview on 12/02/2025 at 2:08 p.m., Resident 41 was lying in bed. The resident's call light was out of reach, on recliner underneath a blanket. The call light was activated for a test. CNA 2 came in the room and indicated he was responsible to ensure Resident 41 had her call light within reach. CNA 2 indicated he assisted Resident 41 to lay down and the roommate requested something and he forgot to give Resident 41 her call light. CNA 2 provided the resident with her call light. During the observation Resident 41 had no fluids available in her room. During an observation on 12/03/2025 at 2:33 p.m., Resident 41 had no fluids available in room. Resident 41's mouth and lips were dry and her lips were sticking to her teeth. Resident 41 indicated she would like to have something to drink, sometimes the staff gave her fluids and sometimes they did not. Resident 41 activated her call light. During an observation and interview on 12/03/2025 at 2:40 p.m., CNA 1 came into Resident 41's room, the resident requested something to drink. CNA 1 indicated she did not know why the resident did not have fluids available. CNA 1 provided the resident with a Styrofoam cup of ice water with a straw. Resident 41 took two large drinks of the water independently and indicated it tasted good. Review of the clinical record of Resident 41, on 12/04/2025 at 11:26 a.m., indicated the resident's diagnoses included, but were not limited to, history of urinary tract infection, muscle weakness, age related debility, chronic kidney disease, constipation and major depression. The physician's recapitulation for Resident 41, dated December 2025, indicated the resident diet order was thin liquids and encourage fluids as allowed by resident every shift (original date 11/25/25). The care plan for Resident 41, dated 11/26/25, indicated the resident had a urinary tract infection and was on antibiotics. The interventions included, but were not limited to, encourage adequate fluid. The care plan for Resident 41, dated 12/4/25, indicated the resident had the potential for dehydration related to diuretic medication use. The goal was to maintain moist mucous membranes. 2. During an observation and interview on 12/02/2025 at 2:36 p.m., Resident 10 was lying in her bed, the call light was behind the head board of her bed on the floor. The roommates call light was activated. CNA 2 came into the resident's room and indicated CNA 5 was taking care of Resident 10 and was on break. CNA 2 indicated he told CNA 5, before she went on break, to ensure all the residents she was caring for had their call lights available. CNA 2 provided Resident 10 with her call light. Resident 10 did not have water available, she had a cup of coffee on her bedside table out of reach. During an observation on 12/05/2025 at 1:23 p.m., Resident 10 was eating an drinking independently. During an interview with Resident 10 on 12/08/2025 at 10:47 a.m., the resident indicated it happened frequently that she did not have water available and sometimes her call light was out of reach. Resident 10 indicated when this happened she would have her roommate use her call light for her, if her roommate was in the room when that happened. The resident was observed to not have fluids in her room at this time except for a small medication cup with water in it. Review of the clinical record for Resident 10 on 12/08/2025 at 10:51 a.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, anemia, anxiety, arthritis, hypertension, muscle weakness and dementia. The quarterly Minimum Data Set (MDS) for Resident 10, dated 11/1/25, indicated the resident was moderately impaired for daily decision. The resident required set up only for drinking. The bowel care plan for Resident 10, dated 5/19/25, indicated the resident was at risk for constipation related to medication use and decrease mobility at times. The interventions included, but were not limited to, call bell in within reach, remind to use as needed and encourage fluids. The bowel and bladder care plan for Resident 10, dated 5/19/25, indicated the resident was at risk for alteration in elimination of bowel and bladder related to urinary and bowel incontinence. The interventions included, but were not limited to, call bell within reach, remind to use call bell as needed and encourage fluids. The hydration care plan for Resident 10, dated 5/19/25, indicated the resident was at at risk for alteration in hydration related to needing some set up with fluids, required reminded at times to increase fluids. The intervention included, provide, encourage and assist with fluids as needed. 3. During an observation and interview on 12/03/2025 at 10:40 a.m., Resident 5 did not have fluids available in his room. The resident indicated it happened occasionally that staff did not provide fluids to him. The resident activated his call light and requested something to drink from the staff. Review of the clinical record of Resident 5 12/05/2025 at 10:24 a.m., indicated the resident's diagnoses included, but were not limited to, depression, muscle weakness, diabetes, anxiety and vitamin deficiency. The physician's order for Resident 5, dated December 2025, indicated the resident was to receive a regular diet with thin liquid. The quarterly MDS assessment for Resident 5, dated 10/31/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident required set up for eating and drinking fluids. During an observation on 12/5/25 at 12:50 p.m., Resident 5 was drinking independently in his room. The hydration policy provided by the Director Of Nursing (DON) on 12/8/25 at 10:20 a.m., indicated the facility would offer each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The protocol included, but were not limited to, ensure beverages were available and within reach. The call light policy provided by the DON on 12/8/25 at 10:25 a.m., indicated the facility would ensure a call light was at each residents bedside. Staff would ensure the call light was within reach of the resident and secured. The call system would be accessible to residents while in their bed. 3.1-3(v)(1)

Based on interview and record review, the facility failed to file a grievance for a resident with missing clothing for 1 of 1 resident reviewed for grievances. (Resident 34)Findings include:The clinical record for Resident 34 was reviewed on 12/4/25 at 2:34 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (brain tissue death caused by a blockage in a blood vessel) affecting right dominant side and dry eye syndrome.The Quarterly Minimum Data Set (MDS) assessment, dated 10/20/25, indicated Resident 34 was cognitively intact for daily decision making.During an interview on 12/3/25 at 11:45 a.m., Resident 34 indicated he had two sweaters that came up missing approximately three months ago. One sweater was gray, had cost over $100.00, and meant a lot to him because his step-daughter had given it to him. The other sweater was green and he had gotten it last Christmas. Resident 34 indicated he told the Executive Director (ED) about a month ago and was told that they would look for them and get back with him and if he had to, they would be replaced. Resident 34 indicated no one had been back in to follow up on the missing items.Grievances were reviewed for the last six months and no grievances were filed for Resident 34's missing sweaters.During an interview with the ED on 12/4/25 at 2:18 p.m., The ED indicated Resident 34 had mentioned something to him about missing sweaters as he was passing by one day. The ED indicated Resident 34 told him he spoke with Laundry/Housekeeping Aide 2 about the missing sweaters and indicated Laundry/Housekeeping Aide 2 told him she spoke with Resident 34's wife, so I figured it was handled. The ED indicated he did not follow up with Resident 34 and indicated he should have filled out a grievance for these missing items.During an interview with Laundry/Housekeeping Aide 2 on 12/4/25 at 2:27 p.m., they indicated Resident 34 did tell them that he had missing sweaters and his wife went into the laundry room with her and they still could not be found. Laundry/Housekeeping Aide 2 indicated she spoke with the ED and he indicated to her he would follow up with Resident 34. Laundry/Housekeeping 2 indicated she never heard anything else about the missing sweaters after that and indicated she should have filled out a grievance form when she was first told about the missing items.The Resident and Family Grievances policy was provided by the ED on 12/4/25 at 2:50 p.m. It indicated,.8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member.10. Procedure:.b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form.c. Forward the grievance form to the Grievance Official as soon as possible.e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.12. The facility will make prompt efforts to resolve grievances. 3.1-7(a)(2)

Based on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for a resident's call light to be within reach and failed to implement a touch call light for a resident at high risk for falls for 1 of 2 residents reviewed for care plan implementation of interventions. (Resident 41). Finding include:During an observation and interview on 12/02/2025 at 2:08 p.m., Resident 41 was lying in bed, the resident's call light out of reach, on recliner underneath a blanket, the call light was activated for a test. CNA 2 came in the room and indicated he was responsible to ensure Resident 41 had her call light within reach. CNA 2 indicated he assisted Resident 41 to lay down and the roommate requested something and he forgot to give Resident 41 her call light. CNA 2 provided the resident with her call light. During an observation and interview on 12/04/2025 at 2:34 p.m., Resident 41 was lying in bed with her call light. CNA 3 verified Resident 41 did not have a pad touch call light. Review of the record of Resident 41 on 12/04/2025 at 11:26 a.m., indicated the resident's diagnoses included, but were not limited to, history of urinary tract infection, muscle weakness, age related debility, chronic kidney disease, constipation and major depression. The fall care plan for Resident 41, dated 8/5/25, indicated the resident was at risk for falls related to deconditioning and history of falls. The interventions included, but were not limited to, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and touch pad call light. The quarterly Minimum Data Set (MDS) assessment for Resident 41, dated 10/15/25, indicated the resident was moderately impaired for daily decision making. The resident required substantial/maximal assistance with transfers, the resident did not ambulate. The resident had one fall with injury since prior assessment. The fall risk assessment for Resident 41, dated 11/9/25, indicated the resident was at high risk for falls. The fall prevention policy provided by the Director Of Nursing (DON) ON 12/8/25 at 10:20 a.m., indicated the resident would be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The protocol included, but were not limited to call light and frequently used items were within reach, provide interventions that address unique risk factors and alternate call system access. 3.1-35(b)(1)

Based on interview and record review, the facility failed to initiate the continuation of care, related to the administration of a resident's comfort eye drops, for 1 of 1 resident reviewed for Quality of Care. (Resident 9) Findings include: The clinical record for Resident 9 was reviewed on 12/2/25 at 2:00 p.m. Her diagnosis included, but was not limited to, cataracts. The impaired visual function care plan, revised 7/6/25, indicated the goal was for the resident to have no indications of acute eye problems through the next review date. An intervention was to arrange consultation with the eye care practitioner as required. The physician's orders indicated she may see an ophthalmologist and/or optometrist, starting 9/4/25. An interview was conducted with Resident 9 on 12/2/25 at 2:01 p.m. She indicated she saw the optometrist a couple of weeks ago, who ordered eye drops for her, but she had not yet begun receiving them. The Plan section of the optometry consultation note, dated 11/14/25, indicated the resident received a new medication order for Refresh Dry Eye Therapy solution, one drop in both eyes, twice daily for indefinitely. The Action Required By Nursing Home Staff section of the note indicated there were new orders. The physician's orders in the clinical record did not include an order for Refresh eyedrops. An interview was conducted with the SSD (Social Services Director) on 12/4/25 at 1:05 p.m. She indicated she was responsible for residents seeing the eye doctor. Their provider last came on 11/14/25. The SSD reviewed Resident 9's 11/14/25 optometry consultation note and orders from the electronic health record. She indicated she was unsure what happened with the Refresh eyedrops, as she did not see an order for them. Nursing were responsible for administering them. An interview was conducted with the DON (Director of Nursing) on 12/4/25 at 1:16 p.m. She indicated nursing did not receive orders or consultation notes from the eye doctor. Only social services received them. She did not generally know who the eye doctor saw when they came. An interview was conducted with UM (Unit Manager) 5 on 12/4/25 at 1:24 p.m. She indicated the eye doctor gave orders to the SSD, who gave the orders to nursing. She was unaware of the Refresh eye drop orders for Resident 9. An interview was conducted with Resident 9 on 12/4/25 at 1:21 p.m. She indicated she still hadn't begun receiving the eye drops. Her eyes felt like they had sand in them. The Hearing and Vision Services policy was provided by the DON on 12/4/25 at 1:38 p.m. It indicated, The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtaining history from medical records, the family, and the resident regarding hearing and vision abilities.c. Ongoing monitoring of sensory problems; d. Care plan development and implementation. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to offer a resident his elbow splint, per the restorative nursing plan, for 1 of 2 residents reviewed for positioning and mobility. (Resident 1)Findings include:The clinical record for Resident 1 was reviewed on 12/2/25 at 2:10 p.m. His diagnoses included, but were not limited to, contractures and right-side hemiplegia. The Restorative Nursing PROM (Passive Range of Motion) program care plan, dated 1/3/24 and revised 12/2/25, indicated the resident participated in the program due to contractures and decreased range of motion. The goal was for him to tolerate PROM to his RUE (right upper extremity) and PROM/Stretch of his right upper extremity elbow and hand, for three sets of up to 15 repetitions in preparation for donning splint. An intervention indicated, Splint/Brace: Assistance with Splint or brace (Splint to elbow, carrot or palm guard) The resident was to wear the orthotic elbow extension splint and carrot or palm to RUE for up to 2 or more hours daily, 6 days per week. The staff responsible for this intervention was the RNA (restorative nurse aide.) The tasks section of the electronic health record indicated the above intervention was not completed eight of the last 30 days. There was no documentation to indicated he refused or was unavailable.An observation and interview with Resident 1 were conducted in his room on 12/4/25 at 2:28 p.m. He was not wearing an elbow splint. He indicated he did not use an elbow splint, only the carrot for his hand. There was no elbow splint visible in his room.An interview was conducted with UM (Unit Manager) 5 on 12/4/25 at 2:35 p.m. She indicated the therapy department was responsible for implementing the restorative nursing program, including PROM and splint application. The TD (Therapy Director) created the program and RNA 8 implemented it. An interview was conducted with the TD on 12/4/25 at 2:38 p.m. The TD indicated therapy oversaw the restorative nursing/PROM program at the facility, and RNA 8 implemented it. An interview was conducted with RNA 8 on 12/4/25 at 2:38 p.m. She indicated she began working at the facility as the restorative aide in March, 2025. Resident 1 had a carrot and palm protector for his right hand. He liked the carrot better than the palm protector and he used it about four hours a day, six days a week. He did not use any splints at all, and she did not offer an elbow splint to Resident 1, as she was unaware that he had one. An observation of Resident 1 and his belongings was made in his room with the TD and RNA 8 on 12/4/25 at 2:38 p.m. The TD retrieved Resident 1's elbow splint from a nightstand behind Resident 1's bed.The Restorative Nursing Programs policy was provided by the DON (Director of Nursing) on 12/5/25 at 9:50 a.m. It indicated, Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include: b. Splint or brace assistance.The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented.The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan.3.1-42(a)(2)

Based on observation, interview and record review the facility failed to provide routine dental service for a resident with improper fitting dentures for 1 of 3 residents reviewed for dental services (Resident 5). Finding include:During an observation and interview on 12/03/2025 at 10:49 a.m., Resident 5 indicated he had dentures but they were too big and they were in his bathroom. The resident indicated he would like to have dentures that fit. He did not have problems with eating but did miss things like corn on the cob that he could not eat due to not having dentures that fit. The resident did not remember the last time he wore his dentures and they had not fit him for a long time. The resident's dentures were observed in the bathroom in a denture cup with the resident's name on them, the resident was observed with no dentures in his mouth. Review of the clinical record for Resident 5 on 12/05/2025 at 10:24 a.m., indicated the resident's diagnoses included, but were not limited to, depression, muscle weakness, diabetes, anxiety and vitamin deficiency. The last dental note for Resident 5, dated 11/2/23, indicated the resident was edentulous, had poor oral hygiene and was recommended for routine dental exams. The annual Minimum Data Set (MDS) assessment for Resident 5, dated 5/27/25, indicated the resident had no natural teeth and was edentulous. The quarterly MDS assessment for Resident 5, dated 10/31/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident required set up for eating and drinking fluids. The care plan for Resident B, dated 11/25/25, the resident has potential for oral problems related to edentulous status. The interventions included, but were not limited to, coordinate arrangements for dental care, transportation as needed/as ordered. The physician recapitulation for Resident 5, dated December 2025, indicated the resident may see the dentist. During an interview with the Social Service Director (S.S.D.) on 12/4/25 at 3:32 p.m., she indicated she was responsible to ensure Resident 5 was seen by a dentist. see ancillary services. During an interview with the S.S.D. on 12/5/25 at 9:55 a.m., she indicated she was unable to find any documentation that Resident 5 had seen a dentist since 11/2/23. The S.S.D. was going to contact the dental company to see if they had any further documentation. During an interview with S.S.D. on 12/5/25 at 2:04 p.m., she indicated there was no documentation that the facility had contacted the dentist to schedule an appointment for Resident 5 after his last dental appointment in November 2023. The dental service policy provided by the Director Of Nursing (DON) on 12/8/25 at 10:15 a.m., the DON indicated the facility would assist residents in obtaining routine and emergency dental services. Routine dental services meant an annual inspection of the oral cavity for sings of disease, minor partial or full denture adjustments, taking impressions for dentures and fitting dentures. 3.1-24(a)(1)

Based on interview and record review, the facility failed to ensure 2 of 5 residents reviewed for abuse (Resident D and Resident F) were free from sexual abuse from a resident with known inappropriate behaviors (Resident E), resulting in inappropriate touching (Resident D); and psychological harm of feeling upset and gross (Resident F). Finding included:1.The clinical record for Resident E was reviewed on 11/24/2025 at 4:20 p.m. The medical diagnoses included, but were not limited to, Wernicke's Encephalopathy and Substance Abuse Disorder. A Quarterly minimum data set assessment (MDS), dated [DATE], indicated Resident E was independent with transferring and walking. A care plan, dated 5/1/2025, indicated Resident E had behavioral issues of grabbing staff in appropriate areas, wanting to lay head on other residents' shoulders, and self-pleasuring in the room with his roommate present. Interventions included, but were not limit to, administer medications, monitor for effectiveness, anticipate the needs of the resident, to keep appropriate distance when communicating with the resident to allow space for the resident to remain focused on the conversation and redirect if the resident attempts to lay on a staff members shoulder, and to redirect the resident when attempting to grab/touch inappropriate areas. A care plan, dated 9/24/2025, indicated Resident E was at high risk of inappropriate behaviors of making loud inappropriate comments to staff and other residents. Interventions included encouraging Resident E to avoid making inappropriate comments and providing appropriate direction for resident to engage in activities that he enjoys. A behavior note, dated 8/7/2025, indicated Resident E was found self-pleasuring in the room with his roommate and yelling vulgarities. A behavior note, dated 8/7/2025, indicated Resident E was making inappropriate sexual comments in front of other residents. A behavior note, dated 8/7/2025, indicated Resident E had an intervention of being .moved to new room in which he can self-pleasure with privacy. A psychiatry progress note, dated 9/22/2025, indicate Resident E was asking other residents for fellatio (the practice of performing oral sex on a male). Per the facility census, Resident E had a roommate (Resident F) move-in on 10/30/2025. A social service progress note, dated 11/4/2025, indicated staff report Resident E was making .comments about kissing and going to another resident's room. A psychiatry visit note, dated 11/4/2025, indicated no new intervention for Resident E and .no concerns by staff . A Social Service note, dated 11/14/2025 at 9:50 a.m., indicated they met with .resident in his room as to address concerns reported by staff during smoke break. SSD educated resident on the importance in avoiding inappropriate verbal behaviors. Resident continued to make inappropriate comments to staff. SSD reminded resident to avoid verbal comments that are inappropriate in nature . A nursing progress note, dated 11/14/2025, indicate Resident E's roommate (Resident F) stated .he does not feel safe in same room with [Resident E], that he [Resident E] will ask him [Resident F] to suck his di*k, Resident E would watch him when toileting and make inappropriate comments regarding his butt, and roommate (Resident F) wants to be moved to another room. During an interview with SSD, on 11/24/2025 at 5:20 p.m., she indicated she was not aware of Resident E's self-pleasure behaviors. She was not aware of any new interventions when Resident E obtained a roommate and did not increase supervision. She believed Resident E had a private room per his preference, not as a behavior management tool. During an interview with LPN 4, on 11/25/2025 at 11:30 a.m., she indicated she was unaware of any behavior management interventions for Resident E. If he had behaviors, she would use the baseline intervention of assuring his safety and then notify the DON/ED. She was unaware of needing to redirect, monitor, or keep distance when interacting with Resident E. During an interview with CNA 5, on 11/25/2025 at 1:30 p.m., she indicated she was unaware of any behavioral management interventions for Resident E. The clinical record for Resident F was reviewed on 11/24/2025 at 4:45 p.m. The resident's diagnosis included, but were not limited to, spinal stenosis and major depressive disorder. A Quarterly MDS Assessment, dated 10/6/2025, indicated Resident F was cognitively intact, needed partial/moderate assistance for dressing, was independent with chair transfer and locomotion with a manual wheelchair, and ambulation not attempted due to safety concerns.A care plan, dated 1/30/2024 and revised on 11/17/2025, indicated Resident F had depression and anxiety. The interventions included, but were not limited to, mental health services and nursing facility staff to provide supportive counseling.During an interview, on 11/24/2025 at 2:35 p.m., Resident F reported his former roommate (Resident E) was inappropriate with him. On three different occasions, Resident E had asked Resident F to show Resident E his penis. Resident F indicated Resident E would . make comments about my butt and try to watch me in the bathroom. These comments made Resident F upset and feel gross and .I don't want [Resident E] as my roommate.During an interview, on 11/25/2025 at 12:10 p.m., DON indicated there were no additional interventions put into place or increased supervision when Resident F was moved into Resident E's room on 10/30/2025. 2. A statement by Staff Member 7, dated 11/14/2025 (with no time documented), indicated that Resident E was observed to be acting suspicious around the center hall where Resident D's room was located. A nursing progress note, dated 11/14/2025, indicate two residents were yelling out. When the residents were asked why they were yelling out, resident Resident D indicated Resident E had touched him inappropriately. The clinical record for Resident D was reviewed on 11/25/2025 at 11:05 a.m. The medical diagnoses included intellectual disabilities and anxiety. A Quarterly MDS Assessment, dated 11/6/2025, indicated Resident D was cognitively impaired, needed partial to moderate assistance with dressing and transferring, and was independent with locomotion in a wheelchair. A care plan, dated 9/17/2025, indicated Resident D used medication to help manage a diagnosis of anxiety. The interventions included, but were not limited to, monitoring medication and psychiatry evaluation. A nursing progress note, dated 11/14/2025, indicated Resident D .indicated to staff that another resident had touched him inappropriately. The other resident was immediately removed from the situation and the accused resident placed on 1:1 [one staff to one resident supervision] immediately.A written statement, dated 11/14/2025, was signed by Resident D. The statement indicated, . [Resident E] came into his [Resident D's] room around 8 pm and touched him [Resident D] down there pointing to his private part. He touched me under my pants (clothes) with his hand. I told him to stop. A policy entitled, Abuse, Neglect, and Exploitation, was provided by the Director of Nursing on 11/25/2025 at 12:00 p.m. The purpose of the policy was to protect 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. The policy indicated the facility would work toward preventing abuse by, .Establishing a safe environment.identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors. The deficient practice was corrected on 11/14/2025, after the facility implemented a systemic plan of staff education, auditing, and monitoring to ensure implementation of the in-servicing was monitored related to abuse. This citation relates to Intakes 2674247 and 2674760.3.1-27(a)

Based on interview and record review, the facility staff failed to be knowledgeable of behavioral health interventions for 1 of 5 residents review for behavioral health management. (Resident E) Findings include: The clinical record for Resident E was reviewed on 11/24/2025 at 4:20 p.m. The medical diagnoses included Wernicke's Encephalopathy (neurological symptoms caused by biochemical lesions of the central nervous system) and Substance Abuse Disorder. A Quarterly MDS, dated [DATE], indicated Resident E was independent with transferring and walking. A care plan, dated 5/1/2025, indicated Resident E had behavioral issues of grabbing staff in appropriate areas, wanting to lay head on other residents' shoulders, and self-pleasuring in the room with his roommate present. The interventions included, but were not limited to, administer medications, monitor for effectiveness, anticipate the needs of the resident, to keep appropriate distance when communicating with the resident to allow space for the resident to remain focused on the conversation and redirect if the resident attempts to lay on a staff members shoulder, and to redirect the resident when attempting to grab/touch inappropriate areas. A care plan, dated 9/24/2025, indicated Resident E was at high risk of inappropriate behaviors of making loud inappropriate comments to staff and other residents. Interventions included encouraging Resident E to avoid making inappropriate comments and providing appropriate directions for the resident to engage in activities that he enjoys. A staff management solution system, provided on 11/25/2025 at 3:00 p.m., indicated the resident's behaviors interventions was for staff to do the educating Resident E to avoid inappropriate and/or sexual behaviors, arranging to receive mental health services, providing the opportunity to express mental health needs to staff, observation of mental health, providing opportunities to identify mental health needs, and to offer activities to redirect to activities. During an interview with SSD, on 11/24/2025 at 5:20 p.m., she indicated she was not aware of Resident E's self-pleasure behaviors. She was not aware of any new interventions when Resident E obtained a roommate and did not increase supervision. She believed Resident E had a private room per his preference, not as a behavior management tool. During an interview with CNA 3, on 11/25/2025 at 10:50 a.m., she indicated she had worked with Resident E often, but not always. She stated he had some behaviors that needed redirection, but she was not sure the last time he had them or what exactly they were. She had heard .other staff talk about. the behaviors. She was unaware of the interventions to keep distance when interacting with Resident E. During an interview with LPN 4, on 11/25/2025 at 11:30 a.m., she indicated she was unaware of any behaviors management interventions for Resident E. If he had behaviors, she would use the baseline intervention of assuring his safety and then notify the DON/ED. She was unaware of needing to redirect, monitor, or keep distance when interacting with Resident E. During an interview with CNA 5, on 11/25/2025 at 1:30 p.m., she indicated she had worked with Resident E the whole time he was here, but he did everything himself, so he didn't require much help. CNA 5 was unaware of any behavioral management interventions for Resident E to include redirecting and keeping distance when communicating to Resident E. A policy entitled, Behaviors Health Services, was provided by the Director of Nursing on 11/25/2025 at 12:00 p.m. The purpose of the policy was to ensure all residents received behavioral health services to assist in reaching and maintaining their highest level of mental and psychosocial function and well-being. The policy indicated to .utilize MDS and care area assessments.Assess and develop a person-centered care plan. and .share concerns to the intradisciplinary team.The deficient practice was corrected on 11/14/2025, after the facility implemented a systemic plan of staff education, auditing, and monitoring to ensure implementation of the in-servicing was monitored related to behaviors. This citation relates to Intakes 2674247 and 2674760. 3.1-43(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident who required more than limited assistance with transfers received adequate assistance and supervision to prevent accidents related to only one staff person assisting during a transfer without the utilization of gait belt and ensure the resident's wheelchair was free from sharp objects resulting in the resident requiring 18 sutures to the left lower leg for 1 of 3 residents reviewed for accidents (Resident C). This deficient practice was corrected on 2/28/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff to ensure residents were transferred safely, conducted an audit of all residents' wheelchairs to ensure they were free from any sharp objects, and conducted audits on safe transfers and wheelchair safety with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: The clinical record for Resident C was reviewed on 3/5/25 at 9:45 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, chronic kidney disease, anxiety disorder, congestive heart failure, vascular dementia, and acute respiratory failure. The resident was admitted to the facility on [DATE]. The fall risk assessment for Resident C, dated 1/31/25, indicated the resident was at high risk for falls. The plan of care for Resident C, dated 1/31/25, indicated the resident was at high risk for falls due to medication use. The interventions included, but were not limited to, determine the resident's ability to transfer. The Admission Minimum Data Set (MDS) assessment for Resident C, dated 2/3/25, indicated the resident utilized a wheelchair. The resident required substantial/maximal assistance (helper does more than half the effort) to sit to stand and transfer from chair to bed. The resident did not ambulate. The plan of care for Resident C, dated 2/10/25, indicated the resident had an activity of daily living (ADL) performance deficit related to limited mobility and cognitive loss. The interventions included, but were not limited to, the resident required extensive assistance of 1-2 staff to transfer. At the time of increased weakness, a sit to stand lift may be utilized, initiated on 2/18/25. A progress note for Resident C, dated 2/18/25 at 7:30 p.m., indicated the nurse was called to the resident's room by another nurse who reported the resident needed to go to the hospital. Upon entering the room, a very large skin tear was observed to the resident's left lower leg. Emergency Medical Services (EMS) was called. Pressure was applied to the wound with towels until EMS arrived and applied a pressure dressing. The hospital emergency department note for Resident C, dated 2/18/25 at 9:08 p.m., indicated the resident presented to the emergency room with a left leg laceration from the Extended Care Facility (ECF). The resident was being transferred from the wheelchair to the bed and her leg was injured by the bed frame versus the wheelchair causing a left lower leg laceration. The resident complained of worsening pain to the left leg wound when touched or movement of the left lower extremity. The resident was given a tetanus shot and lidocaine. The laceration length was 18.5 centimeters (cm) long and was closed with 18 sutures. A statement from Certified Nurse Aide (CNA) 1, dated 2/18/25, indicated she went to get the sit to stand mechanical lift to transfer Resident C. Resident C asked if she (CNA 1) would let her stand with the bar and the CNA explained that she was told the resident was supposed to utilize the sit to stand lift. The resident asked the CNA not to use it because it hurt her. The CNA scooted the wheelchair beside the bed and got in front of the resident and put both arms under the resident's arms and counted to three. When the resident sat down on the bed she started to cry. The resident put her hand down to her leg and the CNA seen the tear to the resident's leg. The CNA ran to the nurse and told the nurse to call 911 and she needed help. A statement from Licensed Practical Nurse (LPN) 2, (no date), indicated she was alerted there was an emergency in Resident C's room. The resident's left outer leg was bleeding profusely. CNA 1 indicated the resident's leg got caught while she was transferring her. The resident was currently on her way to the hospital. A statement from LPN 3, (no date) at 7:25 p.m., indicated staff had alerted her there was an emergency in Resident C's room. The resident had a wound on the left leg with a gaping hole and flapping skin. During an observation and interview with Resident C on 3/5/25 at 10:24 a.m., the resident was sitting in a wheelchair with a bandage around her left lower leg. When queried about what happened to her left leg the resident indicated a girl was trying to help her from the wheelchair to the bed. She lifted the resident up underneath her arms and tried to put Resident C into the bed and when the resident turned around, she lost her balance and fell into the bed and hit her left leg on the leg of the bed. The resident began crying and indicated it hurt really bad, and she had to go to the hospital. The resident rated her current pain of the left leg at medium, a 5 on the 1-10 pain scale. During an interview with the Therapy Manager on 3/5/25 at 11:10 a.m., they indicated Resident C had been assessed prior to the incident on 2/18/25. Resident C fluctuated between three different ways of transferring. The resident fluctuated between a two person transfer, a sit to stand mechanical lift, and a sling mechanical lift (Hoyer lift). The therapy manager indicated it was not good practice to transfer a resident by lifting them under their arms and a gait belt should have been utilized unless a resident was independent. The CNA should have been utilizing two staff for the transfer on 2/18/25. During an interview with the Director of Nursing (DON) on 3/5/25 at 11:32 a.m., she indicated the facility investigation into the incident, on 2/18/25, with Resident C indicated it was the resident's wheelchair that caused the skin tear. The wheelchair was missing a rubber/plastic piece and there was a sharp metal edge exposed. The DON indicated CNAs were supposed to utilize gait belts during transfers and only in an emergency situation would it be acceptable to lift a resident under their arms. During an interview with the DON on 3/5/25 at 12:44 p.m., she indicated CNA 1 must have obtained, during shift report, that the resident was to be utilizing a sit to stand lift. During an interview with the DON on 3/5/25 at 1:00 p.m., she verified Resident C did not have a care plan on how she was supposed to be transferred until the incident on 2/18/25. The safe resident handling/transfer policy provided by the DON, on 3/5/25 at 12:45 p.m., indicated the facility would ensure residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident. Handling aides may include gait belt, transfer boards, and other devices. Resident lifting and transferring would be performed according to the resident's individual plan of care. The accidents and supervision policy provided by the DON, on 3/5/25 at 2:15 p.m., indicated the resident environment would remain as free of accident hazards as was possible. Each resident would be provided with adequate supervision and assistive devices to prevent accidents. Accident refers to any unexpected or unintentional incident, which resulted in an injury to a resident. This citation relates to Complaint IN00453938. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to document a resident's death, the notification of a resident's death to the physician, family, responsible party, disposition of the resident's body, personal possessions, medications, or a complete and accurate notation of the resident's condition preceding the resident's death in the clinical record for 1 of 1 resident reviewed for death (Resident B). Findings include: During an interview with the Director of Nursing (DON) on [DATE] at 12:20 p.m., she indicated Resident B died , on [DATE], on day shift. The facility did not document anything about the resident's death in the clinical record because the facility's legal department did not want anything documented as a late entry. During an interview with Licensed Practical Nurse (LPN) 5 on [DATE] at 1:23 p.m., they indicated, on [DATE], a Certified Nurse Aide (CNA) came and got her and said they needed her help on the other unit with Resident B. LPN 5 checked Resident B's code status when she got to the unit and he was a Do Not Resuscitate (DNR) code status. When LPN 5 entered Resident B's room, Registered Nurse (RN) 6 was there checking for the resident's pulse and reported she could not find a pulse. LPN 5 then checked Resident B for a pulse and respirations, and he did not have a pulse or respirations. During an interview with RN 6 on [DATE] at 1:45 p.m., she indicated she was not caring for Resident B, on [DATE], when he died . Qualified Medication Aide (QMA) 7 came to RN 6's office to get her. When RN 6 got to Resident B's bedroom, he was lying on the bed, he had no pulse, one eye closed and one eye open and fixed, and he had no respirations. RN 6 requested LPN 5 to come to the resident's room and verify that he did not have a pulse or respirations. During an interview with CNA 8 on [DATE] at 3:23 p.m., she indicated, on [DATE], she was caring for Resident B when he died . CNA 8 indicated she went to check on Resident B and found him lying in his bed with a plastic bag over his head. CNA 8 removed the bag and felt the resident's chest to see if it was moving and it was not. CNA 8 ran and got help. The clinical record for Resident B was reviewed on [DATE] at 11:05 a.m. The diagnoses included, but were not limited to, dementia, psychotic disturbance, bipolar disorder, depression, suicidal ideations, and anxiety disorder. The resident's code status was DNR. The last documentation in Resident B's clinical record, dated [DATE] at 9:00 a.m., indicated the Social Service Director (S.S.D.) went to the resident's room to complete a psychosocial assessment. The resident was fully dressed and asleep in the recliner. The S.S.D. also noted that the resident's room was clean and orderly. During an interview with the [NAME] President of the facility, on [DATE] at 12:07 p.m., they indicated the facility team made the decision not to document Resident B's death, on [DATE], in the clinical record and the legal department agreed. The facility did this to ensure accuracy of documentation due to it was a high stress situation. The documentation in the medical record policy provided by the DON, on [DATE] at 2:15 p.m., indicated each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation shall be accurate, relevant, and complete. Documentation shall be timely and in chronological order. This citation relates to Complaint IN00454495. 3XXX,d+[DATE](a)(1) 3XXX,d+[DATE](a)(2) 3XXX,d+[DATE](j)(1) 3XXX,d+[DATE](j)(2) 3XXX,d+[DATE](j)(3)

Based on observation and interview, the facility failed to ensure open medication bottles were dated in 2 of 2 medication carts observed for medication storage and four open, un-identified medications laying in medication drawers in 2 of 2 medication carts observed. Findings include: During an observation of Extended Care Unit (ECU) Medication Cart 1 with Registered Nurse (RN) 1, on 11/6/24 at 9:45 a.m., several medication bottles were noted not to have open dates marked on the bottles. Bottles included: one 236 milliliter (ml) Guaifenesin, one 433 ml Enulose, three Polyethylene Glycol 3350 8.3 ounce (oz) bottles, one 473 ml Milk of Magnesia, three 355 ml oral simethicone, one 473 ml Guaifenesin, two Almacone bottles, one 236 ml Dermal Wound Cleanser, and one 10 ml Refresh Optive Advanced. One Fluticasone Propionate inhalation powder was noted to not have a resident label or dates labeled on it. One half of a loose orange oblong pill was laying in the medication drawer. During an interview on 11/6/24 at 9:45 a.m., RN 1 indicated she was unsure where the open pill came from, and it should have been discarded if not used. RN 1 indicated when a new medication bottle is opened, they were to put an open date and expiration date on them. During an observation of the ECU Medication Cart 2 with Licensed Practical Nurse (LPN) 2 on 11/6/24 at 10:00 a.m., one loose blue pill was noted in medication drawer. LPN 2 indicated she was unsure who's medication it was or where it came from, and open medications should not be stored in the medication cart. One Albuterol 90 microgram (mcg) inhaler with spacer was noted laying in the bottom drawer with no resident label on it. LPN 2 indicated, she was unsure who the medication belonged to, and it should be labeled. LPN 2 discarded all loose and unidentified medications. During an observation of the ECU Medication Cart 2 with LPN 2 on 11/6/24 at 10:00 a.m., several medication bottles were noted not to have open dates labeled on them. Bottles included: one 473 ml Enulose, four Guaifenesin 473 ml bottles, one Max Tussin 300 ml bottle, one Milk of Magnesia 473 ml bottle, one 8.3 oz. Polyethylene Glycol, and one Potassium Chloride 10% 473 ml bottle. LPN 2 indicated when a bottle was opened, the open date should be recorded on them. During an interview with the Director of Nursing Services (DNS) on 11/8/24 at 1:20 p.m., they indicated nursing puts the open date and the dispose date anytime a new medication bottle is opened. The DNS indicated they keep a binder at the nurses' stations that has what the discard time lengths should be for different medications. A Medication Storage Policy provided by the Executive Director, on 11/6/24 at 11:22 a.m., indicated the following, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, or deteriorated medications with worn, illegible, or missing labels This citation relates to Complaint IN00446364. 3.1-25(j) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document self-administration of medications were clinically appropriate for 1 of 6 residents reviewed for medication administration. (Resident T) Findings include: The clinical record for Resident T was reviewed on 11/8/24 at 10:20 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, dry eye syndrome, and chronic viral hepatitis. An Annual Minimum Data Set (MDS) assessment, completed 9/18/24, indicated she was cognitively intact for daily decision making. On 11/6/24 at 10:55 a.m., Resident T had one blue oblong pill sitting in a medicine cup at the bedside. Resident T indicated she did not want the pill, but did not tell the nurse she didn't, so it was left at the bedside. During an observation of Resident T on 11/7/24 at 11:47 a.m., one bottle of Visine eye drops was sitting on the bedside table. Resident T indicated, a nurse just left it here one time, so she just left it. During an interview on 11/7/24 at 11:53 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident T should not have any medications at the bedside and was not sure who left it there. LPN 3 indicated Resident T cannot have any medications left at the bedside nor self-administer medications. During an interview on 11/8/24 at 1:58 p.m., the Director of Nursing Services (DNS) indicated Resident T had not had a self-administration of medication order or care plan in place for self-administration of medications. On 11/12/24 at 12:05 p.m. a Resident Self-Administration of Medications Policy was provided by Unit Manager. The policy indicated, .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely This citation relates to Complaint IN00446364. 3.1-11(a)

Based on interview and record review, the facility failed to ensure a proper code status order and care plans were in place for 2 of 4 residents reviewed for code status and care plans. (Resident EE & Resident GG) Findings include: 1. The clinical record for Resident EE was reviewed on 11/8/24 at 1:55 p.m. The diagnoses included, but were not limited to, essential tremor, peripheral vascular disease, and chronic respiratory failure. Resident EE had a Physician Orders for Scope and Treatment (POST) form dated 4/29/24. The form indicated Resident EE was a Do Not Resuscitate (DNR). Resident EE had a physician order for DNR status placed on 7/30/24. An Advance Directive care plan, initiated 12/7/23, indicated Resident EE was a full code. During an interview with the Director of Nursing Services (DNS) on 11/8/24 at 1:50 p.m., she indicated Resident EE had a full code care plan because it had not been updated properly. 2. The clinical record for Resident GG was reviewed on 11/8/24 at 12:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus, depression, and chronic ischemic heart disease. The clinical record indicated Resident GG was admitted to the facility on [DATE]. No POST form, code status order, or code status care plan were present in the clinical record. During an interview with the DNS on 11/12/24 at 12:25 p.m., she indicated Resident GG had not made her mind up yet about her code status. So, we treat them as a full code, and nothing is documented in the Electronic Health Record (EHR) until we get everything signed and completed. A Communication of Code Status Policy provided by the Unit Manager, on 11/12/24 at 12:04 p.m., indicated the following, .It is policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .2. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to . a. Full Code, b. Do Not Resuscitate .4. The designated sections of the medical record are: Orders Section This citation relates to Complaint IN00446364. 3.1-4(f)(5)

Based on interview and record review the facility failed to provide privacy for residents' medical condition by taking pictures and videos on personal cell phones for 2 of 4 residents reviewed for privacy (Resident KK and Resident W). Findings include: During an interview with Licensed Practical Nurse (LPN) 5 on 11/8/24 at 10:40 a.m., she indicated she had called the on-call Nurse Practitioner (NP) about Resident KK's wound on her leg, and they responded with continuation to monitor the area. LPN 5 indicated she was a new nurse and did not feel comfortable with that. LPN 5 took a picture of the wound on her cell phone and sent it to the Director of Nursing Services (DNS) to get her opinion. LPN 5 indicated she did not send the picture to anyone else and deleted the picture off her phone. During an interview with LPN 4 on 11/8/24 at 2:41 p.m., she indicated she did take a video of Resident W and sent it to the DNS. LPN 4 indicated she was working third shift, and Resident W had a total change in condition. The resident was making a snoring sound, breathing weird, hitting himself, banging on his chest, banging on the walls and tore up his bedroom. This was out of character for the resident. LPN 4 indicated she had tried to call the DNS and when she did not answer she video tapped Resident W and sent it to the DNS. LPN 4 indicated she wanted the DNS to understand how serious the situation was. LPN 4 indicated she did not send the video to anyone else, and she deleted it from her cell phone. During an interview with the DNS on 11/12/24 at 12:13 p.m., she indicated the facility previously had the capability to send pictures of wounds via the electronic health record system and they no longer had that option. LPN 5 and LPN 4 did send the DNS a picture and video of residents because the nurses did not feel like the provider was responding appropriately about these situations and wanted my help. The DNS indicated Resident W was delusional and having hallucinations on the video. Resident W was yelling and hitting himself. LPN 4 had called the on-call Nurse Practitioner (NP), and she gave an order for Ativan (antianxiety medication), and it did not help Resident W. That was why LPN 4 called her and sent the video to her. The resident photograph policy provided by the Executive Director, on 11/6/24 at 10:20 a.m., indicated taking photographs and/or videos of residents was a violation of the residents rights' to privacy and confidentiality. This citation relates to Complaint IN00446364. 3.1-3(o)

Based on observation, interview, and record review the facility failed to utilize smoking aprons during smoking for safety of the residents as assessed for 3 of 3 residents reviewed for smoking safety (Resident J, Resident Z and Resident BB). Findings include: 1. During an observation on 11/7/24 at 11:43 a.m., Resident J was outside smoking with other residents and a staff member. Resident J did not have on a smoking apron. During an interview with Resident J on 11/7/24 at 12:00 p.m., he indicated he did not wear a smoking apron when smoking. Resident J indicated the smoking apron was only for residents who drop things and were not safe during smoking. Review of the record of Resident J, on 11/8/24 at 2:18 p.m., indicated the diagnoses included, but were not limited to, chronic respiratory failure, difficulty walking, chronic obstructive pulmonary disease, diabetes, heart failure and dependence on nicotine. The plan of care for Resident J, dated 7/9/24, indicated the resident was at risk for smoking related injury. The interventions included, but were not limited to, provide a smoking apron while smoking. The Quarterly Minimum Data Set (MDS) assessment for Resident J, dated 8/29/24, indicated the resident was cognitively intact for daily decision making. The smoking and safety assessment for Resident J, dated 10/29/24, indicated the resident was lethargic/falls asleep easily during task or activities. The intervention included, but were not limited to, utilize a smoking apron. 50436 2a. During an observation of the designated smoking area, on 11/6/24 at 11:41 a.m., Resident Z and Resident BB were smoking without a smoking apron in place. The clinical record for Resident Z was reviewed on 11/8/24 at 10:46 a.m. The diagnoses for Resident Z included, but were not limited to, flaccid hemiplegia (neurological condition with a loss of voluntary movement in a limb) affecting left non-dominant side, dependence on supplemental oxygen, and vascular disease. An Annual Minimum Data Set (MDS) assessment, dated 9/17/24, indicated Resident Z was cognitively intact and had limited range of motion of upper extremity on one side and utilized a wheelchair for ambulation. A Smoking and Safety assessment provided by the Director of Nursing Services (DNS), on 11/8/24 at 9:30 a.m., indicated Resident Z had limited or no Range of Motion (ROM) in arms or hands and was to utilize a smoking apron. During an interview on 11/7/24 at 1:50 p.m., Resident Z indicated she occasionally wore a smoking apron and was aware that she was supposed to at all times. Resident Z indicated she had never had any burns while smoking. 2b. The clinical record for Resident BB was reviewed on 11/8/24 at 10:47 a.m. The diagnoses included, but were not limited to, essential hypertension, hypothyroidism, and chronic obstructive pulmonary disease (COPD). A Quarterly MDS assessment, dated 10/2/24, indicated Resident BB had moderate cognitive impairment and was wheelchair dependent for mobility. A Smoking and Safety assessment provided by the DNS, on 11/8/24 at 9:30 a.m., indicated Resident BB was to utilize a smoking apron. During an interview on 11/7/24 at 1:46 p.m., Resident BB indicated he would wear a smoking apron every now and then, when you guys were here. Resident BB indicated he was aware that he was supposed to utilize a smoking apron at all times while smoking. He indicated he had never been burned while smoking but he had gotten ashes on his clothing that caused burn holes in his clothing. During an interview on 11/6/24 at 11:41 a.m., the DNS indicated the facility does a smoking assessment on all residents who smoke. That assessment assesses their abilities to safely smoke. If a resident triggers for not being able to smoke without a risk, they will trigger for a smoking apron to be worn. If they do not trigger, then they are not required to wear one. A Resident Smoking Policy was provided by the Executive Director (ED) on 11/6/24 at 10:20 a.m. The policy indicated the following, .it is the policy of the facility to provide a self and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all .10. All safe smoking measures will be documented on each resident's care plan This citation relates to Complaint IN00446364. 3.1-45(a)(2)

Based on interview and record review, the facility failed to obtain physician orders to crush medications for 3 of 5 residents reviewed for medication administration. Findings include: 1. The clinical record for Resident L was reviewed on 11/7/2024 at 1:30 p.m. The medical diagnoses included diabetes. During an interview with Resident L, on 11/6/2024 at 1:15 p.m., they indicated they take their medication crushed since they were admitted to the facility. The physician orders did not reflect an active order to crush medications as needed. 2. The clinical record for Resident O was reviewed on 11/7/2024 at 1:40 p.m. The medical diagnoses included diabetes. The physician orders did not reflect an active order to crush medications as needed. 3. The clinical record for Resident P was reviewed on 11/7/2024 at 1:45 p.m. The medical diagnoses included chronic obstructive pulmonary disease. The physician orders did not reflect an active order to crush medications as needed. During a confidential staff interview completed during the survey, the staff member indicated they crush medications based on nursing judgement. Resident L, Resident O, and Resident P take their medications crushed and have since the staff member has worked with them. The staff member verified Resident L, Resident O, and Resident P do not have orders to crush medications. An interview with Registered Nurse (RN) 1, on 11/6/2024 at 1:41 p.m., indicated they had issues with medication not being able to be crushed, but the pharmacy was unaware of the resident taking medications crushed because of not having physician orders when they review medications. RN 1 stated they provided the Director of Nursing Services (DNS) and the Executive Director (ED) with a list of residents that take crushed medications, but no orders have been obtained for those residents. A blank nursing report sheet was provided by the DNS on 11/7/2024 at 2:30 p.m. The document indicated Resident L, Resident O, and Resident P received crushed medications. A policy, entitled Medication Administration, was provided by the ED on 11/6/2024 at 10:20 a.m. The policy indicated, .Crush medications as ordered . This citation relates to Complaint IN00446364. 3.1-25(b)

Based on interview and record review the facility failed to follow-up with monitoring and have an indication for use on a one-time order for Ativan (antianxiety medication) for a resident who was experiencing an acute change in condition for 1 of 3 residents reviewed for change in condition (Resident W). Findings include: During an interview with Licensed Practical Nurse (LPN) 4 on 11/8/24 at 2:41 p.m., she indicated she did take a video of Resident W and sent it to the Director of Nursing Services (DNS). LPN 4 indicated she was working third shift, and Resident W had a total change in condition. The resident was making a snoring sound, breathing weird, hitting himself, banging on his chest, banging on the walls and tore up his bedroom, which was out of character for the resident. LPN 4 indicated she had tried to call the DNS and when she did not answer she video tapped Resident W and sent it to the DNS, on 10/18/24 around 2:30 a.m. LPN 4 indicated she wanted the DNS to understand what a serious situation that was. LPN 4 indicated she did not send the video to anyone else, and she deleted it from her cell phone. During an interview with the DNS on 11/12/24 at 12:13 p.m., she indicated LPN 4 did send the DNS a video of Resident W because the nurse did not feel like the provider was responding appropriately about the situation and wanted my help. The DNS indicated Resident W was delusional and having hallucinations on the video. Resident W was yelling and hitting himself. LPN 4 had called the on-call Nurse Practitioner (NP), and she gave an order for Ativan (antianxiety medication), and it did not help Resident W. That was why LPN 4 called her and sent the video to her. Review of the record of Resident W, on 11/12/24 at 10:36 a.m., indicated the diagnoses included, but were not limited to, opioid dependence, hypertension, muscle weakness, and fatigue. The Admission Minimum Data Set (MDS) assessment, dated 9/30/24, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident did not have hallucinations, delusions, or behaviors. A progress note for Resident W, dated 10/18/24 at 3:32 a.m., indicated the resident had been in his room since early A.M., around 1:30 a.m., with altered mental status. The resident was standing with eyes rolling in the back of his head, laying on the couch halfway, screaming out, stating that someone was going to push him off his bed if he got on it. The resident was beating on his chest and face with his fists, while seemingly being asleep. The resident was not getting any better, only worse. This nurse sat resident down numerous times to keep him safe and prevent him from falling. There was nothing that was helping the situation. The on-call provider was notified, and the DNS was notified. A progress note for Resident W, dated 10/18/24 at 3:37 a.m., indicated the Nurse Practitioner (NP) response was to administer Ativan two milligrams (mg); one dose. The clinical record did not indicate what the Ativan two milligrams was utilized for or indication of follow up if the Ativan was effective or not effective for Resident W. A progress note for Resident W, dated 10/18/24 at 6:52 a.m., indicated the resident was thrashing on the couch uncontrollably, vital signs were normal, and was unable to answer questions appropriately. The writer suspects resident had taken unprescribed medication. The NP was called, and an order was received to send the resident to the emergency room . A progress note for Resident W, dated 10/18/24, indicated since around midnight the resident had been thrashing, yelling, hitting himself, eyes rolling back in head and general disoriented to person, time, and place. The resident had refused care of his cellulitis this past week and could be septic although his vital signs were normal. The resident became very disoriented, combative with staff, and hitting himself. Ativan two mg was given, around 2:00 a.m., with little effect on his demeanor. The resident was experiencing hallucinations and agitation. The resident was disoriented with mental status changes, usually this resident was very kind and respectful and was currently yelling and hitting himself. The resident was unable to answer if he had taken any substance that he was not supposed to or why his condition suddenly spiraled out of control. The resident was being transported to the emergency room . The progress note was electronically signed by NP 2. A progress note for Resident W, dated 10/18/24 at 7:10 a.m., indicated the fired department was at the facility to transport the resident, NP 2 was in the resident's room as well. The hospital records for Resident W, dated 10/18/24, indicated the resident was admitted to the local hospital with toxic encephalopathy (sudden, severe change in mental function) secondary to cocaine and amphetamine use. The resident had left the long-term care facility yesterday and when he returned, he was altered and confused. The resident remained in the emergency room for several hours, with attempts at metabolizing, but despite this he remained quite sleepy and had to be placed on oxygen. Given the prolonged period of observation in the emergency department, still without return to baseline I do feel that patient will warrant further inpatient management. The provision of physician ordered services policy provided by the Executive Director, on 11/12/24 at 3:00 p.m., indicated the purpose of this policy was to provide reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. This citation relates to Complaint IN00446364. 3.1-48(a)(3) 3.1-48(a)(4)

Based on interview and record review, the facility failed to ensure an order and care plan were in place for a resident receiving hospice services for 1 of 3 residents reviewed for hospice. (Resident DD) Findings include: The clinical record for Resident DD was reviewed on 11/6/24 at 1:26 p.m. The diagnoses included, but were not limited to, anxiety disorder, diabetes mellitus, and chronic pain syndrome. Resident DD's hospice binder indicated he was placed on hospice on 9/15/24. The clinical record indicated there was not an order for hospice nor a hospice care plan in the Electronic Health Record (EHR). During an interview with the Director of Nursing Services (DNS) on 11/7/24 at 10:29 a.m., they indicated Resident DD's physician put a one-time order in for a hospice services consult for one day only, then the order fell off the EHR after that day, and an order was not put in after that. An interview with the DNS on 11/8/24 at 10:00 a.m., they indicated the facility recently switched over their care plan library for auditing purposes, on 10/28/24, and all of the old care plans were disappearing. A hospice care plan, dated 11/7/24, indicated interventions to coordinate plan of care with hospice services and to obtain physician order and appropriate referral. A Coordination of Hospice Services Policy was provided by the Executive Director (ED) on 11/6/24 at 2:40 p.m. The policy indicated the following, .the facility and hospice provider will coordinate a plan of care and will implement interventions .5. The facility will monitor and evaluate the resident's response to the hospice care plans This citation relates to Complaint IN00446364. 3.1-37(a)

Based on interview, observations, and record review, the facility failed to ensure Resident 44 had a self-administration of medications assessment completed for 1 of 1 resident reviewed for self-administration of medications. Findings include: The clinical record for Resident 44 was reviewed on 9/11/2024 at 11:20 a.m. The medical diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) assessment, dated 8/29/2024, indicated Resident 44 was cognitively intact and did not have behaviors. A self-administration care plan, initiated on 9/10/2024, indicated an intervention of completing a self-administration assessment per the facility's protocol. During an interview and observation, on 9/5/2024 at 11:21 a.m., indicated Resident 44 had two medication nasal sprays. Resident 44 indicated they kept the two medicated nasal sprays on the over-bed table, staff knew about the medicated nasal sprays, and staff told them to just keep the medicated nasal sprays in one spot. During an interview on 9/5/2024 at 11:30 a.m., QMA 6 indicated Resident 44 utilized over the counter nasal sprays that the family provided, and Resident 44 kept at the bedside. During an observation on 9/10/2024 at 1:55 p.m., Resident 44 had two medicated nasal sprays on the bedside table. A self-administration assessment, dated 9/10/2024 at 6:29 p.m., indicated that Resident 44 was fully capable of self-administration for nasal decongestants. A policy entitled, Resident Self-Administration of Medications, was provided by the Director of Nursing Services on 9/12/2024 at 9:40 a.m. The policy indicated, .A resident may only self-administer medications after the facility's intradisciplinary team has determined which medications may be self-administered safely .the opportunity to self-administer medications during the routine assessment . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to provide fresh water daily for 1 of 1 resident reviewed for hydration. (Resident C) Findings include: During an observation and interview with Resident C on 9/9/24 at 11:30 a.m., the resident had two cups of thickened juice on the bedside table and no water. Resident C indicated she liked juice but would like to have fresh water every day also. During an observation on 9/10/24 at 1:59 p.m., Resident C had a cup of thickened coffee and a cup of thickened juice. The resident did not have any water. During an observation and interview with Resident C on 9/11/24 at 2:52 p.m., the resident had a cup of thickened coffee and juice. The resident did not have any water. Resident C indicated she had not had any water in the last five days. During an observation on 9/12/24 at 1:17 p.m., Resident C had a cup of thickened coffee and a cup of thickened juice. The resident did not have any water. Review of the clinical record of Resident C, on 9/11/24 at 2:15 p.m., indicated the diagnoses included, but were not limited to, congestive heart failure, pneumonia, dementia, chronic obstructive pulmonary disease, hypertension, anxiety, dysphagia, and history of pressure ulcer to the right buttock. A physician order for Resident C, dated September 2024, indicated the resident was to be up in a chair for all meals. The resident was ordered a regular diet and thickened liquids with nectar/mildly thick consistency. The plan of care for Resident C, dated 8/11/23, indicated the resident was at risk for constipation. The interventions included, but were not limited to, encourage fluids. The plan of care for Resident C, dated 8/11/23, indicated the resident had alteration in elimination of bowel and bladder. The interventions included, but were not limited to, encourage fluids. During an interview with the Director of Nursing Services on 9/12/24 at 2:00 p.m., they indicated the nursing staff were responsible to ensure Resident C had fresh water daily. The hydration policy provided by the Executive Director, on 9/13/24 at 1:00 p.m., indicated the facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, requiring the operation of the mechanical lift to be conducted by 2 staff members, resulting in a fall from the mechanical lift and a fracture for 1 of 3 residents reviewed for falls and the use of mechanical lifts. (Resident B and CNA 3) The deficient practice was corrected on 4-25-24, prior to the start of the survey, and was therefore past noncompliance. The facility had completed an assessment of the resident who had experienced a fall from a mechanical lift and was sent to an area emergency room , began an immediate investigation into the circumstances of the fall, conducted education and skills checkoffs with staff for safe transfers and use of mechanical lifts, inspected all mechanical lifts in the facility, conducted audits of the clinical records of residents who utilize mechanical lifts and began random care observations for safe mechanical lift operations with staff, and updated her care plans upon return to the facility on [DATE]. Findings include: The clinical record of Resident B was reviewed on 5-3-24 at 10:33 a.m. Her diagnoses included, but were not limited to, cerebral infarction with left non-dominant side affected, diabetes with neuropathy, morbid obesity, cognitive communication disorder, hypertensive with heart disease and chronic kidney disease and general muscle weakness. Her most recent Minimum Data Set (MDS) assessment, dated 2-21-24, indicated she is cognitively intact, is non-ambulatory, uses a wheelchair for mobility and is dependent for all transfers from one surface to another. A review of her care plans indicated she requires a mechanical lift for transfers, with two assist transfers at all times. The facility sent a report of a fall with fracture to the Indiana Department of Health's Long-Term Care Division on 4-19-24 and a follow-up report on 4-26-24. It indicated Resident B while transferring from her chair to bed, encountered a fall. It indicated she complained of pain and upon notification to the physician, orders were obtained to send her to a local hospital's emergency room for further evaluation. An immediate investigation was begun. The follow-up detailed a new fracture was identified, which was an area of a previous fracture of the left tibial plateau (around the area of the patella/knee cap). It indicated the orthopedic consultant found the fracture to be inoperable and placed a knee immobilizer for resident comfort. It indicated staff education was conducted on safe transfers and mechanical lift procedures immediately. The resident returned to the facility on [DATE], with staff monitoring and treating the resident for pain, with no concerns observed. A psychosocial follow-up for 3 days post return for 3 days with no concerns noted. The interdisciplinary team (IDT) met and reviewed the resident for fall interventions and updating of her care plan. In an interview with the Corporate Executive Director (ED) on 5-3-24 at 10:40 a.m., she shared Resident B is a long-term resident. She explained on the date of the fall, 4-18-24, around 8:00 p.m., Resident B being transferred with a mechanical lift by CNA 3. The aide thought she had the 4 straps secured well and as she went to reach for the resident's cell phone that had fallen, something happened and she (Resident B) fell from the lift. She ended up fracturing her knee and was sent out to the hospital. She did not have surgery for the knee fracture. In a second interview with the Corporate ED on 5-3-24 at 11:45 a.m., she indicated the type of mechanical lift used for this resident requires two (2) persons to operate. She shared CNA 3 was hired in January, 2024, had her normal skills checkoff, as well as participated in the building's annual skills checkoff on 1-10-24, which included mechanical lifts and was successful. The Corporate ED indicated the facility obtained a written statement from CNA 3 and she was placed on suspension, pending investigation and was terminated related to not following the facility's policies regarding mechanical lifts require two (2) persons to operate and this resulted or contributed to a fall with a fracture for Resident B. A signed statement from CNA 3, dated 4-18-24, indicated Resident B had requested to be put to bed and CNA 3 took her from the dining room to her room to do so, via a Broda chair. CNA 3 indicated the mechanical lift sling was already in place under the resident, hooked resident on the sling on yellow on the top and the bottom was on green .raised her up and removed the chair. Legs were spread on the [brandname of mechanical lift]. When turning the [brandname of mechanical lift] to the bed .realized the bed was too high .walked away from [brandname of mechanical lift] to lower the bed .heard phone fall to the floor that was on the resident's chest. As .turned .saw resident doing roll out of the [brandname of mechanical lift] to the floor .immediately yelled to nurse on the floor for assistance. Resident was laying on back on the floor .sat with resident on the floor to provide comfort while nurse was completing assessment. A review of CNA 3's employment record was conducted. It indicated she began employment on 12-7-23, has possessed a CNA certification since 10-11-18, completed her general orientation to the facility on [DATE], participated in an inservice on Safe Transfer on 1-10-24 and completed her job specific orientation, including Transfer using [brandname of mechanical lift] on 1-23-24. A facility document, dated 4-18-24, indicated her suspension began on 4-18-24, related to Staff person was not using proper techniques when using [brandname of mechanical lift]. Resident fell . It indicated this infraction was deemed, gross misconduct and are subject to immediate suspension, pending investigation for termination if the violation is substantiated. An IDT [interdisciplinary team] note, dated 4-25-24, reviewed the details of Resident B's fall which occurred on 4-18-24. It indicated the root cause of the fall was, Staff attempting to transfer resident with 1 assist [staff member]. It identified the immediate interventions were to transfer the resident to a local emergency room for further evaluation and treatment. It added other interventions initiated included, Clinical education and evaluation of the function and operation of [brand name of mechanical lift] life [sic]. It indicated Resident B's care plans were reviewed and updated. On 5-3-24 at 11:55 a.m., the Corporate ED provided a binder, entitled, Ad Hoc QAPI binder related to a fall from a mechanical lift of 4-18-24, dated 4-19-24. This binder included the following information: -An audit was completed for all residents who use a mechanical lift to ensure plans of care were up to date. -Education was completed with all staff on safe use of mechanical lifts for transfers with ongoing monitoring to be completed for safe transfers with ongoing monitoring of 3 staff members to be observed weekly for 4 weeks, then monthly for 4 months to complete 6 months. Observations to be completed on alternating shifts and alternating staff. Results will be be brought to QAPI for 6 months to identify trends and to make recommendations. If no trends/issues are identified, then the review will be completed on a prn (as needed basis. This process to be monitored by the ED/designee. A mechanical lift validation checklist for staff was conducted, beginning 4-18-24 and 4-19-24, with ongoing audits 4-25-24 and 5-1-24. - A Care Plan audit of residents who require the use of mechanical lift was conducted with 4 of 22 residents's care plans requiring updating. -An education inservice/training entitled, Safe Resident/Handling Transfer related to mechanical lifts was conducted with 35 staff members, dated 4-19-24. -A mechanical lift inspection was conducted on 4-19-24, and all other mechanical lift with no concerns noted by the maintenance department. Monthly routine mechanical lift inspections are conducted on all mechanical lifts. Records reflect no mechanical lift concerns for over four months. On 5-3-24 at 12:30 p.m., the Corporate Nurse provided a copy of a policy entitled, Safe Resident Handling/Transfers, dated 2023. This policy indicated It is the policy of this facility to ensure that residents are handled in and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .Two staff members must be utilized when transferring residents with a mechanical lift . This Federal tag relates to Complaint IN00432977. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident who admitted to the facility with an identified skin concern received timely treatment and services that was later identified with an unstageable pressure ulcer that had worsened and became infected (Resident E) and failed to ensure a resident received treatment for incontinence associated dermatitis (IAD) who was later identified with a stage 3 pressure ulcer (Resident D) for 2 of 3 residents reviewed for skin integrity. The deficient practice was corrected on 2/1/24, prior to the start of the survey, and was therefore past noncompliance. The facility had completed full skin assessments on all of the residents, conducted in-service education for wound treatment management, documentation of wound treatments, skin assessments, changes in condition, and pressure injury prevention/management, conducted audits for residents with identified wounds, and conducted audits for new admissions for skin integrity and treatment initiation. Findings include: 1. The clinical record for Resident E was reviewed on 4/16/24 at 3:30 p.m. The diagnoses included, but were not limited to, bipolar disorder, major depressive disorder, malnutrition, muscle weakness, need for assistance with personal care, and rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury). Resident E was admitted to the facility on [DATE]. A Braden Scale (a scale that assesses a patient's risk of developing a pressure ulcers), dated 1/4/24, indicated Resident E was at risk for pressure ulcer development. A care plan for activities of daily living (ADLs), initiated on 1/9/24, indicated Resident E had interventions listed for 2 staff person assist with bathing, bed mobility, dressing, and morning and bedtime routine. A care plan for skin, initiated on 1/31/24, indicated Resident E admitted to the facility with a pressure ulcer to the coccyx. The interventions included, but were not limited to, weekly assessment of the skin and treatments as ordered. A care plan for skin, initiated on 1/31/24, indicated Resident E admitted to the facility with a pressure ulcer to the lower, mid-back. The interventions included, but were not limited to, weekly assessment of the skin and treatments as ordered. A progress note, type: Clinical Admission and dated for 1/3/24 at 10:11 p.m., indicated Resident E had an abrasion to his right knee. A progress note, type: Skin Only Evaluation and dated for 1/4/24 at 7:35 a.m., indicated Resident E had an abrasion to the right knee. There was documentation of Scabs on his right and left cheeks and chin. Skin tear on his lower back with 0.1 in diameter [sic]. There was no further description of the skin alterations for Resident E. A progress note, dated 1/7/24, indicated Resident E was admitted to the hospital. A hospital discharge summary, dated 1/10/24, indicated the following, .was admitted on [DATE] due to altered mental status and lethargy .Patient does have multiple Pressure ulcers of mid spine, left spine, left sacrum, right sacrum, and right metatarsal, all present upon admission. Patient will benefit from close outpatient follow-up with Wound Care, as well as frequent position change to avoid worsening of pressure ulcers A progress note, dated 1/10/24 at 7:45 p.m., indicated Resident E was readmitted to the facility from the hospital. A skin assessment was completed and noted resident still has skin tear on his sacrum, lower back and right foot. Dressing placed on his lower back & sacrum A Weekly Skin Review, dated 1/11/24, indicated skin tears that were Pre-existing were marked. The document indicated skin tears present to the coccyx, sacrum, and right foot. There were no further assessments that included measurements, condition of the wounds, etiology of the wounds, and/or treatment of such wounds. The electronic medication administration record (EMAR) and electronic treatment administration record (ETAR) of January of 2024 was reviewed and did not indicate any treatments for Resident E's skin upon admission to the facility on [DATE] and upon readmission to the facility on [DATE]. A wound assessment report, dated 1/16/24, indicated a stage 3 pressure ulcer to Resident E's coccyx that was Present on Admission. The treatment was listed as cleanse the area with wound cleanser, apply Triad paste, and leave open to air twice daily. A wound assessment report, dated 1/16/24, indicated a stage 3 pressure ulcer to Resident E's lower back that was Present on Admission. The treatment was listed as cleansing the area with wound cleanser, apply hydrogel, cover with bordered gauze, and change daily. The EMAR and ETAR of January of 2024 was reviewed and didn't note any treatment orders for Resident E's skin on 1/16/24. A physician order, dated 1/18/24, was noted to Resident E's mid-lower back to cleanse with normal saline and pat dry, apply collagen to wound bed and cover with bordered foam. A physician order, dated 1/18/24, was noted to Resident E's sacrum to cleanse with normal saline, pat dry, apply collagen to wound bed and cover with border foam. These orders were not consistent with the wound assessment report treatment plan from 1/16/24. A physician order, dated 1/22/24, was noted to Resident E's mid-lower back to cleanse with wound cleanser and pat dry. Apply hydrogel to wound bed and covered with bordered gauze. Change daily and as needed. The order was discontinued on 1/28/24. A physician order, dated 1/22/24, was noted to Resident E's sacrum to cleanse with wound cleanser and pat dry. Apply Triad paste to wound bed and leave open to air. Complete BID (twice daily) and PRN (as needed). The order was discontinued on 1/28/24. The ETAR for January of 2024 indicated the Triad paste to Resident E's sacrum to be conducted twice daily but was signed off, as administered, on a daily basis from 1/23/24 to 1/28/24. A wound assessment report, dated 1/24/24, indicated a stage 3 pressure ulcer to Resident E's coccyx that was stable. The treatment was listed to cleanse the area with wound cleanser, apply Dakins moistened fluffed gauze ((Dakin's solution is a dilute solution of sodium hypochlorite (0.4% to 0.5%) and other stabilizing ingredients, traditionally used as an antiseptic, e.g. to cleanse wounds in order to prevent infection)), cover with bordered foam, and change daily. A wound assessment report, dated 1/24/24, indicated a stage 3 pressure ulcer to Resident E's lower back that was stable. The treatment was listed to cleanse the area with wound cleanser, apply Dakins moistened fluffed gauze, cover with bordered foam, and change daily. Physician orders, dated 1/28/24, was noted for Dakins soaked fluffed gauze treatment to Resident E's coccyx and mid-lower back daily. The orders were discontinued on 2/13/24. A wound assessment report, dated 1/31/24, indicated a stage 3 pressure ulcer to Resident E's coccyx. There was blue and green drainage noted. The treatment remained the same with Dakins moistened fluffed gauze daily. A wound assessment report, dated 1/31/24, indicated a stage 3 pressure ulcer to Resident E's lower back. There was blue and green drainage noted. The treatment remained the same with Dakins moistened fluffed gauze daily. A care plan for wounds, dated 1/31/24, indicated Resident E had a wound infection to the coccyx and lower back area. The interventions included, but were not limited to, treatments as ordered and obtain and monitor lab/diagnostic work as ordered. A progress note, dated 2/1/24, indicated Resident E's pressure ulcers were worsening and will order to get wound culture. A progress note, dated 2/5/24 at 10:05 p.m., indicated a wound culture was obtained of Resident E's sacrum and taken to the lab. A progress note, dated 2/7/24 at 12:36 a.m., indicated a wound culture was obtained and sent to the lab within the past 2 days. The lab called and stated that both times the specimen was sent in the wrong collection tubes. The facility did not have the correct specimen tubes. Someone needed to go get the tubes from the lab. A wound assessment report, dated 2/7/24, indicated an unstageable pressure ulcer to Resident E's coccyx that had worsened and was malodorous (smelling very unpleasant). A wound assessment report, dated 2/7/24, indicated a stage 3 pressure ulcer to Resident E's lower back. The wound was stable and there were no changes to the treatment. A skin and wound note, dated 2/7/24 at 4:16 a.m., indicated the following, .lower back pressure ulcer stable noblue [sic] green drainage this week. Coccyx pressure ulcer now classified as unstageable, much worse than last week, new odor and measuring much larger in size. Patient absolutely would not let staff assess wounds properly, let alone debride wounds as they need to be debrided, patient was yelling, cursing and hitting staff .Noted WBC [white blood cell] elevated at almost 30k [30,000]. Wound culture was obtained by staff as previously recommended. Recommend to send patient to ER [emergency room ] for further evaluation of coccyx wound due to abrupt worsening status A hospital document, dated 2/7/24, indicated the following, .Physical Exam .Musculoskeletal .Comments: Approximately 4 cm [centimeters] decubitus ulcer present near the left sacrum with malodorous drainage with tenderness. No significant erythema or warmth .ED [Emergency Department] Course .presenting from ECF [extended care facility] .concerns for infection of decubitus ulcer .Fournier's gangrene with in the right perineum extending from a decubitus ulcer and abscess .recommends transfer to a tertiary center for higher level of care 2. The clinical record for Resident D was reviewed on 4/16/24 at 2:45 p.m. The diagnoses included, but were not limited to, congestive heart failure, muscle weakness, chronic pain syndrome, and edema. A care plan for skin, revised 1/18/24, indicated Resident D was at risk for pressure ulcer development. The interventions included, but were not limited to, conduct weekly skin inspection and treatments as ordered. A Braden Scale, dated 12/5/23, indicated Resident D was at risk for pressure ulcer development. A Skin Only Evaluation, dated 12/16/23, indicated a laceration to the left buttock and excoriation to the perineal area. There were no physician orders for Resident D's skin for 12/16/23. A skin and wound note, dated 12/20/23, indicated incontinence associated dermatitis (IAD) was present to the left posterior thigh and left buttock. The plan was to cleanse both areas with water, pat dry, apply triad paste to the wound, leave open to air, and change twice daily. A skin and wound note, dated 12/27/23, indicated IAD was present to the left posterior thigh and left buttock. The treatment plan remained the same with triad paste to both areas, leave open to air, and change twice daily. There were no orders for triad paste in Resident D's EMAR and/or ETAR for December of 2023. A skin and wound note, dated 1/3/24, indicated IAD to the left posterior thigh that was improving. The left buttock was previously classified as MASD [moisture-associated skin damage], progression into PU [pressure ulcer] with full thickness and listed as a stage 3. The treatment plan consisted of triad paste to the left posterior thigh and triad paste with hydrogel to the base of the wound located on the left buttock. There were no treatment orders to Resident D's buttocks and/or posterior thigh on the EMAR or ETAR for January of 2024. A progress note, dated 1/4/24, indicated Resident D was not feeling well and sent out to the hospital for a low hemoglobin (a protein containing iron that facilitates the transport of oxygen in red blood cells) level. Resident D didn't return to the facility. An interview conducted with the Director of Nursing (DON), on 4/17/24 at 12:10 p.m., indicated she had been the DON for a couple of months. When she started working at the facility she started reviewing residents' charts. When she reviewed the charts of the residents with identified skin concerns, she noticed the lack of either having wound assessments, orders for treatment to such wounds, and following the physicians' orders. So, an audit was conducted of the residents with wounds currently at that time and the Nurse Practitioner (NP) from the wound consulting company assisted with doing a full skin sweep of the facility. That was completed on 2/1/24. The facility brought the Assistant Director of Nursing (ADON) on board with being the primary person for the wound management program as the line of focus for them. A policy titled Pressure Injury Prevention and Management, revised 2/1/24, was provided by the DON on 4/17/24 at 8:35 a.m. The policy indicated the following, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .3. Assessment of Pressure Injury Risk .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .d. Assessments of pressure injuries will be performed by a licensed nurse, and documented on the N Adv Skin Only Evaluation. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [minimum data set] .4. Interventions for Prevention and to Promote Healing .b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .5. Monitoring .d. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAPI [Quality Assurance and Performance Improvement] Committee Schedule, and as needed when actual or potential problems are identified This citation relates to Complaints IN00428308 and IN00429661. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident with dementia, a history of agitation, anxiety, and combativeness, remained free from physical and verbal abuse, which resulted in a staff member holding the wrists of a resident during care that was later identified with bruising to the bilateral hands and wrists. Using the reasonable person concept, it was likely that this would lead to chronic or recurrent fear and anxiety. (Resident B) The Immediate Jeopardy began on 4/30/23, when Resident B was held by the wrists during care that was later identified with bruising to the wrist and hands. Area [NAME] President and [NAME] President of Clinical Operations were notified of the Immediate Jeopardy on 5/17/23 at 1:38 p.m. The Past Noncompliance Immediate Jeopardy began on 4/30/2023. The Immediate Jeopardy was removed and corrected on 5/10/23, before entrance into the facility, when the facility completed staff education for abuse, ensure resident-specific behavior care plans were followed, ensure interventions did not include manual method, and ensure allegations of abuse were reported to the appropriate person timely. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident B was reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding on the privacy or activity of others, yes to significant disruption of care or living environment, and rejection of care within 1-3 days. Resident B required the need of extensive assistance with 2 staff person for bed mobility, transfers, dressing, toilet use, and personal hygiene. An interview conducted with Family Member 8 during the survey indicated Resident B requested his [NAME] device to utilize while he was at the facility. He utilized the device at home and since there was no roommate there wasn't the concern for others privacy. During the last week of being at the facility prior to being hospitalized , Resident B had fallen and acting extra anxious while also picking at his arms. Resident B was having behaviors but Family Member 8 wondered why Resident B was yelling and so upset. The facility staff kept mentioning it was dementia, but it seemed like something else was wrong. Family Member 8 had the ability to review the camera footage that was located on the [NAME] device in Resident B's room. Someone was holding Resident B's wrists and when the other girl applied a shirt on Resident B he commented quit holding my arm and he [male caregiver] didn't. Resident B ended up with bruises to his wrists. The male caregiver commented I'm so high I could burn you up for supper and admitted to being high. He was a new CNA and worked night shift. The male CNA also mentioned I'm going to put my 10.5 up your butt. The staff were being rough and in a hurry while caring for him. Resident B became sensitive and had distrust with others during his stay. It appeared to be a trauma response. Family Member 8 noticed Resident B was sleeping a lot more recently. Family Member 8 reported the incident when she observed it on the camera footage a couple days after it occurred on 4/30/23. A care plan, dated 2/20/23, indicated Resident B had impaired neurological status related to Alzheimer's disease. The interventions listed were to assist in activities of daily living (ADLs), mobility as needed, and monitor ADLs for assistance and render care as needed. A care plan, dated 2/24/23, indicated Resident B felt down, depressed, or hopeless, along with difficulty falling or staying asleep, and feeling bad about oneself. The interventions listed were to encourage activity involvement, offer food and beverages to ones liking, and take the time to discuss ones feelings when feeling sad. A care plan, dated 2/24/23, indicated impaired cognition for Resident B. The interventions listed were to help maintain dignity, help with reminders and cues as needed, allow resident to do what he was capable of doing, at his own pace in his own way, and remember that I (Resident B) am an adult and treat him accordingly. A behavioral care plan, dated 3/6/23, indicated the following, .I [Resident B] sometimes have incidents of being uncooperative with care AEB [as evidenced by]; anxiousness, pinching, grabbing at staff, lifting my feet off ground during transfers, being verbally aggressive with staff (cursing, yelling), swinging at staff/attempting to hit .Interventions .Approach me one caregiver at a time. Multiple people talking in the room may agitate me .Attempt one task at a time with short simple instructions. Don't rush me .Explain to resident in simple terms what you are trying to do and how it will benefit him/her .Offer fluids or snack .Offer toileting/incontinent care when needed .Play some jazz music if I am combative or restless .Please explaining [sic] what you are doing and allow me time to comprehend before attempting .Provide a quiet calm area for me to unwind when agitated. Loud noises can cause me agitation .Provide care in pair when agitated .Provide me with drumsticks and an object to drum on when agitated. Place me away from others I may inadvertently injure [sic] A trauma care plan, dated 3/6/23, indicated the following, .I have a hx [history] of trauma r/t [related to] Physical/Verbal abuse, physical/emotional neglect, sudden unexpected loss of family member, witness to violence. If experiencing a trigger from history of Trauma, I may display signs and symptoms of Anxiety, fear, irritability, being easily startled, outburst of anger or rage, emotional swings/detachment, self-blame, and shame The interventions listed were to arrange for mental health services as indicated, encourage to express thoughts and feelings in a safe place, identify the items that lessen the effects of trauma and provide comfort, observe for signs and symptoms of depression, anxiety, eating disorders, sleep disturbances, and substance use disorder, and provide a quiet, non threatening environment with decreased stimulation. A care plan, dated 4/10/23, indicated Resident B refused care at times. An intervention was listed to re-approach resident when he refused care. A psychiatry progress note, dated 4/11/23, indicated Resident B was anxious, had agitation, general weakness, easily fatigued, and negative for aggression. There was severe impairment for judgement, insight, and disengaged for Resident B's attitude/rapport. A Quarterly MDS assessment, dated 4/13/23, noted Resident B with severe cognitive impairment, yes to feeling down, depressed or hopeless for 12 to 14 days, and yes to trouble concentrating on things for 12 to 14 days. A wound assessment report, dated 4/26/23, indicated a cluster of small skin tears from self inflicted scratching noted measuring 9 x 2.5 centimeters. A progress note, dated 4/30/23 at 1:43 p.m., indicated the following, .CNA brought camera from resident room that was positioned to point at his bed. Camera was hidden near TV. Camera removed from resident room, brought to nurses station and battery removed An encounter note, dated 5/3/23, indicated the following, .Spoke to daughter in lengthy period overall patient?s [sic] condition .Daughter also would like to talk to Psych/mental health provider A progress note, dated 5/4/23, indicated the following, .ALZHEIMER'S DISEASE .worsening, verbally and physically combative with staff .if continues patient needs to be send out to inpatient psych .Restlessness and agitation .buspar discontinued, as daughter worries makes her dad lethargic An incident reported to the Indiana State Department of Health survey report system, reported on 5/5/23, indicated Resident B's daughter presented to the facility to pick up a camera located in Resident B's room on 4/30/23 while staff were providing care. The daughter of Resident B allowed the Executive Director (ED) to view a small clip of two Certified Nursing Assistants (CNAs) providing care to Resident B on 4/30/23. One male CNA (CNA 2) entered the room and stated to Resident B They brought me in here to set you straight, I am going to put my foot up your butt. While female CNA (CNA 4) provided care to Resident B, CNA 2 was observed on video holding Resident B's forearms. CNA 2, before leaving Resident B's room, told Resident B that he would keep him straight if he continued to hit, kick, and spit, that he would stick his 10.5 up his butt. The follow up, dated 5/10/23, indicated skin assessments were conducted on Resident B with no concerns noted. Employee education completed on Abuse and Neglect, and reporting policy. CNA 2 was terminated for violation of abuse and CNA 4 was terminated for violation of reporting abuse. A typed statement of an interview with CNA 2, dated 5/5/23, indicated the following, .I [CNA 2] held his [Resident B's] hands for [Name of CNA 4] because he is combative. I had my hand around his wrists but didn't use any force or anything. I am bigger than him. He was hitting, kicking, and smacking. I don't remember saying They brought me in here to set you straight, I am going to put my foot up your butt., or I am going to keep you straight if you continue to hit, kick and spit, I will stick my 10.5 up your butt. I wasn't harming him and I know it is illegal for that camera to be in there. A typed follow-up statement of an interview with CNA 2, dated 5/8/23, indicated the following, .In response to the question regarding holding [Name of Resident B's] wrist, [Name of CNA 2] stated he did that to keep the female caregiver from being hit. [Name of CNA 2] stated he did not use any force and that he would do it again to keep the facility staff safe. [Name of CNA 2] stated he did not recall stating he would put his foot up [Name of Resident B's] butt but acknowledged it was on the video and he shouldn't have said that. A document titled 3 Step Employee Memorandum, dated 5/5/23, indicated CNA 2 was terminated from employment for Resident abuse or neglect (physical, sexual, verbal or mental). A typed statement of an interview with CNA 4, dated 5/5/23, indicated the following, .[Name of CNA 4] reported to the building for her shift and was taken to the conference room .ED spoke to [Name of CNA 4] about the events that had taken place on Sunday 4.30.23 [4/30/2023]. She [CNA 4] stated they had found a camera in [Name of Resident B's] room while providing care .explained to [Name of CNA 4] that she was on video providing care with a male caregiver. In the videov is [sic] was observed that the male care giver stated They brought me in here to set you straight, I am going to put my foot up your butt. While she provided care to the resident the male caregiver [CNA 2] was observed in the video holding [Resident B's] forearms. The male caregiver before leaving the room stated to the resident I am going to keep you straight if you continue to hit, kick, and spit, I will stick my 10.5 up your butt. When I asked [Name of CNA 4] why she hadn't reported the event, she stated, I had an ear bud in my ear listening to a podcast and I didn't hear it. When questioned about her reaction to the camera when finding it, she stated oh no, were going to be in trouble, she didn't recall it. A typed follow-up statement of an interview with CNA 4, dated 5/8/23, indicated the following, .[Name of CNA 4] stated that when she went to ask for help with [Name of Resident B] because he was combative earlier in the morning. She asked [Name of CNA 6], but he was busy assisting another caregiver. [Name of CNA 4] stated she went to ask [Name of CNA 2] for assistance but was hesitant because he makes out of pocket remarks towards female co-workers. [Name of CNA 4] stated she didn't hear [Name of CNA 2] make any statements regarding putting his foot up [Name of Resident B's] butt. Female caregiver stated she thought it was okay that the male caregiver held [Name of Resident B's] arms because he was protecting her [CNA 4] from getting hit. [Name of CNA 4] stated she said oh no, we're going to be in trouble at the end of the video because she was concerned about [Name of CNA 2] holding [Name of Resident B's] arms. A document titled, 3 Step Employee Memorandum, dated 5/9/23, indicated CNA 4 was terminated from employment for failure to report observed resident abuse or neglect, or a physical injury of a resident. A skin evaluation, dated 5/4/23 at 4:00 p.m., indicated the following skin issues: - Skin Issue #1 of bruising to left hand between index finger and middle finger measuring 1 x 1 centimeter, - Skin Issue #2 of bruising to left first knuckle measuring 1 x 1 centimeter, - Skin Issue #3 of bruising to left wrist measuring 2 x 2 centimeters, - Skin Issue #4 of bruising to left hand between thumb and index finger measuring 2 x 1 centimeters, - Skin Issue #5 of bruising to left arm measuring 6 x 5.5 centimeters, - Skin Issue #6 of bruising to right wrist measuring 2 x 3.5 centimeters, - Skin Issue #7 of bruising to right hand measuring 7 x 4.7 centimeters, - Skin Issue #8 of bruising to right fifth knuckle measuring 0.5 x 1 centimeter, & - Skin Issue #9 of bruising under the right eye measuring 0.5 x 0.5 centimeters. A typed statement for CNA 5, dated 5/5/23, indicated the following, .We block his arms [Resident B] while we are providing care and I haven't seen anything alarming while providing his care. When you approach and tell him what you're doing he doesn't strike as much A typed statement for LPN (Licensed Practical Nurse) 3, dated 5/5/23, indicated the following, .staff would just block him [Resident B] when he became combative .He usually calms down as you talk to him A typed statement for CNA 6, dated 5/5/23, indicated the following, .I do hold his [Resident B's] wrists, but I do that to protect other staff members while they are providing care .He was concerned about the camera because he was worried, he may be on there holding the resident's wrist .Employee [CNA 6] educated on how to handle resident's that are combative and to be restraint free immediately before returning to the floor A Social Services note, dated 5/8/23 at 9:54 a.m., indicated psychosocial follow up with Resident B was conducted. No distress noted at that time. There were no previous Social Services notes in regards to the follow up of the incident reported on 5/5/23. An interview conducted with CNA 6, on 5/17/23 at 1:05 p.m., indicated on a few occasions he attempted to hold Resident B's wrists during personal care. He was not aware that it was considered a restraint or abuse. The facility had CNA 6 retake a class on abuse and now he knows what to do the next time this were to happen. The CNA class he participated in did not go over behaviors or how to deal with residents with dementia. He has worked at the facility for approximately 3 years and there was a lot of agency staff and they would discuss their history of working at the State hospital in regards to restraining residents. The staff would try to hold Resident B's hands but he continued to focus on the CNA providing care but sometimes we would hold his wrists in attempt to calm him. An interview conducted with Director of Nursing (DON), on 5/17/23 at 1:30 p.m., indicated she reviewed video footage of CNA 2 grabbing Resident B's wrists during care as well as making comments that were inappropriate and not acceptable at the facility. An interview conducted with CNA 2, on 5/17/23 at 3:00 p.m., indicated Resident B was physical during care with hitting and kicking at the staff members. He cared for Resident B on 2 occasions. At the beginning of Resident B's care he would attempt to bribe him with ice cream. As soon as the other female CNA (CNA 4) started to care for Resident B, he starting flailing his arms. CNA 2 stated he previously worked at a behavioral unit in the long-term care facility and they conducted procedures like manual methods. The other staff members at the facility are the ones that told CNA 2 they usually handle Resident B with manual methods like holding his hands and wrists. He had only worked at the facility for a couple of weeks and only received 1 day of orientation and then he was working by himself. A policy titled Abuse, Neglect and Exploitation, revised October 2022, was provided by the Area [NAME] President on 5/16/23 at 9:52 a.m. The policy indicated the following, .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 .Policy Explanation and Compliance Guidelines .1. The facility will develop and implement written policies and procedures that .a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property .b. Establish policies and procedures to investigate such allegations .c. Include training for new and existing staff on activities that constitute abuse .reporting procedures, and dementia management and resident abuse prevention This Federal deficiency relates to Complaint IN00408060. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to ensure an assisted fall to the floor was reported in a timely manner, which in turn resulted in an untimely physical assessment for a resident who was assisted to the floor for 1 of 3 residents reviewed for falls in a total sample of 4. The resident was diagnosed with [REDACTED]. (Resident #A) Findings include: Resident #A's clinical record was reviewed on 2-3-14 at 2:55 p.m.. Her [DIAGNOSES REDACTED]. Her most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11-27-13, indicated she was severely cognitively impaired, required extensive assistance of 2 or more persons for bed mobility and was dependent of 1-2 persons with transfers from one surface to another. It indicated she did not stand or walk; it indicated she was able to move from one surface to another or on/off the toilet, but was unsteady and required human assistance to stabilize her with these movements. Her care plan indicated she required the use of a mechanical lift and 2 persons for transfers from one surface to another, such as transfer from bed to wheelchair. An "Aide Assignment Sheet" for the last week of January, 2014, was provided by the Assistant Director of Nursing on 2-3-14 at 10:15 a.m. It indicated Resident #A was totally dependent for care and required the use of a mechanical lift for transfers. A quarterly nursing assessment, dated 11-27-13, indicated Resident #A was at low risk for falls. Her care plan indicated she was at risk for potential falls. Her MDS assessment, dated 11-27-13, indicated she had no falls in the previous quarter. Review of "Post Fall Investigation/Plan", dated 2-2-14, indicated, "CNA lowered her (Resident #A) to the floor and then got her back up using a gait belt per CNA interview-resident is a Marissa (mechanical) lift. CNA should have reported immediately after she lowered her (Resident #A) to the floor for a nurse to assess." This document indicated this incident occurred 1-25-14 at 9:30 a.m. Review of "Verification of Investigation" for Resident #A indicated, "Upon interview with (name of CNA #1), she states that on 1-25-14 in the am, she was making resident's bed and had her sitting on the side of the bed and she started to lean to one side and then started sliding off the bed. CNA states that she lowered her (Resident #A) to the floor and then got her back into bed using a gait belt. CNA did not report at this time...States that she was trying to straighten out the bed linens and had resident sitting on the side of the bed. Resident began to lean over and then started sliding off the bed. States that she lowered her to the floor. States she got her up of (sic) the floor with a gait belt by herself. States that she had another CNA come help straighten her up in the bed." In review of the nursing progress notes from 1-20-14 until transfer to the local emergency roiagnom on [DATE], there was no documentation which indicated any type of fall had occurred. Documentation on 1-30-14 at 4:07 a.m. which indicated Resident #A had been admitted to the local hospital with bilateral femur fractures. In an interview with the Executive Director (ED) on 2-3-14 at 8:15 a.m., he indicated he was informed on 1-30-14 at 5:30 a.m. by the Director of Nursing (DON) that X-ray results from overnight for Resident #A indicated she had bilateral femur fractures and the facility was unaware of how this occurred. He indicated Resident #A had been monitored closely by the facility since 1-27-14 due to declining oral intake and with increasing lethargy by 1-29-14. He indicated the family and physician had been notified of these events with the attending physician and nurse practitioner providing care for the resident. He indicated he was aware of Resident #A being treated by the physician for an elevated anticoagulant level on 1-29-14 and the staff had not noted any bruising of any kind until the same date. The ED indicated in the multiple staff interviews he had conducted in regards to Resident #A, only one CNA indicated she had noticed the resident being in any pain during the last week of January, 2014. The ED indicated a family member of Resident #A had come into the facility on Wednesday, 1-29-14, to visit. He indicated Resident #D, the roommate of Resident #A, told the family member during this visit that on Friday, 1-24-14, that a CNA "had dropped" the resident (Resident #A) onto her knees. He indicated when he interviewed Resident #D, it was determined this event happened after breakfast on Saturday, 1-25-14. He indicated in further interview with Resident #D, she did not tell anyone of this information until Tuesday, 1-28-14, when she shared this information with 2 CNA's who immediately shared this information with LPN #8. He indicated Resident #D also shared this information with RN #2, the Unit Manager, that same afternoon, during bingo. In an interview with CNA #1 on 2-3-14 at 1:17 p.m., she indicated she provided care for Resident #A on Saturday, 1-25-14, and Tuesday, 1-28-14. She indicated on 1-25-14, she was assisting the resident with care. She indicated she had the resident sitting on the side of bed while she was changing the sheets. She indicated the resident told her she felt like she was falling, so she went around the bed and found the resident to be sitting on the edge of the bed. She indicated she tried to scoot her back up onto the bed. She indicated she asked the resident if she could stand and the resident indicated she could not do so. She indicated, "I then eased her, slid her, to the floor." She indicated she had placed a gait belt on the resident prior to sliding her onto the floor. She indicated the resident's bottom was on the floor. She indicated she did not recall the resident's knees coming in contact with the floor. She indicated she needed assistance to get her back onto the bed, so she stepped to the doorway and yelled for assistance from the first person she saw. She indicated CNA #4 came in to assist her get Resident #A back onto the bed. She indicated they were able to utilize the gait belt and placing their arms under Resident #A's arms to get her back onto the bed. She indicated she did not recall CNA #4 commenting on anything regarding the situation as she her priority at the time was getting the resident back to bed. CNA #1 indicated, "I didn't say anything to the nurse about her being on the floor, since she didn't actually fall, but I slid her down...No, I didn't report sliding (name of Resident #A) to the floor. I didn't let her fall, just slid her to the floor. With her legs like they were and her not being able to walk, I didn't really think of it as an unusual thing. So, no, I didn't say anything about it to the nurse. Well, I guess looking back, I should have told the nurse she was slid to the floor. I guess I just didn't think about it." In an interview with CNA #4 on 2-3-14 at 12:14 p.m., she indicated CNA #1 had asked her to assist with repositioning Resident #A on 1-25-14 around 9:15 a.m. and she did so. She indicated Resident #A was lying on the bed when she arrived in the room. She indicated she did not recall seeing a gait belt on the resident. She indicated she did not recall the resident complaining of pain or seeming to be in pain. In an interview with RN #2 on 2-3-14 at 12:35 p.m., she indicated on Tuesday, 1-28-14, Resident #D informed her CNA #1 had tried to "make" Resident #A get up and Resident #A had told CNA #1 "no." She did not indicate she was aware of any type of fall with this resident. She indicated she did follow up with Resident #A that same day regarding if anyone had tried to force her to do anything she did not want to do. She indicated Resident #A shook her head "no." She indicated the resident indicated she was not in any pain. She did not indicate if she informed the ED or DON of this event. In an interview with CNA #5 on 2-3-14 at 12:45 p.m., she indicated during the weekend of 1-25-14 and 1-26-14, Resident #D had told her and CNA #7 that CNA #1 had attempted to get Resident #A up and the resident had fallen to her knees. She then indicated this conversation took place on Monday, 1-27-14. She indicated she then informed LPN #8 of this on Monday morning, 1-27-14. She indicated Resident #A did not complain of any pain during care and repositioning on 1-27-14, nor did she have any reddened areas or bruised areas on her skin. In review of the "as worked" nursing work schedule, CNA #5 was not scheduled to work on Saturday, 1-25-14, nor on Sunday, 1-26-14. She was scheduled to work day shift on Monday, 1-27-14, on the unit on which Resident #A resided. CNA # 7 was scheduled to work on the unit on which Resident #A resided on evening shift on Saturday, 1-25-14 and day shift on Monday, 1-27-14. In an interview with CNA # 7 on 2-3-14 at 1:05 p.m., she indicated she and CNA #5 worked with Resident #A on 1-27-14. She indicated while providing care to Resident #A, the resident complained of leg pain. She indicated the roommate, Resident #D, then told them on Saturday, 1-25-14, CNA #1 had tried to stand Resident #A up. She indicated Resident #D indicated since the curtain between them was closed, she could only hear what was going on. She indicated Resident #D indicated Resident #A kept telling CNA #1 that she could not stand. She indicated Resident #D did say if CNA #1 responded in any manner to Resident #A's statements of being unable to stand. She indicated Resident #D told them at some point, (date unknown) Resident #A did indicate to her (Resident #D) that she (Resident #A) had fallen to her knees. CNA #7 indicated on 1-27-14, Resident #A seemed to more uncomfortable than usual. She indicated she did not recall Resident #A having any reddened or bruised areas on her skin; that she appeared to be normal for the resident. She indicated immediately after completing Resident #A's care, she and CNA #5 went to inform the nurse, LPN #8 of what they had been told by Resident #D. In an interview with LPN #8 on 2-3-14 at 11:50 a.m., she indicated she had worked with Resident #A on 1-27-14, 1-28-14 and 1-29-14. She indicated on 1-27-14 , she notified the attending physician of the resident's weakened state, stable vital signs and an elevated white blood count obtained via a recent routine blood draw. She indicated the Nurse Practitioner ordered a urinalysis. She indicated she did notify the family of the change in condition and new orders. She indicated on 1-28-14, the urine sample was obtained and sent to the lab. She indicated the resident was running a low grade fever and treated with Tylenol for that. She indicated the attending physician ordered additional lab tests to rule out the flu. She indicated on 1-29-14, the resident seemed even weaker and was only taking small bites of food and sips of water. She indicated she asked CNA #6 to assist the resident into a geriatric chair (via mechanical lift) in order to go to the dining room for lunch with closer supervision with the lunch meal. She indicated a routine/weekly lab test for her anticoagulant was obtained around lunch which came back elevated. She indicated the attending physician ordered medication to correct the elevation. She indicated she notified Resident #A's daughter of the medication changes. She indicated during all of this, the resident did not complain of pain. She indicated toward the end of her shift, around the time of shift change report, she was notified by CNA #6 there seemed to be a problem with the resident's leg. She indicated the oncoming evening shift nurse went to check the resident's leg. LPN #8 did not indicate she was informed by CNA #5 or CNA #7 of the statements from Resident #D regarding Resident #A having a fall to her knees on 1-25-14. In an interview with CNA #6 she indicated she cared for Resident #A on Sunday, 1-26-14. She indicated the resident was able to sit on the side of the bed to eat breakfast as she normally did. She indicated that morning she seemed weaker than normal and only ate 25% of her meal. She indicated she reported this to the nurse. She indicated, for lunch, the resident was assisted into a wheelchair via a mechanical lift and seemed more alert, but only ate 25% of her meal. She indicated Resident #A did not appear to be in any pain, nor complained of any pain. She indicated she next cared for Resident #A on Wednesday, 1-29-14. She indicated the resident seemed much more lethargic and her color seemed somewhat gray to her. She indicated LPN #8 asked her to get the resident up into a wheelchair for lunch. She indicated she did not feel comfortable doing this, so she and LPN #8 got her up with the mechanical lift into a geriatric chair for lunch. She indicated the resident seemed more alert once she was up. She indicated Resident #A did not appear to be in any pain, nor complained of any pain. She indicated in the afternoon, when she went to roll her in bed during care, her left leg did not roll with her. She indicated Resident #A could usually assist with rolling or turns. She indicated she reported this to LPN #8. In an interview with RN #3, on 2-3-14 at 10:57 a.m., he indicated he had worked with Resident #A on the evening shift on 1-25-14, 1-26-14, 1-27-14 and 1-29-14. He indicated, "She seemed to be herself until Wednesday (1-29-14)." He indicated on 1-29-14, he indicated he observed her to be lethargic and appeared to have declined. He indicated he received new orders around 4:00 p.m. from the attending physician in regards to the elevated coagulant level and labs to be obtained. He indicated he spoke to the resident's daughter in regards to the new orders. He indicated when he spoke to the daughter, she indicated she had been told by the roommate, Resident #D, that on Saturday, 1-25-14, a CNA had stood Resident #A up and the resident had fallen. He indicated the daughter did not say if she had spoken to Resident #D in person or via telephone. He indicated when he heard this, he documented the conversation on a grievance form and placed it in the Unit Manager's folder for her to review. He indicated he then went to assess Resident #A. He indicated her lower extremities appeared as they normally did with a slight amount of swelling around the left ankle. He indicated the knees had several "spots" of a gray-colored bruising which he indicated he attributed to the elevated coagulant levels. He indicated the resident did not complain of any pain. He indicated a family member was present and requested to have the resident repositioned in bed. He indicated he and another staff member did as requested. He indicated during the repositioning, the resident did utter, "oh," but he indicated this was a normal response for this resident with any positioning. He indicated around 9:30 p.m., family members requested to speak to the physician. He indicated around 10:00 p.m., the attending physician called the facility and ordered for the resident to be sent to the local emergency room for evaluation of leg pain and elevated coagulant levels. In an interview with Resident #D on 2-3-14 at 2:40 p.m., she indicated she could not recall if the events with her roommate, Resident #A occurred on Friday, 1-24-14 or Saturday, 1-25-14. She indicated her memory is not as good as it used to be. She indicated she did not actually see anything, as the curtain was pulled by CNA #1 while she provided care to Resident #A. She indicated, "I only heard things." She indicated on that morning, she heard CNA #1 talking with Resident #A. She indicated the CNA was needing to change the bed linens as apparently there were food crumbs in the bed. She indicated she heard Resident #1 say, "I can't stand," several times. She indicated she heard CNA #1 respond in a somewhat gruff tone several times, "Don't say can't" or "Can't can't do anything." She indicated she then heard Resident #A say, "Oh, no. Help me, Lord." She indicated after CNA #1 left the room, she asked Resident #A if she was okay. She indicated Resident #A told her she had told CNA #1 that she could not stand, but ended up on her knees. She indicated she later asked CNA #1 if she had dropped Resident #A and was told "no." She indicated she did not recall anyone coming into the room to help get Resident #A up off of the floor or to reposition her in the bed during the care while the curtain was pulled. She indicated she told the Unit Manager, RN #2, during a bingo game on Monday, 1-27-14. She did not elaborate as to what information was shared with the nurse. The activities calendar for January, 2014 indicated bingo was played in the facility on 1-27-14 and 1-28-14. In an interview with the ED on 2-6-14 at 9:15 a.m., he indicated the facility expects any type of fall, including assisted falls, to be reported immediately to the nurse in order for an assessment to be conducted. He indicated once the facility was made aware of the fractures of Resident #A, an immediate investigation was initiated. He indicated the investigation was conducted as an unusual occurrence, as well as an injury of unknown origin. He indicated he would consider an assisted fall to be an unusual occurrence as it does not occur on a regular basis. On 2-3-14 at 2:30 p.m., the ED provided a copy of policy entitled, "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Property." This policy indicated, "It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws while involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violations"), are reported immediately to the Executive Director (hereinafter "ED") of the facility. Such violations will also be reported to state agencies in accordance with existing state law...During orientation, new employees shall be trained or the obligation to report alleged violations. Training shall include definitions of alleged violations and examples of reportable incidents to assist staff in detection of such incidents....Any employee who suspects an alleged violation shall immediately notify the ED or his/her designee. On 2-3-14 at 2:30 p.m., the ED provided a copy of policy entitled, "Falls Management Clinical Guidelines." This policy indicated, "Following a fall:...The licensed nurse (immediately) assesses the resident for injuries (including neuro checks if indicated) and provides necessary treatment and initiates the Change in Condition Report - Post Fall/Trauma. The physician and resident's representative is notified..." This Federal tag relates to Complaint IN 695. 3.1-45 (a)

Based on interview and record review, the facility failed to ensure staff members followed each resident's plan of care during transfers which resulted in 2 assisted falls with no injuries for 2 of 2 assisted falls reviewed in a sample of 3. (Resident #F and Resident #G) Findings include: 1. Resident #G's clinical record was reviewed on 3-27-14 at 9:50 a.m. Her [DIAGNOSES REDACTED]. In review of Resident #G's most recent Minimum Data Set (MDS) Assessment, a significant change MDS, dated [DATE], indicated she had significant cognitive impairment, did not ambulate, required extensive assistance with bed mobility of 2 or more persons and required extensive assistance with transfers of one person. Her most recent fall risk assessment, dated 2-13-14, indicated she was at high risk for falls. In review of Resident #G's plan of care, it indicated the resident was at risk for falls related to the "use of medication and incontinence and need for assist with transfers." The goal of no falls with injury through the next review period was indicated. Interventions listed to address the fall risk were indicated to include, "Gait belt with transfers assist of 2 staff." The plan of care indicated two separate entries for this concern of falls. Both entries indicated a date of initiation for this concern of fall risk to be 2-28-14. For the intervention listed, one entry indicated the initiation date of 10-10-13; the second entry indicated the initiation date of 3-19-14 with a revision date of 3-21-14. In review of the "CNA Assignment Sheet" for Resident #G, provided by the Executive Director (ED) on 3-27-14 at 11:20 a.m., it indicated she required 2 persons to assist her with transfers; it indicated with toileting she required 2 persons and a gait belt to assist her. In an interview with the ED on 3-27-14 at 11:20 a.m., he indicated the CNA Assignment Sheets are updated daily and the previous ones are not kept on file. He indicated this was a current CNA Assignment Sheet for Resident #G. In review of a document entitled, "Verification of Investigation," dated 3-21-14, it indicated, "(Name of CNA #1) was attempting to transfer res (resident) from bed to wc (wheelchair) when res stopped helping with transfer and had to be lowered to floor by staff." It indicated she was needing to be toileted. The document indicated CNA#1 failed to use a gait belt. It indicated the resident sustained [REDACTED]. On 3-27-14 at 2:00 p.m., the ED provided a copy of a document entitled, "Personnel Conference" for CNA #1, dated 3-27-14 and signed by RN #3. This document indicated the CNA Assignment Sheet for Resident #G indicated she was to have 2 persons to assist her with transfers, as well as the use of a gait belt with transfers. It indicated CNA #1 failed to follow the plan of care via the CNA Assignment Sheet and utilized only 1 person to transfer and failed to use a gait belt with the transfer for Resident #G. This document indicated the conference was conducted by telephone with CNA #1. In an interview with the ED on 3-27-14 at 11:20 a.m., he indicated CNA #1 worked at the facility "on a casual (not routinely scheduled) basis." At this time, the ED provided a copy of CNA #1's time card summary which indicated she has worked for the facility a total of 15.47 hours for 2014, with 7.53 of those hours in the month of March, 2014. The time card summary indicated on 3-15-14, CNA #1 clocked in at 7:00 p.m. and clocked out at 9:32 p.m. It indicated she had not clocked in at the facility since that date. He indicated CNA #1 had not been counseled at this time regarding the assisted fall of Resident #G which occurred on 3-15-14. CNA #1 was unable to be reached by phone or in person for an interview. 2. Resident #F's clinical record was reviewed on 3-27-14 at 9:25 a.m. His [DIAGNOSES REDACTED]. In review of Resident #F's Admission Minimum Data Set (MDS) Assessment, dated 2-1-14, it indicated he had moderate cognitive impairment, did not ambulate and required extensive assistance with bed mobility and transfers of 2 or more persons. The most recent fall risk assessment, dated 1-25-14, indicated he was at high risk for falls. In review of Resident #F's plan of care, it indicated the resident was at risk for falls related to falls in the last 3 months. The goal for this concern was indicated as, "No fall related injuries." Interventions listed to address the fall risk were indicated to include, "Gait belt with transfers x2 staff (2 staff members)." The date for the plan of care indicated for this concern of fall risk to be 1-29-14. For the intervention listed, it indicated the date of initiation as 1-29-14 with a revision date of 1-30-14. In review of the "CNA Assignment Sheet" for Resident #F, provided by the Executive Director (ED) on 3-27-14 at 11:20 a.m., it indicated he required 2 persons and a gait belt to assist him with transfers. In an interview with the ED on 3-27-14 at 11:20 a.m., he indicated the CNA Assignment Sheets are updated daily and the previous ones are not kept on file. He indicated this was a current CNA Assignment Sheet for Resident #F. In review of a document entitled, "Verification of Investigation," dated 3-21-14, it indicated, "Resident was being transferred to w/c (wheelchair) when he lost his balance regardless of CNA assist with gait belt. CNA was able to ease Resident to the floor, as he slid down at front of CNA." The document indicated a contributing factor could have been the need for 2 persons to assist with the transfer. It indicated the resident sustained [REDACTED]. On 3-27-14 at 11:20 a.m., the ED provided a copy of a document entitled, "Personnel Conference" for CNA #2, dated 3-19-14. This document indicated,"CNA Assignment Sheet specifically stated assist of 2 with gait belt to transfer (sic)...Always follow CNA sheet instructions on how to transfer residents." This document was signed by CNA #2 and RN #3. CNA #2 was unable to be reached by phone or in person for an interview. In an interview with PT #4 on 3-27-14 at 12:20 p.m., he indicated both Resident #F and Resident #G were being followed by physical therapy for services at the time of their assisted falls. He indicated that although the therapy notes for around the time of their assisted falls indicated each was making some progress, he would not generally recommend any changes to the plan of care for nursing staff until the resident's progress was more consistent. He indicated for both Resident #F and Resident #G, neither resident's progress at the time of their assisted fall, or currently, was consistent enough to suggest changing nursing's plan of care from a 2 person assistance with the gait belt for any transfers. In an interview with the ED on 3-27-14 at 12:20 p.m., he indicated the facility does not have a policy on "CNA Assignment Sheets." He indicated it is understood that one would follow the information on the sheet. On 3-27-14 at 2:00 p.m., the ED provided a copy of a policy entitled, "Gait Belts." This policy indicated, "Gait belts provide increased security for the resident and staff, and prevent injury during movement of a resident. A designated staff member uses a gait or ambulation belt during ambulation or movement of a resident who needs security and assistance. A gait belt is not used unless the resident has been evaluated, and it has been approved for use by licensed nurse..." This Federal tag relates to the Post Survey Revisit for Complaint IN 695. This deficiency was cited on February 6, 2014. the facility failed to implement a systemic plan of corrections to prevent recurrence. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a CNA demonstrated the competency to safely care for a resident in that the resident was lowered to the floor and the nurse was not notified of the incident. The resident was diagnosed with [REDACTED]. This deficient practice affected 1 of 3 residents reviewed for falls in a total sample of 4. (Resident #A, CNA #1) Findings include: Her most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11-27-13, indicated she was severely cognitively impaired, required extensive assistance of 2 or more persons for bed mobility and was dependent of 1-2 persons with transfers from one surface to another. It indicated she did not stand or walk; it indicated she was able to move from one surface to another or on/off the toilet, but was unsteady and required human assistance to stabilize her with these movements. Her care plan indicated she required the use of a mechanical lift and 2 persons for transfers from one surface to another, such as transfer from bed to wheelchair. An "Aide Assignment Sheet" for the last week of January, 2014, was provided by the Assistant Director of Nursing on 2-3-14 at 10:15 a.m. It indicated Resident #A was totally dependent for care and required the use of a mechanical lift for transfers. A quarterly nursing assessment, dated 11-27-13, indicated Resident #A was at low risk for falls. Her care plan indicated she was at risk for potential falls. Her MDS assessment, dated 11-27-13, indicated she had no falls in the previous quarter. Review of "Post Fall Investigation/Plan", dated 2-2-14, indicated, "CNA lowered her (Resident #A) to the floor and then got her back up using a gait belt per CNA interview-resident is a Marissa (mechanical) lift. CNA should have reported immediately after she lowered her (Resident #A) to the floor for a nurse to assess." This document indicated this incident occurred 1-25-14 at 9:30 a.m. Review of "Verification of Investigation" for Resident #A indicated, "Upon interview with (name of CNA #1), she states that on 1-25-14 in the am, she was making resident's bed and had her sitting on the side of the bed and she started to lean to one side and then started sliding off the bed. CNA states that she lowered her (Resident #A) to the floor and then got her back into bed using a gait belt. CNA did not report at this time...States that she was trying to straighten out the bed linens and had resident sitting on the side of the bed. Resident began to lean over and then started sliding off the bed. States that she lowered her to the floor. States she got her up of (sic) the floor with a gait belt by herself. States that she had another CNA come help straighten her up in the bed." In an interview with the Executive Director (ED) on 2-3-14 at 8:15 a.m., he indicated he was informed on 1-30-14 at 5:30 a.m. by the Director of Nursing (DON) that X-ray results from overnight for Resident #A indicated she had bilateral femur fractures and the facility was unaware of how this occurred. He indicated Resident #A had been monitored closely by the facility since 1-27-14 due to declining oral intake and with increasing lethargy by 1-29-14. He indicated the family and physician had been notified of these events with the attending physician and nurse practitioner providing care for the resident. He indicated he was aware of Resident #A being treated by the physician for an elevated anticoagulant level on 1-29-14 and the staff had not noted any bruising of any kind until the same date. The ED indicated in the multiple staff interviews he had conducted in regards to Resident #A, only one CNA indicated she had noticed the resident being in any pain during the last week of January, 2014. The ED indicated a family member of Resident #A had come into the facility on Wednesday, 1-29-14, to visit. He indicated Resident #D, the roommate of Resident #A, told the family member during this visit that on Friday, 1-24-14, that a CNA "had dropped" the resident (Resident #A) onto her knees. He indicated when he interviewed Resident #D, it was determined this event happened after breakfast on Saturday, 1-25-14. He indicated in further interview with Resident #D, she did not tell anyone of this information until Tuesday, 1-28-14, when she shared this information with 2 CNA's who immediately shared this information with LPN #8. He indicated Resident #D also shared this information with RN #2, the Unit Manager, that same afternoon, during bingo. In an interview with CNA #1 on 2-3-14 at 1:17 p.m., she indicated she provided care for Resident #A on Saturday, 1-25-14, and Tuesday, 1-28-14. She indicated on 1-25-14, she was assisting the resident with care. She indicated she had the resident sitting on the side of bed while she was changing the sheets. She indicated the resident told her she felt like she was falling, so she went around the bed and found the resident to be sitting on the edge of the bed. She indicated she tried to scoot her back up onto the bed. She indicated she asked the resident if she could stand and the resident indicated she could not do so. She indicated, "I then eased her, slid her, to the floor." She indicated she had placed a gait belt on the resident prior to sliding her onto the floor. She indicated the resident's bottom was on the floor. She indicated she did not recall the resident's knees coming in contact with the floor. She indicated she needed assistance to get her back onto the bed, so she stepped to the doorway and yelled for assistance from the first person she saw. She indicated CNA #4 came in to assist her get Resident #A back onto the bed. She indicated they were able to utilize the gait belt and placing their arms under Resident #A's arms to get her back onto the bed. She indicated she did not recall CNA #4 commenting on anything regarding the situation as she her priority at the time was getting the resident back to bed. CNA #1 indicated, "I didn't say anything to the nurse about her being on the floor, since she didn't actually fall, but I slid her down...No, I didn't report sliding (name of Resident #A) to the floor. I didn't let her fall, just slid her to the floor. With her legs like they were and her not being able to walk, I didn't really think of it as an unusual thing. So, no, I didn't say anything about it to the nurse. Well, I guess looking back, I should have told the nurse she was slid to the floor. I guess I just didn't think about it." In an interview with CNA #4 on 2-3-14 at 12:14 p.m., she indicated CNA #1 had asked her to assist with repositioning Resident #A on 1-25-14 around 9:15 a.m. and she did so. She indicated Resident #A was lying on the bed when she arrived in the room. She indicated she did not recall seeing a gait belt on the resident. She indicated she did not recall the resident complaining of pain or seeming to be in pain. In an interview with the ED on 2-6-14 at 9:15 a.m., he indicated the facility expects any type of fall, including assisted falls, to be reported immediately to the nurse in order for an assessment to be conducted. He indicated once the facility was made aware of the fractures of Resident #A, an immediate investigation was initiated. He indicated the investigation was conducted as an unusual occurrence, as well as an injury of unknown origin. He indicated he would consider an assisted fall to be an unusual occurrence as it does not occur on a regular basis. In review of CNA #1's employee record on 2-4-14 at 12:15 p.m., it indicated she began employment with the facility on 5-28-13. Her CNA certification indicated her initial certification was issued on 5-17-13. The "General Orientation Checklist" indicated the section on "Safety Videos" had been checked off to indicate she had viewed one entitled, "Slips, Trips and Falls" and was indicated to include general safety guidelines. In interview with the ED on 2-4-14 at 12:15 p.m., he indicated this video specifically indicated any kind of a fall or near fall should be reported to the nurse immediately so an assessment could be conducted on the person who had fallen. This orientation checklist was signed by CNA #1 and dated 5-28-13. CNA #1's "Certified Nursing Assistant Skills Checklist" indicated she had successfully completed all items on the checklist by 6-3-13, including "Instruction in prevention, management and reporting S/S (signs and symptoms) of Unusual Distress", as well as "Transfers, Ambulation, ROM (range of motion activities), Transfer Equipment." CNA #1's employee record also included 4 employment counselings she had received during the time period of July through December, 2013 for poor job performance. On 2-3-14 at 2:30 p.m., the ED provided a copy of policy entitled, "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Property." This policy indicated, "It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws while involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violations"), are reported immediately to the Executive Director (hereinafter "ED") of the facility. Such violations will also be reported to state agencies in accordance with existing state law...During orientation, new employees shall be trained or the obligation to report alleged violations. Training shall include definitions of alleged violations and examples of reportable incidents to assist staff in detection of such incidents....Any employee who suspects an alleged violation shall immediately notify the ED or his/her designee. The Indiana State Department of Health, Division of Long Term Care, "Nurse Aide Training Program" Manual (July, 1998) indicated, "Topic 3: Observing and Reporting 1. Observing and reporting is the most important way the CNA assists the nurse and other members of the health care team to identify the needs of the residents...1. b. 3. Immediate reporting must be done at the time the observation is made and includes:...(c) Unusual incidents (i.e., falls, signs or suspicions of abuse)...Topic 8: Emergencies...4.b Falls-preventing falls is the best way to avoid serious injury. If a resident begins to fall, never try to stop the fall. Gently ease the resident to the floor and 1) Call for help immediately. Keep the resident in the same position until the nurse [MEDICATION NAME] the resident. 2) Be calm, reassure the resident and follow nurse's instructions." This Federal tag relates to Complaint IN 695. 3.1-14 (i)

Based on interview and record review, the facility failed to ensure staff members followed each resident's plan of care during transfers which resulted in 2 assisted falls with no injuries for 2 of 2 assisted falls reviewed in a sample of 3. (Resident #F and Resident #G) Findings include: 1. Resident #G's clinical record was reviewed on 3-27-14 at 9:50 a.m. Her [DIAGNOSES REDACTED]. In review of Resident #G's most recent Minimum Data Set (MDS) Assessment, a significant change MDS, dated [DATE], it indicated she had significant cognitive impairment, did not ambulate, required extensive assistance with bed mobility of 2 or more persons and required extensive assistance with transfers of one person. Her most recent fall risk assessment, dated 2-13-14, indicated she was at high risk for falls. In review of Resident #G's plan of care, it indicated the resident was at risk for falls related to the "use of medication and incontinence and need for assist with transfers." The goal of no falls with injury through the next review period was indicated. Interventions listed to address the fall risk were indicated to include, "Gait belt with transfers assist of 2 staff." The plan of care indicated two separate entries for this concern of falls. Both entries indicated a date of initiation for this concern of fall risk to be 2-28-14. For the intervention listed, one entry indicated the initiation date of 10-10-13; the second entry indicated the initiation date of 3-19-14 with a revision date of 3-21-14. In review of the "CNA Assignment Sheet" for Resident #G, provided by the Executive Director (ED) on 3-27-14 at 11:20 a.m., it indicated she required 2 persons to assist her with transfers; it indicated with toileting she required 2 persons and a gait belt to assist her. In an interview with the ED on 3-27-14 at 11:20 a.m., he indicated the CNA Assignment Sheets are updated daily and the previous ones are not kept on file. He indicated this was a current CNA Assignment Sheet for Resident #G. In review of a document entitled, "Verification of Investigation," dated 3-21-14, it indicated, "(Name of CNA #1) was attempting to transfer res (resident) from bed to wc (wheelchair) when res stopped helping with transfer and had to be lowered to floor by staff." It indicated she was needing to be toileted. The document indicated CNA#1 failed to use a gait belt. It indicated the resident sustained [REDACTED]. On 3-27-14 at 2:00 p.m., the ED provided a copy of a document entitled, "Personnel Conference" for CNA #1, dated 3-27-14 and signed by RN #3. This document indicated the CNA Assignment Sheet for Resident #G indicated she was to have 2 persons to assist her with transfers, as well as the use of a gait belt with transfers. It indicated CNA #1 failed to follow the plan of care via the CNA Assignment Sheet and utilized only 1 person to transfer and failed to use a gait belt with the transfer for Resident #G. This document indicated the conference was conducted by telephone with CNA #1. In an interview with the ED on 3-27-14 at 11:20 a.m., he indicated CNA #1 worked at the facility "on a casual (not routinely scheduled) basis." At this time, the ED provided a copy of CNA #1's time card summary which indicated she has worked for the facility a total of 15.47 hours for 2014, with 7.53 of those hours in the month of March, 2014. The time card summary indicated on 3-15-14, CNA #1 clocked in at 7:00 p.m. and clocked out at 9:32 p.m. It indicated she had not clocked in at the facility since that date. He indicated CNA #1 had not been counseled at this time regarding the assisted fall of Resident #G which occurred on 3-15-14. CNA #1 was unable to be reached by phone or in person for an interview. 2. Resident #F's clinical record was reviewed on 3-27-14 at 9:25 a.m. His [DIAGNOSES REDACTED]. In review of Resident #F's Admission Minimum Data Set (MDS) Assessment, dated 2-1-14, it indicated he had moderate cognitive impairment, did not ambulate and required extensive assistance with bed mobility and transfers of 2 or more persons. The most recent fall risk assessment, dated 1-25-14, indicated he was at high risk for falls. In review of Resident #F's plan of care, it indicated the resident was at risk for falls related to falls in the last 3 months. The goal for this concern was indicated as, "No fall related injuries." Interventions listed to address the fall risk were indicated to include, "Gait belt with transfers x2 staff (2 staff members)." The date for the plan of care indicated for this concern of fall risk to be 1-29-14. For the intervention listed, it indicated the date of initiation as 1-29-14 with a revision date of 1-30-14. In review of the "CNA Assignment Sheet" for Resident #F, provided by the Executive Director (ED) on 3-27-14 at 11:20 a.m., it indicated he required 2 persons and a gait belt to assist him with transfers. In an interview with the ED on 3-27-14 at 11:20 a.m., he indicated the CNA Assignment Sheets are updated daily and the previous ones are not kept on file. He indicated this was a current CNA Assignment Sheet for Resident #F. In review of a document entitled, "Verification of Investigation," dated 3-21-14, it indicated, "Resident was being transferred to w/c (wheelchair) when he lost his balance regardless of CNA assist with gait belt. CNA was able to ease Resident to the floor, as he slid down at front of CNA." The document indicated a contributing factor could have been the need for 2 persons to assist with the transfer. It indicated the resident sustained [REDACTED]. On 3-27-14 at 11:20 a.m., the ED provided a copy of a document entitled, "Personnel Conference" for CNA #2, dated 3-19-14. This document indicated,"CNA Assignment Sheet specifically stated assist of 2 with gait belt to transfer (sic)...Always follow CNA sheet instructions on how to transfer residents." This document was signed by CNA #2 and RN #3. CNA #2 was unable to be reached by phone or in person for an interview. In an interview with PT #4 on 3-27-14 at 12:20 p.m., he indicated both Resident #F and Resident #G were being followed by physical therapy for services at the time of their assisted falls. He indicated that although the therapy notes for around the time of their assisted falls indicated each was making some progress, he would not generally recommend any changes to the plan of care for nursing staff until the resident's progress was more consistent. He indicated for both Resident #F and Resident #G, neither resident's progress at the time of their assisted fall, or currently, was consistent enough to suggest changing nursing's plan of care from a 2 person assistance with the gait belt for any transfers. In an interview with the ED on 3-27-14 at 12:20 p.m., he indicated the facility does not have a policy on "CNA Assignment Sheets." He indicated it is understood that one would follow the information on the sheet. On 3-27-14 at 2:00 p.m., the ED provided a copy of a policy entitled, "Gait Belts." This policy indicated, "Gait belts provide increased security for the resident and staff, and prevent injury during movement of a resident. A designated staff member uses a gait or ambulation belt during ambulation or movement of a resident who needs security and assistance. A gait belt is not used unless the resident has been evaluated, and it has been approved for use by licensed nurse..." The Indiana State Department of Health, Division of Long Term Care, "Nurse Aide Training Program" Manual (July, 1998) indicated, "Topic 1: Health Care Delivery...The Comprehensive Care Plan (care plan) is a written plan of action developed by the Health Care Team to meet each resident's highest functional, medical, nursing, mental and psychosocial needs. The plan includes the identification of the cause and nature of a resident's needs, the short term and long term goals for the resident, the individualized approaches to reach those goals, and the disciplines responsible for meeting those goals. The comprehensive care plan fosters Continuity of Care (sic). CNA's role: a. Provide care according to the resident's comprehensive care plan..." This Federal tag relates to the Post Survey Revisit for Complaint IN 695. This deficiency was cited on February 6, 2014. the facility failed to implement a systemic plan of corrections to prevent recurrence. 3.1-14(i)

Based on interview and record review, the facility failed to ensure the physician's written orders were followed for 1 of 4 residents reviewed for accidents in a total sample of 4 as evidenced by not utilizing the resident's safety belt when up in the wheelchair, resulting in two falls from the wheelchair. The first fall resulted in no injury and the second fall resulted in him receiving a laceration to the forehead which required an evaluation in the local emergency room and subsequent stitches to close the laceration. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 7-9-12 at 11:32 a.m. His [DIAGNOSES REDACTED].) His most recent Minimum Data Set assessment, dated 6-20-12, indicated he has moderately impaired cognitive abilities. It indicated he does not walk, but uses a wheelchair for mobility. It indicated he has impairment of his upper and lower extremities. A discharge summary, dated 3-14-12, from his previous home setting of a group home indicated he had declined in general over the previous several months. It indicated he has limited speech abilities, but has a limited vocabulary, and can use "yes" and "no" and gestures to get his wants and needs met. Review of the clinical record indicated he was physician ordered upon admission on 3-14-12 for the use of a seat belt while up in his wheelchair to help maintain a safe upright position. Additionally, on the same date, his written nursing plan of care indicated, "Lap belt while up in wheelchair to help prevent falls. Resident has poor sitting balance (related to) [MEDICAL CONDITION]." On 3-15-12 at 4:32 p.m., the nursing notes indicated the staff heard a cup of water fall in Resident #B's room. Upon investigation, the staff found the resident to be sliding out of his wheelchair. It indicated he landed on his knees and fell forward onto his right side. It indicated an assessment yielded no findings of injury. It did not indicate if the seat belt was in place as ordered. In interview with LPN #1 on 7-9-12 at 4:35 p.m., she indicated she was unsure if the seat belt was in place before he fell . Review of the facility's investigation of this fall indicated nursing staff were educated after the fall on the routine use of the seat belt and foot pedals for the wheelchair. On 6-25-12 at 9:30 p.m., nursing notes indicated Resident #B was being pushed down the hall in his wheelchair by an CNA when he fell out of the wheelchair and received a laceration to his forehead, measuring 4 centimeters (cm) by 0.2 cm. It indicated the assessment indicated his neurological evaluation was within normal limits and first aide was administered to him. The physician was contacted and he ordered the resident to be sent to a local emergency room for evaluation and treatment. The facility's investigation into the fall indicated the resident's safety belt was not in place at the time of the fall and the resident did return from the emergency room with stitches to the laceration on his forehead. In interview with CNA #2 on 7-9-12 at 4:35 p.m., she indicated she had not placed the safety belt on Resident #B on 6-25-12 after his shower. She indicated CNA #3 and CNA #4 assisted her with transferring the resident from the shower chair into his wheelchair prior to being pushed down the hall toward his room. She indicated she had worked with Resident #B once or twice before. CNA #2 indicated she has been a CNA for almost 3 years and has worked at this same facility during this almost 3 years. In interview with CNA #3 on 7-10-12 at 1:54 p.m., she indicated on the evening of 6-25-12, CNA #2 was the aide caring for Resident #B. She indicated she and CNA #4 assisted CNA #2 in transferring Resident #B from his wheelchair to the shower chair prior to his shower and then after he received his shower and care from CNA #2, they assisted CNA #2 to get him back into his wheelchair. She indicated after assisting with the transfer, she went to get a drink (from the water fountain) and was in the process of returning to care for her assigned residents when she heard CNA #2 yell for help. She indicated immediately prior to the call for help, she heard a "thud." She indicated at that time, she yelled for assistance from the nurse. She indicated she had provided care previously for Resident #B and was aware he required the use of the safety belt. She indicated she assumed that CNA #2 would place the safety belt on the resident once he was transferred into his wheelchair. In interview with CNA #4 on 7-10-12 at 2:04 p.m., she indicated on the evening of 6-25-12, CNA #2 was the aide caring for Resident #B. She indicated she and CNA #3 assisted CNA #2 in transferring Resident #B from his wheelchair to the shower chair prior to his shower and then after he received his shower and care from CNA #2, they assisted CNA #2 to get him back into his wheelchair. She indicated CNA #2 then asked if she could assist her in getting the resident transferred from his wheelchair to his bed. She indicated she agreed to do this, but momentarily stepped out of the shower room to gather dirty linens. She indicated she assumed CNA #2 had placed the seat belt and did not think to check to see that the seat belt was in place. She indicated when she returned to the shower room, she began pushing the wheelchair. She indicated she was talking to CNA #2 while pushing the wheelchair when she heard CNA #2 say, "Oh," as she saw the resident begin to fall forward out of the wheelchair. She indicated she tried to catch him, but could not do so. She indicated Resident #B immediately began to bleed from his forehead. She indicated she yelled for the nurse and first aide was administered to the resident. She indicated when she had provided care to Resident #B previously, "the aide assignment sheet said he was a fall risk and has the seat belt listed under alarms. To me, this means he needs it on at all times when he's up (in his wheelchair.)" A copy of the current CNA assignment sheet for Resident #B was provided by the Director of Nursing on 7-10-12 at 9:58 a.m. Under the "Comments" section, it indicated, "(Safety) Belt on while up in chair." In interview with the Administrator on 7-10-12 at 3:30 p.m., he indicated the facility does not have a written policy on following physician orders. He indicated, "It's just the standard of practice that we follow the doctor's orders." This federal tag relates to complaint number IN 617 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure the physician's written orders were followed for 1 of 4 residents reviewed for accidents in a total sample of 4 as evidenced by not utilizing the resident's safety belt when up in the wheelchair, resulting in two falls from the wheelchair. The first fall resulted in no injury and the second fall resulted in him receiving a laceration to the forehead which required an evaluation in the local emergency room and subsequent stitches to close the laceration. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 7-9-12 at 11:32 a.m. His [DIAGNOSES REDACTED].) His most recent Minimum Data Set assessment, dated 6-20-12, indicated he has moderately impaired cognitive abilities. It indicated he does not walk, but uses a wheelchair for mobility. It indicated he has impairment of his upper and lower extremities. A discharge summary, dated 3-14-12, from his previous home setting of a group home indicated he had declined in general over the previous several months. It indicated he has limited speech abilities, but has a limited vocabulary, and can use "yes" and "no" and gestures to get his wants and needs met. Review of the clinical record indicated he was physician ordered upon admission on 3-14-12 for the use of a seat belt while up in his wheelchair to help maintain a safe upright position. Additionally, on the same date, his written nursing plan of care indicated, "Lap belt while up in wheelchair to help prevent falls. Resident has poor sitting balance (related to) [DIAGNOSES REDACTED]." On 3-15-12 at 4:32 p.m., the nursing notes indicated the staff heard a cup of water fall in Resident #B's room. Upon investigation, the staff found the resident to be sliding out of his wheelchair. It indicated he landed on his knees and fell forward onto his right side. It indicated an assessment yielded no findings of injury. It did not indicate if the seat belt was in place as ordered. In interview with LPN #1 on 7-9-12 at 4:35 p.m., she indicated she was unsure if the seat belt was in place before he fell . Review of the facility's investigation of this fall indicated nursing staff were educated after the fall on the routine use of the seat belt and foot pedals for the wheelchair. On 6-25-12 at 9:30 p.m., nursing notes indicated Resident #B was being pushed down the hall in his wheelchair by an CNA when he fell out of the wheelchair and received a laceration to his forehead, measuring 4 centimeters (cm) by 0.2 cm. It indicated the assessment indicated his neurological evaluation was within normal limits and first aide was administered to him. The physician was contacted and he ordered the resident to be sent to a local emergency room for evaluation and treatment. The facility's investigation into the fall indicated the resident's safety belt was not in place at the time of the fall and the resident did return from the emergency room with stitches to the laceration on his forehead. In interview with CNA #2 on 7-9-12 at 4:35 p.m., she indicated she had not placed the safety belt on Resident #B on 6-25-12 after his shower. She indicated CNA #3 and CNA #4 assisted her with transferring the resident from the shower chair into his wheelchair prior to being pushed down the hall toward his room. She indicated she had worked with Resident #B once or twice before. CNA #2 indicated she has been a CNA for almost 3 years and has worked at this same facility during this almost 3 years. In interview with CNA #3 on 7-10-12 at 1:54 p.m., she indicated on the evening of 6-25-12, CNA #2 was the aide caring for Resident #B. She indicated she and CNA #4 assisted CNA #2 in transferring Resident #B from his wheelchair to the shower chair prior to his shower and then after he received his shower and care from CNA #2, they assisted CNA #2 to get him back into his wheelchair. She indicated after assisting with the transfer, she went to get a drink (from the water fountain) and was in the process of returning to care for her assigned residents when she heard CNA #2 yell for help. She indicated immediately prior to the call for help, she heard a "thud." She indicated at that time, she yelled for assistance from the nurse. She indicated she had provided care previously for Resident #B and was aware he required the use of the safety belt. She indicated she assumed that CNA #2 would place the safety belt on the resident once he was transferred into his wheelchair. In interview with CNA #4 on 7-10-12 at 2:04 p.m., she indicated on the evening of 6-25-12, CNA #2 was the aide caring for Resident #B. She indicated she and CNA #3 assisted CNA #2 in transferring Resident #B from his wheelchair to the shower chair prior to his shower and then after he received his shower and care from CNA #2, they assisted CNA #2 to get him back into his wheelchair. She indicated CNA #2 then asked if she could assist her in getting the resident transferred from his wheelchair to his bed. She indicated she agreed to do this, but momentarily stepped out of the shower room to gather dirty linens. She indicated she assumed CNA #2 had placed the seat belt and did not think to check to see that the seat belt was in place. She indicated when she returned to the shower room, she began pushing the wheelchair. She indicated she was talking to CNA #2 while pushing the wheelchair when she heard CNA #2 say, "Oh," as she saw the resident begin to fall forward out of the wheelchair. She indicated she tried to catch him, but could not do so. She indicated Resident #B immediately began to bleed from his forehead. She indicated she yelled for the nurse and first aide was administered to the resident. She indicated when she had provided care to Resident #B previously, "the aide assignment sheet said he was a fall risk and has the seat belt listed under alarms. To me, this means he needs it on at all times when he's up (in his wheelchair.)" A copy of the current CNA assignment sheet for Resident #B was provided by the Director of Nursing on 7-10-12 at 9:58 a.m. Under the "Comments" section, it indicated, "(Safety) Belt on while up in chair." In interview with the Administrator on 7-10-12 at 3:30 p.m., he indicated the facility does not have a written policy on following physician orders. He indicated, "It's just the standard of practice that we follow the doctor's orders." This federal tag relates to complaint number IN 617. 3.1-45(a)(2)