Every finding on record at Brookside Care Strategies

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse and neglect from staff when a CNA refused to answer a resident's call light, refused to provide personal hygiene assistance, and told the resident to not use his call light for 1 of 3 residents reviewed for abuse. (Resident 10). This deficient practice resulted in the resident being afraid of the CNA (CNA 9), being left in soiled bedding, and being tearful and crying.Finding includes:During an interview, on 5/17/26 at 1:04 p.m., Resident 10 indicated he had filed a complaint about CNA 9 and did not know what was going on with the complaint. He was very upset and speaking with his voice high. He had reported to the facility that he had his call light on, and CNA 9 came into his room and told him he was on his call light too much. She yelled at him. She left him in a urine-soaked bed all night. He had not received care until the next shift. This was not the first time this had happened. He had told another CNA, who then completed the paperwork for him to file a grievance. He indicated he was still very upset and wanted to be assured that this behavior would not happen again. He pointed at Activity Assistant 8 and indicated she knew who took the statement from him and what happened. During an interview, on 5/17/26 at 1:07 p.m., Activity Assistant 8 indicated CNA 11 had taken the written statement for Resident 10's grievance. During an interview, on 5/17/26 at 1:08 p.m., LPN 3 indicated she had been present when CNA 11 had written a grievance form for Resident 10. She believed the CNA placed the grievance form in the Administrator, Social Service Designee, or DON's mailbox. During an interview, on 5/17/26 at 1:10 p.m., the Administrator indicated he had no knowledge of Resident 10's concern or a filed grievance. He would look into the matter and provide answers. During an interview on 5/17/26 at 1:59 p.m., the Administrator indicated CNA 11 completed the grievance form on behalf of Resident 10 and his concerns. She had put the form in the Social Service Designee's and the Administrator's mailboxes. She had not called to inform leadership of a report of neglect and/or abuse. The facility had now reported the allegation and began their investigation. CNA 9 was suspended pending investigation. Review of a Resident/Family Concern/Grievance Form, dated 5/16/26 at 7:10 a.m. indicated Resident 10 had a concern of grievance from 5/15/26 as follows: The form was completed by CNA 11. The allegation was that CNA 9 had yelled at the resident and told him to turn off his call light. She told him not to use his call light for the rest of the night because she didn't have time to keep coming to his room. Review of a written statement of a phone conversation with CNA 11, dated 5/17/26, indicated the following: The Administrator and Social Service Director spoke with CNA 11 regarding the Report of Concern form from Resident 10. CNA 11 stated that LPN 4 and CNA 10 were both present when he made the complaint against CNA 9. CNA 11 stated she filled out the form and put it in Social Service's mailbox. Management discussed with CNA 11 the accepted procedure for reporting. Review of a 5/17/26 investigation statement from CNA 10 indicated the following; Resident 10 stated that CNA 9 was always rude and refusing to change his colostomy (an opening in the abdomen to reroute the intestine) bag. Resident 10 said he told CNA 9 to not provide care to him, because she came into his room and stated he always had his call light on. On 5/16/26, CNA 10 did provide care to Resident 10 in place of CNA 9 per the resident's request. CNA 10 did hear Resident 10 tell CNA 9 to get out of his room. Resident 10 was upset and had also been upset on 5/16/26. CNA 10 did tell the nursing staff and wrote a statement about what was said at that time. During an interview on 5/20/26 at 10:05 a.m., the DON indicated she was not aware of what prior written statement CNA 10 was referencing. She would investigate the matter and provide more information. On 5/20/26 at 10:10 a.m., the DON provided a 5/15/26 written statement from CNA 10. She indicated she hadn't read the 5/15/26 statement until a couple of minutes ago. It had been in her mailbox, and she hadn't associated the two events. The 5/15/26, written statement from CNA 10 was provided by the DON on 5/20/26 at 10:10 a.m., and indicated CNA 10 was out with residents for smoke break. CNA 9 was sitting in a chair. There were call lights on for Resident 10's room and another resident's room. CNA 10 asked CNA 9 to answer the call lights. CNA 9 told her it was Resident 10's call light and she knew his [colostomy] bag wasn't full and he always had his call light on. The other resident needed a patch and there wasn't anything she could do about it. An activities staff member and a laundry staff member were also present. CNA 10 told CNA 9 there were 45 minutes until dinner, so answering the call lights would make sure the residents didn't need anything else. CNA 9 said no, so CNA 10 proceeded to smoke. The activities staff member answered the call lights and came back out and said Resident 10 needed his colostomy bag burped (opened enough to let gas out). Another CNA ended up emptying Resident 10's colostomy bag because CNA 9 left his bag open and it leaked all over. Another CNA pulled CNA 9 aside and tried to explain in private about Resident 10's concern and how to seal the bag. CNA 9 sat outside the whole time to chat. She walked past lights. CNA 10 told the Dietary Manager that CNA 9 needed retrained or more help and what had happened. CNA 10 proceeded to assist Resident 10 because his sheets were wet. CNA 9 sat at the nursing station and then went to ask Resident 10 what he needed, and he told her to leave. Resident 10 was pretty upset and crying tears. During a phone interview, on 5/20/2026 at 10:31 a.m., CNA 10 indicated the following: She wrote a statement regarding her concerns with Resident 10's care on 5/15/26. She put the statement in the DON's mailbox as the DON instructed. She didn't know if what occurred was abuse or neglect. Care was not provided, and the resident cried and was distressed. Because she did not know if what occurred was abuse or neglect, she did know it was wrong, so she went to the Dietary Manager, who was the only department head in the building, and told her about the concerns with CNA 9 refusing to answer Resident 10's call light and withholding care. The Dietary Manager called the DON and they both spoke with her. She reported her concerns to the DON and was asked to write a statement. The event happened between 3:45 p.m. and 4:30 p.m. During the event, she herself provided care to Resident 10. Resident 10's bed had been saturated with urine, and he was distressed and cried. During a phone interview with the Dietary Manager, on 5/20/26 at 10:57 a.m., she indicated the following: The evening of 5/15/26 CNA 10 and some other staff were upset about how CNA 9 was providing care and her failure to provide care. CNA 20 was also upset about the care given to Resident 10. CNA 20 said the resident was crying and upset and didn't want CNA 9 in his room. The Dietary Manager called the DON and told her about the concerns. She then passed the phone to CNA 10, who told the DON about her concerns with CNA 9 failing to provide care and providing incorrect care to Resident 10. At the end of the call, the Dietary Manager was instructed to have all staff who were present for the events complete written statements and place their statements in the DON's mailbox. A 5/15/26, written investigation statement by CNA 20 indicated the following: Around 4:00 p.m., CNA 9 was told to stay on the hall while the other CNAs went out to smoke. CNA 9 was outside ignoring call lights. CNA 9 spoke about resident business out loud in front of other residents and was complaining about residents and call lights. CNA 20 went inside to answer the call lights. When she got to Resident 10's room, his colostomy bag had been left with the clip not properly closed. Resident 10 told CNA 20 that CNA 9 had asked the resident how to close it and then made him do it. CNA 20 went outside and pulled CNA 9 to the side and told her how to properly close the clip. CNA 9 indicated she had never been trained to close a colostomy bag. CNA 9 continued to complain about Resident 10's call light. CNA 20 had to change Resident 10 bedding two days back-to-back because CNA 9 forces him to sleep in urine covered sheets. One day she refused him a brief. Resident 10 is scared. CNA 9 is neglectful. An undated written investigation statement from Activity Assistant 8 indicated she answered Resident 10's call light on the day in question. The resident indicated he needed his colostomy bag checked. CNA 20 went to assist the resident. CNA 9 complained that Resident 10 always has his call light on. The Activity Assistant explained that the light needed to be answered, no matter how often the resident turned it on. Resident 10 called for the Activity Assistant as she walked by his room. He indicated to her that CNA 9 wouldn't help him and he started to get upset and teary eyed and he was worried that CNA 9 would be assigned to care for him all night. She reassured him. He was in tears, saying he was scared. During an interview on 5/20/2026 at 11:06 a.m., the DON indicated she did not remember any mention of withholding care or neglect of Resident 10 during the phone call on 5/15/25. She thought everyone was upset about colostomy care. A 5/17/26 written investigation statement by LPN 3 indicated she was off work on Friday 5/15/26 and when she came into work on 5/16/26, she saw CNA 11 talking to Resident 10 with a grievance form, however, did not ask about what the grievance was about. A written, undated, investigation statement by LPN 4 indicated Resident 10 came up to the writer and stated CNA 9 was always rude and did not want to help him. A 5/15/26 at 5:39 p.m. screenshot text from CNA 9 to the Business Office Manager indicated Resident 10 began screaming and yelling at her to get out, but she had not been in his room since she got there because another aide was assigned to him. He kept cussing her out and screaming at her and calling her inappropriate names because he was upset that she didn't answer the call light the second he turned it on and got upset she was helping another resident and wasn't giving him attention. A 5/17/26 telephone interview from CNA 9 indicated the following: CNA 20 took [room number] and she went in when the call light came on. As CNA 9 was walking past Resident 10's room to go to the common room, the resident started screaming at her to get out of his room and calling her inappropriate names. CNA 9 wasn't even in his room, just walking by to go to the common area. He continued calling her inappropriate names to other people, telling them that she wasn't taking care of him. Another time, the resident put on his light and started screaming help, but CNA 9 didn't hear him because she was changing another resident. Resident 10 got mad and told people she wasn't taking care of him, but she was getting another resident ready for bed and just had not gotten to him yet. CNA 9 was unavailable for interview during the survey dates. CNA 20 was unavailable for interview during the survey dates. The nurse staffing schedule for Thursday 5/14/26, Friday 5/15/26, and Saturday 5/17/26 indicated CNA 9 worked each day. During the three days, she worked from 2:00 p.m. to 10:00 p.m. She had not been sent home pending investigation of the allegation on 5/15/26. Resident 10's clinical record was reviewed on 5/18/25 at 11:58 a.m. Current diagnoses included mild intellectual disabilities, post-traumatic stress disorder, blindness of the right eye, low vision of left eye, anxiety disorder, major depressive disorder, and ileostomy. A 4/21/26, admission, Minimum Data Set (MDS) assessment indicated the resident had mild cognitive impairment, usually understood others, had unclear speech, was understood by others, usually understood, and had displayed no maladaptive behaviors during the assessment period. A current, 4/21/26, care plan indicated a problem/need regarding potential/actual impairment to skin integrity that may affect tissue perfusion, ileostomy status, anemia, nail dystrophy. Approaches to this need included assistance with routine toileting as needed and check routinely for incontinence and provide incontinent care as needed, notify nurse of redness or irritation. A current, 4/21/26, care plan indicated a problem/need regarding a diagnosis of anxiety with a history of symptoms such as increase in heart rate, racing thoughts, thinking about the same thing without being able to shift focus. A current, 4/21/26, care plan indicated a problem/need regarding depression with a history of symptoms such as tearfulness, sadness, and isolation. A current, September 2022, facility policy titled, Identifying Types of Abuse, provided by the DON via email on 5/21/26 at 10:48 a.m., indicated the following: Neglect/Deprivation of Goods and Services by Staff.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Mental and Verbal Abuse.Examples of mental and verbal abuse include, but are not limited to:.threatening residents, including but not limited to, depriving a resident of care. The following situation are recognized as those that are likely to cause psychosocial harm.When facility staff as punishment, threaten to.withhold care from the resident. A current, Indiana Department of Health Policy, titled Long-Term Care Abuse and Incident Reporting Policy, effective date: 12/8/22-9/1/27, provided by the DON via email on 5/21/26 at 10:48 a.m., and identified as a facility policy indicated: Alleged violation: Alleged violation is a situation or occurrence that is observed or reported by staff.but has not yet been investigated and if verified, could be noncompliance with the federal requirements.Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Choose not to do it or acknowledge the request. Abuse and incidents will be reported and submitted to the Indiana Department of Health in compliance with federal and/or state rules and regulations.Ensure that all alleged violations involving abuse, neglect.are reported immediately, but no later than two hours after the allegation is made. Instructions For Submitting an Incident Report:.h. Immediate action taken to respond to the event and protect the resident. i. Preventative measures taken while the investigation is in progress. 410 IAC (Indiana Administrative Code) 16.2-3.1 -27(a)410 IAC 16.2-3.1-27(b)

Based on interview and record review, the facility failed to report an allegation of verbal abuse and neglect to the Administrator immediately to allow for implementation of the facility's abuse prohibition policy, and also resulting in a delay of reporting to the Indiana Department of Health immediately or no later than two hours of the abuse allegation for 1 of 3 residents reviewed for abuse (Resident 10). Findings include:During an interview, on 5/17/26 at 1:04 p.m., Resident 10 indicated he had filed a complaint about CNA 9 and did not know what was going on with the complaint. He was very upset and speaking with his voice high. He had reported to the facility that he had his call light on, and CNA 9 came into his room and told him he was on his call light too much. She yelled at him. She left him in a urine-soaked bed all night. He had not received care until the next shift. This was not the first time this had happened. He had told another CNA, who then completed the paperwork for him to file a grievance. He indicated he was still very upset and wanted to be assured that this behavior would not happen again. He pointed at Activity Assistant 8 and indicated she knew who took the statement from him and what happened. During an interview, on 5/17/26 at 1:07 p.m., Activity Assistant 8 indicated CNA 11 had taken the written statement for Resident 10's grievance. During an interview, on 5/17/26 at 1:08 p.m., LPN 3 indicated she had been present when CNA 11 had written a grievance form for Resident 10. She believed the CNA placed the grievance form in the Administrator, Social Service Designee, or DON's mailbox. During an interview, on 5/17/26 at 1:10 p.m., the Administrator indicated he had no knowledge of Resident 10's concern or a filed grievance. He would look into the matter and provide answers. During an interview on 5/17/26 at 1:59 p.m., the Administrator indicated CNA 11 completed the grievance form on behalf of Resident 10 and his concerns. She had put the form in the Social Service Designee's and the Administrator's mailboxes. She had not called to inform leadership of a report of neglect and/or abuse. The facility had now reported the allegation and began their investigation. CNA 9 was suspended pending investigation. Review of a Resident/Family Concern/Grievance Form, dated 5/16/26 at 7:10 a.m. indicated Resident 10 had a concern of grievance from 5/15/26 as follows: The form was completed by CNA 11. The allegation was that CNA 9 had yelled at the resident and told him to turn off his call light. She told him not to use his call light for the rest of the night because she didn't have time to keep coming to his room. Review of a written statement of a phone conversation with CNA 11, dated 5/17/26, indicated the following: The Administrator and Social Service Director spoke with CNA 11 regarding the Report of Concern form from Resident 10. CNA 11 stated that LPN 4 and CNA 10 were both present when he made the complaint against CNA 9. CNA 11 stated she filled out the form and put it in Social Service's mailbox. Management discussed with CNA 11 the accepted procedure for reporting. Review of a 5/17/26 investigation statement from CNA 10 indicated the following; Resident 10 stated that CNA 9 was always rude and refusing to change his colostomy (an opening in the abdomen to reroute the intestine) bag. Resident 10 said he told CNA 9 to not provide care to him, because she came into his room and stated he always had his call light on. On 5/16/26, CNA 10 did provide care to Resident 10 in place of CNA 9 per the resident's request. CNA 10 did hear Resident 10 tell CNA 9 to get out of his room. Resident 10 was upset and had also been upset on 5/16/26. CNA 10 did tell the nursing staff and wrote a statement about what was said at that time. During an interview on 5/20/26 at 10:05 a.m., the DON indicated she was not aware of what prior written statement CNA 10 was referencing. She would investigate the matter and provide more information. On 5/20/26 at 10:10 a.m., the DON provided a 5/15/26 written statement from CNA 10. She indicated she hadn't read the 5/15/26 statement until a couple of minutes ago. It had been in her mailbox, and she hadn't associated the two events. The 5/15/26, written statement from CNA 10 was provided by the DON on 5/20/26 at 10:10 a.m., and indicated CNA 10 was out with residents for smoke break. CNA 9 was sitting in a chair. There were call lights on for Resident 10's room and another resident's room. CNA 10 asked CNA 9 to answer the call lights. CNA 9 told her it was Resident 10's call light and she knew his [colostomy] bag wasn't full and he always had his call light on. The other resident needed a patch and there wasn't anything she could do about it. An activities staff member and a laundry staff member were also present. CNA 10 told CNA 9 there were 45 minutes until dinner, so answering the call lights would make sure the residents didn't need anything else. CNA 9 said no, so CNA 10 proceeded to smoke. The activities staff member answered the call lights and came back out and said Resident 10 needed his colostomy bag burped (opened enough to let gas out). Another CNA ended up emptying Resident 10's colostomy bag because CNA 9 left his bag open and it leaked all over. Another CNA pulled CNA 9 aside and tried to explain in private about Resident 10's concern and how to seal the bag. CNA 9 sat outside the whole time to chat. She walked past lights. CNA 10 told the Dietary Manager that CNA 9 needed retrained or more help and what had happened. CNA 10 proceeded to assist Resident 10 because his sheets were wet. CNA 9 sat at the nursing station and then went to ask Resident 10 what he needed, and he told her to leave. Resident 10 was pretty upset and crying tears. During a phone interview, on 5/20/26 at 10:31 a.m., CNA 10 indicated the following: She wrote a statement regarding her concerns with Resident 10's care on 5/15/26. She put the statement in the DON's mailbox as the DON instructed. She didn't know if what occurred was abuse or neglect. Care was not provided, and the resident cried and was distressed. Because she did not know if what occurred was abuse or neglect, she did know it was wrong, so she went to the Dietary Manager, who was the only department head in the building, and told her about the concerns with CNA 9 refusing to answer Resident 10's call light and withholding care. The Dietary Manager called the DON and they both spoke with her. She reported her concerns to the DON and was asked to write a statement. The event happened between 3:45 p.m. and 4:30 p.m. During the event, she herself provided care to Resident 10. Resident 10's bed had been saturated with urine, and he was distressed and cried. During a phone interview with the Dietary Manager, on 5/20/26 at 10:57 a.m., she indicated the following: The evening of 5/15/26 CNA 10 and some other staff were upset about how CNA 9 was providing care and her failure to provide care. CNA 20 was also upset about the care given to Resident 10. CNA 20 said the resident was crying and upset and didn't want CNA 9 in his room. The Dietary Manager called the DON and told her about the concerns. She then passed the phone to CNA 10, who told the DON about her concerns with CNA 9 failing to provide care and providing incorrect care to Resident 10. At the end of the call, the Dietary Manager was instructed to have all staff who were present for the events complete written statements and place their statements in the DON's mailbox. A 5/15/26, written investigation statement by CNA 20 indicated the following: Around 4:00 p.m., CNA 9 was told to stay on the hall while the other CNAs went out to smoke. CNA 9 was outside ignoring call lights. CNA 9 spoke about resident business out loud in front of other residents and was complaining about residents and call lights. CNA 20 went inside to answer the call lights. When she got to Resident 10's room, his colostomy bag had been left with the clip not properly closed. Resident 10 told CNA 20 that CNA 9 had asked the resident how to close it and then made him do it. CNA 20 went outside and pulled CNA 9 to the side and told her how to properly close the clip. CNA 9 indicated she had never been trained to close a colostomy bag. CNA 9 continued to complain about Resident 10's call light. CNA 20 had to change Resident 10 bedding two days back-to-back because CNA 9 forces him to sleep in urine covered sheets. One day she refused him a brief. Resident 10 is scared. CNA 9 is neglectful. An undated written investigation statement from Activity Assistant 8 indicated she answered Resident 10's call light on the day in question. The resident indicated he needed his colostomy bag checked. CNA 20 went to assist the resident. CNA 9 complained that Resident 10 always has his call light on. The Activity Assistant explained that the light needed to be answered, no matter how often the resident turned it on. Resident 10 called for the Activity Assistant as she walked by his room. He indicated to her that CNA 9 wouldn't help him and he started to get upset and teary eyed and he was worried that CNA 9 would be assigned to care for him all night. She reassured him. He was in tears, saying he was scared. During an interview on 5/20/2026 at 11:06 a.m., the DON indicated she did not remember any mention of withholding care or neglect of Resident 10 during the phone call on 5/15/25. She thought everyone was upset about colostomy care. A 5/17/26 written investigation statement by LPN 3 indicated she was off work on Friday 5/15/26 and when she came into work on 5/16/26, she saw CNA 11 talking to Resident 10 with a grievance form, however, did not ask about what the grievance was about. A written, undated, investigation statement by LPN 4 indicated Resident 10 came up to the writer and stated CNA 9 was always rude and did not want to help him. A 5/15/26 at 5:39 p.m. screenshot text from CNA 9 to the Business Office Manager indicated Resident 10 began screaming and yelling at her to get out, but she had not been in his room since she got there because another aide was assigned to him. He kept cussing her out and screaming at her and calling her inappropriate names because he was upset that she didn't answer the call light the second he turned it on and got upset she was helping another resident and wasn't giving him attention. A 5/17/26 telephone interview from CNA 9 indicated the following: CNA 20 took [room number] and she went in when the call light came on. As CNA 9 was walking past Resident 10's room to go to the common room, the resident started screaming at her to get out of his room and calling her inappropriate names. CNA 9 wasn't even in his room, just walking by to go to the common area. He continued calling her inappropriate names to other people, telling them that she wasn't taking care of him. Another time, the resident put on his light and started screaming help, but CNA 9 didn't hear him because she was changing another resident. Resident 10 got mad and told people she wasn't taking care of him, but she was getting another resident ready for bed and just had not gotten to him yet. CNA 9 was unavailable for interview during the survey dates. CNA 20 was unavailable for interview during the survey dates. The nurse staffing schedule for Thursday 5/14/26, Friday 5/15/26, and Saturday 5/17/26 indicated CNA 9 worked each day. During the three days, she worked from 2:00 p.m. to 10:00 p.m. She had not been sent home pending investigation of the allegation on 5/15/26. Resident 10's clinical record was reviewed on 5/18/25 at 11:58 a.m. Current diagnoses included mild intellectual disabilities, post-traumatic stress disorder, blindness of the right eye, low vision of left eye, anxiety disorder, major depressive disorder, and ileostomy. A 4/21/26, admission, Minimum Data Set (MDS) assessment indicated the resident had mild cognitive impairment, usually understood others, had unclear speech, was understood by others, usually understood, and had displayed no maladaptive behaviors during the assessment period. A current, 4/21/26, care plan indicated a problem/need regarding potential/actual impairment to skin integrity that may affect tissue perfusion, ileostomy status, anemia, nail dystrophy. Approaches to this need included assistance with routine toileting as needed and check routinely for incontinence and provide incontinent care as needed, notify nurse of redness or irritation. A current, 4/21/26, care plan indicated a problem/need regarding a diagnosis of anxiety with a history of symptoms such as increase in heart rate, racing thoughts, thinking about the same thing without being able to shift focus. A current, 4/21/26, care plan indicated a problem/need regarding depression with a history of symptoms such as tearfulness, sadness, and isolation. A current, September 2022, facility policy titled, Identifying Types of Abuse, provided by the DON via email on 5/21/26 at 10:48 a.m., indicated the following: Neglect/Deprivation of Goods and Services by Staff.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Mental and Verbal Abuse.Examples of mental and verbal abuse include, but are not limited to:.threatening residents, including but not limited to, depriving a resident of care. The following situation are recognized as those that are likely to cause psychosocial harm.When facility staff as punishment, threaten to.withhold care from the resident. A current, Indiana Department of Health Policy, titled Long-Term Care Abuse and Incident Reporting Policy, effective date: 12/8/22-9/1/27, provided by the DON via email on 5/21/26 at 10:48 a.m., and identified as a facility policy indicated: Alleged violation: Alleged violation is a situation or occurrence that is observed or reported by staff.but has not yet been investigated and if verified, could be noncompliance with the federal requirements.Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Choose not to do it or acknowledge the request. Abuse and incidents will be reported and submitted to the Indiana Department of Health in compliance with federal and/or state rules and regulations.Ensure that all alleged violations involving abuse, neglect.are reported immediately, but no later than two hours after the allegation is made. Instructions For Submitting an Incident Report:.h. Immediate action taken to respond to the event and protect the resident. i. Preventative measures taken while the investigation is in progress. 410 IAC (Indiana Administrative Code) 16.2-3.1 -28(c)

Based on interview and record review, the facility failed to implement their policy to immediately begin an investigation of an allegation of staff to resident verbal abuse and neglect, including taking action to protect residents and implementing preventative measures pending investigation for 1 of 3 residents reviewed for abuse (Resident 10). Findings include:During an interview, on 5/17/26 at 1:04 p.m., Resident 10 indicated he had filed a complaint about CNA 9 and did not know what was going on with the complaint. He was very upset and speaking with his voice high. He had reported to the facility that he had his call light on, and CNA 9 came into his room and told him he was on his call light too much. She yelled at him. She left him in a urine-soaked bed all night. He had not received care until the next shift. This was not the first time this had happened. He had told another CNA, who then completed the paperwork for him to file a grievance. He indicated he was still very upset and wanted to be assured that this behavior would not happen again. He pointed at Activity Assistant 8 and indicated she knew who took the statement from him and what happened. During an interview, on 5/17/26 at 1:07 p.m., Activity Assistant 8 indicated CNA 11 had taken the written statement for Resident 10's grievance. During an interview, on 5/17/26 at 1:08 p.m., LPN 3 indicated she had been present when CNA 11 had written a grievance form for Resident 10. She believed the CNA placed the grievance form in the Administrator, Social Service Designee, or DON's mailbox. During an interview, on 5/17/26 at 1:10 p.m., the Administrator indicated he had no knowledge of Resident 10's concern or a filed grievance. He would look into the matter and provide answers. During an interview on 5/17/26 at 1:59 p.m., the Administrator indicated CNA 11 completed the grievance form on behalf of Resident 10 and his concerns. She had put the form in the Social Service Designee's and the Administrator's mailboxes. She had not called to inform leadership of a report of neglect and/or abuse. The facility had now reported the allegation and began their investigation. CNA 9 was suspended pending investigation. Review of a Resident/Family Concern/Grievance Form, dated 5/16/26 at 7:10 a.m. indicated Resident 10 had a concern of grievance from 5/15/26 as follows: The form was completed by CNA 11. The allegation was that CNA 9 had yelled at the resident and told him to turn off his call light. She told him not to use his call light for the rest of the night because she didn't have time to keep coming to his room. Review of a written statement of a phone conversation with CNA 11, dated 5/17/26, indicated the following: The Administrator and Social Service Director spoke with CNA 11 regarding the Report of Concern form from Resident 10. CNA 11 stated that LPN 4 and CNA 10 were both present when he made the complaint against CNA 9. CNA 11 stated she filled out the form and put it in Social Service's mailbox. Management discussed with CNA 11 the accepted procedure for reporting. Review of a 5/17/26 investigation statement from CNA 10 indicated the following; Resident 10 stated that CNA 9 was always rude and refusing to change his colostomy (an opening in the abdomen to reroute the intestine) bag. Resident 10 said he told CNA 9 to not provide care to him, because she came into his room and stated he always had his call light on. On 5/16/26, CNA 10 did provide care to Resident 10 in place of CNA 9 per the resident's request. CNA 10 did hear Resident 10 tell CNA 9 to get out of his room. Resident 10 was upset and had also been upset on 5/16/26. CNA 10 did tell the nursing staff and wrote a statement about what was said at that time. During an interview on 5/20/26 at 10:05 a.m., the DON indicated she was not aware of what prior written statement CNA 10 was referencing. She would investigate the matter and provide more information. On 5/20/26 at 10:10 a.m., the DON provided a 5/15/26 written statement from CNA 10. She indicated she hadn't read the 5/15/26 statement until a couple of minutes ago. It had been in her mailbox, and she hadn't associated the two events. The 5/15/26, written statement from CNA 10 was provided by the DON on 5/20/26 at 10:10 a.m., and indicated CNA 10 was out with residents for smoke break. CNA 9 was sitting in a chair. There were call lights on for Resident 10's room and another resident's room. CNA 10 asked CNA 9 to answer the call lights. CNA 9 told her it was Resident 10's call light and she knew his [colostomy] bag wasn't full and he always had his call light on. The other resident needed a patch and there wasn't anything she could do about it. An activities staff member and a laundry staff member were also present. CNA 10 told CNA 9 there were 45 minutes until dinner, so answering the call lights would make sure the residents didn't need anything else. CNA 9 said no, so CNA 10 proceeded to smoke. The activities staff member answered the call lights and came back out and said Resident 10 needed his colostomy bag burped (opened enough to let gas out). Another CNA ended up emptying Resident 10's colostomy bag because CNA 9 left his bag open and it leaked all over. Another CNA pulled CNA 9 aside and tried to explain in private about Resident 10's concern and how to seal the bag. CNA 9 sat outside the whole time to chat. She walked past lights. CNA 10 told the Dietary Manager that CNA 9 needed retrained or more help and what had happened. CNA 10 proceeded to assist Resident 10 because his sheets were wet. CNA 9 sat at the nursing station and then went to ask Resident 10 what he needed, and he told her to leave. Resident 10 was pretty upset and crying tears. During a phone interview, on 5/20/26 at 10:31 a.m., CNA 10 indicated the following: She wrote a statement regarding her concerns with Resident 10's care on 5/15/26. She put the statement in the DON's mailbox as the DON instructed. She didn't know if what occurred was abuse or neglect. Care was not provided, and the resident cried and was distressed. Because she did not know if what occurred was abuse or neglect, she did know it was wrong, so she went to the Dietary Manager, who was the only department head in the building, and told her about the concerns with CNA 9 refusing to answer Resident 10's call light and withholding care. The Dietary Manager called the DON and they both spoke with her. She reported her concerns to the DON and was asked to write a statement. The event happened between 3:45 p.m. and 4:30 p.m. During the event, she herself provided care to Resident 10. Resident 10's bed had been saturated with urine, and he was distressed and cried. During a phone interview with the Dietary Manager, on 5/20/26 at 10:57 a.m., she indicated the following: The evening of 5/15/26 CNA 10 and some other staff were upset about how CNA 9 was providing care and her failure to provide care. CNA 20 was also upset about the care given to Resident 10. CNA 20 said the resident was crying and upset and didn't want CNA 9 in his room. The Dietary Manager called the DON and told her about the concerns. She then passed the phone to CNA 10, who told the DON about her concerns with CNA 9 failing to provide care and providing incorrect care to Resident 10. At the end of the call, the Dietary Manager was instructed to have all staff who were present for the events complete written statements and place their statements in the DON's mailbox. A 5/15/26, written investigation statement by CNA 20 indicated the following: Around 4:00 p.m., CNA 9 was told to stay on the hall while the other CNAs went out to smoke. CNA 9 was outside ignoring call lights. CNA 9 spoke about resident business out loud in front of other residents and was complaining about residents and call lights. CNA 20 went inside to answer the call lights. When she got to Resident 10's room, his colostomy bag had been left with the clip not properly closed. Resident 10 told CNA 20 that CNA 9 had asked the resident how to close it and then made him do it. CNA 20 went outside and pulled CNA 9 to the side and told her how to properly close the clip. CNA 9 indicated she had never been trained to close a colostomy bag. CNA 9 continued to complain about Resident 10's call light. CNA 20 had to change Resident 10 bedding two days back-to-back because CNA 9 forces him to sleep in urine covered sheets. One day she refused him a brief. Resident 10 is scared. CNA 9 is neglectful. An undated written investigation statement from Activity Assistant 8 indicated she answered Resident 10's call light on the day in question. The resident indicated he needed his colostomy bag checked. CNA 20 went to assist the resident. CNA 9 complained that Resident 10 always has his call light on. The Activity Assistant explained that the light needed to be answered, no matter how often the resident turned it on. Resident 10 called for the Activity Assistant as she walked by his room. He indicated to her that CNA 9 wouldn't help him and he started to get upset and teary eyed and he was worried that CNA 9 would be assigned to care for him all night. She reassured him. He was in tears, saying he was scared. During an interview on 5/20/2026 at 11:06 a.m., the DON indicated she did not remember any mention of withholding care or neglect of Resident 10 during the phone call on 5/15/25. She thought everyone was upset about colostomy care. A 5/17/26 written investigation statement by LPN 3 indicated she was off work on Friday 5/15/26 and when she came into work on 5/16/26, she saw CNA 11 talking to Resident 10 with a grievance form, however, did not ask about what the grievance was about. A written, undated, investigation statement by LPN 4 indicated Resident 10 came up to the writer and stated CNA 9 was always rude and did not want to help him. A 5/15/26 at 5:39 p.m. screenshot text from CNA 9 to the Business Office Manager indicated Resident 10 began screaming and yelling at her to get out, but she had not been in his room since she got there because another aide was assigned to him. He kept cussing her out and screaming at her and calling her inappropriate names because he was upset that she didn't answer the call light the second he turned it on and got upset she was helping another resident and wasn't giving him attention. A 5/17/26 telephone interview from CNA 9 indicated the following: CNA 20 took [room number] and she went in when the call light came on. As CNA 9 was walking past Resident 10's room to go to the common room, the resident started screaming at her to get out of his room and calling her inappropriate names. CNA 9 wasn't even in his room, just walking by to go to the common area. He continued calling her inappropriate names to other people, telling them that she wasn't taking care of him. Another time, the resident put on his light and started screaming help, but CNA 9 didn't hear him because she was changing another resident. Resident 10 got mad and told people she wasn't taking care of him, but she was getting another resident ready for bed and just had not gotten to him yet. CNA 9 was unavailable for interview during the survey dates. CNA 20 was unavailable for interview during the survey dates. The nurse staffing schedule for Thursday 5/14/26, Friday 5/15/26, and Saturday 5/17/26 indicated CNA 9 worked each day. During the three days, she worked from 2:00 p.m. to 10:00 p.m. She had not been sent home pending investigation of the allegation on 5/15/26. Resident 10's clinical record was reviewed on 5/18/25 at 11:58 a.m. Current diagnoses included mild intellectual disabilities, post-traumatic stress disorder, blindness of the right eye, low vision of left eye, anxiety disorder, major depressive disorder, and ileostomy. A 4/21/26, admission, Minimum Data Set (MDS) assessment indicated the resident had mild cognitive impairment, usually understood others, had unclear speech, was understood by others, usually understood, and had displayed no maladaptive behaviors during the assessment period. A current, 4/21/26, care plan indicated a problem/need regarding potential/actual impairment to skin integrity that may affect tissue perfusion, ileostomy status, anemia, nail dystrophy. Approaches to this need included assistance with routine toileting as needed and check routinely for incontinence and provide incontinent care as needed, notify nurse of redness or irritation. A current, 4/21/26, care plan indicated a problem/need regarding a diagnosis of anxiety with a history of symptoms such as increase in heart rate, racing thoughts, thinking about the same thing without being able to shift focus. A current, 4/21/26, care plan indicated a problem/need regarding depression with a history of symptoms such as tearfulness, sadness, and isolation. A current, September 2022, facility policy titled, Identifying Types of Abuse, provided by the DON via email on 5/21/26 at 10:48 a.m., indicated the following: Neglect/Deprivation of Goods and Services by Staff.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Mental and Verbal Abuse.Examples of mental and verbal abuse include, but are not limited to:.threatening residents, including but not limited to, depriving a resident of care. The following situation are recognized as those that are likely to cause psychosocial harm.When facility staff as punishment, threaten to.withhold care from the resident. A current, Indiana Department of Health Policy, titled Long-Term Care Abuse and Incident Reporting Policy, effective date: 12/8/22-9/1/27, provided by the DON via email on 5/21/26 at 10:48 a.m., and identified as a facility policy indicated: Alleged violation: Alleged violation is a situation or occurrence that is observed or reported by staff.but has not yet been investigated and if verified, could be noncompliance with the federal requirements.Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Choose not to do it or acknowledge the request. Abuse and incidents will be reported and submitted to the Indiana Department of Health in compliance with federal and/or state rules and regulations.Ensure that all alleged violations involving abuse, neglect.are reported immediately, but no later than two hours after the allegation is made. Instructions For Submitting an Incident Report:.h. Immediate action taken to respond to the event and protect the resident. i. Preventative measures taken while the investigation is in progress.410 IAC (Indiana Administrative Code) 16.2-3.1 -28(d)410 IAC 16.2-3.1-28 (e)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were informed of and given notice of transfer/discharge and bed hold documents for 2 of 4 residents reviewed for hospitalization. (Residents 26 and 42) Findings include: 1.Resident 42's record was reviewed on 3/19/26 at 9:10 a.m. Medical diagnoses included alcohol dependence, anxiety, and traumatic brain injury.A 10/7/25 social service note indicated the resident was transported to a neuropsychiatric hospital at 4:50 p.m. A notice of transfer/discharge was not signed by the resident or representative.A 2/5/26 social service note indicated the resident was transported to a neuropsychiatric hospital at 3:01 a.m. A notice of transfer/discharge was not signed by the resident or representative.A 3/5/26 nurse's note indicated resident 42 was transported to a neuropsychiatric hospital at 8:12 p.m. The record lacked a notice of transfer/discharge and bed hold policy for this date.The record lacked resident and/or representative notification regarding notice of transfer/discharge and bed hold policy.2.Resident 26's record was reviewed on 3/19/26 at 9:56 a.m. Medical diagnoses included dementia, insomnia, and hypertension.A 2/23/26 social service note indicated the resident was sent to an inpatient psychiatric hospital at 3:46 a.m. A notice of transfer/discharge and bed hold policy was not signed by the resident or representative.During an interview, on 5/21/26 at 9:32 a.m., QMA 15 indicated when a resident was sent to the hospital, a medication list and bed hold policy was given to the emergency medical technicians (EMTs). She could not recall if the documents needed to be given to a resident or representative.During a 5/21/26 interview at 10:06 a.m., LPN 16 indicated residents were sent to an outside hospital with a medication list and bed hold policy. This paperwork was given to the EMTs. She could not recall if the documents needed to be given to the resident or representative.During an interview, on 5/21/26 at 10:07 a.m., the Social Services Director indicated nursing staff were supposed to send residents to the hospital with a medication list, notice of transfer/discharge, and bed hold policy. The paperwork was given to the EMTs and a copy placed in the medical records office. Family and resident representatives were notified of the transfer.An Indiana State Form 49669 titled Notice of Transfer and Discharge, provided by the DON via email on 5/20/26 at 3:53 p.m. and identified as the form used by the facility for resident transfers and discharges indicated as follows: .A transfer and discharge notice must include the effective date, where the resident was to be discharged to, the reason for transfer or discharge, and the resident's appeal rights .410 Indiana Administrative Code 16.2-3.1-12(a)(6)(A)

A. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control measures regarding contact isolation during insulin administration for 1 of 10 residents reviewed for medication administration. (Resident 11)B. Based on observation and interview, the facility failed to utilize infection prevention and control measures while handling medications with bare hands for 1 of 10 residents reviewed for medication administration. (Resident 36)C. Based on observation and interview, the facility failed to utilize infection prevention and control measures regarding enhanced barrier precautions (EBP) during catheter care for 1 of 3 residents reviewed for enhanced barrier precautions. (Resident 1)Findings include: A. During an observation, on 5/17/26 at 11:46 a.m., LPN 3 entered Resident 11's contact isolation room wearing only gloves and obtained the resident's blood glucose. She doffed her gloves, returned the glucometer to a barrier on the medication cart in the hallway, and performed hand hygiene. LPN 3 prepared the resident's insulin, donned gloves, and re-entered the resident's contact isolation room without a gown. She leaned in against the resident's bed sheets with her pant leg, cleansed the skin of the resident's right upper arm, and administered the insulin. The contact isolation sign above the resident's bed indicated everyone must don a gown and gloves prior to entry to the resident's room. During an interview, on 5/17/26 at 1:46 p.m., LPN 3 indicated Resident 11 was in contact isolation due to a MRSA (Methicillin-resistant Staphylococcus aureus) wound infection. The resident's right lateral foot wound required a wound VAC (vacuum-assisted closure for wound healing). She believed the contact isolation should have been followed during wound care instead of insulin administration. On 5/17/26 at 2:08 p.m., LPN 3 indicated she found out personal protective equipment for contact isolation rooms must be donned prior to entering the resident's room and providing care. Resident 11's clinical record was reviewed on 5/17/26 at 2:37 p.m. Diagnoses included type 2 diabetes mellitus with foot ulcer. Current orders included contact barrier precautions every shift for right lateral foot wound drainage (3/30/26). Discontinued orders included doxycycline hyclate (broad spectrum antibiotic)100 mg tablet twice daily for MRSA for 28 administrations (2/26/26). A current care plan, initiated 11/3/25, indicated the resident had a right foot diabetic foot ulcer with enhanced barrier precautions. Interventions included a wound vac to the right foot (3/26/26). The care plan was last revised on 3/26/26. The comprehensive care plan lacked revisions related to a MRSA wound infection with contact isolation. A progress note, dated 5/17/26 at 8:46 a.m., indicated the resident remained on contact isolation with a wound vac to the right foot. The wound vac had foul odorous drainage suctioned into the canister. During an interview, on 5/17/26 at 4:01 p.m., the DON indicated Resident 11 was in contact isolation due to a MRSA wound infection. Staff were required to don a gown and gloves prior to entering residents' rooms with contact isolation. On 5/17/26 at 4:35 p.m., the DON indicated Resident 11's comprehensive care plan should have been updated with contact isolation precautions related to the MRSA wound infection. A current facility policy, revised 4/2019, titled Administering Medications, provided by the DON on 5/17/26 at 4:24 p.m., indicated the following: Policy Statement. Medications are administered in a safe and timely manner, and as prescribed. 25. Staff follows established facility infection control procedures (e.g. isolation precautions, etc.) for the administration of medications, as applicable. B1. During an observation, on 5/17/26 at 1:01 p.m., LPN 4 opened the drawers to the East Unit medication cart and popped Resident 36's medications into a medication cup without performing hand hygiene. The medications included quetiapine fumarate (schizophrenia) 25 mg half a tablet, buspirone (anxiety) 15 mg one tablet, ropinirole (Parkinson's disease) 0.25 mg one tablet, and divalproex sodium (seizures) delayed release oral capsule 125 mg four capsules. LPN 4 removed the quetiapine fumarate from the medication cup with her bare fingers and placed it into the vanilla pudding. She crushed the buspirone and ropinirole and placed it into the pudding. LPN 4 used her bare hands to open the four quetiapine fumarate capsules and poured the contents into the pudding. The contaminated medications were administered to Resident 36 on 5/17/26 at 1:05 p.m. Resident 36's clinical record was reviewed on 5/17/26 at 3:38 p.m. Diagnoses included Parkinson's disease, paranoid schizophrenia, general anxiety disorder, major depressive disorder, and mood disorder due to known physiological condition with manic features. Current orders included quetiapine fumarate 25 mg give 0.5 tablet in the afternoon (2/28/26), divalproex sodium delayed release 125 mg give four capsules by mouth three times a day (2/28/26), ropinirole hydrochloride 0.25 mg three time a day (8/24/24), and buspirone hydrochloride 15 mg three times a day. During an interview, on 5/17/26 at 3:26 p.m., LPN 4 indicated she should not have handled medications with her bare hands due to cross contamination. On 5/17/26 at 4:01 p.m., the DON indicated staff should not handle medications with their bare hands. A current facility policy, revised 4/2019, titled Administering Medications, provided by the DON on 5/17/26 at 4:24 p.m., indicated the following: Policy Statement. Medications are administered in a safe and timely manner, and as prescribed. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. C. During a general facility observation, on 5/20/26 at 1:09 p.m., Resident 1 was resting in a low bed. An EBP sign on the resident's door read as follows: EVERYONE MUST: clean their hands including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. During a catheter care observation, on 5/21/26 at 10:20 a.m., CNA 14 entered Resident 1's room wearing gloves. CNA 14 opened the spout of Resident 1's catheter collection bag and emptied the urine into a graduated cylinder. Hand hygiene was performed and the resident's blankets were adjusted. During an interview concurrent with the observation, the Infection Preventionist (IP) and CNA 14 indicated that a gown was supposed to be worn during high contact care for residents on enhanced barrier precautions. A current facility policy titled Enhanced Barrier Precautions, revised December 2024, and provided by the DON on 5/17/26 at 4:24 p.m. indicated the following: .1.Enhance barrier precautions (EBPs refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organism (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained.5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies.6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharged from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen 7. EBPS employ targets gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing high contact resident care activities (as opposed to before entering the room).8 Examples of high-contact resident care activities required the use of gown and gloves for EBPs include: .i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).16. Staff are trained prior to caring for residents on EBPs. 17. Signs are posted on the door or wall outside the resident's rooms which communicate the type of precautions and PPE required. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a) 410 IAC 16.2-3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure the Indiana Department of Health Annual Survey Report was readily available for review for residents and visitors without requiring to request the report from a staff member. Findings include:During a Resident Group Interview, on 5/19/26 at 9:55 a.m., the residents indicated they did not know where the Indiana Depart of Health Survey Report was available for review. Two residents indicated they would like to review the annual survey report and did not know where it was located.During an observation, on 5/19/26 at 10:40 a.m., a framed sign posted on the wall by the entrance/exit front doors adjacent to the nurses station, approximately 8 inches by 10 inches, had multiple lines of information listed. The sign was posted over 6 feet high. The last line of posted information indicated the Annual Survey results were available at the nurse's desk.During an interview and observation, on 5/19/26 at 10:46 a.m., LPN 3 indicated she believed the Indiana Depart of Health Annual Survey Report binder was located somewhere behind the nurse's station/desk. She looked around the area and found the binder located under the nurse's desk. She indicated residents and guests were not allowed behind the nurse's desk. They would need to ask a staff member for the report binder and the staff member would have to obtain the binder for them. During an interview and observation, on 5/21/26 at 9:25 a.m., QMA 12 indicated the Annual Survey Binder was located behind the nurse's station behind the desk. She looked around her surroundings and located the binder. She indicated residents, their representatives, and guests could not go behind the nurse's desk. They could not access the survey binder for themselves. They would have to have an employee obtain the survey binder for them. During an interview and observation, on 5/21/26 at 9:27 a.m., the Administrator indicated the Indiana Department of Health Annual Survey Report Binder was located behind the nurse's desk at the nurse's station. He walked behind the desk. He looked at a bookshelf under the desk, taking a few moments to locate the binder. He indicated residents, their representatives, and guests were not allowed behind the nurse's station and would have to request a staff member obtain the survey binder for their review. He also indicated the sign regarding the location of the survey binder was located about 6 feet high and could be difficult for individuals in wheelchairs to read. A current, October 2025, facility policy titled, Resident Rights, provided by the DON via email indicated the following: Federal and state laws guarantee certain basic rights to all residents. the resident's right to.w. examine survey results; State rules: 410 IAC (Indiana Administrative Code) 16.2-3.1(b)(2)

Based on observation and interview, the facility failed to ensure daily staff posting was readily accessible and visible to residents and visitors for 5 of 5 days reviewed for staff posting. Findings include: During a general facility observation on 5/17/26 at 10:18 a.m. the daily staff posting was framed on a wall behind the nurse's station and located such that it could not be read without entering the nurse's station.During a general facility observation on 5/18/26 at 10:10 a.m. the daily staff posting was framed on a wall behind the nurse's station and located such that it could not be read without entering the nurse's station.During a general facility observation on 5/19/26 at 8:03 a.m. the daily staff posting was framed on a wall behind the nurse's station and located such that it could not be read without entering the nurse's station.During a general facility observation on 5/20/26 at 8:34 a.m. the daily staff posting was framed on a wall behind the nurse's station and located such that it could not be read without entering the nurse's station.During a general facility observation on 5/21/26 at 8:58 a.m. the daily staff posting was framed on a wall behind the nurse's station and located such that it could not be read without entering the nurse's station.During an interview, on 5/20/26 at 8:29 a.m., QMA 15 indicated she was unable to read the daily staff posting from her position at the medication cart in front of the nurse's station (approximately eight (8) feet from the wall where the staff posting was affixed).During an interview, on 5/20/26 at 9:28 a.m., LPN 3 indicated she was unable to read the daily staff posting from her position in front of the nurse's station. (approximately eight (8) feet from the wall where the staff posting was affixed).During an interview, on 5/20/26 at 10:17 a.m., QMA 12 indicated she was unable to read the daily staff posting from her position in front of the nurse's station. (approximately eight (8) feet from the wall where the staff posting was affixed).During an interview, on 5/21/26 at 9:32 a.m., the Administrator indicated he was unable to read the daily staff posting from his position in front of the nurse's station (approximately eight (8) feet from the wall where the staff posting was affixed). He indicated residents and visitors were not allowed to go behind the desk in the nurse's station to read the daily staff posting.A current facility policy, titled, Posting Direct Care Daily Staff Numbers, revised August 2022, provided by the DON on 5/21/26 at 10:41 a.m., indicated the following: .1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.4. The form may by typed or handwritten. If completed electronically, the recorded information will be a minimum font size of 12 points. If the information is handwritten, it must be legibly printed in black ink and written so that staffing data can be easily seen and read by residents, staff, visitors, or others who are interested in our facility's daily staffing information.

Based on record review and interview, the facility failed to protect a resident's right to be treated with respect and dignity when a staff member made a derogatory statement about the resident within hearing distance of the resident for 1 of 3 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 3/20/26, prior to the start of survey, and was therefore past noncompliance. Findings include:Resident B's clinical record was reviewed on 3/30/26 at 1:06 p.m. Diagnoses included moderate dementia in other diseases classified elsewhere with mood disturbance and cognitive communication deficit.An 11/11/25, admission, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. A progress note, dated 2/23/26 at 3:00 p.m., indicated, on 2/20/26, a staff member made an inappropriate statement to a staff member about Resident B and in front of Resident B. The resident stated he did not hear the statement made and denied any psychosocial distress. A current care plan, dated 2/23/26, indicated the resident was at risk for psychosocial well-being problem related to an inappropriate statement made to another staff member in front of the resident. Interventions included removal of the resident to a calm safe environment allowing the resident to share feelings when conflict arises (2/23/26).During an interview on 3/31/26 at 10:12 a.m., QMA 4 indicated, on 2/20/26, she was at the nurses station and holding Resident B's hand when CNA 3 came from behind QMA 4. When CNA 3 was near the edge of the nurse station, CNA 3 told QMA 4 she should probably bleach her hands because she was holding Resident B's hand. This was said in front of Resident B, who was next to QMA 4. QMA 4 felt the statement was disrespectful and undignified. Resident B was cognitively impaired and may not have been able to process what CNA 3 said in front of him. Resident B was talking to QMA 4 when the statement was made, but it was said within distance that the resident could have heard it. If Resident B was cognitively intact, the statement would have hurt Resident B's feelings. QMA 4 reported the information to the Business Office Manager, DON, and the Administrator immediately. CNA 3 was removed from duty.On 3/31/26 at 1:16 p.m., CNA 3 indicated she walked up to the nurse's station on 2/20/26 and Resident B was touching QMA 4's hands and arms. CNA 3 muttered to QMA 4 that she would use bleach wipes after that. She meant after Resident B had his hands touching QMA 4. She did not intend for Resident B to hear what was said, but the resident was within hearing distance when she said it. CNA 3 was not sure if Resident B heard what was said, but he was next to QMA 4. CNA 3 did not believe her statement was humiliating or demeaning. CNA 3 was notified her employment was terminated for verbal abuse to the resident.On 3/31/26 at 2:19 p.m., the DON indicated she was notified on 2/20/26 in the morning before lunch about CNA 3 making a remark to QMA 4, who was holding Resident B's hand, that QMA 3 would wash her hands in bleach if she were QMA 4. The remark was made while in the presence of Resident B and had the potential to hurt Resident B's feelings. This should not have been said at all, and specifically not in the presence of the resident.On 3/31/26 at 3:07 p.m., the Administrator indicated Resident B was cognitively impaired. The DON obtained a statement from CNA 3. He believed the statement was disrespectful, undignified, and a form of verbal abuse. The facility had ongoing abuse education every month for all staff. They also included abuse in their quality assurance performance improvement plan.On 3/31/26 at 3:30 p.m., the Administrator indicated the facility was specifically working on respect, dignity, and deescalation techniques in their Crisis Prevention Verbal Interventions Training. The first group of eight management staff received the training on 3/20/26. The next classes for CNAs, QMAs, and Nurses were scheduled for 4/8/26 and 4/9/26. Ancillary staff would receive the same training after all the clinical staff have completed the training.A facility reported incident submitted to Indiana Department of Health, on 2/20/26 at 11:30 a.m., indicated it was reported to the Administrator that a CNA made an inappropriate statement about Resident B to a staff member in front of the resident. No injury was noted. Immediate action taken: On 2/20/26 the Administrator, DON, physician, family and police were notified. The staff member involved was suspended pending investigation. Preventative measures taken: On 2/20/26 an investigation was initiated, statements were received, and interviews were completed. Social services were to provide psychosocial monitoring. The plan of care was reviewed and updated as needed. Follow up added: On 2/24/26 the facility investigation was completed. The allegation was substantiated and the staff member involved was terminated. Interviews were completed and no other residents were involved. Psychosocial monitoring will be provided as needed. The physician and family were notified.A facility investigation provided by the DON on 3/30/26 at 1:01 p.m. included the following:A handwritten interview with CNA 3 indicated she told another staff member in front of the resident that she would wash her hands probably with bleach after holding the resident's hand. The facility incident report regarding a staff to resident abuse incident on 2/20/26Resident B's updated care plan.On 2/23/26, thirty-seven resident questionnaires regarding abuse were conducted. No abuse concerns were identified.A facility abuse in-service sign-in sheet, dated 3/18/26, contained 58 signatures.Quality Assurance Performance Improvement Minutes, dated 3/31/26, indicated the facility was continuing Crisis Prevention Verbal Intervention Training for nurses and aides scheduled for 4/8/26 and 4/9/26. A facility document, dated 3/6/19, titled Resident rights, provided by the DON on 3/31/26 at 1:58 p.m., indicated the following: .(a) The resident has a right to a dignified existence. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The deficient practice was corrected by 3/20/26 after the facility implemented a systemic plan that included a facility in-service regarding abuse on 3/18/26 and Crisis Prevention Verbal Intervention training started on 3/20/26.This citation relates to Intake 2779920.410 Indiana Administrative Code (IAC) 16.2-3.1-3(a)

Based on interview and record review the facility failed to report an allegation of abuse involving a housekeeper (Housekeeper 6) kissing a resident (Resident E) and messaging the resident on a social media platform for 1 of 3 reportable events reviewed. Findings include:An anonymous report submitted to the Indiana Department of Health indicated a staff member was having an affair with a resident and facility management failed to act upon the allegation. During an interview on 2/19/26 at 3:24 p.m., the Administrator indicated while CNA 7 was assisting Resident E with a shower, Resident E told CNA 7 that she and Housekeeper 6 had kissed. CNA 7 reported the allegation to management as the Administrator was not in the building at the time. The Administrator called the Housekeeping Supervisor and told her to suspend Housekeeper 6. The Administrator handled the incident as a reportable, he suspended Housekeeper 6, investigated the allegation and interviewed other residents. Housekeeper 6 denied the allegation of kissing Resident E but admitted that he and Resident E messaged each other on a social media platform. When Resident E was first interviewed about the allegation, she confirmed that she had kissed Housekeeper 6 then in a follow up interview Resident E recanted the statement and indicated she made it up to get closer to Housekeeper 6. The Administrator indicated that he did not report the allegation to the state agency due to the statement made by Resident E was not truthful.The Administrator provided the investigation related to Housekeeper 6 and Resident E on 2/19/26 at 3:55 p.m. The investigation included the following statements:A written statement by CNA 7 dated 11/11/25 indicated while assisting Resident E with a shower, Resident E confided in her that she had been upset over the weekend, but Housekeeper 6 made her feel way better. Resident E asked CNA 7 not to tell anyone because she didn't want to get anyone in trouble. Resident E indicated when she was sad, Housekeeper 6 asked what he could do to make her feel better and Resident E said a kiss, so Housekeeper 6 kissed her on the lips three times. After the shower she reported it to the Infection Prevention Nurse.A typed statement dated 11/11/25 indicated it was brought to the Infection Prevention Nurse and the Business Office Manager's attention that Housekeeper 6 had been in Resident E's room, and kissed Resident E. When Resident E was questioned about the interaction, she indicated the kiss was wanted and she didn't want to get Housekeeper 6 into trouble. The interaction had been going on for about a week, and they had been messaging back and forth through a social media platform. A current facility policy titled Care Strategies Abuse and Prevention Policy, and provided by the DON on 2/20/26 at 12:11 p.m. indicated the following: .7. Reporting/Response: a. The facility will ensure that alleged violations involving .or abuse .are reported immediately to the Administrator of the facility or his/her designee. When required by law or regulation, the facility shall ensure timely notification to the Department of Health This citation relates to Intake 2730891. 3.1-28(c)

Based on record review and interview, the facility failed to protect a resident's right to be free from verbal abuse (Resident D) by a staff member (Activity Assistant 1) for 1 of 3 residents reviewed for abuse.Findings include:Resident D'S clinical record was reviewed on 12/18/25 at 2:19 p.m. Diagnoses included schizophrenia, chronic pneumothorax muscle wasting and atrophy, and depressive disorder.Review of the most current quarterly Minimum Data Set assessment, dated 12/2/25, indicated the resident refused care daily.A facility reported incident, dated 10/4/25, indicated Activity Assistant 1 and Resident D had a verbal altercation.Review of the facility's investigation indicated the following:Housekeeper 2's written statement, dated 10/4/25, indicated Resident D called Activity Assistant 1 a dumb a**. Activity Assistant 1 responded with, You can't breathe and chooses to sit in between 2 smokers. So [sic] who's [sic] the dumba**? Activity Assistant 1 continued with, I treat people the way I want to be treated. Treat me with disrespect, I treat you with disrespect.Activity Assistant 1's undated written statement indicated Resident D called her a dumba** after she told him not to sit there and complain about the cigarette smoke. Activity Assistant 1 then indicated she called the resident a dumba**. Activity Assistant 1 was not available for interview during the survey.Resident D declined interview during the survey. During an interview on 12/18/25 at 1:29 p.m., the Housekeeping Supervisor indicated, on 10/4/25, Housekeeper 2 reported Resident D told Activity Assistant 1 that he was given his cigarette last on purpose was upset and called Activity Assistant 1 a dumba**. The Activity Assistant responded, You are the one out here on oxygen with a bunch of smokers.and I am the dumba**? Abuse education was completed routinely during orientation, was part of the computer education program, and reviewed during all staff meetings.During an interview on 12/18/25 at 1:44 p.m., Housekeeper 2 indicated he and Activity Assistant 1 were outside with the residents for a smoke break. While on the smoke break, Activity Assistant 1 and Resident D got into it. Resident D was upset because he did not get his cigarette lit at the time he wanted and called Activity Assistant 1 a dumba**. Activity Assistant 1 responded with, You are outside smoking and you can't breathe. So, who is really the dumba**? Housekeeper 2 thought the Activity Assistant was going to continue arguing with the resident but stopped herself and said, Let me stop before you can't breathe anymore. Housekeeper 2 indicated the facility provided abuse education on the computer and they also review it in the all-staff meetings. During an interview on 12/18/25 at 1:51 p.m., Housekeeper 9 indicated the facility provided abuse education at least monthly.During an interview on 12/18/25 at 2:07 p.m., CNA 8 indicated the facility provided abuse education at least monthly.During an interview on 12/18/25 at 2:12, BCS (Behavioral Care Specialist) 7 indicated the facility provided abuse education at least monthly.A current policy, dated 5/2024, titled Abuse Prevention, Identification, and Reporting Policy was proved by the SSD on 12/19/25. The policy indicated the following: . DEFINITIONS .10. Mistreatment: Mistreatment means inappropriate treatment or exploitation of a resident.15. Verbal Abuse: Verbal abuse may be considered a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds to residents within hearing distance, regardless of age, ability to comprehend or disability.This citation is related to Intake 2635017.3.1-27(b)

Based on record review and interview, the facility failed to ensure a cognitively impaired resident was free from staff-to-resident verbal abuse for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes:Resident B's clinical record was reviewed on 9/25/25 at 11:49 a.m. Diagnoses included Asperger's syndrome, unspecified altered mental status, malignant neoplasm of parotid gland, and generalized anxiety disorder. An 8/26/25, significant change Minimum Data Set (MDS) assessment indicated Resident B was severely cognitively impaired. Behaviors included other behavioral symptoms not directed towards others and rejection of care. The resident quired substantial staff assistance for oral hygiene, toileting hygiene, bathing, upper and lower body dressing, and footwear assistance. He required set-up assistance from staff for ambulation and transfers. Resident B's current care plans included the following:A 6/7/23 problem of impaired safety awareness related to Asperger's syndrome. Interventions included calling family as/if needed.A 9/2/25 problem of potential for psychosocial wellbeing related to an allegation with staff. Interventions included allow the resident time to answer questions and verbalize feelings, perceptions and fears (9/2/25), observe/document the resident's usual response to problems: external- expects others to control problems or leaves to fate or luck, internal - how individual makes own changes(9/2/25), when conflict arises, move residents to a calm safe environment and allow the resident to share their feelings (9/2/25).A progress note, dated 9/2/25 at 11:31 a.m., indicated a maintenance staff member had a verbal altercation with Resident B on 8/29/25. The resident continued to deny any distress and continued with his daily routine. Review of a facility reported incident, dated 8/29/25 at 10:01 a.m. indicated the following: Description added On 8/29/25 it was reported to the Administrator that Resident B was in a verbal altercation with a maintenance staff member. No injury was noted. Follow up indicated the investigation was completed. The allegation was substantiated, and the involved staff member was terminated from employment.A review of the facility investigation file, provided by the facility after entrance on 8/25/25, contained the following information:A handwritten statement from QMA 2, dated 8/29/25 at 7:00 a.m., indicated QMA 2 was at the medication cart and Resident B was seated in the chair next to the door. Resident B was doing his repetitive verbalizations with multiple questions, stood up and reached out towards QMA 2 with open arms and palms. QMA 2 was in the process of redirecting Resident B by putting her arm up in a halting position, explained that it was inappropriate behavior, and he needed to sit down. Before QMA 2 could finish redirecting Resident B, the Maintenance Assistant 4 came from behind QMA 2 and got close to Resident B. Resident B then told Maintenance Assistant 4 to shut up. Maintenance Assistant 4 responded to Resident B by telling him to shut up. Maintenance Assistant 4 then told Resident B to touch me. The resident moved towards the Maintenance staff member then with open arms and palms open and extended. Maintenance Assistant 4 then told Resident B, If you touch me, I will put you on the ground. The resident understood it was a threat and quickly left. Maintenance Assistant 4 then turned to QMA 2 and said, See? He's smarter than that. He does his thing and then mouths off. He spoke poorly of Resident 8 in front of QMA 2 and other staff. A handwritten statement from LPN 3, dated 8/29/25, indicated Resident B was in the front lobby at approximately 6:40 a.m. Maintenance Assistant 4 was also in the front lobby and was provoking Resident 8 to approach Maintenance Assistant 4. When Resident B did approach Maintenance Assistant 4, Maintenance Assistant 4 told the resident, If you put your hands on me, I'll lay you on the floor. The resident told Maintenance Assistant 4 to shut up and Maintenance Assistant 4 told the resident to shut up. Resident 8 was removed from the situation and sat in the chair in the lobby with staff supervision before being taken to shower. A typed statement, dated 8/29/25, indicated the Maintenance Assistant 4 reported he was doing his early morning check at the facility. Resident B had the nurse cornered in the building and was grabbing her butt and breast. Maintenance Assistant 4 stepped in to intervene and asked the resident to stop. The resident made a step towards Maintenance Assistant 4 and Maintenance Assistant 4 stated, Don't come any closer or I will put you on the floor. Maintenance Assistant 4 felt the nurse was distressed and needed his intervention. Maintenance Assistant 4 stated he knew he should not have said that as soon as it came out of his mouth.A Termination Documentation Form, dated 8/29/25, indicated Maintenance Assistant 4 was terminated upon conclusion of an investigation regarding a verbal altercation with a resident.During an interview on 9/25/25 at 1:48 p.m., LPN 3 indicated she was at the nurse's station by the computer on the morning of 8/29/25 and witnessed the verbal altercation between Resident B and Maintenance Assistant 4. Resident B was up and as usual with his repetitive verbalizations near the medication cart in front of the nurse's station where QMA 2 was standing. Maintenance Assistant 4 started getting on Resident B to not touch QMA 2. No physical contact was made, but Maintenance Assistant 4 was antagonizing Resident B. Maintenance Assistant 4 dared the resident to come at him and threatened the resident to lay him out on the ground if the resident put his hands on Maintenance Assistant 4. Both Resident B and Maintenance Assistant 4 told each other to shut up. LPN 3 jumped up from the nurse's station and started around the corner, but QMA 2 had placed herself in between to remove the resident from Maintenance Assistant 4. Resident B then walked away. Maintenance Assistant 4 was at the nurse's station desk and said, I can't stand Resident B. He never used to be like that, and he knows what he is doing. Then Maintenance Assistant 4 left the building. LPN 3 indicated the witnessed intimidation and threatening statements from Maintenance Assistant 4 to Resident B was verbal/mental abuse. She had never seen Maintenance Assistant 4 be abusive to any residents prior to this, but Maintenance Assistant 4 seemed uncomfortable when he came into the building.During a telephone interview on 9/25/25 at 2:57 p.m., Maintenance Assistant 4 indicated on 8/29/25 he was at the nurse's desk in the morning and Resident B, who spits and scratches himself, was getting aggressive with the QMA. Maintenance Assistant 4 told Resident 8 to stop and leave the QMA alone, then the resident started coming toward him. He told the resident to get away from him as he did not want to deal with him on that day. He said, Resident B knows what he is doing if he can ask for milk and cookies. He told the resident, We will end up being on the ground. He was suspended pending an investigation. Administration called him a little later and told him they watched the video surveillance, and he was being terminated for being verbally abusive to a resident. He indicated what he said was inappropriate. According to his facility education, it was abusive to humiliate, intimidate, or threaten the residents.During a telephone interview, on 9/26/25 at 8:23 a.m., QMA 2 indicated she witnessed a verbal altercation between Maintenance Assistant 4 and Resident B early in the morning on 8/29/25. Resident B had a lot of repetitive vocalizations which was his usual. Due to cognitive impairments, Resident B did not recognize personal space, but he did not mean any harm. The resident required frequent redirection throughout every day. She was preparing medications that morning and Resident B was asking repetitively for water and if he could go outside while standing near QMA 2. Maintenance Assistant 4 walked in and walked between her and Resident B. She did not recall what was said prior, but Maintenance Assistant 4 told Resident 8 to come at him in a provoking manner. Resident B started towards Maintenance Assistant 4 because the resident does not understand a lot of things. Then Maintenance Assistant 4 took a step forward and told the resident he would put him on the floor. When Maintenance Assistant 4 threatened to put the resident on the floor, the resident turned and went away from Maintenance Assistant 4. Then Maintenance Assistant 4 turned to QMA 2 and said, Sometimes you just have to put them in their place. QMA 2 and LPN 4 discussed that they needed to report the incident immediately to the Administrator. QMA 2 remained near the front door to ensure Maintenance Assistant 4 did not return to the building while LPN 3 called and notified the Administrator. On 9/26/25 at 11:33 a.m., the Administrator indicated LPN 3 notified him via telephone on 8/29/25 a little before 7:00 a.m. about a verbal altercation between Resident B and Maintenance Assistant 4. He was aware Maintenance Assistant 4 had left the building, so he called corporate human resources and notified them that Maintenance Assistant 4, who worked between two sister facilities, needed suspended immediately pending an investigation. The investigation outcome was termination of Maintenance Assistant 4 due to verbal abuse to a resident.A current facility policy, revised 5/2024 and titled Abuse Prevention, Identification, and Reporting Policy, provided by the DON on 9/25/25 at 11:15 a.m., indicated the following: Policy: To establish guidelines for preventing, identifying, and reporting abuse. All residents have the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.This citation relates to Intake 2603715.3.1-27(b)

Based on interview and record review, the facility failed to ensure a Registered Nurse was present in the facility for 8 hours during a 24-hour period for 25 days of the 2nd Quarter of 2025 reviewed for sufficient staffing. This deficiency had the potential to affect 39 of 39 residents residing in the facility.Findings include: A Payroll-Based Journal (PBJ) Staffing report, for the second quarter of 2025, indicated the facility failed to have Registered Nurse coverage for 1/3, 1/6, 1/9, 1/10, 1/11, 1/12, 1/17, 1/20, 1/23, 1/24, 1/25, 1/26, 1/27, 1/31, 2/3, 2/6, 2/7, 2/8, 2/9, 3/8, 3/9, 3/23, 3/29, and 3/30. During an interview, on 8/21/25 at 10:00 a.m., the Administrator indicated he was aware the facility had issues with staffing RNs in January, February, and March of 2025. He ran the clock-in/clock-out reports every Monday and sent them to the corporate office where they were reviewed and sent in to report the RN hours. He indicated the situation was resolved as the facility now had multiple RNs on staff to ensure the 8 hours of RN coverage. QMA 9 was responsible for scheduling in the facility. During an interview, on 8/21/25 at 1:30 p.m., the DON indicated she utilized the clock-in/clock-out process for her scheduled shifts. She usually worked during the day from 9:00 a.m.- 5:00 p.m., but often worked later and covered other shifts as needed. She was usually the RN coverage contact person and available by telephone at all times. QMA 9 was responsible for the scheduling of the facility staff. The situation was resolved as there are more RNs on staff now to cover the RN hours needed. During an interview, on 8/21/25 at 1:45 p.m., QMA 9 indicated she was responsible for the scheduling of the facility and tried to ensure there was 8 hours of RN coverage daily. She made multiple attempts to fill the RN hours through the company messaging system and calling the sister facilities to gain access to additional RNs. This situation was resolved since the facility hired more staff to cover the daily RN hours. A record review, on 8/22/25 at 10:26 a.m. of the facility clock-in/clock-out reports indicated there was no RN coverage for 1/3, 1/6, 1/9, 1/10, 1/11, 1/12, 1/17, 1/20, 1/23, 1/24, 1/25, 1/26, 1/27, 1/31, 2/3, 2/6, 2/7, 2/8, 2/9, 3/8, 3/9, 3/23, 3/29, and 3/30. A facility policy, revised 8/06, titled, Department Duty Hours, Nursing Services, provided by the DON on 8/22/25 at 12:47 p.m., indicated the following: 1. Nursing service is provided twenty-four (24) hours per day, seven days a week. The requirements for long term care facilities require that a skilled nursing facility provided 24- hours licensed nursing services, and RN for 8 consecutive hours per day, 7 days a week . 3.1-17(b)(3)

Based on record review and interview, the facility failed to ensure licensed nursing coverage 24-hour basis for 11 days of the second (2nd) quarter of 2025 reviewed for sufficient staffing. This deficiency had the potential to affect 39 of 39 residents residing in the facility.Finding includes: A Payroll-Based Journal (PBJ) Staffing report, for the second quarter of 2025, indicated the facility failed to ensure Licensed Nursing Coverage 24/7 on the following dates: 1/6, 1/11, 1/13, 2/6, 2/7, 2/8, 2/9, 2/10, 2/17, 2/20, and 3/30.Review of the current Facility Assessment, on 8/20/25 at 9:37 a.m., updated 8/1/25, the resident acuity (the level of care and supervision) affecting licensed nurses was as follows: Respiratory treatments for 3 residents, Behavioral/Mental health for 39 residents, Medication Administration for 39 residents, Hospice Care for 1 resident, and Wound Care for 2 residents. The facility overall staffing needs indicated 2 Registered Nurses (RNs) providing direct care and 4 Licensed Practical Nurses (LPNs) providing direct care. The facility available staff were documented as 4 RNs available to provide direct care, 4 LPNs available to provide direct care, and 3 Qualified Medication Aides (QMAs).During an interview, on 8/21/25 at 10:00 a.m., the Administrator indicated he was aware the facility had issues with licensed nurse staffing in January, February, and March of 2025. He ran the clock-in/clock-out reports every Monday and sent them to the corporate office, where they were reviewed and sent in to report the licensed nurse coverage hours. He indicated the situation was resolved, as the facility had been able to hire more nursing staff. QMA 9 was responsible for scheduling in the facility. During an interview, on 8/21/25 at 1:45 p.m., QMA 9 indicated she was responsible for the scheduling of the facility and tried to ensure there was licensed nurse coverage 24 hours a day. She made multiple attempts to fill the nursing hours through the company messaging system and called sister facilities to gain access to additional staff. This situation was resolved since the facility hired more staff to cover the continuous licensed nurse hours.During an interview, on 8/22/25 at 1:57 p.m., the DON indicated she was not aware of any shift without and LPN or RN on staff. She started her role as DON on 1/1/25. The nursing staff worked either 8 or 12 hour shifts. She usually worked during the day from 9:00 a.m.- 5:00 p.m., but often worked later and covered other shifts as needed. She was usually the RN coverage contact person and available by telephone 24/7. She indicated she would not be able to verify which staff members were working on the days listed in the PBJ report as she did not have access to the clock- in/clock-out reports. A record review, on 8/22/25 at 2:38 p.m., of the clock-in/clock- out reports, provided by the Business Office Manager (BOM), indicated the following days/times lacked 24/7 licensed nurse coverage: 1/6/25: 6:00 a.m. - 9:51 a.m., 2:39 p.m.- 9:48 p.m., and 1:28 a.m.- 6:00 a.m. 1/11/25: 6:00 a.m.- 9:57 a.m., 2:51 p.m.- 10:00 p.m., and 10:00 p.m.- 6:00 a.m.1/13/25: 6:00 a.m.- 7:53 a.m. and 5:48 p.m. - 7:37 p.m. 2/6/25: 6:00 a.m.- 6:15 a.m., 6:46 p.m.- 10:00 p.m., and 10:00 p.m.- 6:00 a.m.2/7/25: 4:32 p.m.- 6:30 p.m. and 2:58 a.m. - 6:00 a.m.2/8/25: 10:02 a.m. - 6:00 p.m. and 11:51 p.m.- 6:00 a.m.2/9/25: 11:47 a.m.- 2:00 p.m., 2:00 p.m. - 6:00 p.m., and 2:55 a.m. - 6:00 a.m.2/10/25: 6:00 a.m.- 10:14 a.m. and 5:25 p.m. - 10:04 p.m.2/17/25: 6:00 a.m.- 6:25 a.m., 3:10 p.m.- 6:09 p.m., and 11:57 p.m.- 6:00 a.m.2/20/25: 6:00 p.m.- 6:30 p.m. and 10:27 p.m.- 6:00 a.m.3/30/25: 6:00 p.m.- 7:01 p.m. and 12:10 a.m.- 6:00 a.m. A facility policy, revised 8/06, titled, Department Duty Hours, Nursing Services, provided by the DON on 8/22/25 at 12:47 p.m., indicated the following: 1. Nursing service is provided twenty-four (24) hours per day, seven days a week. The requirements for long term care facilities require that a skilled nursing facility provided 24-hour licensed nursing services . 3.1-17(a)

Based on interview and record review, the facility failed to ensure residents, for whom the facility managed funds, or their representatives, received quarterly funds statements for 2 of 3 residents reviewed for quarterly statements. (Residents F and H)Findings include:A current 8/19/25, facility Trail Balance resident funds statement indicated the facility managed personal funds for 32 residents. Residents E, F and H names were listed on the account list.Quarterly statements were requested of facility management for review for Residents E, F, and H. Residents F and H did not have quarterly statements for review. During an interview on 8/20/25 at 1:36 p.m., the Administrator and Business Office Manager both indicated that quarterly statements had not been given to residents who did not have a responsible party to receive them. This had been an error and residents should have received the statements themselves.A current, 2017, facility policy titled, Deposit of Resident Funds, provided by the Business Office Manager on 8/20/21 at 1:38 p.m., indicated The resident is provided a confidential quarterly statement on funds on deposit with the facility.This citation relates to Complaint 2588630. 3.1-6(g)

Based on interview and record review, the facility failed to provide a surety bond in sufficient amount to safeguard all resident funds. This deficient practice had the potential to impact 32 of 32 residents for whom the facility managed funds. Findings include: Review of a current 8/19/25, facility Trail Balance resident funds statement indicated the facility managed resident funds for 32 residents.Review of the facility's current, April 1, 2022, surety bond agreement indicated the resident funds were covered in liability surety for the amount of $30,000.00 (thirty thousand dollars).A review of bank statements for July 2025 (7/1/25 to 7/31/25), June 2025 (5/31/25 to 6/30/25) and May 2025 (5/1/25 to 5/30/25) indicated 23 days had a daily ledger balance greater than $30,000.00 as follows: 7/3/25 $41,381.03, 7/7/25 $41,422.03, 7/9/25 $43,429.03, 7/13/25 $42,740.03, 7/16/25 $43,099.03, 7/21/25 $31,950.82, 7/22/25 $32,192.32, 7/23/25 $31,869.32, 7/25/25 $31,773.27, 7/28/25 $30,109.89, 6/3/25 $42,544.15, 6/4/25 $48,374.65, 6/5/25 $39,050.65, 6/6/25 $37,644.65, 6/9/25 $38,670.65, 6/11/25 $38,802.65, 5/2/25 $42,023.85, 5/7/25 $42,188.85, 5/8/25 $42,658.85, 5/9/25 $47,217.85, 5/12/25 $46,917.85, 5/14/25 $46,096.55, and 5/21/25 $30,107.55.During an interview on 8/20/25 at 9:30 a.m., the Business Office Manager indicated the facility did not complete the reviews to ensure the surety bond was sufficient for the coverage of the balance of resident funds. It was completed through the home office.A current, 2017, facility policy titled, Management of Residents' Personal Funds, provided by the Business Office Manager on 8/20/21 at 1:38 p.m., indicated .Should the facility manage the resident's funds, the facility will act as a fiduciary of the resident funds and hold, safeguard manage, and account for the personal funds of the resident. This citation relates to Complaint 2588630. 3.1-6(i)

Based on observation, interview, and record review, the facility failed to obtain physician orders for oxygen services for 1 of 1 residents reviewed for oxygen use. (Resident 5)Finding includes:During an interview with Resident 5 on 8/19/25 at 10:05 a.m., he indicated he used oxygen at 3 liters per minute (lpm) via nasal cannula all the time, except when smoking. During the interview, the resident's oxygen concentrator was observed to be on 4 lpm of oxygen. The resident indicated he had not adjusted the flow rate. During an interview with Resident 5 on 8/20/25 at 8:42 a.m., he indicated his oxygen flow had not been adjusted. The oxygen concentrator remained on 4 lpm.Resident 5's record was reviewed on 8/20/25 at 10:35 a.m. Diagnoses included acute and chronic respiratory failure, atrial fibrillation (abnormal heart rhythm), and generalized anxiety disorder.Current physician orders included change nebulizer tubing weekly on Sunday night shift every Sunday, nebulizer machine for as needed (PRN) albuterol (respiratory medication) nebulization (changing a liquid medication into a gas).The record lacked orders regarding oxygen administration and flow rate.A 7/17/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. Specialized services included continuous oxygen therapy.A current care plan initiated on 3/6/25 indicated the resident had acute and chronic respiratory failure. Interventions included oxygen per physician orders.An advanced practice registered nurse (APRN) note dated 4/4/25 at 9:35 p.m. indicated the resident's oxygen was set on 3 lpm.An APRN note dated 5/9/25 at 11:56 p.m. indicated the resident 's oxygen was set on 4.5 lpm.On 8/21/25 at 9:04 a.m., Resident 5's oxygen concentrator was set on 4 lpm.During an interview with LPN 7 on 8/21/25 at 10:33 a.m., she indicated Resident 5 was normally on 2 lpm of oxygen.During an interview with Resident 5 on 8/22/25 at 8:43 a.m., he indicated his oxygen had not been adjusted. His oxygen concentrator was on at 4 lpm.During an interview with the DON on 8/22/25 at 11:01 a.m., she indicated Resident 5 used continuous oxygen and was on 2 lpm per physician order. During an interview with the DON on 8/22/25 at 12:29 p.m., she indicated Resident 5 did not have a current order for oxygen, but should have had an order.A current facility policy titled, Oxygen Administration and provided by the IP on 8/22/25 at 11:05 a.m. indicated the following, .Procedure: 1. Heck physician's order for O2, liter flow, and method of administration.7. At regular intervals, check liter flow of oxygen, fluid level in humidifier, and assess resident's respiration to determine effectiveness of oxygen therapy.3.1-47(a)(6)

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. Findings include:Review of the Summary Statement of Deficiencies, for the facility's last annual Recertification and State Licensure Survey completed on 9/26/24, indicated the facility failed to ensure nurse staffing information readily available in a readable format to residents and visitors daily. The plan of correction indicated, A new updated form was completed and placed in accessible area to resident and visitors, all staff that complete the daily nurse staffing information forms have been provided a revised form and provided education on the completion and accessibility to resident and visitors. Each morning, upon arrival to the facility the Administrator and/or Designee will ensure the current day's nurse staffing information was completed. Repeat concerns regarding complete and accurate daily nurse staffing posting were cited during the August 18, 2025, survey as follows: Based on observation and interview, the facility failed to ensure complete and accurate daily nurse staffing information was posted and readily available for residents and resident representatives. This deficiency had the potential to affect 39 of 39 residents residing in the facility.During and interview, on 8/22/25 at 1:07 p.m., the Administrator indicated the facility completed the Plan of Correction for last year's citation on 1/17/25. The audits tools utilized indicated there were no concerns and the daily staffing was posted appropriately. A previous citation's plan of correction was usually completed within six months and if there were no concerns it would be considered completed. This issue was not reviewed in QAPI after this date. A facility policy, dated 4/19, titled, Quality Assurance & Performance Improvement (QAPI) Program Process, provided by the DON on 8/22/25 at 11:05 a.m., indicated the following: Goal: To provide consistent, comprehensive and ongoing quality resident care .3. To identify areas in need of improvement .5. To implement action for resolution of known problem areas at the time ., 6. To provide audit tools whereby immediate implementation of corrective action is taken at the point of care delivery .Cross reference F732.3.1-52(b)(2)

Based on observation and interview, the facility failed to ensure complete and accurate daily nurse staffing information was posted and readily available for residents and resident representatives. This deficiency had the potential to affect 39 of 39 residents residing in the facility. Finding includes:During an observation, on 8/18/25 at 7:34 a.m., the 'Daily Staffing Posting without Units' information sheet was dated Thursday, 8/14/25. This was posted on the wall behind the nurse's station. On 8/18/25 at 9:30 a.m., the Daily Staffing Posting without Units was dated Monday, 8/18/25 and indicated there were no Registered Nurses (RN) or Licensed Practical Nurses (LPN) scheduled for the evening and night shifts, and there were no Certified Nursing Assistants (CNA) scheduled for the night shift. On 8/20/25 at 9:32 a.m., the 'Daily Staffing Posting without Units' indicated there were no RNs or LPNs on the evening shift. During an interview, on 8/21/25 at 1:45 p.m., QMA 9 indicated she was responsible for updating the nurse staffing post everyday. She arrived at work between 8:30 and 9:00 a.m. and printed the document from the online system. The online system populated the information from the schedule she completed. She indicated when there were open shifts in the schedule she filled them as quickly as possible and updated both the schedule and daily nurse staff posting. She printed the weekend nurse staff postings on Friday and the floor staff were responsible for changing the posting on Saturday and Sunday. A review of the facility staffing clock-in/clock- out sheets, on 8/21/25 at 2:14 p.m., indicated on 8/18/25 there was an RN present on the evening and night shifts, and an LPN present for the evening shift. There were 2 CNAs present. On 8/20/25 there was one LPN present on the evening shift. During an interview, on 8/21/25 at 2:34 p.m., the Administrator indicated QMA 9 was responsible for completing the daily staff posting. This task was to be completed every morning. A facility policy, revised 7/16 and titled, Posting Direct Care Daily Staffing Numbers, provided by the Administrator on 8/21/25 at 10:15 a.m., indicated the following: .Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RN, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .When computing hours of direct care working split shifts, count only the total numbers of hours the individual is actually scheduled to work for the shift information being posted

Based on observation, interview, and record review the facility failed to provide social services regarding financial management regarding the management of cash savings and spending down of resources to remain eligible for Medicaid for 2 of 3 residents reviewed for assistance to manage finances. ( Resident C and D)Findings include:1.During an interview, Resident C's representative indicated the resident's funds had not been managed correctly. The resident had cash funds stored in the Social Service office, not the business office. There was no method to account for what funds had been spent. At the time of discharge, the representative was given cash in the amount of $700 dollars, and the family thought their loved one should have more money. The facility staff informed them the resident purchased lots of snacks, when they questioned the amount of money returned to them.During an interview on 8/21/25 at 1:00 p.m., the Administrator indicated he had not known Resident C had cash in the Social Service office until he witnessed it being given to the family at the resident's discharge.During an interview on 8/21/25 at 1:08 p.m., the Social Services Director (SSD) indicated the following:She had stored Resident C's personal money in a locked file cabinet in the Social Service office. She had received $900.00 in cash from the resident shortly after the resident's admission. The resident had a fear of banks. The SSD had not had the resident sign any form or paperwork indicating her money was stored in the SSD's office. The SSD had not kept a record of money the resident had received, nor had she had the resident sign any receipt for said money. The SSD had not talked to the resident's family member about the money being locked in the SSD office. She had not considered if the money would be covered by the surety bond or facility insurance. She had not developed any type of care plan for the resident regarding the safety and use of her money, which was stored in the SSD office. She had made purchases for the resident using said money. She had given the resident every receipt. The resident mostly purchased snacks. She was unsure if the Administrator was aware of said money being in the SSD office. She had given Resident C's family member $700 dollars at the time of the resident's discharge.Resident C's clinical record was reviewed on 8/19/25 at 12:31 p.m. Diagnoses included paranoid schizophrenia and hypertension.A 5/27/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident C was moderately cognitively impaired and required assistance with decision making.2. A current, facility, 8/19/25, Trail Balance resident funds statement indicated Resident D had a current balance of $20,619.36. A resident specific quarterly statement indicated Resident D received a deposit of $22,466.00 in March 19, 2025. The facility was the resident's representative payee.Four letters addressed to Resident D, titled Resident Funds Balance Notification, dated April 30, 2025, May 30, 2025, June 30, 2025, and July 31, 2025 indicated the following: This letter is to notify you that your current Resident Funds Balance is within $200.00 or exceeding what is allowed under Medical Assistance. Please contact your Social Worker within the next 7 days to discuss ways to assure continuance of Medicaid benefits. None of the 4 letters indicated the information had been verbally shared with the resident, nor did it indicated assistance had been offered.During an interview on 8/21/25 at 10:00 a.m., Resident D indicated he didn't believe he had any extra money to spend. If he had extra money, he'd really like to look into a different place to live. Additionally, if he had to stay at the facility, he'd spend his money on clothes and room decorations such as posters. During an observation at this time, the resident's room lacked any room decorations.Resident D's record was reviewed on 8/19/25 at 2:29 p.m. Current diagnoses included hypertension, diabetes, major depressive disorder, and unspecified dementia. The resident received Medicaid benefits.A 7/11/25, significant change, MDS assessment indicated the resident was moderately cognitively impaired and required assistance with decision making.A current 8/19/25 care plan indicated the resident had impaired decision making. The care plan originated 11/2024.A current 12/10/24 care plan indicated the resident had an alteration in mental functioning due to mental health diagnoses. The clinical record lacked documentation or plan of care regarding the resident's need to spend his money in order to remain eligible for Medicaid.During an interview on 8/21/2025 at 11:38 a.m., the Business Office Manager indicated the facility had no documentation of action taken to assist Resident D in spending his resources. The Corporate Director of Business Office Operation had told her because the resident had nine months to spend down his resources, the facility had not needed to assist the resident yet. The cooperate consultant hadn't assisted him yet and planned to come and start Monday, 8/25/25. This citation relates to Complaint 2588630. 3.1-34(a)

Based on interview and record review, the facility failed to notify a resident's representative regarding change in condition for 1 of 3 residents reviewed for change in condition. (Resident C)Finding includes: Resident C's record was reviewed on 8/19/25 at 12:31 p.m. Medical diagnoses included paranoid schizophrenia, hypertension, and gastro-esophageal reflux disease (acid reflux).A 5/27/25, quarterly, quarterly Minimum Data Set (MDS) indicated the resident was mildly cognitively impaired.A nurse's note, dated 7/22/25 at 12:39 p.m. indicated the resident was found cool, clammy, tachycardic (high heart rate), and hypertensive (high blood pressure). The resident was encouraged to take her blood pressure medication and drink fluids, but verbally refused and swatted at a cup containing the medication. The note lacked notification of family or the resident representative.A progress note dated 7/22/25 at 2:57 p.m. indicated the resident was excessively sweating, tachycardic, hypertensive, and tachypneic (high respiratory rate) and continued to refuse medications and fluids. The nurse practitioner (NP) was contacted and an order received to send the resident to the emergency room (ER). The resident's representative was informed of the transfer.During an interview with the Infection Preventionist (IP) on 8/20/25 at 1:56 p.m., she indicated Resident C was a very private person, but would often say hello to her during the day. On the morning of 7/22/25, the resident did not say hello to her and was not acting at her baseline. The IP noted the resident was cold, restless, and sweaty. The IP informed the DON, who attempted to get the resident to drink fluids and take her medication. The resident adamantly refused. Around approximately 2 p.m., a CNA approached the IP and indicated the resident remained altered, tachycardic, and more restless than previously. The IP called the NP, who told her to send the resident to the ER.During an interview with the DON, on 8/21/25 at 9:18 a.m., she indicated Resident C was a very private person and frequently refused her medications. On 7/22/25, the DON was approached by staff who indicated the resident was altered and had an elevated blood pressure. The DON attempted to give the resident her blood pressure medication, but the resident verbally refused and swatted at the medicine cup. The DON indicated later on that day, she was approached by the IP, who indicated the resident remained altered and was being sent to the hospital.During an interview with LPN 7 on 8/21/25 at 10:33 a.m., she indicated when a change of condition occurred, the resident would be assessed first, then depending on the condition of the resident, the provider and family would be contacted.During an interview with the DON on 8/21/25 at 10:40 a.m. she indicated when she worked with Resident C on 7/22/25, she was not acting at her baseline. When a change of condition was identified, staff were supposed to fill out an electronic interaction (e-Interact) form, which included notification of family or the resident representative.During an interview with the DON on 8/22/25 at 10:59 a.m., she indicated nursing staff were expected to contact family and resident representatives when a change of condition was identified and this would be charted in a progress note.A current facility policy, titled Change in a Resident's Condition or Status, and provided by the DON on 8/22/25 at 11:05 a.m. indicated the following, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., change in level of care, billing/payments, resident rights, etc.) .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. There is a significant change in the resident's physical, mental, or psychosocial status; .e. It is necessary to transfer the resident to a hospital/treatment center This citation relates to Complaint 2588630.3.1-5(a)(2)3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure facility policies were implemented to allow a resident to return to the facility for care following an emergency room visit. The resident was not provided adequate notice to appeal the discharge prior to being transported to and left at a hotel 26 miles away from the facility. The Immediate Jeopardy that began on 8/16/24, when the facility failed to allow a resident to return to the facility after a hospital visit per facility policy. This deficient practice put the resident at risk for harm related to lack of a safe environment, placing the resident at risk of serious accidents. The Administrator, Social Services Director (SSD), and the Housekeeping Supervisor were notified of the Immediate Jeopardy on 8/20/24 at 4:37 p.m. The Immediate Jeopardy was removed when the facility completed education of management and nurses regarding discharge rights and the facility policy for resident discharge on 8/22/24, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm. Findings include: Review of the Facility Assessment, dated 8/2/24 and provided by the Administrator on 8/21/24 at 9:20 a.m., indicated the facility had an average daily census of 26 and cared for residents with the following needs: psychiatric/mood disorders including psychosis (hallucinations, delusions, etc.) impaired cognition, mental disorder, depression, mania/depression, schizophrenia, post-traumatic stress disorder (PTSD), anxiety disorder, and behavior plural? that needed interventions. The facility's population included five residents with behavioral symptoms and cognitive performance needs and ten with behavioral/mental health needs. Services offered by the facility included, but were not limited to, management of medical conditions and medication-related issues causing psychiatric symptoms and behavior and implementation of interventions to help support residents with psychiatric diagnoses and intellectual or developmental disabilities. Discharge planning included assistance with financial implications, referral to local contact agencies as needed, discharge medication list, and assistance with medical supplies. Resident C's clinical record was reviewed on 8/19/24 at 11:28 a.m. Diagnoses included mild cognitive impairment, alcohol use, history of cerebral infarction, mood disorder, cocaine abuse, and epileptic syndrome. A current, quarterly, Minimum Data Set assessment, dated 6/6/24, indicated the resident was cognitively intact. Behaviors were listed as: Verbal behavioral symptoms directed towards others occurred 1-3 days of the assessment period. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1-3 days of the assessment period. He used a cane or crutches for mobility. He was occasionally incontinent of urine and required assistance of one for dressing the lower part of his body. He was dependent for bathing. Review of progress notes indicated, on 8/15/24 at approximately 9:35 p.m., Resident C physically assaulted another resident. The police were called and Resident C was taken to the emergency department for evaluation. Review of an Emergency Department Progress note, dated 8/15/24 at 10:23 p.m., indicated Resident C was seen following an altercation. He had been hit in the back, and was experiencing back pain. The nursing facility informed the emergency department the resident was not welcome back there. The resident underwent psychiatric and social work evaluations and was to proceed back to Brookside Care Strategies despite them not wanting to accept him back. No significant behavioral changes were noted. An emergency department note, dated 8/16/24, indicated Resident C had received a psychiatric and social work evaluation. The resident was being sent back to the facility despite them not wanting to accept him back. Review of a hospital nursing note, dated 8/16/24, indicated the resident verbalized a desire to return to the facility. The resident stated he had been at the facility for approximately one month and considered the facility his home. A Social Service note, dated 8/16/2024 at 11:03 a.m., indicated the resident was discharged to a homeless shelter located 61 miles from the facility. The resident was given all of his belongings, medications, $20.00 cash, a lighter, and a pack of cigarettes. A Discharge Summary Note, dated 8/16/2024 at 11:18 a.m., indicated the resident was discharged with his face sheet, medications, money, and cigarettes. A Transfer/Discharge Notice, dated 8/16/24, indicated Resident C was discharged to a homeless shelter in downtown Indianapolis, 61 miles away from the facility. The Interdisciplinary, Social Service, and transfer/discharge documentation, dated from 8/15/2024 through 8/16/2024, did not include information to determine the facility provided a thirty-day written notice of impending discharge to Resident C. The clinical record did not contain documentation the resident had returned from the emergency room visit in a condition that was different from baseline that would warrant an emergency discharge. The resident was not given an opportunity to appeal the transfer or make choices on this discharge location. During an interview on 8/19/24 at 2:49 p.m., the Administrator indicated, on 8/16/24, the hospital called and indicated the resident was being released back to the facility. The Administrator did not feel comfortable with the resident being back in the facility due to his behaviors. When the resident arrived at the facility via ambulance, the Administrator met them in the parking lot. He asked the resident if he remembered what had happened the night before. The resident responded that he knew what he had done. Resident C said he knew he was not wanted in the facility and he would sign any paperwork they needed him to sign. He just wanted his cigarettes. The Administrator asked the SSD (Social Service Director) to look for a homeless shelter that could take the resident. The Administrator indicated he gave the resident $20.00, a bag of food, his belongings, and cigarettes. The resident told the Administrator he did not have anyone and he did not need anyone. The Administrator transported the resident to the homeless shelter in his private car. During an interview on 8/20/24 at 9:18 a.m., a representative from the named homeless shelter indicated Resident C had not been admitted . No one by that name and date of birth had been in the shelter for over a decade. During an interview on 8/20/24 at 3:47 p.m., the Administrator indicated he had taken the resident to the homeless shelter, but he did not feel it was safe. He took the resident to another town (26 miles from facility) and paid for a two-night stay at a hotel. The hotel would provide the resident with breakfast. The resident said he would contact his brother. The undated face sheet, included, but was not limited to, information to contact two family members in the event of an emergency. The family members could not be contacted for interview using the information on the face sheet. During the survey, the whereabouts of the resident could not be determined until on, 8/22/24 at 11:00 a.m., when the Administrator provided a referral sent from a local hospital requesting a bed for Resident C. The referral indicated the resident had arrived at the hospital on 8/18/24. The Administrator indicated he was told the resident had been picked up by the police after being found lying on the sidewalk in front of a local homeless shelter. Local police were contacted during the survey and no report was available. Review of an 8/18/24 emergency room report indicated Resident C was being admitted to the hospital for treatment of dehydration, acute kidney injury, and abnormal laboratory values after being found on the sidewalk outside of a shelter. The hospital was able to treat the dehydration with intravenous fluids, but the resident continued to have elevated creatine kinase (CK) levels (indicative of heart, muscle, or brain injury or excessive drug or alcohol use). The facility discharge policy was requested on 8/21/24 at 9:50 a.m. and again at 10:10 a.m., when a partial copy of a Discharge Policy dated 1/2023 was provided. The Administrator indicated, on 8/21/24 at 11:05 a.m., he was awaiting a copy of the policy from the corporate offices. Review of a facility policy, dated December 2016, and titled Transfer or Discharge Notice, provided by the DON on 8/21/24 at 11:45 a.m., indicated the facility shall provide a thirty-day written notice of an impending transfer or discharge. The notice would be given as soon as practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; c. The safety of individuals in the facility is endangered: 5. The reasons for the transfer or discharge will be documented in the resident's medical record; 11. in determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interest of the resident. Review of a current facility policy provided by the Administrator on 8/21/24 at 9:50 a.m., dated 1/2023 and titled Resident Discharge indicated the purpose was to provide guidelines for discharging a resident for including, but not limited to, needs cannot be met or the resident's clinical and behavioral status endangered the health and safety of other residents. The immediate jeopardy that began on 8/16/24 was removed on 8/22/24, when the facility provided education to managers and nurses regarding transfer and discharge rights. This citation relates to Complaint IN00440457. 3.1-12(a)(4)(A) 3.1-12(a)(4)(C) 3.1-12(a)(4)(D)

Based on record review and interview, the facility failed to honor a resident's right to return to the facility from an emergency room visit following a resident-to-resident altercation (Resident C). The facility failed to demonstrate inability to meet the resident's needs or that the resident was an immediate danger to others with interventions attempted. The Immediate Jeopardy began on 8/16/24 when the facility discharged the resident with his belongings to a hotel located 26 miles away from the facility, with a two-day paid stay. This deficient practice put the resident at risk for harm related to lack of a safe environment, placing the resident at risk of serious accidents. The Immediate Jeopardy was removed on 8/22/24, when the facility provided education to managers and nurses regarding transfer and discharge rights, but noncompliance remained at the lower scope and severity of harm that is not Immediate Jeopardy because the resident was found on a sidewalk by police back in the same city the facility is located in and was hospitalized for dehydration and acute kidney injury . Findings include: Review of the Facility Assessment, dated 8/2/24 and provided by the Administrator on 8/21/24 at 9:20 a.m., indicated the facility had an average daily census of 26 and cared for residents with the following needs: psychiatric/mood disorders including psychosis (hallucinations, delusions, etc.) impaired cognition, mental disorder, depression, mania/depression, schizophrenia, post-traumatic stress disorder (PTSD), anxiety disorder, and behaviors that needed interventions. The facility's population included five residents with behavioral symptoms and cognitive performance needs and ten with behavioral/mental health needs. Services offered by the facility included, but were not limited to, management of medical conditions and medication-related issues causing psychiatric symptoms and behavior and implementation of interventions to help support residents with psychiatric diagnoses and intellectual or developmental disabilities. Discharge planning included assistance with financial implications, referral to local contact agencies as needed, discharge medication list, and assistance with medical supplies. Resident C's clinical record was reviewed on 8/19/24 at 11:28 a.m. Diagnoses included mild cognitive impairment, alcohol use, history of cerebral infarction, mood disorder, cocaine abuse, and epileptic syndrome. Current medication orders at the time of discharge included acetaminophen (analgesic) 500 mg 2 by mouth every 8 hours as needed for pain, aspirin (antiplatelet) 81 mg by mouth every morning, atorvastatin calcium (for cholesterol) 20 mg by mouth at bedtime, cholecalciferol (Vitamin D supplement) 50 mcg by mouth once daily, Keppra (anticonvulsant) 500 mg by mouth twice daily, and ziprasidone HCL (antipsychotic) 40 mg by mouth twice daily. A current, quarterly, Minimum Data Set assessment, dated 6/6/24, indicated the resident was cognitively intact. Behaviors were listed as: Verbal behavioral symptoms directed towards others occurred 1-3 days of the assessment period. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1-3 days of the assessment period. He used a cane or crutches for mobility. He was occasionally incontinent of urine and required assistance of one for dressing the lower part of his body. He was dependent for bathing. A current care plan, dated 3/9/24, indicated Resident C wished to remain at the facility for long term care, and to only be asked about discharge plans on comprehensive assessments. Interventions included: 1. The facility will contact appropriate community agencies if needed. Date Initiated: 3/9/24. 2. Encourage the resident to discuss feelings and concerns about remaining in the facility. Date Initiated: 3/9/24. 3. Observe for and address episodes of anxiety, fear and/or distress. Date Initiated: 3/9/24. 4. Resident will be asked about returning to the community with each full assessment and as needed. Date Initiated: 3/9/24. A current care plan, dated 3/13/24, indicated Resident C had a mood problem related to mood disorder, was being seen by mental health services, and may express the following: trouble concentrating some days, verbal aggression, feeling hopeless at times, missing their independence, feeling like no one cared about them, struggling with conflict and getting along with peers, increased depression, frustration due to having a roommate, and being easily annoyed by peers. Interventions included the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 3/13/24. 2. Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. Date Initiated: 3/13/24. 3. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.). Date Initiated: 3/13/24. 4. Educate the resident/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. Date Initiated: 3/13/24. 5. Mental health clinician will work with resident on building rapport with roommate and help identify ways to experience joy in facility. Date Initiated: 7/22/24. 6. Mental health clinician will work with resident on negative thought no one care and helping identify supports. Date Initiated: 5/20/24. 7. Mental health clinician will work with resident on negative thought of hopelessness/helplessness and identifying strengths. Date Initiated: 3/26/24. 8. Mental health clinician will work with resident on negative thought of loss of control and help identify things in his life he has control over. Date Initiated: 4/30/24. 9. Mental health clinician will work with resident on negative thought of loss of control and identify thing in his control. Date Initiated: 6/17/24. 10. Mental health clinician will work with resident on positive peer interactions and identify ways to take breaks. Date Initiated: 5/27/24. 11. Mental health clinician will work with resident on positives of facility and identify ways to take breaks. Date Initiated: 8/12/24. 12. Mental health clinician will work with resident on ways he contributes to conflict and deep breathing. Date Initiated: 7/29/24. 13. Mental health clinician will work with resident on ways to use compromise and explores ways to use I statements. Date Initiated: 6/10/24. 14. Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Date Initiated: 3/13/24. 15. Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Date Initiated: 3/13/24. 16. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Date Initiated: 3/13/24. 17. Monitor/report to Nurse any risk for harm to self or suicidal idealization. Date Initiated: 3/13/24. 18. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. Date Initiated: 3/13/24. A current care plan, dated 3/19/24, indicated the resident had the potential to be verbally aggressive with threatening behavior. Interventions included the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 3/19/24. 2. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 3/19/24. 3. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 3/19/24. 4. Assess resident's coping skills and support system. Date Initiated: 5/3/24. 5. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Date Initiated: 3/19/24. 6. Monitor behaviors. Document observed behavior and attempted interventions. Date Initiated: 6/21/24. 7. Offer to take resident for a walk, etc. Date Initiated: 8/5/24. 8. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Date Initiated: 3/19/24. 9. Psych NP/Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 3/19/24. 10. The resident's triggers for verbal aggression are others getting close to him. The resident's behaviors is de-escalated by keeping wanderers away from him. Date Initiated: 4/29/24. 11. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 3/19/24. A current care plan, dated 4/1/24, indicated the resident had the potential to be physically aggressive to others, shoving others, attempting to hit others, and hitting others. Interventions included the following: 1. Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 6/20/24. 2. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 4/1/24. 3. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 4/1/24. 4. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 4/1/24. 5. Assess and address for contributing sensory deficits. Date Initiated: 4/1/24. 6. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 4/1/24. 7. COMMUNICATION: Encourage seeking out of staff member when agitated. Date Initiated: 4/1424. 8. COMMUNICATION: provide physical and verbal cues to alleviate anxiety. Date Initiated: 4/14/24. 9. Encourage resident to verbalize source of agitation. Date Initiated: 5/23/24. 10. Monitor/document/report PRN any signs or symptoms of resident posing danger to self and others. Date Initiated: 4/1/24. 11. Notify Psych NP of behaviors. Date Initiated: 4/1/24. 12. Offer to take resident to enclosed court yard as/if able when he exhibits any agitation, etc. Date Initiated: 8/16/24. Review of progress notes indicated, on 8/15/24 at approximately 9:35 p.m., Resident C physically assaulted another resident. The police were called and Resident C was taken to the emergency department for evaluation. A police report, dated 8/15/24 at approximately 9:12 p.m., indicated the police were called to the facility in regards to a fight. Staff informed the police that Resident C had stomped on another resident's head (Resident D). The police observed blood on the floor of Resident C's room. When asked, Resident C told the police he had beat his a_ _ and was unsure of how many times he stomped on the other resident's head. The resident told the police he had been woken up by the other resident when they walked into his room. Staff told the police Resident C knew right from wrong and provided statements about what they had witnessed. The police also visited the other resident (Resident D) while they were being seen in the emergency room . The police documented a large gash on the resident's forehead. Resident D remained non-verbal. Review of an emergency department progress note, dated 8/15/24 at 10:23 p.m., indicated Resident C was seen following an altercation. He had been hit in the back, and was experiencing back pain. The nursing facility informed the emergency department the resident was not welcome back there. The resident underwent psychiatric and social work evaluations and no significant behavioral changes were noted. Resident C was to proceed back to Brookside Care Strategies, despite them not wanting to accept him back. Review of a hospital nursing note, dated 8/16/24, indicated the resident verbalized a desire to return to the facility. The resident stated he had been at the facility for approximately one month and considered the facility his home. An emergency department note, dated 8/16/24, indicated Resident C had received a psychiatric and social work evaluation. The resident was being sent back to the facility despite them not wanting to accept him back. The resident had no behavioral changes. A Social Service note, dated 8/16/2024 at 11:03 a.m., indicated the resident was discharged to a homeless shelter located 61 miles from the facility. The resident was given all of his belongings, medications, $20.00 cash, a lighter, and a pack of cigarettes. A Discharge Summary Note, dated 8/16/2024 at 11:18 a.m., indicated the resident was discharged with his face sheet, medications, money, and cigarettes. A Transfer/Discharge Notice, dated 8/16/24, indicated Resident C was discharged to a homeless shelter in downtown Indianapolis, 61 miles away from the facility. The Interdisciplinary, Social Service, and transfer/discharge documentation, dated from 8/15/2024 through 8/16/2024, did not include information to determine the facility provided a thirty-day written notice of impending discharge to Resident C. The clinical record did not contain documentation the resident had returned from the emergency room visit in a condition that was different from baseline that would warrant an emergency discharge. The resident was not given an opportunity to appeal the transfer or make choices on this discharge location. During an interview on 8/19/24 at 2:49 p.m., the Administrator indicated, on 8/16/24, the hospital called and indicated the resident was being released back to the facility. The Administrator did not feel comfortable with the resident being back in the facility due to his behaviors. When the resident arrived at the facility via ambulance, the Administrator met them in the parking lot. He asked the resident if he remembered what had happened the night before. The resident responded that he knew what he had done. Resident C said he knew he was not wanted in the facility and he would sign any paperwork they needed him to sign. He just wanted his cigarettes. The Administrator asked the SSD (Social Service Director) to look for a homeless shelter that could take the resident. The Administrator indicated he gave the resident $20.00, a bag of food, his belongings, and cigarettes. The resident told the Administrator he did not have anyone and he did not need anyone. The Administrator transported the resident to the homeless shelter in his private car. During an interview on 8/20/24 at 9:18 a.m., a representative from the named homeless shelter indicated Resident C had not been admitted . No one by that name and date of birth had been in the shelter for over a decade. During an interview on 8/20/24 at 3:47 p.m., the Administrator indicated he had taken the resident to the homeless shelter, but he did not feel it was safe. He took the resident to another town (26 miles from facility) and paid for a two-night stay at a hotel. The hotel would provide the resident with breakfast. The resident said he would contact his brother. The undated face sheet, included, but was not limited to, information to contact two family members in the event of an emergency. The family members could not be contacted for interview using the information on the face sheet. During the survey, the whereabouts of the resident could not be determined until on, 8/22/24 at 11:00 a.m., when the Administrator provided a referral sent from a local hospital requesting a bed for Resident C. The referral indicated the resident had arrived at the hospital on 8/18/24. The Administrator indicated he was told the resident had been picked up by the police after being found lying on the sidewalk in front of a local homeless shelter. Local police were contacted during the survey and no report was available. Review of an 8/18/24 emergency room report indicated Resident C was being admitted to the hospital for treatment of dehydration, acute kidney injury, and abnormal laboratory values after being found on the sidewalk outside of a shelter. The hospital was able to treat the dehydration with intravenous fluids, but the resident continued to have elevated creatine kinase (CK) levels (indicative of heart, muscle, or brain injury or excessive drug or alcohol use). The facility discharge policy was requested on 8/21/24 at 9:50 a.m. and again at 10:10 a.m., when a partial copy of a Discharge Policy dated 1/2023 was provided. The Administrator indicated, on 8/21/24 at 11:05 a.m., he was awaiting a copy of the policy from the corporate offices. Review of a facility policy, dated December 2016, and titled Transfer or Discharge Notice, provided by the DON on 8/21/24 at 11:45 a.m., indicated the facility shall provide a thirty-day written notice of an impending transfer or discharge. The notice would be given as soon as practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; c. The safety of individuals in the facility is endangered: 5. The reasons for the transfer or discharge will be documented in the resident's medical record; 11. in determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interest of the resident. Review of a current facility policy provided by the Administrator on 8/21/24 at 9:50 a.m., dated 1/2023 and titled Resident Discharge indicated the purpose was to provide guidelines for discharging a resident for including, but not limited to, needs cannot be met or the resident's clinical and behavioral status endangered the health and safety of other residents. The immediate jeopardy that began on 8/16/24 was removed on 8/22/24, when the facility provided education to managers and nurses regarding transfer and discharge rights, but noncompliance remained at the lower scope and severity of harm that is not Immediate Jeopardy because the resident was found on a sidewalk by police back in the city the facility is located in and was hospitalized for dehydration and acute kidney injury. This citation relates to Complaint IN00440457. 3.1-12(a)(3) 3.1-12(a)(4)

Based on observation, record review and interview, the facility failed to ensure a cognitively impaired resident who wandered (Resident D) was free from resident-to-resident physical abuse perpetrated by a resident known to be physically abusive towards others when approached (Resident C) for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident D sustaining a head laceration and required emergent treatment at the hospital with six sutures to repair. Findings include: Review of an Incident Report sent to the Indiana Department of Health's reporting system indicated, on 8/15/24 at 9:01 p.m., Resident D was found lying on the floor in Resident C's room. Resident D had a laceration on the left side of his head and bruising to his chest and head. Resident C indicated there had been an altercation. A local police department's case report, dated 8/15/24 and provided by the Director of Nursing (DON) on 8/21/24 at 10:25 a.m., indicated as the officer got to the door of Resident C's room, blood was observed on the floor inside the entryway. Resident C was asked about what happened and he advised that Resident D had walked into his room while he was asleep. Resident C was unsure how many times he stomped on Resident D's head. Resident C also stated that he had thoughts of harming others. An employee had indicated to the officer they had not seen the incident, but witnessed Resident C standing over the top of Resident D while yelling. Resident C's clinical record was reviewed on 8/19/24 at 11:28 a.m. Diagnoses included mild cognitive impairment, alcohol use, history of cerebral infarction, mood disorder, cocaine abuse, and epileptic syndrome. A current care plan, revised on 5/3/24, indicated the resident had potential to be verbally aggressive and had threatening behaviors when others were loud, repetitive, or when there lacked space at a dining room table he wanted to sit. An intervention indicated the resident's triggers for verbal aggression were when others come too close to him. The behaviors were de-escalated by keeping wanderers away from him. The most recent quarterly Minimum Data Set (MDS) assessment, dated 6/6/24, indicated resident was cognitively intact, had verbal behaviors directed at others on one to three days during the assessment period and physical behaviors directed towards himself on one to three days during the assessment period. A current care plan, revised on 6/20/24, indicated the resident had potential to be physically aggressive to others, shoved others, and attempted to hit others. Interventions included intervene before agitation escalates, guide away from source of distress, engage in conversation, and if aggressive, walk away and approach later. The resident was to be encouraged to seek out a staff member when agitated. On 8/16/24, an intervention was added to this care plan to offer to take resident to the courtyard if agitated. A Behavior Management Monthly Review, dated 8/6/24, indicated Resident C had 18 incidents of verbal behaviors, 16 incidents of physical behaviors and 18 incidents of yelling in a common area. The behaviors currently being monitored were verbal yelling and physical behaviors in common areas. The report indicated the interventions were successful. A social services progress note, dated 8/12/24 at 10:54 a.m., indicated the resident had seen the mental health provider on 8/9/24. During the session, the resident had expressed to the clinician his frustration with loud peers. He wished he could live on his own. The clinician worked with the resident on positives of living in the facility and helped him identify ways to take breaks. A nurse's note, dated 8/15/24, indicated Resident C was in his room when he attacked another resident. Resident C indicated he had been trying to sleep. Resident C boasted about stomping on the other resident's head. The police removed Resident C from the facility and took him to the emergency department. The clinical record for Resident D was reviewed on 8/20/24 at 10:08 a.m. Diagnoses included mild neurocognitive disorder without behavioral disturbances, anxiety disorder, psychotic disorder, and insomnia. A current care plan, initiated on 9/5/23, indicated the resident had periods of restlessness. Interventions included to involve the resident in diversional activities as possible and to redirect the resident away from doors. A current care plan, revised on 1/10/24, indicated the resident was a wanderer related to impaired safety awareness, wandering up and down the halls. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, a book, and to ensure safety with wandering. The care plans lacked a interventions regarding supervision to manage Resident D wandering and entering other resident rooms. A current care plan, revised 4/4/24, indicated the resident had potential to be physically aggressive and agitated and at times, felt he was protecting others. Interventions included to increase activities and one on one's (continuous supervision) when resident showed increased wandering behaviors and monitor and document signs and symptoms of the resident posing danger to self and others. A current care plan, revised 5/3/24, indicated the resident had impaired verbal communication as evidenced by absent speech, weak voice, problems finding correct words and decreased auditory comprehension. Interventions included to ask mostly yes or no questions, give him 5-10 seconds to respond, speak slowly and simply with a reassuring, calm tone, and use non-verbal gestures (i.e.: thumbs up, thumbs down, smile, etc.) An annual MDS assessment, dated 7/30/24, indicated the resident had a severe cognitive deficit and major mental illness. The resident had unclear speech and difficulty communicating some words or finishing thoughts. He usually understood others, but missed some part or intent of conversations. He had episodes of wandering on one to three days of the assessment period. He required substantial assistance for eating and was dependent on staff for hygiene, toileting, showering, and dressing. He was independent with ambulation. A progress note, dated 8/16/2024 at 3:15 a.m., indicated Resident D returned to the facility from the emergency room with six sutures to the left side of his forehead, with multiple scratches on his face, neck and chest. During an interview on 8/19/2024 at 2:49 p.m., CNA 1 indicated, on the evening of 8/15/24, staff heard someone yelling for help. CNA 1 found Resident D on the floor of Resident C's room. Resident C was standing over Resident D. Resident C appeared aggressive and Resident D was laying on the floor in a pool of blood. Resident C told CNA 1 he had beaten Resident D because he had woken him up. CNA 1 asked if he had kicked Resident D, and Resident C stated he had stomped him six to seven times. CNA 1 stayed with Resident C while other staff members removed Resident D from the room. During an interview on 8/19/2024 at 3:30 p.m., QMA 2 indicated she had heard a faint yell. CNA 1 had found Resident D on the ground, bloody, and Resident C was standing over him. QMA 2 and CNA 1 stood between the residents. QMA 2 indicated she went with Resident D and held pressure to his head until the ambulance arrived. She asked Resident C what he had done, and he indicated he had stomped on Resident D's head. During an interview on 8/19/24 at 3:46 p.m., the DON indicated the staff had heard someone yell out for help, and she observed Resident D in Resident C's room, laying on the floor. Resident D had blood on his head and on the floor. CNA 1 was trying to keep Resident C from Resident D. The DON indicated she left the room and called for more help. CNA 1 stayed with Resident C. The staff removed Resident D from the room while the DON called the police and the ambulance. During an interview on 8/20/2024 at 1:26 p.m., RN 3 indicated Resident C had a prior incident two months ago when he had shoved Resident D. RN 3 indicated she verbalized her concerns related to Resident C staying in the facility due to his behaviors. The staff asked Resident C if he wanted to go to go to a homeless shelter and he responded no. On 8/22/24 at 9:29 a.m. CNA 4 indicated Resident C remained in his room much of the time, but when he was out, he had a flashy temper. Noise seemed to irritate him. The staff would try to redirect him to his room, which was mostly effective. She was not aware of any other interventions for his behaviors. The resident kept his blinds closed and just wanted to be left alone. On 8/22/24 at 9:41 a.m., Activity Aide 5 indicated Resident C kept to himself a lot. He would become verbally aggressive if someone got close to him. The Activity Aide calmed him down by talking with him and providing reassurance. She would talk with him when someone got close to him and reassure him, they were not approaching him. Sometimes he could not be calmed or redirected. She knew of no other interventions to try other than talking to him and redirecting him. On 8/22/24 at 9:54 a.m., QMA 6 indicated Resident C remained in his room most of the time. Noise bothered him and he would go off. When a person got too close to him, he became agitated and would have behaviors. The QMA knew to move other resident's away from Resident C and redirect him to his room. She tried to assure when Resident C was seated with other residents to eat in the dining room that they were not loud. She was unaware of other interventions to manage the resident's behaviors. On 8/22/24 at 10:08 a.m., the Activities Director indicated a couple of months ago, she was assisting Resident D, who lacked balance, as he walked by Resident C's table in the main dining room. Resident C stood from his chair and punched Resident D in the chest. On another occasion, Resident C was outside, and another resident bumped Resident C's leg with his wheelchair, and Resident C stood up and began to yell and curse the other resident. The staff were able to calm him down. During an interview on 8/22/24 at 9:32 a.m., CNA 4 indicated Resident D wandered up and down the hallways most of the day, every day. Resident D couldn't sit for any length of time. He went into other's rooms frequently and was easily redirected. She was unaware of other interventions for his wandering, but to redirect him to the hallway. During an interview on 8/22/24 at 9:42 a.m., Activity Aide 5 indicated Resident D was very sweet and wandered up and down the hallways. He would go into other resident's rooms. She indicated she would redirect him out of other's rooms when she saw him enter them or found him in someone else's room. During an interview on 8/22/24 at 9:47 a.m., QMA 6 indicated Resident D mostly walked up and down in the hallway and would go into other resident's rooms. He was easily redirected, but could become agitated at times. He would calm, and cooperated upon re-approaching. During an interview on 8/22/24 at 10:04 a.m., the Human Resources Director indicated Resident D was very sweet and wandered up and down the hallways. She had seen him enter other resident's rooms. He entered her office at times and was easily re-directed. During an interview on 8/20/24 at 1:03 p.m., CNA 21 indicated when Resident D returned to the facility from the emergency department, he was reluctant to leave his room. Staff encouraged him to continue his normal activities and assured him he was safe. During an observation on 8/22/24 at 10:30 a.m., Resident D was observed walking up and down the length of the hallway. The resident would stop occasionally and hold on the rail and adjust his shoe, then continue to ambulate in the hall. During an observation on 8/22/24 at 1:07 p.m., Resident D was ambulating in the hallway with an unsteady gait. He entered another resident's room, who was not in the room during the observation. The resident stood in the corner of the room and looked around and entered the bathroom. No staff were observed in the area. A current facility policy, revised 5/2024, titled, Abuse Prevention, Identification, and Reporting Policy, provided by the Administrator on 8/2/24 at 9:24 a.m., indicated the following: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms It shall be the policy of the facility to follow the Indiana Department of Health Policies and Procedures for Long-term Care Abuse and Incident Reporting . This citation relates to complaint IN00441003. 3.1-27(a)(1)

Based on interview and record review, the facility failed to develop and implement an individualized behavior plan that maximized the resident's dignity for 1 of 5 residents reviewed (Resident B) when the SSD indicated to Resident B he would be able to be discharged to a group home if he had good behavior for 14 days. This practice resulted in his fixation on the date he was to be discharged to go to a group home and contributed to his increased frustration and behaviors of self harm, yelling at staff, throwing items, and banging his head, which lead to an inpatient stay at a psychiatric hospital. Findings include: Review of video footage with audio, on 8/29/23 at 11:00 a.m., indicated on 8/19/23 Resident B was being escorted in his wheelchair to his room from the nurses station area. CNA 12 pushed his wheelchair while CNA 23 walked backwards holding his legs from touching the ground. LPN 8 held a gown on the right side of him to shield the other staff member from him spitting on them. As they entered his room, a staff member called Resident B a nasty a--. Resident B's clinical record was reviewed on 8/29/23 at 10:38 a.m. Diagnoses included uncomplicated alcohol dependence, Wernicke's encephalopathy, delusional disorders, mild cognitive impairment of uncertain or unknown etiology, other seizures, drug induced subacute dyskinesia, major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, psychotic disorder with hallucinations due to known physiological condition, impulse disorder, and diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter. His medications included levetiracetam (treat seizures) 250 mg (milligram) three times daily, divalproex sodium (treat seizures) 375 mg twice daily, quetiapine fumarate (treat psychotic features) 150 mg at bedtime, brexpiprazole (treat mood disorders) 3 mg daily, and folic acid-vitamin B6-vitamin B12 (treat Wernicke's encephalopathy) daily. Special instructions on his orders indicated, per his mother, Resident B could call her twice daily only from 12:30 p.m. - 1:00 p.m. (after lunch) and 5:30 p.m. - 6:00 p.m. (after dinner). If he yelled at others or was being inappropriate, the call could be held. An admission MDS (Minimum Data Set) assessment, dated 7/21/23, indicated he was cognitively intact. He required extensive assistance of one staff member for bed mobility, dressing, toilet use and personal hygiene. He required extensive assistance of two staff members for transferring. He required supervision with locomotion on and off the unit. He used a wheelchair. He had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days during the assessment period. His current care plans included the following: He had behaviors of yelling out in common areas (7/17/23). His interventions included to allow him time to voice frustrations (revised 8/12/23), approach calmly and in a soothing, non-judgmental manner (revised on 8/12/23), assess for pain and toileting needs (revised 8/12/23), give him your full attention to answer questions he had (revised 8/9/23), if he was in the common area/high activity area, please take him to his room to assist him (revised 8/12/23), offer him a snack or a drink (revised 8/12/23), praise him for all appropriate behaviors (8/22/23), take him to a quiet area (revised 8/12/23), and talk to him about the feelings and rights of others who are exposed to the negative behavior (8/21/23). He had the potential for psychosocial well-being problem related negative interaction with staff (7/25/23). His interventions included allow him time to answer questions and to verbalize feelings, perceptions, and fears (7/25/23), monitor/document his usual response to problems: internal and external (7/25/23), monitor/document his feelings relative to incident with peer (7/25/23), when conflict arose, remove him to a calm, safe environment and allow him to vent/share his feelings (7/25/23). He had the potential to be verbally aggressive by yelling and cursing at staff, calling staff derogatory names, etc. (revised 8/9/23). His interventions included analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document (revised 8/12/23), assess his understanding of the situation, allow time for him to express himself and feelings towards the situation (revised 8/12/23), provide positive feedback for good behavior, emphasize the positive aspects of compliance (revised 8/12/23), when he became agitated; intervene before agitation escalate, guide him away from the source of distress, engage calmly in conversation, if his response was aggressive, staff were to walk away calmly and approach later (revised 8/12/23). He had behaviors of throwing items i.e.: books, water pitcher, threatening to tip over medication carts, pour water on computers, throw feces on staff, throwing cups, etc.(revised 8/16/23). His interventions included ask him what you can do to help him (8/21/23), explain to him the behavior was inappropriate (8/12/23), offer to take him to quiet area to talk (revised 8/12/23), praise him for appropriate behavior (8/22/23), remove him from the area (revised 8/12/23), specific behavior management intervention: ask him if he would like to call his mother (revised 8/12/23), talk to him about the feelings and rights of others who are exposed to negative behavior (revised 8/12/23), and turn on soothing music (8/16/23). He had a behavior problem of self injurious behavior by banging on table, hitting the wall, threatening to break a window, etc. (revised 8/18/23). His interventions included answer his questions (8/18/23), approach/speak in a calm manner (revised 8/12/23), divert attention as necessary (revised 8/12/23), monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations, document behavior and potential causes (revised 8/12/23), praise any indication of his progress/improvement in behavior (revised 8/12/23), remove from situation and take to alternate location as needed (8/12/23), and turn on soothing music for him in a quiet area (8/16/23). He had the potential to be physically aggressive i.e.: threats of harm to staff, scratching staff, etc. (revised 8/21/23). His interventions included to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document (revised 8/12/23), assess and address for contributing sensory deficits (revised 8/12/23), assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. (revised 8/12/23), assist to set goals for more pleasant behavior and assist verbalization of source of agitation (8/21/23), when he became agitated, intervene before agitation escalates, guide him away from source of distress, engage calmly in conversation, if response is aggressive; staff were to walk away calmly and approach later (revised 8/12/23). His progress notes indicated the following: On 8/1/23 at 8:49 a.m., he continued to ask staff when was leaving to go to a group home. Staff replied he would need to change his behaviors to go to group home. He was agreeable. He then continued to ask the same questions. On 8/1/23 at 6:30 p.m., he came to the nurses station several times that shift and asked when he could go to the group home and asked the nurse to write it down. When he was reminded he had it on his notepad, he would get loud and cuss. He was reminded his behaviors had to improve prior to him discharging from the facility. He stated understanding and his behavior improved for only short amount of time before it started all over again. On 8/19/23 at 12:07 p.m., he was in the common area yelling at staff. He continued to make threats about harming himself and other residents. He called staff racial slurs and made bigoted statements. The nurse practitioner was aware of the situation, and no new orders were given. The facility was advised to give redirection to the date of potential discharge. On 8/19/23 at 2:31 p.m., he continuously yelled and shouted out racial slurs and derogatory names such b--ches, chubby, and fat a--. He was redirected to his room where he began to throw various items such as remotes, dresser pieces and his trash can. He took a water pitcher and threw it into the hallway, barely missing a staff member. He made threats to staff that he would take the dresser and beat you upside the head, [racial slur]. He continued to make threats of harm to staff. On 8/19/23 at 2:59 p.m., a staff member came into to help IT (Information Technology) to get the internet and the phone working. Resident B proceeded to threaten to throw urine and water pitchers on the staff member. The staff member was on the phone with IT and could not react to Resident B's questions. He was creating a hostile environment. On 8/19/23 at 6:03 p.m., he hocked up his spit, threatening to spit on an African- American staff member. He called staff names, when redirected by four staff members to his room, he began to spit on staff multiple times. He grabbed a CNA by her chest and began to scratch another CNA. He threw items and caused destruction in his room. He cursed loudly while continuing to spit. 911 was called by a staff member due to their injuries. The DON, psychiatric nurse practitioner, the administrator in training, and the manager on duty was aware. EMTs escorted him via ambulance. His mother was called and made aware of the situation. On 8/20/23 at 4:45 a.m., he returned from the local hospital via stretcher. He was awake and alert to person and place. He was transferred from stretcher to bed. A report from nurse at the ER indicated he was totally calm and cooperative while at the ER, other than he refused lab work when he first arrived. He agreed to lab work shortly after he refused. He had no other behaviors. No new orders were received. He denied any wants/needs at that time and his call light was in reach. On 8/21/23 at 12:53 p.m., he resorted to yelling for staff across the room, to get their attention for a continuously repeated reading of today's date and when he could depart. He continued to repeat requests for reading today's date. This would not change, but his behaviors were definitely belligerent. If staff did not stop in their tracks to repetitively answer today's date and his potential departure date. He would curse and threaten self harm or toss something at staff. He had no means or the mental capacity to harm himself. On 8/21/23 at 11:34 p.m., an SSD note indicated he could be easily redirected, but due to memory issues and behaviors he was redirected hundreds of times a day. His behaviors and questions on the date and when he was leaving were repetitively asked. It was difficult to get him on a task due to this complication of his disease process. At times, his memory was better than others. On 8/22/23 at 6:22 p.m., he sat at the nurses station consistently asked questions, Can I call my mom? and Its August 22nd, and I am leaving August 3? He carried around paper with this statement. Staff reminded him that only if behaviors decreased and if he followed his plan of care. He would state I am going to hurt myself tonight. Staff tried to console him and he started with the same repetitive questions. This behavior had been constant for the last an hour and a half and he rotated between the staff. He had been unable to be redirected. He was listened to and he was talked to about his current plan of care and goals, they were ineffective and would often worsen the behaviors. On 8/23/23 at 10:35 a.m., he sat in his wheelchair outside of the Human Resource office, where the morning meeting was going on. The Administrator opened the door, answered his repetitive question regarding the date and when he could leave. The door was shut to commence with the meeting. He started yelling and cussing saying he was going to kill himself. The office door was opened and he was bashing his head into the door and door knob repetitively. Staff intervened and separated him from the door. The NP was notified and gave an order to send to him to the ER for evaluation, treatment and to be sent for a psych stay. 911 was called. On 8/23/23 at 3:29 p.m., he returned to the facility with a diagnoses of a UTI, and he quickly began cursing and threatened to harm self. On 8/23/23 at 6:31 p.m., he had been demanding since returning from the hospital. He was reminded to be patient with staff who answered his questions and he was going to go to psychiatric hospital as soon as a bed was confirmed this evening or Thursday the 24th. He was very verbally repetitive. If staff didn't answer his repetitive questions, he would threaten to harm self. He went so far as to say he was going to break the mirror on the wall with his head. He tried to bang his head on the wall. He was reminded him to be kind and to stop threatening to harm self every time someone does not answer him immediately. He yelled across the room to get staff's attention. He was called some of the staff the N word, as well. On 8/24/23 at 7:55 p.m., he was on a leave of absence to an inpatient psychiatric hospital. Confidential interviews were conducted during the course of the survey. During a confidential interview, it was indicated Resident B was very confused. He knew he was confused, he wanted to know why he repeated himself and why he couldn't remember things. They tried to think of things to get his mind off his notebook. He constantly said he was going to kill himself or hurt himself and said he did not like living like that. He wanted to live in a group home. The SSD had told him he was going to a group home if he didn't have behaviors for two weeks. The SSD started writing the date in a notebook he carried. They told him if he had a behavior they would push the date back. The confidential interview didn't know why they gave him a date and then changed it if he had a behavior. They heard the SSD and the Environmental Supervisor tell him he had to stay longer because he had behaviors. The confidential interview felt this made him have more behaviors and frustrated him. They kept telling him he had to go two more weeks because he had a behavior. During an interview with the Interim Administrator, on 8/29/23 at 2:12 p.m., she indicated she started at the facility on 8/20/23. She became aware of the incident with staff and Resident B, on 8/25/23, while investigating a workman's comp issue. She was told Resident B had hurt two staff members during a behavior incident with Resident B on 8/19/23 at 5:20 p.m., and it lead her to view the video footage. After watching the video, she reported the incident to the State Agency and suspended the three staff members. They said Resident B had behaviors most of the day on 8/19/23. They tried to give him a date for discharge, they told him if he didn't have behaviors for 14 days he could go to the group home. There was a facility behavior care specialist that had a good relationship with him, and tried to redirect him. She was able to calm him after the incident. Another resident, Resident D, was protective of the staff. He watched Resident B's behaviors increase and he was going to potentially intervene by using metal from a cat food can to hurt Resident B. She thought the staff were trying to remove Resident B from the situation to keep him safe as well as others. He was to the point where he was unmanageable. Staff called the police, they came and took him to a local hospital, and the hospital sent him back to the facility. CNA 12 called Resident B a nasty a--. She tried to contact CNA 12 and she did not show up for work. The nurse practitioner had made some changes to his medication and attempted to do things in-house. During an interview with the Administrator, on 8/29/23 at 2:53 p.m., she indicated Resident B had a notebook that said he was going to a group home. She had initially thought he was really going to a group home. She spoke with the SSD about what group home he was going to, and she told her he wasn't going to a group home. He had to be good for 14 days before he could go. During an interview with the SSD, on 8/29/23 at 4:02 p.m., she indicated she was working on finding a group home for Resident B. She had reached out to three group homes. One was close to where his family lived. They said he could not have physical/aggressive behaviors for 14 to 30 days. He had not been accepted yet. She told him when he met his goals, she would fax the group homes the information they needed. Everyday they wrote the date and how many days he had left at the facility before he was going to a group home. He carried the notebook around with him all day. He threatened to throw urine at the staff, he made self injurious threats. A couple weekends ago, he was spitting, threatened to throw urine, called staff names and threw a dresser drawer into the hall. If there were a lot of people around, he wanted all the attention focused on him. If there were less people around, he was more controllable . An undated current facility policy, titled ABUSE PREVENTION AND PROHIBITION POLICY, provided by the Interim DON, on 8/30/23 at 11:00 a.m., indicated the following: .Policy .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to verbal .and mental abuse .VERBAL ABUSE: Threatening a resident verbally, raising your voice to a resident in a scolding or abrupt manner, using offensive term/words .MENTAL ABUSE .saying anything to a resident which might cause him/her to worry or become alarmed .threats of punishment or deprivation This Federal tag relates to complaint IN00416170. 3.1-27(a)(1) 3.1-27(b)

A. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 2 of 6 residents reviewed for abuse (Residents P and N). Resident P experienced being bitten by Resident N. He was sent to the hospital and required antibiotics to treat the resulting wound. B. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 6 residents reviewed for abuse (Resident J). Findings include: A. During an interview with Resident P, on 8/9/23 at 12:36 p.m., he indicated he was bitten on his wrist by Resident N about two weeks ago. It was the second time he had been bitten while at the facility, but not by the same person. Resident N was pi--ing him off and everyone around him was telling Resident N to shut up so he put his hand over his mouth and he bit him. He bled like a stuck pig. The area hurt after he was bitten but it didn't hurt now, unless he bumped it. He was sent to the hospital, where they wrapped his arm and put him on an antibiotic. Resident N was a dumb a--. During the interview, Resident P's left wrist had two irregular shaped, dime sized scabs on it and the top of his left hand was bruised. Resident P's clinical record was reviewed on 8/9/23 at 9:52 a.m. Diagnoses included other specified disorders of brain, slurred speech, personal history of traumatic brain injury, post-traumatic stress disorder, chronic, and major depressive disorder, recurrent severe without psychotic features. His medications included duloxetine (depression) 30 mg (milligram) daily, divalproex sodium (mood stabilizer) 500 mg three times daily, risperidone (antipsychotic) 0.75 mg twice daily, and medroxyprogesterone acetate (hypersexuality)10 mg daily. He was administered amoxicillin potassium clavulanate (antibiotic) 875-125 mg every 12 hours for his left arm for seven days (7/21/23 - 7/28/23). A quarterly MDS (Minimum Data Set), dated 6/18/23, indicated he was severely cognitively impaired. He did not exhibit behaviors. He required extensive assistance of one staff member for transfers. He required supervision when walking in his room or the corridor. He used a walker and a wheelchair. He had a care plan for the potential for psychosocial well-being problems related to the incident with his peer (7/21/23). His interventions included consult with: pastoral care, social services, psychiatric services, etc. (7/21/23), encourage participation to make his own decisions (7/21/23), monitor/document his usual response to problems: Internal - how individual made his own changes, External - expected others to control problems or leaves to fate, or luck (7/21/23), and when conflict arose, remove him to a calm safe environment and allow him to vent/share feelings (7/21/23). He had a revised care plan for a history of physical aggression towards staff such as hitting, pushing, and shaking fists and placing hand over others mouth, etc. (7/21/23). His interventions included analyze times of day, places, circumstances, triggers, and what de-escalated the behavior and document (12/9/22), assess and address for contributing sensory deficits (12/9/22), encourage seeking out of staff member when agitated (7/21/23), and when he became agitated: intervene before agitation escalated, guide him away from sources of distress, engage calmly in conversation, if his response was aggressive, staff were to walk calmly away, and approach him later (12/9/22). His nurses notes indicated the following: An incident note, dated 7/21/23 at 12:57 a.m., indicated Resident P was sitting with another resident who was yelling, and he put his hand over the other resident's mouth. The other resident grabbed his arm and bit him on the arm, wrist, and hand. The aide and the nurse separated the residents. His arm was cleaned and the nurse called for an ambulance. He returned from the hospital with a dressing on his arm and antibiotics were given. His vitals were taken. A Social Service note, dated 7/21/23 at 10:41 a.m., indicated the night prior, Resident P was sitting by the nurses station next to a peer. The peer started yelling out and Resident P placed his hand over the peer's mouth and the peer bit him. The staff were able to separate them immediately and get them each to a safe area. The staff cleaned the area and he was sent to the hospital to be treated. He returned with a dressing to his arm and he was given antibiotics. He was unable to recall the incident this morning and he denied any psychosocial distress. A Nurse Practitioner (NP) visit note, dated 7/21/23, indicated the NP was notified the night prior, Resident P was involved in a peer to peer physical altercation. He allegedly put hand over another resident's mouth and the peer bit him. An order was given to send him to the ER (emergency room ) where his wound was addressed and he was started on antibiotic therapy. Today, he was at his baseline. No psychosocial distress was noted. His left arm was bandaged with bruising on his hand and his arm area. A skin/wound note, dated 7/22/23 at 4:49 p.m., indicated he had some large purple bruising on both hands and bite marks located on his left hand. There was swelling present and some drainage at the site. A nurses note, dated 7/22/23 at 4:51 p.m., indicated the resident had complaints of pain and discomfort at the site of the bite. A new dressing was applied due to drainage. A Social Service note, dated 7/24/23 at 2:20 p.m., indicated he denied any psychosocial distress related to incident with peer and he was unable to recall what happened. A social service note, dated 7/26/23 at 4:43 p.m., indicated he had no recall of the incident with the peer from last week and denied any psychosocial distress. Resident N was observed on 8/9/23 at 12:30 p.m. ambulating in the hallway near his room. He was talking loudly to himself with extra emphasis to each last word of a phrase he spoke loudly (don't do drugs, don't steal you will go to jail). He ambulated into his room and sat on his bed and continued to speak loudly to himself. Resident N's clinical record was reviewed on 8/9/23 at 10:15 a.m. Diagnoses included schizophrenia, profound intellectual disabilities, syngap1-related intellectual disability and generalized anxiety disorder. His medications included doxepin (anxiety) 50 mg three times daily, risperidone (schizophrenia) 1 mg in the afternoon and 4 mg twice daily, trazodone (insomnia) 150 mg daily, olanzapine (schizophrenia) 5 mg three times daily, perampanel (convulsions) 6 mg daily, benztropine mesylate (epilepsy) 1 mg twice daily, lacosamide (epilepsy) 200 mg twice daily and clobazam (convulsions) 10 mg twice daily. A significant change MDS, dated [DATE], indicated he was moderately cognitively impaired. He did not exhibit behaviors. He required supervision while walking in the corridor, and locomotion on and off the unit. He walked in his room independently. He had a revised behavior care plan for yelling out in the common area. He yelled he was given the wrong medication and yelled for Dr. Bombay, etc. (8/8/23). His interventions included allow him time to voice frustration (5/28/22), approach calmly and in a soothing, non-judgmental manner (5/28/22), assess for pain and toileting needs (5/28/22), if in a common area/high activity area, please take him to his room to assist him (5/28/22),offer him a shower (6/26/23), offer him a snack or drink (5/28/22), offer to call his father for him to talk to (6/13/22), and turn the TV to [NAME] of Hazard, Smokey and the Bandit, [NAME], etc. (6/26/23). He had a revised care plan for repetitive verbalizations i.e.: will yell over and over for Dr. Bombay, talk about dogs, etc. (5/28/22). His interventions included allow him to express feelings and concerns (5/28/22),establish a caring relationship with him (5/28/22), offer him a Dr. Pepper (6/13/22), offer him a shower (6/13/22), praise him for attempts to gain attention appropriately (5/28/22), relay accurate information to him (5/28/22), talk to him in a calm voice (6/13/22), and try to determine the reason for preoccupation with questions and verbalization (5/28/22). He had a revised care plan for the potential to be physically aggressive to others related to poor impulse control, grabbing at others, or/and attempting to/or hit/bite at others, tried to choke staff/placed arm around the staffs neck, he spat at the staff, he attempted to hit the staff, he poked his fingers in the staff faces', and bite others, etc. (7/21/23). His interventions included two staff members were to redirect him with aggression/increase agitation for safety (6/11/23), when he was agitated attempt to assist him to an area away from peers (6/11/23), and when he became agitated; intervene before the agitation escalated, guide him away from the source of distress, engage him calmly in conversation, if his response was aggressive, staff were to walk calmly away, and approach him later (12/6/21). He had a revised care plan for the potential to be physically aggressive to others related to poor impulse, grab at others, or/and attempt to/or hit/bite at others, try to choke staff/place arm around staffs neck, spit at staff, attempt to hit staff, poke his fingers in staff faces, bite others, etc. (7/21/23). His interventions included assess and address for contributing sensory deficits (12/6/21), assess and anticipate his needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. (12/6/21), monitor/document/report PRN (as needed) any sign or symptoms of resident posing danger to self and others (12/6/21), observe for any attempts to bite others and redirect as/if needed (5/15/23), offer snack/Dr. Pepper (7/21/23), offer to call his father for him to talk to (7/21/23), offer to put on Smokey and the Bandit, [NAME] of Hazard, or [NAME] (7/21/23), and offer to take him outside for a walk (7/18/23). A behavior note, dated 5/6/23 at 9:21 a.m., indicated he had been quietly walking around the common area dining room, hall, and lounge. A female resident was heard yelling out from in the front of the nurse's station. Resident N was found standing beside a female resident who was in her Broda (high back chair with wheels) chair with top of her right hand bruised and a bleeding from a skin tear. The QMA reported he just had her hand in his mouth. The residents were separated immediately. Resident N stated he wouldn't had to hurt her if she didn't hurt him. He was redirected to his room. A nurses note, dated 6/1/23 at 10:42 a.m., indicated he was readmitted from an inpatient stay at a neuropsychiatric hospital. He was started on 15-minute checks. An incident note, dated 6/7/23 at 10:33 p.m., indicated Resident N was being escorted to his room, as he had an increase in aggressive behaviors. Per the nurse report, Resident N bit her on her shoulder and placed his arm around her neck tightly. He then followed her as she came to the nurses station where he continued with his behaviors, throwing himself onto the floor and banging his body onto the floor. A call was placed to 911 dispatch to report incident. The police and EMT's arrived at the facility and Resident N continued shouting and threw himself on the floor. He was escorted by stretcher to a local hospital ER. A nurses note, dated 6/8/23 at 7:15 a.m., indicated he was transferred to a local psychiatric hospital. An admission summary note, dated 6/9/23 at 8:05 p.m., indicated he was readmitted to the facility from being treated for aggression, paranoid schizophrenia, and TBI (Traumatic Brain Injury). There were no new orders or changes received from his hospital discharge. The Psychiatric NP was in the facility and new orders were received to increase his risperidone 1 mg to three times daily from twice daily. He was calm and cooperative at the time, walking through-out facility with his visitor. He was alert to self and some situations. He was able to verbalize simple needs. His speech was loud and clear and his hearing was adequate. An incident note, dated 7/21/23 at 3:42 a.m., indicated Resident N was sitting by the nursing station along side another resident. Resident N was yelling and the other resident put his hand over his mouth. He grabbed the other residents arm and bit him. An aide and a nurse separated the residents and made sure they were in a safe area. The ambulance was called for both residents. Resident N did calm down and went with the ambulance people with no problems. A nurses note, dated 7/21/23 at 3:45 a.m., indicated Resident N arrived back from the hospital. He had no new orders from the hospital. He walked up and down the hallway talking to himself. He was asked if he wanted to lay down and rest. He declined and stated he wasn't tired. A social service note, dated 7/21/23 at 10:35 a.m., indicated Resident N was yelling by the nurses station. A peer was sitting next to him and placed his hand over his mouth. He grabbed the peers arm and bit him. During an interview with the Social Service Director, on 8/9/23 at 11:46 a.m., she indicated Resident P had verbal and physical behaviors. There were no other recent incidents besides putting his hand over Resident N's mouth. Resident N repetitively talked, he would put himself on the floor, bang on the wall, and he bit someone else months ago. She was not sure where the biting was coming from, but Resident P did put his hand over his mouth. She was not able to find anyone to take Resident N for a psychiatric stay. B. Review of a facility-reported incident, dated 7/25/23, indicated a staff member had expressed agitation towards a resident verbally. During an interview with Resident J, on 8/9/23 at 12:13 p.m., he indicated he did not have any concerns with the staff members in the facility and everyone was nice to him. He asked what the date was and that he would be going home on August 22. On 8/9/23 at 4:48 p.m., Resident J was observed sitting in his wheelchair in front of nurses station talking with staff. Resident J's clinical record was reviewed on 8/8/23 at 12:43 p.m. Diagnoses included alcohol dependence, Wernicke's encephalopathy, delusional disorders, mild cognitive impairment of uncertain or unknown etiology, drug induced subacute dyskinesia, major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, and psychotic disorder with hallucinations due to known physiological condition. His medications included, divalproex sodium (mood stabilizer) 750 mg twice daily, valbenazine tosylate (tardive dyskinesia) 40 mg daily, lithium carbonate (mood disorders)150 mg twice daily, quetiapine fumarate (depression) 300 mg at bedtime and 50 mg daily. An Admission MDS, dated [DATE], indicated he was cognitively intact. He had delusions. He had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds that occurred one to three days of the assessment period. He required supervision for locomotion on and off the unit. He had an impairment on one side of his lower extremity. He used a wheelchair. He had a care plan for the potential for psychosocial well-being problem related negative interaction with staff (7/25/23). His interventions included allow the him time to answer questions and to verbalize feelings, perceptions, and fears (7/25/23), monitor/document his usual response to problems: Internal - how individual makes own changes, External - expects others to control problems or leaves to fate, or luck (7/25/23), Monitor/document his feelings relative to incident with peer (7/25/23), when conflict arises, remove him to a calm safe environment and allow him to vent/share feelings (7/25/23). He had a behavior care plan for yelling in the common areas (7/17/23). His intervention included allow him time to voice frustrations (7/17/23), approach him calmly and in a soothing, non-judgmental manner (7/17/23), assess for pain and toileting needs (7/17/23), if he was in common area/high activity area, please take him to his room to assist him (7/17/23), and offer him a snack or a drink (7/17/23). During an interview with the Social Service Director, on 8/9/23 at 11:46 a.m., she indicated she followed up with Resident J afterwards, and they completed an investigation and reported the allegation. Dietary Aide 12 did not have a history of saying things to the residents like that. Resident J would ask repetitive questions, for example, what date was it, when was he going to the group home, and why did he have to stay at the facility. During a phone interview with Dietary Aide 12, on 8/9/23 at 2:27 p.m., he indicated his employment at the facility was terminated because Resident J wanted to call his mom and he was throwing a fit. While he was trying to get the phone for him, he tried to run over three or four nurses with his wheelchair near the nurse's desk. Resident J was about to hit him with his wheelchair, and was threatening to kill himself and the staff. The Dietary Aide was very touchy about the staff being hurt by the residents. He heard Resident J had assaulted police officers in the past. He had also attacked a nurse, bit her, and put her in a head lock. He told the resident not to be a f--king d--k. Resident J had alcoholic dementia, he wasn't going to remember anything that he said to him, and getting mad at him was pointless. He apologized to Resident J for cussing at him. He was just being over protective of the nurses. During an interview with the DON, on 8/9/23 at 12:42 p.m., she indicated she had heard Dietary Aide 12 called Resident J a d--k, but she did not hear it herself. Review of a current facility policy titled, ABUSE PREVENTION AND PROHIBITION POLICY, provided by the Interim Administrator, on 8/8/23 at 12:31 p.m., indicated the following: .Policy .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to physical, verbal .abuse This Federal tag relates to complaint IN00413773. 3.1-27(a)(1) 3.1-27(b)

Based on observation, record review and interview the facility failed to prevent physical abuse of a dependent resident (Resident B) by another resident (Resident E) for 1 of 4 residents reviewed for abuse. This deficient practice resulted in Resident B being sent to the hospital for evaluation of pain and experiencing fear for safety and ridicule when returning to the facility. Findings include: During an interview on 3/29/2023 at 9:50 a.m., Resident B indicated Resident E had entered her room and sat on her feet. The resident indicated her feet were very sensitive and Resident E had caused significant pain. Resident E had also loved on her breast. She had blown a whistle several times to call for help during the incident and repeatedly asked Resident E to leave. The resident was holding a whistle in her right hand during the interview and indicated she kept it with her at all times for safety. During an interview on 3/29/2023 at 10:21 a.m., Resident C, roommate of Resident B, indicated Resident E entered their room and she told him to leave. Resident E did not leave and walked to Resident B's side of the room. Resident C indicated she could see Resident B's bed and saw Resident E get on the bed and lay on Resident B's feet. Resident C indicated Resident B blew her whistle several times to call for help and Resident C put on the call light. Staff came and removed Resident E from their room. Resident C indicated no one had asked her what she witnessed or anything about the incident. During an interview on 3/29/2023 at 12:50 p.m., CNA 5 indicated Resident E was physically strong. The CNA did not believe Resident E had the cognitive ability to know how to climb onto Resident B's bed. Resident B kept the bed in a higher position. During an interview on 3/29/2023 at 11:18 a.m., the Director of Nursing (DON) indicated, on 3/17/2023, she was working late and the police had arrived in response to a 911 call for an allegation of sexual assault. The facility did not know who called the police. The police said Resident B had called them. Paramedics also responded. When the facility and police interviewed Resident B, the resident indicated she called because of pain in her feet and she wanted to go to the hospital. The resident was transported to the hospital for evaluation. The DON indicated the facility had reviewed the security video and it showed, during the day, only one male resident had entered the room and was in the room for only a short period of time. The police call report, provided by the Administrator on 3/30/2023 at 9:05 a.m., indicated the 911 call came in on 3/17/2023 at 11:41 p.m. The report indicated the resident alleged another resident sat on her feet and laid on top of her. The resident requested an ambulance due to pain in her feet and demanded to talk to a police officer. The police report indicated the DON told officers the security cameras showed no one had entered the resident's room. During a interview on 3/31/2023 at 10:44 a.m., the hospital Case Manager indicated the DON had indicated the facility security video showed Resident E was in Resident B's room for approximately ten seconds. The DON told the Case Manager Resident E would have been unable to climb onto Resident B's bed. The Case Manager indicated they had known the resident for several years and Resident B had a diagnoses of Post Traumatic Stress Disorder and the cause was believed to be sexual in nature. The hospital discharge report, dated 3/18/2023, indicated Resident B alleged another resident entered her room and sat on her feet, climbed on the bed, and fondled her breast. The resident denied sexual assault stating the other resident did not know what he was doing. The resident was medicated with Toradol (analgesic) for pain. The resident did not want to press charges and did not want to return to the facility, due to not feeling safe. The resident reported hyperalgesia (increased pain or sensitivity) in the feet and had increased pain in bilateral feet since the incident. The resident was also bothered by the facility staff telling EMS they were sorry for wasting their time while they were transporting the resident out of the facility, and felt her concerns were not being taken seriously. Review of hospital bilateral ankle x-rays, dated 3/18/2023, indicated no acute displaced fractures, symmetric dorsal soft tissue swelling of feet, and severe bone demineralization due to patient being non-ambulatory as a result of cerebral palsy. An undated, written statement by CNA 2 indicated at 8:40 a.m. (no date given) Resident B's whistle was heard. The CNA entered the room and found Resident E leaning on the resident's wheelchair, eating one of her cupcakes. Resident B told the CNA that Resident E had been on her chair and never indicated anything about Resident E assaulting her. During an interview on 3/29/2023 at 12:23 p.m., CNA 2 confirmed the written statement. The CNA indicated she forgot to date the statement but it was written a couple of days after the incident. The incident happened the day after Resident B's birthday, because Resident E was eating the birthday cupcakes provided by the DON. During an interview on 3/29/2023 at 12:57 p.m., CNA 6 indicated the day of the incident she had heard Resident B blowing her whistle and CNA 2 had responded. Review of the facility security audio/video for 3/17/29023 at 8:24 a.m. through 9:07 a.m., completed on 3/20/2023 at 11:00 a.m. with the Assistant Director of Nursing (ADON), indicated the following: a. At 8:25 a.m. Resident E was seen entering Resident B's room. b. At 9:02 a.m. a whistle could be heard being blown multiple times. c. At 9:05 a.m. a staff member was observed passing the room, while the whistle was being blown, without investigating. d. At 9:07 a.m. Resident E was seen leaving Resident B's room. He had been in the room a total of 42 minutes. No staff member was observed entering or leaving the resident's room during the time period reviewed on the video. During an interview at the time of the video review, the ADON indicated she had not been in the facility during the day on 3/17/2023, but had been working that night. The ADON indicated she was present when the police arrived and reported Resident B had made an allegation of sexual assault. The DON told her Resident B had denied the sexual assault and was sent to the hospital for pain in her feet. The ADON indicated Resident E was strong enough to climb onto Resident B's bed. 1. The clinical record for Resident B was reviewed on 3/29/2023 at 9:11 a.m. Diagnoses included, cerebral palsy, scoliosis, post-traumatic stress disorder, anxiety, depression, borderline personality disorder, and paranoid personality disorder. The most recent admission Minimum Data Set (MDS) assessment, dated 1/30/2023, was reviewed on 3/29/2023 at 9:11 a.m. The MDS indicated the resident required extensive assistance of 2 persons for bed mobility, transfers, toilet use, personal hygiene and dressing. The resident had impairment in the upper and lower extremities on both sides. Resident B was assessed as being cognitively intact. A progress noted, dated 3/18/2023 at 12:09 a.m., indicated Resident B had called the police with an allegation of sexual assault. The resident denied sexual assault when interviewed by the police and facility staff, but complained of pain in both feet. The resident was taken to the hospital for evaluation. 2. During an observation on 3/29/2023 at 1:40 p.m., Resident E was going from sit to stand without assistance, and was ambulating in the hallway independently. During an observation on 3/30/2023 at 1:47 p.m., Resident E was observed ambulating in the hallway while holding hands with a female resident. Resident E stopped and grabbed handrails and jerked repeatedly, as if trying to pull them off the wall. He was redirected by staff and continued to ambulate in the hallway. The clinical record for Resident E was reviewed on 3/29/2023 at 1:23 p.m. Diagnoses included, Wernicke's encephalopathy, anxiety disorder, violent behaviors, dementia with behavioral disturbances and severe agitation, depression, hallucinations, and delusional disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 3/9/2023, indicated the resident was severely cognitively impaired. Resident E had a care plan, dated 2/6/2023, indicated a potential to be physically aggressive. Goal: The resident will not harm self or others through the review date. Resident E had a care plan, dated 2/6/2023, for wandering aimlessly without regards to needs or safety. Goal: Resident will not wander from facility nor injure self or others while wandering daily through next review. 3. The clinical record for Resident C was reviewed on 3/29/2023 at 12:13 p.m. The most recent admission MDS assessment, dated 3/1/2023, indicated the resident was cognitively intact. During an interview on 3/29/2023 at 2:07 p.m., the Social Services Director indicated Resident C was reliable with no behaviors of making false allegations. An undated policy, titled ABUSE PREVENTIONS AND PROHIBITION POLICY, provided by the DON on 3/29/2023 at 12:51 p.m., indicated the following: .PURPOSE: To ensure the resident's right to remain free from .physical abuse .POLICY .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to physical .abuse This Federal tag relates to complaint IN00404302. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by Resident C and Resident E for 4 of 4 residents reviewed for abuse (Resident B and Resident D). This deficient practice resulted in fear and tearfulness for Resident B, and using the reasonable person concept, would cause fear and anxiety for Resident D. Findings include: 1. During an interview with Resident B, on 2/24/23 at 11:28 a.m., she indicated Resident C had grabbed her by her neck and choked her, she didn't know why she had done it. She had been crying, but she was somewhat okay now. Review of Resident B's nurse's notes indicated the following: On 2/10/23 at 5:30 p.m., the CNA called the nurse to Resident B's room. The CNA had just been coming back up the hall and saw Resident C in the room, hitting Resident B and choking her. She had stopped Resident C and separated the residents. The nurse spent several minutes calming Resident B and doing relaxed breathing exercises. Resident B said thank you. I love you, grandma, and she didn't want Resident C with her no more. Fifteen-minute checks were initiated. The Administrator, and the psychiatric NP (Nurse Practitioner) were notified. On 2/10/23 at 7:17 p.m., a social service note indicated Resident C was in her room when staff walked by and observed Resident C hugging Resident B aggressively. The staff had separated the residents immediately. Nursing completed a skin assessment, and she denied any distress related to the incident. She was moved to another room and her care plan was updated. During an interview with RN 26, on 2/24/23 at 1:30 p.m., she indicated she saw nothing. She charted just what the aide told her. There was no indication that Resident C had her hands on Resident B. Resident B said Resident C was choking her and had hit her in her breast. She did not have red marks; she had a tiny pale mark on her right clavicle area. Resident B was dramatic. This day, Resident B had asked why there was a camera and she indicated to her cameras don't lie. Resident C had escalated the day in question. She did believe Resident C had touched Resident B, and went to her bedside, but she had never seen Resident C be physically violent. She punched at the air and got loud, very loud. She did not see Resident C push Resident D down, as she was sitting behind the nurse's station at the time, and she couldn't see over the desk. She couldn't remember who, but someone else said later it wasn't a push. During an interview with CNA 13, on 2/24/23 at 2:16 p.m., she indicated she was assisting another resident when she heard CNA 7 hollering for a nurse. She went to Resident B's and C's room and saw that she was in bed with Resident C's hands around her neck, her face was red, and she was gasping for air. They were trying to separate them, but Resident C kept trying to get to her, and CNA 7 was in the middle of them. The nurse was not in the room yet, so she went to get her. Once they got them separated, she tried to talk to Resident C, and for her to think about what she was doing and had tried to redirect her. She had never seen Resident C put her hands on another resident. She would get worked up every once in a while and was known to yell at residents and slam doors. She liked her privacy and didn't like for people to go through her stuff. During an interview with CNA 17, on 2/24/23 at 2:31 p.m., he indicated he heard staff screaming for help and entered Resident B's room. Resident B and C were mostly separated when he entered the room. Resident B's face was red and her lips were blue. She was lying in bed, with her covers on, and Resident C was on the side of her bed, between her bed and the window. Resident C was actively swinging at Resident B, and was hitting her on the side of her head with the side of her hand. CNA 7 was behind Resident C, trying to pull her off Resident B. They had to physically remove Resident C from the room for Resident B's safety. He spent between 30 to 40 minutes walking with Resident C, trying to calm her down while nurses were checking on Resident B. She calmed down, but was still in a distressed state, and she was not excited to see the EMTs at the facility. She didn't normally assault anyone. She would scream almost to the point of passing out and could almost be manic. She had behaviors, but not violent with the residents. She gave a lot of warning signs before she would get violent. During an interview with Laundry Aide 8, on 2/24/23 at 4:12 p.m., she indicated Resident C was in the hallway rambling, and doing her schizophrenic thing at the nurse's station. Resident D was standing near the short wall, and she intentionally pushed Resident D with both hands on her chest, and she fell to the floor and onto her bottom, another resident was behind her and bent down to keep her from hitting her head on the half wall. Resident D was helped up off the floor and didn't act like she was hurt. Resident C kept acting out, rambling and swinging at RN 26 but didn't hit her. She refused to go on the ambulance. A couple CNAs got her to go outside and got her on the gurney. She seemed to have her screaming outbursts more often. She had never seen her touch another resident or staff until that day. Resident B was shook up by what Resident C had done to her. During an interview with CNA 7, on 2/27/23 at 10:02 a.m., she indicated she took a resident to her room, and when she walked back by Resident B and C's room, Resident C was yelling and screaming. The curtain was pulled but it looked like Resident C was pounding on something. Resident C was on Resident B's right side between her bed and the window, she was pounding on Resident B with the bottom of her fist in her chest area Resident B was screaming but couldn't hear her because of her voice is so low, then Resident C had both hands around Resident B's neck and was choking her. Resident B was turning blue. She started yelling and screaming for help. CNA 17 walked past the room and grabbed Resident C's other hand and redirected her out of the room. CNA 17 also yelled for help. RN 26 came down to the room and checked Resident B's neck. Once Resident C was removed from the room she immediately started pushing and yelling at staff in the halls. She pushed Resident D down hard with both hands to her chest area and Resident D hit the floor. She was yelling and cussing and telling everyone to get out of her way, they tried to calm her down. RN 26 immediately tried to step in front of Resident D while they were helping her up and Resident C started hitting RN 26. By then the EMTs were at the facility and they couldn't force her to go. Herself and another aide proceeded to grab Resident C from hitting other residents and she kicked QMA 24 in the leg. She had never seen Resident C be aggressive or have physical contact with another resident. She would just go off, by yelling and screaming. Resident B's clinical record was reviewed on 2/24/23 at 9:42 a.m. Diagnoses included major depressive disorder, recurrent, down syndrome, schizoaffective disorder, bipolar disorder, mild cognitive impairment of uncertain or unknown etiology, need for assistance with personal care, and muscle weakness (generalized). Her medications included hydrocodone-acetaminophen (narcotic pain reliever) 5-325 mg (milligram) twice daily, fluoxetine (treat depression) 20 mg daily, asenapine maleate (treat mental disorders) 10 mg twice daily, trazodone (treat sleep disorder) 200 mg daily, and olanzapine (treat mental disorders) 15 mg daily. An admission MDS (Minimum Data Set), dated 1/30/23, indicated she was moderately cognitively impaired. She required limited assistance for bed mobility and locomotion on and off the unit. She required extensive assistance for transfer, dressing, toilet use and personal hygiene. She required supervision for walking in her room and the corridor. She used a wheelchair. She had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred one to three days during the assessment period. She had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days during the assessment period, and she wandered one to three days during the assessment period. She had a current care plan for the potential for psychosocial well-being problem, related to an incident with a peer, initiated on 2/10/23. Her interventions were initiated on 2/10/23 and included the following: pastoral care, social services, psychiatric services, etc., encourage participation from resident who depends on others to make own decisions, increase communication between resident/family/caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options, monitor/document resident's usual response to problems: internal - how she made her own changes, external - expects others to control problems or leaves to fate, or luck, provide opportunities for her and family to participate in care, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. 2. Review of Resident D's nurse's notes indicated the following: On 2/2/23 at 8:15 a.m., Resident D was walking in the hallway, and Resident E came up behind her, and hit her in the neck and upper back area. There were no skin issues, distress or discomfort noted. On 2/10/23 at 5:45 p.m., in the front, left side of the nurse's station, a CNA asked the nurse if she had seen Resident C reach between the EMTs and push Resident D down to the ground. ROM (Range of Motion) was checked, and she was able to move all four extremities without difficulty. She had no signs or symptoms of pain or discomfort. She had no verbal response, per her baseline. She was free of reddened, discolored, or open areas. She was assisted onto her feet by two CNAs, with extensive assistance. She walked away into the dining room. On 2/24/23 at 1:30 p.m., Resident D was observed ambulating independently in the hall and common area. On 2/27/23 at 10:27 a.m., she was observed sitting on the couch in the common area with her head down. On 2/27/23 at 1:00 p.m., she was observed sitting on the couch in the common area. Resident D's clinical record was reviewed on 2/24/23 at 11:18 a.m. Diagnoses include unsteadiness on feet, other lack of coordination, restlessness and agitation, generalized anxiety disorder, muscle weakness (generalized), cognitive communication deficit, delusional disorders, unspecified dementia, severe, with psychotic disturbance, agitation, anxiety, and other behavioral disturbance. Medications included buspirone (treat anxiety) 10 mg four times daily, medroxyprogesterone acetate (treat hypersexual behaviors) 5 mg daily, escitalopram oxalate (treat depression) 20 mg daily and olanzapine 5 mg twice daily. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance for bed mobility, transfers and toilet use. She required limited assistance for walking in her room and the corridor, and for locomotion on and off the unit. She required extensive assistance for dressing and personal hygiene. She did not use an assistive device. She had delusions. She had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred one to three days during the assessment period. She had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), she rejected evaluation of care and wandered four to six days of the assessment period. She had a current care plan for the potential for psychosocial well-being problem, related to a peer attempted to smack at her initiated on 2/2/23. Interventions were initiated on 2/2/23 to allow her time to answer questions and to verbalize feelings perceptions, and fears, monitor/document her usual response to problems: internal - how individual made her own changes, external - expects others to control problems or leaves to fate, or luck, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. The ADON provided a copy of the 2/10/23 at 5:45 p.m., progress note for Resident D, with a handwritten statement by the ADON dated 2/11/23, indicating the following: Per follow up, it was determined that contact was never made. Nurse did not visually witness and CNA stated it appeared that way but never actually seen contact. So actual push was assumed During an interview with RN 41, on 2/27/23 at 11:27 a.m., she indicated staff were sitting at the nurse's station. Resident E had just come back from the hospital and was having behaviors. Resident D was wandering up and down the hall like she always did. Resident E thought Resident D had on a red sweatshirt that was hers. Resident E open-handed slapped Resident D in the neck and upper back. Resident D just kept walking. Resident E was taken back to her room and Resident D came up by the nurse's station. The incident was reported to Social Service because she was in the building at the time, and she was going to call the Administrator. Skin assessment and vitals were completed under risk management. 3. Resident C's clinical record was reviewed on 2/24/23 at 9:58 a.m. Diagnoses included schizoaffective disorder, bipolar type, unspecified intellectual disabilities, post-traumatic stress disorder, delusional disorder and anxiety disorder. Medications included quetiapine fumarate (treat bipolar disorder) 200 mg twice daily, haloperidol (antipsychotic) 5 mg three times daily and buspirone (treat anxiety) 15 mg four times daily. A quarterly MDS, dated [DATE], indicated she was moderately cognitively impaired. She required extensive assistance for bed mobility and toilet use. She required supervision for locomotion on and off the unit. She required limited assistance for dressing and personal hygiene. She did not use an assistive device. She had hallucinations and delusions. She had a behavior care plan, initiated on 8/23/22 and revised on 2/10/23, for yelling out in common areas, cursing, etc. Her interventions were initiated on 8/23/22 and included allow her time to voice frustrations, approach calmly and in a soothing, non-judgmental manner, assess for pain and toileting needs, if in common area/high activity area, please take me to my room to assist me, offer her a snack or drink and psychiatric consult as needed. She had a care plan, initiated on 2/10/23, for was/had potential to be physically aggressive. Her interventions, initiated on 2/10/23, were administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., monitor/document/report PRN any signs or symptoms of resident posing danger to self and others, when the she became agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of her nurses notes indicated the following: On 2/1/23 at 2:37 p.m., she got upset and threw blue water pitcher down the hall. On 2/1/23 at 4:21 p.m., she was in the common area, in the chair when she began to scream out loudly. Another resident was talking to himself when she rose up from the chair and started to yell at him These terrorists, same s---, different day. On 2/10/23 at 1:15 p.m., she had been rapidly pacing the halls and the common areas, while yelling and screaming in very loud aggressive tone on and off all morning. A call was placed to the psychiatric NP with a new order for no caffeinated coffee and to give afternoon Haldol (antipsychotic), early one time. On 2/10/23 at 5:30 p.m., the nurse was called to her room by the CNA that she needed a nurse right now. I need a nurse right now. The CNA said that she was just coming back up the hall and I saw Resident C on Resident B's side of the room and she was hitting her and choking her. She came in and stopped her right away. Resident C was in the hall screaming that the aliens were yelling and being overdosed on melatonin that was really medical marijuana. She was screaming loudly, her voice becoming hoarse and she was unable to be de-escalated. She paced rapidly. Resident C and B were separated, safety ensured, 15 minute checks were initiated immediately and the Administrator and psychiatric NP was notified a new order was received to send her to the emergency room for evaluation and treatment. A social service note, dated 2/10/23 at 5:31 p.m., indicated upon arrival to facility this morning resident was walking rapidly up and down the halls yelling, cursing, and screaming. Not talking to anyone, but just yelling and cursing. She was asked what was wrong and she stated she was being overdosed with melatonin, the aliens kept her up all night and kept yelling as she was walking. She was able to be calmed down. She continued to have episodes of yelling, cursing up and down the halls about every half hour or so this day. Multiple staff attempted to redirect her with multiple interventions and none were successful but for a few minutes at a time. Around 1:20 p.m. the psychiatric NP was notified about her behaviors and she gave an order for staff to administer her 2:00 p.m. Haldol early. She refused and threw the medication at first. After a few minutes, she took the medication as she was yelling and cursing about being drugged, kidnapped, etc. After the medication was administered she calmed for about 45 minutes, but then started to yell and curse again with talking to no one in particular. On 2/10/23 at 5:45 p.m., two EMTs were present with a stretcher to transfer her to the hospital. She refused to get on the stretcher, and stated she was not going. Then, the CNAs reported she had just reached between them and pushed another resident down on the ground. Staff attempted to calm her, and she pointed her finger aggressively at the nurse and screamed harshly that the nurse f-----g killed [NAME] and reached out and hit the nurse on her left forearm and right hand. Resident C was walked out to the ambulance. A social service note, dated 2/10/23 at 7:12 p.m., indicated Resident C was in her room with her roommate, when staff walked by and seen her aggressively hugging her roommate. Staff intervened immediately and they were separated. She was placed on one on ones while the psychiatric NP was called. The NP wanted her sent to the emergency room for evaluation. When EMT's arrived to take her, she refused to go and was yelling, screaming, and hitting staff. She did get on the stretcher and allowed to be taken to the emergency room . An IDT (Interdisciplinary Team) note, dated 2/12/23 at 9:36 a.m., indicated after interviewing staff and residents, during the altercation she had with the EMTs, it was determined she didn't push the other resident. The other resident in question was wondering the halls and happened to be by the altercation. 4. Resident E's clinical record was reviewed on 2/27/23 at 10:25 a.m. Diagnoses included Parkinson's disease, schizophrenia, major depressive disorder, recurrent, anxiety disorder, altered mental status, cognitive communication deficit, unspecified mood [affective] disorder, severe intellectual disabilities, personal history of traumatic brain injury, unspecified convulsions and anoxic brain damage. Her medications included lacosamide (treat seizures) 150 mg twice daily, risperidone 1 mg three times daily, buspirone 15 mg three times daily, lorazepam (treat anxiety) 1 mg three times daily, and divalproex sodium (anticonvulsant) 500 mg three times daily. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance for bed mobility, transfers and toilet use. She required limited assistance for walking in her room and corridor, locomotion on and off the unit. She required extensive assistance for dressing, and personal hygiene. She had an impairment to one side of her upper extremities. She rejected evaluation or care and wandered one to three days during the assessment period. She had a care plan, initiated on 3/4/21 and revised on 2/2/23, for episodes of physical aggressive and behaviors of throwing items at staff ie: glasses and stuffed animals. She attempted to smack at others due to belief that others had her belongings. Her interventions were initiated on 3/4/21, to administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and anticipate her needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., communication: assist verbalization of source of agitation and give positive feedback, give the her as many choices as possible about care and activities, monitor/document/report PRN (as needed) any signs or symptoms of resident posing danger to self and others, when she became agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. A mental health clinician would work with her on positive and negative ways to display her anger initiated on 4/28/21. She had a current care plan problem of potential for a psychosocial well-being problem related to alleged incident with peer initiated on 12/6/21. Her interventions were monitor/document her usual response to problems: internal - how individual makes own changes, external - expects others to control problems or leaves to fate, or luck and when conflict arises, remove residents to a calm safe environment and allow her to vent/share feelings initiated on 12/6/21. Consult with: pastoral care, social services , psychiatric services revised on 12/11/21. Review of her nurses notes indicated the following: On 2/2/23 at 7:41 a.m., she continuously screamed out and yelled at other residents. She thought other resident's items were hers. She attempted to grab items from others. She got upset with redirection and threw her glasses into the dining room. On 2/2/23 at 8:04 a.m. she was walking down the hall when another resident was in the hallway. She believed her shirt was on the other resident. She began to shout and hit the other resident in the back and the neck. They were separated and she was redirected to her room. She continued to shout as she was redirected. A social service note, dated 2/2/23 at 12:42 p.m., indicated she was yelling and screaming, attempted to grab items from others, due to belief that the items were hers, and when staff attempted to redirect her, she became upset and threw her glasses. A little later she was walking down the hall and believed that a peer had on her shirt. She started yelling and smacked at the residents back. A late entry, IDT note dated 2/6/23 at 7:06 p.m., indicated an intervention of 15 minute checks was implemented. She was safe afterwards. An current, undated, facility policy, titled ABUSE PREVENTIONS AND PROHIBITION POLICY, provided by the Administrator on 2/24/23 at 9:41 a.m., indicated the following: PURPOSE: To ensure the resident's right to remain free from .physical abuse .POLICY .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to physical .abuse Cross reference F609. This Federal tag relates to complaint IN00401525. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to prevent physical and emotional abuse for 1 of 3 residents reviewed for abuse prevention (Resident F). Using the reasonable person concept, it is likely this deficient practice would lead to chronic anxiety, or fear. Findings include: The clinical record for Resident F was reviewed on 11/14/2022 at 10:31 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a current quarterly Minimum Data Set (MDS) assessment, dated 9/15/2022, indicated the resident was severely cognitively impaired. Review of Resident F's current care plans indicated the following: Resident has behaviors not directed towards others of crawling on the floor and into hall. Date Initiated: 02/23/2021 Revision on: 02/23/2021. Goal: Resident will have no injury related to crawling on the floor and in the halls through next review. Date Initiated: 02/23/2021 Revision on: 09/05/2022. Interventions: Assess for pain and toileting needs. Date Initiated: 02/23/2021. Offer snack or drink. Date Initiated: 02/2021. Psych consult as needed. Date Initiated: 02/23/2021. Resident has episodes of disrobing as evidenced by: will take off all of her clothes and come out of room Date Initiated: 02/20/2021 Revision on: 02/20/2021. Goal: Resident will remain adequately clothed, maintain dignity, and will stop disrobing through next review. Date Initiated: 02/20/2021 Revision on: 09/05/2022. Interventions: Asses for pain, toileting need, etc. Date Initiated: 03/03/2021. Instruct resident to not disrobe and reorient to surroundings as needed. Date Initiated: 02/20/2021. Observe resident frequently for intact clothing. Assist with putting clothes back on as needed. Date Initiated: 02/20/2021. Offer food, snack. Date Initiated: 03/03/2021. Question resident to ascertain any possible needs (toileting, etc.) Date Initiated: 02/20/2021. Refer to activities for diversion, if appropriate. Date Initiated: 02/20/2021. A security video, dated 10/30/2022 from 9:04 a.m. to 9:37 a.m., was reviewed on 11/14/2022 at 12:17 p.m. with the acting Administrator. During the review the following was observed: At 9:04 a.m., the resident was observed on the floor, crawling into the hallway, naked. The Laundry Supervisor and the Housekeeping Supervisor were observed in the area. These employees did not approach the resident. At 9:31 a.m., CNA 1 approached the resident. Audio was not clear and no verbal exchange could be heard. The CNA did not cover the resident, nor appear to attempt to assist or direct her back into her room. At 9:36 a.m., CNA 1 was observed dragging the resident into her room. Due to the angle and quality of the video, it was not clear if the CNA dragged the resident by the arm or leg. At 9:37 a.m., CNA 1 observed leaving the resident's room. During the video review, from 9:04 a.m. to 9:37 a.m., the resident could be seen rolling around on the floor and attempting to sit up and fall back onto the floor (for a 33 minute period). During these 33 minutes, several staff members were observed walking past the resident with no attempts to cover the resident or take her back to her room. Several resident's (male and female) were observed walking past or attempting to maneuver around Resident F in wheelchairs. Staff members did not assist or provide interventions. The resident remained on the hallway floor, naked, for thirty-three minutes. At 10:02 a.m., the resident was observed on the floor crawling into the hallway. The resident was again naked. The Laundry Supervisor and the Housekeeping Supervisor were observed walking past the resident. Male and female residents were observed walking or maneuvering wheelchairs around Resident F. At 10:04 a.m., CNA 2 was observed walking around the resident without intervention. At 10:15 a.m., CNA 2 was observed attempting to cover the resident with a gown. CNA 1 and CNA 2 were observed picking the resident up off the floor and taking her into her room. Resident F remained on the floor, naked and without intervention for an additional thirteen minutes. During an interview, at the time of the video viewing, the acting Administrator and the ADON each indicated the staff had not met the resident's needs. The acting Administrator indicated the resident should never have been left on the floor naked in a common area. Staff should have attempted to take the resident back to her room and dressed her or put a gown or covering on her while she was in the hallway. The resident should not have been dragged on the floor. The acting Administrator indicated CNA 1's employment had been terminated. During an interview, on 11/14/2022 at 1:47 p.m., Laundry Aide 7 indicated he had worked on October 30, 2022. The Laundry Aide indicated he saw Resident F on the floor naked. The resident is known for this behavior and does it daily. During an interview, on 11/14/2022 at 1:47 p.m., QMA (Qualified Medication Assistant) 6 indicated on October 30, 2022, she had seen Resident F naked on the floor in hallway several times. The QMA indicated she did not provide covering or any intervention for the resident. We had a lot of behaviors that day. It is not an excuse, to indicate the resident should not been left uncovered. During an interview, on 11/14/2022 at 2:26 p.m., CNA 5 indicated Resident F was known for disrobing in common areas and crawling on the floor. The CNA indicated staff were to attempt to get her back to her room and put clothes on her or cover her while she was in the common area. The CNA indicated it would not have been appropriate to leave the resident naked on the floor. During an interview, on 11/15/2022 at 10:18 a.m., the Assistant Director of Nursing indicated staff did not act appropriately. Resident F should have been redirected to her room and clothed. If the staff could not redirect the resident back to her room, they should have placed a gown on her or covered her while in the hallway. The ADON indicated the resident should not have been dragged across the floor to her room by staff. Review of a current undated policy titled Abuse Prohibition indicated the following: .Procedure . 2. Should an occurrence of abusive behavior be reported or witness, the Administrator shall be notified immediately . 4. The staff who witness or was made aware of the abusive incident will take immediate steps to protect The involved resident from further abuse, including verbal/mental/physical/neglect/involuntary seclusion and/or exploitation. Such steps could include, but are not limited to: a. Physically removing the resident(s) from the abusive environment. b. Physically removing the perpetrator of the abuse from the environment This Federal tag relates to complaint IN 778. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to ensure a severely cognitively impaired resident, who was at risk for elopement and a high risk for falls, received adequate supervision to prevent elopement from the locked facility, as evidenced by the resident being able to exit the facility without detection of the staff. This failure resulted in the resident being without supervision and exposed to hazardous elements/conditions such as: uneven roads, drainage ditches, thick wooded areas, corn fields and no sidewalks for 1 of 3 residents reviewed for elopement. (Resident B) The immediate jeopardy began on 10/18/2021 when a severely cognitively impaired resident eloped from the locked facility and the facility was notified by a concerned citizen. The Administrator was notified of the immediate jeopardy on 10/22/2021 at 2:40 P.M. Findings include: The clinical record for Resident B was reviewed on 10/22/2021 at 10:00 A.M. Diagnoses included, but were not limited to, paranoid [CONDITION(S)], seizures, anxiety disorder, dementia with behavioral disturbances, peripheral [CONDITION(S)]. The resident was admitted to the facility on [DATE]. Review of the most recent Significant Change Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 5 out of 15. The resident also required supervision with set up for ambulation and used a walker. The resident had exhibited worsening wandering behaviors for 4 to 6 days during the MDS assessment period. Review of a behavioral care plan, last revised on 9/7/2020, indicated the resident had a diagnosis of [CONDITION(S)] with symptoms of paranoid thoughts, agitation, [CONDITION(S)], anxiety, and a history of hallucinations, delusions of an imaginary friend with whom she would have discussion or arguments. Review of behavioral care plan, initiated 3/26/2020, indicated the resident had a history of wandering and exit seeking. Interventions included, but were not limited to, checking resident's location frequently. Review of a care plan for anxiety, dated 9/7/2020, indicated the resident had a history of anxiety with symptoms such as: repetitive questions, concerns, and complaints, wringing of hands with conversation, agitation and frustration due to the belief she did not belong in a nursing home. Review of a falls care plan, initiated 1/5/2020, indicated the resident was a high risk for falls. Review of an elopement assessment, dated 10/12/2021, indicated the resident was at high risk for wandering. The Acting Executive Director (ED) indicated the terms wandering and elopement had the same meaning for the assessments and care planning. Review of a nursing progress note, dated 9/17/2021 at 1:02 P.M., indicated the resident verbalized a desire to leave the facility. I am sick of the government controlling us. Then yelling that Staff is locking us in here, I want out. Residentyelling [sic] all her things and brought them to the front of the building when stated that she could not go resident became upset and started to yell. Stated that I am notgoing [sic] to hurt myself or anyone else. Review of a Behavior Management Monthly Review, dated 10/5/2021, indicated the resident demonstrated the following behaviors and frequencies: a. Delusional thoughts 17 times b. Hallucinations 17 times c. Repetitive health related complaints 7 times d. Wandering 11 times e. Depression 4 times f. Increased anxiety 10 times g. Repetitive anxious complaints 12 times Review of a nursing progress note, dated 10/15/2021 at 10:30 P.M., indicated the resident was wandering the hallways all evening, looking out different doors and the window in her room while talking to herself. Staff attempted to re-direct the resident with offers of snacks and activities. The resident continued to talk to herself and her imaginary friend. The resident's anxiety and agitation increased throughout the evening. The resident became aggressive and struck staff while they attempted to engage her in 1 on 1 conversation. The note indicated all interventions were not effective and an order for [MEDICATION(S)] (antipsychotic) was obtained, administered and resident was placed on 15-minute checks. The Acting ED indicated the 15-minute checks were put into place due to the resident's wandering behaviors. Review of a nursing progress note, dated 10/18/ at 11:30 A.M., indicated the resident was not in her room when the CNA (Certified Nursing Assistant) brought the residents lunch tray. Review of a nursing progress note, dated 10/18/2021 at 12:33 P.M., indicated the resident was last seen in her room at 11:15 A.M. At 11:45 A.M., the facility received a call from an unknown citizen stating a woman with a walker and walking funny had been seen walking down the street. At 11:47 A.M., staff left the facility with the intent to bring the resident back to the facility. When staff approached, the resident became combative and refused to return to the facility with staff. A police officer arrived and was able to convince the resident to allow him to escort her back to the facility. Review of a facility timeline provided by the Director of Nursing (DON) on 10/22/2021 at 10:28 A.M., indicated the resident had not exhibited any exit seeking behaviors. At 11:15 A.M., the resident was seen returning to her room. At 11:30 A.M. the resident's lunch tray was delivered to her room, and she was not present. Staff looked for the resident to make sure she knew her lunch tray was in her room. At 11:45 A.M., the facility received a call from a concerned citizen about a woman walking down the street with a walker. At 11:47 A.M., 2 staff members, TNA 6 (Temporary Nurse Aide) and LPN 1 left facility to investigate and return resident to the facility. At 11:55 A.M., the resident returned to the facility. The security video was reviewed on 10/22/2021 at 10:46 A.M., with the Acting ED (from a sister facility) present. The video showed the resident (identified by the Acting ED) walking towards the east exit door with a rollator walker at 11:23 A.M. Due to the angle of the camera, the east exit door could not be seen and the resident could not be seen exiting the facility. A loud noise (thought to be the door slamming shut after the resident exited) was heard, and the resident was not seen walking away from the door. The resident was without supervision from 11:23 A.M., when seen on security video, to 11:47 A.M., when staff arrived at resident's location, for a total of approximately 24 minutes. Review of a revised physician order, dated 10/25/2021 indicated the resident was allowed a leave of absence with responsible party and medications. In a written statement, dated 10/18/2021 at 12:50 P.M., LPN 1 indicated she last saw the resident in the hallway at 11:15 A.M. In a written statement, dated 10/18/2021, CNA 8 indicated she saw the resident between 11:00 A.M. and 11:15 A.M. walking into her room. In a written statement, dated 10/18/2021, CNA 7 indicated she delivered the resident's lunch tray at 11:30 A.M. and the resident was not in her room. CNA 7 thought the resident might have been in the bathroom or in the other hall walking. In a written statement, dated 10/18/2021, CNA 9 indicated she saw the resident walking down the hall at approximately 11:10 A.M. During an interview on 10/22/2021 at 10:00 A.M., the DON indicated on the day of the elopement, she was helping with lunch in the dining room. She had last seen the resident in the hallway at approximately 11:15 A.M. She stated, It was all hands-on deck, staff were busy helping the residents and passing trays. She stated she had viewed the security video and saw the resident hitting the door with her walker and believed that is how she eloped from the facility. She indicated staff were busy and did not hear the resident hitting the door with her walker. During an interview on 10/22/2021 at 10:20 A.M., the Maintenance Director indicated he did not know how the resident was able to elope from the facility. He indicated the door had a punch code. He did not believe the resident knew the code to open the door. The door was secured with a magnetic lock and checked daily. They were checked and found to be in working order. He indicated the staff used the door to go in and out for smoke breaks after screening in at the front door at the beginning of their shift. During an interview on 10/22/2021 at 10:38 A.M., TNA 6 indicated she had been working in the kitchen and was asked to go help escort the resident back to the facility. When they (TNA 6 and LPN 1) arrived, the resident refused to get into the car. A police officer arrived and was able to get the resident into his car. TNA 6 did to know how the police became involved. During an interview on 10/22/201 at 10:41 A.M., LPN 1 indicated she was doing desk work and she received a call from a concerned citizen stating she saw a woman walking funny down the street with a walker and thought she might belong at the facility. LPN 1 left to return the resident to the facility. The citizen and the resident were found in the road without sidewalks. The resident did not want to go back to the facility and denied being a resident at the facility. A police officer came and was able to get the resident into his car and escort her back to the facility. LPN 1 indicated the resident was not safe to be outside of the facility unsupervised. During an observation on 10/22/2021 at 11:02 A.M., the east exit door was viewed, the door had a code lock in place. The door was tested and fully opened and allowed to shut on its own. The door made a loud noise and closed completely and locked. The door was then opened again and allowed to close slowly and not slam shut, the door did not latch and remained open/unlocked. The Acting ED was present. During an observation on 10/22/2021 at 12:04 P.M., the Acting ED and surveyors drove the route and to the location the resident was found. Directions were provided by LPN 1 while on the telephone during the drive. The resident was found approximately 0.8 miles from the facility. The roads the resident had to walk were uneven, had potholes, were lined with thick wooded areas, large drainage ditches and corn fields. The roads the resident walked had no sidewalks. During an interview on 10/22/2021 at 2:06 P.M., the Acting ED indicated the order for admitting the resident to a locked facility could not be found. The facility will continue to look for the order. During an interview on 10/24/2021 at 9:30 A.M., CNA 8 indicated on 10/18/2021 she saw the resident between 11:15 A.M. and 11:30 A.M. She indicated she asked the resident what was wrong. The resident stated, I did not ask to be here. CNA 8 said she told the resident she would get her something to eat, and the resident started walking towards for her room. CNA 8 brought the lunch tray to the resident, but the resident was not in her room. CNA 8 indicated she looked in the bathroom and then told her supervisor she could not find the resident, and everyone started looking for the resident. During an interview on 10/24/2021 at 10:08 A.M., the Acting ED indicated the facility purchased battery operated door alarms for all exit doors. Theses alarms would sound whenever the door was opened if a numeric code was not punched in. Both door alarms (battery operated and magnetic) would sound if both key codes were not activated. The Acting ED indicated the resident was not safe to be out of the facility without supervision. Review of an online mileage calculator: www.online-calculator.org, indicated the following: It takes about 16 minutes to walk 0.8 miles at a speed of 3 mph. The walking time calculator by miles allows one to calculate how long does it take to walk a certain mile based on an average mph. Walk 0.8 Miles Calculator . How long does it take to walk 0.8 miles based on different mph: 0.8 miles 1 mph 48 minutes 0.8 miles 1.5 mph 32 minutes 0.8 miles 2 mph 24 minutes 0.8 miles 2.5 mph 19.2 minutes . The immediate jeopardy that began on 10/18/2021 was removed on 10/25/2021, when the facility installed secondary door alarms on all exit doors, began educating staff on elopement, and began monitoring doors, but the noncompliance remained at no actual harm, but potential for minimal harm because education and monitoring was on-going. This Federal tag relates to Complaint IN 214. 3.1-45(a)(2)

Based on interview and record review the facility failed to protect a cognitively impaired non verbal resident from abuse by another resident who had a history of [REDACTED]. The immediate jeopardy began on 7/9/2018 when Resident C made a sexually inappropriate comment to Resident B and then touched Resident B's genital area. The staff member witnessed the comment being made, did not intervene at that point and called down another staff member. No staff intervened until Resident C had wheeled the wheelchair over and touched Resident B's genital area. The Administrator was notified of the immediate jeopardy on 7/16/2018 at 4:20 PM. Findings include: 1. During an observation on 7/16/2018 at 1:00 PM, Resident B was in his bed curled in a fetal position The resident had his eyes open and was able to track movement. Resident B was asked simple yes or no answer questions. The resident remained silent and did not answer any questions or nod or sake his head in response. During an observation on 7/16/2018 at 3:30 PM, Resident B was observed ambulating with an unsteady shuffled gait in the hallway. When approached and asked if he was doing alright, the resident did not stop nor answer and moved closer to the wall and away from the surveyor. The clinical record for Resident B was reviewed on 7/16/2018 at 11:00 AM. [DIAGNOSES REDACTED]. A quarterly, Minimum Data Assessment (MDS), 6/19/2018 indicated the resident required total assistance for dressing eating and personal hygiene and required extensive assistance for transfers. Review of a current care plan, dated 3/10/2016 and was last updated 3/28/2018, indicated Resident B had communication problems due to [MEDICAL CONDITION]. He was rarely understood and rarely understands. He was unable to make his needs known. He did not converse or even use speech and he did make eye contact. Review of a current care plan, dated 3/10/2016, indicated Resident B displayed short term and long term memory loss due to a [DIAGNOSES REDACTED]. Review of the undated facility investigation indicated Resident C was over heard by Employee 1 making inappropriate sexual comments to Resident B. Employee 1 called for help and Employee 2 arrived to observe Resident C self propelling himself, in his wheelchair, to Resident B's bed and then placed his hand on the outside of Resident B's shorts. The investigation was not specific as to where Resident B was touched. Resident B and C were roommates at the time of the incident. Review of Employee 1's written statement indicated the employee was answering a call light in Residents B and C's room. Upon entering the room Employee 1 overheard Resident C making inappropriate sexual comments to Resident B. Without leaving the room, Employee 1 called for Employee 2 to come to the room. Review of Employee 2's written statement indicated the employee was called to Resident B and C's room by Employee 1. Upon entering the room, Employee 2 was told by Employee 1 that Resident C was making inappropriate sexual comments to Resident B. Employee 2 then observed Resident C wheeling himself to Resident B's bed and touch Resident B. He didn't actually touch skin. Employee 2 intervened at that time. During an interview Employee 1 on 7/16/2018 at 1:45 p.m., indicated she did not intervene but instead called for Employee 2 so Resident C's statements could be heard by someone else. She indicated Resident C said pull that thing out and I will suck it for you. Employee 1 indicated Resident B was afraid. Employee 1 stated she did not intervene immediately because she was in shock and wanted another staff member to hear what Resident C was saying. During an interview on Employee 2 on 7/16/2018 at 1:52 p.m., she indicated she did not hear what Resident C was saying to Resident B. Resident B was fully clothed and laying on top of his bed when Resident C made his way over to Resident B and put his hand on top of the pants of Resident B's genital area. The employee intervened at that time. Employee 2 indicated Resident B looked frightened. During an interview on 7/16/2018 at 3:33 PM, the Administrator indicated Employee 1 should have intervened immediately when she witnessed the inappropriate sexual comments being made by Resident C. Confidential interviews for staff were completed. Exact times and dates withheld to maintain anonymity. During an interview Employee 3 indicated Resident B's behavior had changed since the incident on 7/9/2018 and Resident B was more resistant when staff tried to assist him to bed and became combative when they tried to take him to his room. During an interview Employee 4 indicated Resident B's behaviors had changed since the incident on 7/9/2018. He was not happy for several days following the incident. He would curl up in the corner of his bed and scream. During an interview, Employee 7 indicated Resident B yelled out when staff attempted to provide care. The employee stated Resident B yelled during care before the incident, but now he seems afraid. Employee 7 indicated she calmed him by telling him he was safe and everything was okay. 2. The clinical record for Resident C was reviewed on 7/16/2018 at 11:27 AM. [DIAGNOSES REDACTED]. Review of a current care plan, dated 7/2/2018, indicated Resident C was verbally aggressive as evidenced by: yelling out, demanding statements Review of a current care plan, dated 7/2/2018, indicated Resident C became verbally aggressive with staff and others as evidenced by cursing and calling names. Review of Resident C's discharge packet, from his previous facility, indicated the following: Progress Note, dated 4/26/2018 at 10:27 AM, Discharge planning is to continue but no defined plan as yet. Multiple facilities across the state contacted for referral and assessment and have declined resident for admission due to history of behaviors. Resident does continue to yell out for nurse! and has very little patience when waiting for someone to answer call light, when he elects to use his call light. He is re-directed for a period of time but due to dementia process is unable to consistently recall alternate methods of dealing with his impatience or frustrations. At this time resident is to stay long term and facility will continue to seek alternate placement as(Resident C's name) desires to be closer to his family and that is his goal. Plan of care reviewed. Progress Note, dated 5/24/2018 at 7:35 AM, Resident and another resident had a verbal dispute in the dining room. Staff intervened to stop verbal conflict. Resident has been very verbally aggressive towards other residents and staff. Resident was re-directed with effective outcome. Behavior note, dated 6/20/2018 at 2:18 PM, SSD spoke to (Resident C's name} concerning the incident of sexually inappropriate verbal comments to another resident. (Resident C's name) stated he does not remember what he said to the other resident. (Resident C's name) did tell SSD that he knew what he said was wrong. SSD asked (Resident C's name) how he knew what he said was wrong if he did not remember what he said., (Resident C's name) answered because staff had told him it was wrong. (Resident C's name) has been on 1:1 staffing since this incident. (Resident B's name )asked how much longer he will have 1:1 staffing. SSD informed (Resident C's name) that the IDT will discuss it on Thursday morning and it will be determined then. (Resident B's name) said that was ok with him. SSD to follow up with (Resident B's name) tomorrow concerning 1:1 staffing decision. Behavior note, dated 6/21/2018 at 10:35 AM, Another resident who this resident previously made sexually inappropriate comments to approaches the nurses station at this time. This resident was sitting at the station with his 1:1 caregiver when the other resident said, you want someone to watch him? I'll watch him, I'll take care of him for you. In fact, I'll kick his ass! Review of the discharge packet lacked any investigation, behavior note or progress note for the sexually inappropriate incident. However, the documentation indicated the date of the incident was 6/17/2018. The clinical record lacked any documentation of additional staffing or supervision upon Resident C's arrival to the facility. During an interview with the Administrator on 7/16/2018 at 11:13 a.m., she indicated she reviewed Resident C's chart prior to admission and he seemed to be appropriate for placement in this facility. She indicated she did not see the note from the previous facility indicating Resident C had been sexually inappropriate. During an interview with the SSD on 7/17/2018 at 9:58 a.m., she indicated she reviewed the chart for Resident C prior to admission and he was appropriate for placement there. Review of a current undated policy titled Abuse and Prevention Policy, indicated the following: Policy: This facility shall observe the resident's right to remain free from verbal, sexual, physical, and mental abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and exploitation. Sexual Abuse: 1. Inappropriate touching of any resident. 2. Saying inappropriate comments to or around a resident. 3. Sexual coercion. Review of a current undated policy titled Incidents or Alleged Abuse, indicated the following: Purpose: To ensure the resident's right to remain free from verbal, sexual, physical, and mental abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and exploitation. Procedure: Should any type of abuse or alleged abuse occur, the following procedure is to be followed: 1. Any staff member witnessing an incident of physical, verbal, mental or sexual abuse, must intervene immediately on behalf of the resident. The immediate jeopardy that began was on 7/11/2018 at 4:20 PM was removed on 7/18/2018 when the facility began inservicing staff on the importance of immediate intervention for abuse and to immediately report such incidents to the Administrator and the staff knowledge was confirmed through interviews, but the noncompliance remained at the lower scope and severity of level isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This Federal tag relates to Complaint IN 108. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents who were transferred using a mechanical lift were transferred with sufficient staff assistance to prevent accident and injury for 1 of 1 residents reviewed for accidents. This failure resulted in a laceration to the right parietal and right post-auricular head requiring emergency room services. (Resident E). Findings include: Resident (E) was observed on 3/25/15 at 10:55 a.m., awake in bed. She was again observed on 3/26/15 at 10:30 a.m., dressed and seated in her chair. The clinical record for Resident (E) was reviewed on 3/25/15 at 2:30 p.m. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident (E) was unable to complete the Brief Interview for Mental Status (BIMS). Resident (E) was severely cognitively impaired. Resident (E) received the following Activities of Daily Living (ADL) assistance; bed mobility-total assist with two person assist, dressing, bathing, eating and hygiene-extensive assistance with one person assist. During review of the clinical record, a progress note dated 2/10/15 at 1:20 p.m., indicated Resident (E) fell from the Hoyer lift during transfer. Resident (E) sustained a laceration to the right side of her head and behind her ear. Resident (E) was bleeding from the area. The physician and Power of Attorney (POA) for Resident (E) were notified and the resident was sent to the emergency room . A hospital physician's progress note dated 2/10/15 at 7:00 p.m., indicated a 4 cm (centimeter) laceration to the right parietal head area required 12 staples. A hospital physician's progress note dated 2/10/15 at 9:07 p.m., indicated a 4 cm laceration to the right post-auricular area required 5 sutures. Review of the Indiana State Department of Health Incident Report form dated 2/11/15, indicated Resident (E) was being transferred with a Hoyer lift when she fell . The report indicated CNA #1 was the only staff person involved. During an interview on 3/25/15 at 10:30 a.m., the Administrator indicated the CNA was alone during the transfer. She indicated the CNA was suspended and re-educated on Hoyer transfer policy. During an interview on 3/26/15 at 2:30 p.m., the Administrator and Corporate Nurse indicated the facility policy was for two staff members to be present during all Hoyer lift transfers. A health care plan problem dated 1/2/15, indicated Resident (E) was a fall risk related to medications and Huntington's disease. The approaches for the problem included, but were not limited to, side rails, hipster in the Broda chair and pad on the floor. No care plan was identified for the use of the Hoyer lift. Review of the nurse aide's information sheet for Resident (E) indicated no mode of transfer was listed. Review of the physician's orders [REDACTED]. During an interview on 3/26/15 at 2:30 p.m., CNA #2 and CNA #3 indicated two staff persons had to be present when using the Hoyer lift to transfer a resident. During an interview on 3/26/15 at 3:05 p.m., the Corporate Nurse was unable to identify a list of residents who were transferred by the Hoyer lift. She indicated Resident (E) did not have a care plan and she would have to update those residents who were transferred by the Hoyer lift system. Review of an in-service for proper use of the Hoyer lift dated 12/15/14, CNA #1 demonstrated correct use of the lift. A copy of the manufacturer's instructions were provided. No specific facility policy was provided. This Federal tag relates to Complaint IN 416. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure 3 of 4 residents (Resident #'s B, C, and D) identified at risk for pressure sore development received care and services in a manner to promote healing and/or prevent new pressure sores from developing resulting in an increase in size and pain in the area for 1 of the residents (Resident #C) reviewed for treatment of [REDACTED]. Findings include: 1. During observation of a wound assessment for Resident #C, completed by the DoN and LPN #1 on 5/21/14 at 4 p.m., the following was observed: The wound was below the coccyx, but above the anus, in the buttock fold area. The wound measured 4.2 cm in length along the buttock fold by 0.4 cm in width with a depth of 1 cm. The width of the area could be made much wider if the buttocks were pulled wide apart and not kept in normal body alignment. The 0.4 cm width was the measurement taken in normal body alignment. An assessment and/or visualization of this wound would required two staff members due to the resident's large size. The wound could not be assessed with [REDACTED]. The clinical record for Resident #C was reviewed on 5/21/14 at 10:20 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 4/13/14, indicated Resident #C was severely cognitively impaired and required the extensive assistance from the staff for all activities of daily living. A nursing note entry, dated 3/6/14 at 8 a.m., indicated "Resident has a small area on coccyx between buttocks. Measures 1.5 cm (centimeters) by 0.25 cm. Notified MD (Medical Doctor) - new order received and family notified of new order." A physician's orders [REDACTED]. The order indicated the treatment was to be changed every three days and as needed for soilage. The Treatment Administration Records (TAR) for March 2014 indicated the treatment was completed as ordered. The April 2014 TAR indicated the treatment was completed on 4/1/14. The order was then marked as discontinued on 4/5/14. A handwritten entry on the April 2014 TAR initiated on 4/5/14 indicated the staff were to "monitor area just below coccyx for changes every shift." The area for documentation of the "monitoring" was initialed by nursing staff from 4/5/14 thru 4/12/14. The TAR lacked any treatment for [REDACTED]. The clinical record lacked any physician's orders [REDACTED]. The clinical record lacked any order for the "monitoring" of the wound initiated after the treatment was discontinued on 4/5/14. Skin assessment sheets, included, but were not limited to, wound information on the following dates: 3/27/14 - the area below the coccyx measured "1.3 cm by 0.2 cm". No staging or other information provided. 4/3/14 - "open area to coccyx, treatment continues" (no measurements, staging, or other information provided) 4/12/14 (the next skin assessment sheet for Resident #C) indicated the wound below the coccyx and between the buttocks (in the buttock groove) now measured 5 cm by 3 cm and was 1 cm in depth. No wound staging was documented. The assessment indicated the resident experience pain when the treatment was done. A physician's orders [REDACTED].#C's pressure area. The order indicated the staff were to cleanse the area between the buttocks (below coccyx), dry the area, and apply Duoderm 4 by 4 control gel dressing to be changed every 3 days and as needed for soilage. The April TAR indicated this treatment was initiated on 4/12/14 and completed as ordered during the month of April. The clinical record lacked any order to discontinue this Duoderm treatment noted above. The May 2014 TAR had not been updated to include the Duoderm order. The May 2014 TAR indicated the staff were doing an Elasto-gel treatment to the area. The wound continued to be measured weekly in May 2014. The wound was not consistently measured or staged. The skin assessment sheet, dated 5/14/14, indicated the area measured 1.4 cm by 0.4 cm by 0.3 cm No staging was documented. The wound sheet indicated the Elasto-gel treatment was being given (as documented on the May TAR) and not the Duoderm treatment. The DoN was interviewed on 5/21/14 at 4:15 p.m. Additional information was requested related to lack of consistent wound measurements and staging and wound treatment changed without an order. The DoN and Administrator were interviewed on 5/22/14 at 9:15 a.m. The DoN indicated the above noted pressure area, measured on 5/21/14, would be considered a Stage 3. She indicated she had no information to provide related to why the treatment was "discontinued and the area monitored" on 4/5/14 without an order. She indicated she had no information to provide related to the May 2014 TAR not being updated and an old treatment having been documented as being done. She indicated she had held a "pressure ulcer" inservice and had educated the staff on wound measurement, staging, and obtaining orders for treatments. She indicated the facility would now try to have the same nurse measuring and monitoring wounds. She indicated the resident's physician had been contacted and the Duoderm treatment reinstated. Vitamin C and Zinc had also been ordered to assist with wound healing. She indicated the resident was also going to be seen by the wound center for an evaluation and treatment as necessary to help with wound healing. 2. During observation of a wound assessment for Resident #B, completed by the DoN and LPN #1 on 5/21/14 at 2:40 p.m., the following was observed: The resident had three pressure areas: The area on the lower coccyx was a circular area which measured 0.8 cms in diameter. The area had lost only the very top layer of skin surface and was very superficial. No depth could be measured and it was referred to as a stage 2 denuted area by the DoN. A whitish cream, identified by the DoN as "periguard" was observed on the area. The DoN indicated this was the "house barrier cream" used for incontinent residents. The clinical record lacked any order for a "periguard" treatment. The area on the left inner heel was a 3.4 by and 3.3 oval dark blister. The skin was intact and the blister appeared to be drying up. The blister did not appear to be deep. The DoN indicated this heel was being treated with "skin prep" to help toughen the skin. The area on the right outer heel was a 3.2 by 3 cm dark pink area. The area was identified as a Stage 1. The DoN indicated this heel was being treated with "skin prep" to help toughen the skin. The clinical record for Resident #B was reviewed on 5/21/14 at 11:45 p.m. [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], indicated the resident was moderately cognitively impaired and required the assistance of the staff for bed mobility, transfers, and toileting. The MDS indicated the resident was at risk for pressure ulcer development, but had no current open areas. A health care plan problem, dated 4/11/14, indicated the resident had a potential for impaired skin integrity due to [MEDICAL CONDITION] and incontinence. One of the approaches for this problem was "report first sign of breakdown to physician". The clinical record indicated the resident had a decline in her mental status and physical condition on 5/7/14. She was seen by the Nurse Practitioner (NP) on that date and sent out to the hospital for evaluation and treatment. The clinical record indicated a skin assessment was done prior to the resident leaving for the hospital and a blister to the left heel had been noted at that time. The assessment indicated the area was a "new area" which had just been noted that day. The area was described as a fluid filled blister measuring 8 cm by 5 cm. No other areas were noted. The clinical record indicated the resident returned to the facility following treatment for [REDACTED]. A skin assessment completed upon readmission, dated 5/9/14, indicated the resident had the following pressure areas. Red area to coccyx 1.5 cm by 1 cm - stage 2 Left heel - 2 cm by 2 cm blister The skin assessment, dated 5/9/14, indicated "MD aware. No treatment orders." A physician's orders [REDACTED]. The staff were to "apply skin prep to bilateral heels every shift" and "float heels when in bed". The nursing notes lacked any information related to the physician having been called related to this order or why no order was obtained for the pressure area on the resident's coccyx. The May TAR indicated the treatment to the resident's heels was done as ordered. No treatment was documented for the coccyx wound prior to a new order obtained on 5/22/14. A skin assessment sheet, dated 5/15/14, indicated the resident continued to have areas on her coccyx and heels. The areas were not measured or staged in order to determine healing status. The area on the coccyx was identified only as a "red area". During an interview with the Administrator and DoN on 5/21/14 at 3:05 p.m., additional information was requested related to the lack of wound measurements and staging for the resident's wounds noted above. Additional information was also requested related to the lack of a treatment for [REDACTED]. The facility failed to provide any additional information related to the above requests as of exit on 5/23/14. 3. The clinical record for Resident #D was reviewed on 5/21/14 at 3:35 p.m. [DIAGNOSES REDACTED]. A significant change MDS, dated [DATE], indicated the resident was moderately cognitively impaired. The MDS indicated the resident was at risk for pressure ulcer development and required the assistance of the staff for bed mobility, transfers, and toileting. The clinical record indicated the resident had had a decline in overall condition and had been placed on hospice services on 3/27/14. A skin assessment sheet, dated 4/15/14, indicated a new pressure area had been found on the resident's coccyx. The area was identified as a stage 2 and measured 6 cm by 4 cm. The assessment indicated the current treatment was "periguard prn (as needed)" A physician's orders [REDACTED]. This order was transcribed to the April 2014 TAR as "Periguard prn to keep open area clean". The location of the open area was not documented. The April TAR lacked any initials and/or information related to this order having ever been completed. It was blank in all areas. A skin assessment sheet, dated 4/18/14, indicated the pressure area on the resident's coccyx was a stage 2 and measured 6.2 cm by 4 cm. The assessment indicated "current treatment orders". A physician's orders [REDACTED]. The clinical record indicated the coccyx wound for Resident #D continued to be monitored weekly and a treatment done as ordered. The coccyx wound measured 5.2 cm by 3.5 cm on the 5/16/14 skin assessment record. No stage of the wound was documented. The Administrator and DoN were interviewed on 5/22/14 at 1 p.m. Additional information was requested related to the lack of documentation of the prn periguard treatment having been done to the resident's open area from 4/15/15 through 4/21/14. The DoN indicated a prn treatment should not have been taken for an stage 2 open area and she would review further. The facility failed to provide any additional information as of exit on 5/23/14. 4. Review of current, but undated, facility policy titled "Skin Condition Monitoring", provided by the Administrator on 5/22/14 at 9:10 a.m., included, but was not limited to, the following: "Policy: Residents with [MEDICAL CONDITION]/wounds will be monitored and documented. ...Procedure: 1) When the Charge Nurse is aware of [MEDICAL CONDITION], wounds, venous ulcers, or other skin abnormalities, the area is to be assessed and documented... ...3) Initiate treatment per physician's orders [REDACTED]. a) type of treatment b) how often to be done c) how to be cleansed, if appropriate d) site of application PRN alone is not an acceptable treatment order. All treatments must have a specific frequency ... 4) documentation of skin conditions must occur upon identification and at least once a week. Assessment must include: a) characteristics (i.e. (for example) size, shape, depth, color, presence of granulation tissue, necrotic tissue) b) treatment and response to treatment c) prevention techniques..." This federal tag relates to Complaint IN 013. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to supervise an orientee staff person to ensure that she followed physician order [REDACTED].# A. The facility failed to supervise Resident #A while during food consumption. This failure resulted in the resident receiving solid food which resulted in him choking. The responding nurse was unable to use suction equipment to prevent the resident choking to death for 1 of 3 residents in a sample of 7. (Resident #A). The Immediate Jeopardy began [DATE] when staff failed to follow physician order [REDACTED].#A. The Administrator and the Director of Nursing were notified of the immediate jeopardy at 5:15 p.m., on [DATE]. The immediate jeopardy was removed, but noncompliance remained at the no actual harm with potential for more than minimal harm that is not immediate jeopardy level, on [DATE] Findings include: The clinical record for Resident #A was reviewed on [DATE] at 9:30 a.m. The clinical record indicated the resident's [DIAGNOSES REDACTED]. The nursing note, dated [DATE] at 4:10 a.m., indicated on [DATE] Nurse #1 was passing medications to the resident's roommate. Resident #A was transferred to his wheelchair and stated he was hungry. Nurse #1 indicated she and precepting Certified Nursing Aide (CNA) #2 told orientating CNA #3 to take Resident #A to the dining room and get him some jello from the pantry. Nurse #1 walked up to the front and observed Resident #A sitting at a dining room table with an empty cup of pudding and a empty plastic wrapper. Resident #A's head was tilted back and he was blue in the face. Nurse #1 indicated she called for help from CNA#2 and CNA#3. She then indicated she looked in his mouth and noticed there was something lodged in his throat but she was unable to remove it with a mouth sweep. She indicated she then performed the Heimlich maneuver for approximately 2 minutes but was unable to "get the food out". Resident #A at this time had no pulse or respirations. Resident #A was lowered to the floor and Nurse #1 started CPR. The note further indicated 911 was called but did not indicate the time of the call. The EMT's arrived at 4:20 a.m. and continued CPR. The resident had a weak pulse and was taken to the hospital. The Internal Investigation 5 day follow up, dated [DATE], indicated in "The Complete Over All Review" section: "Nurse #1, CNA #2, CNA #5 and CNA #3, a new orientee, were on the 10:00P-6:00A shift. Nurse #1 was in room #18 while the CNAs were doing bed checks and changing Resident #A. Resident #A complained of being hungry and requested to get up. The Nurse told the new staff CNA, CNA #3 to take him down to the dining room and give home some Jell-o out of the pantry and get another resident a peanut butter sandwich. The CNA inadvertently gave the peanut butter sandwich to the wrong resident. Staff saw that Resident #A was blue and his head was tilted back and he was not breathing. Nurse #1 immediately called out for help. Nurse #1 opened his mouth and could see something was obstructing his airway. She was unable to do a finger sweep due to the obstruction was too far down the throat. She attempted unsuccessfully several times to do the Heimlich on him and he then became unconscious. She lowered him to the floor and told the CNA (CNA#5) to call 911. Nurse #1 continued to perform CPR until EMS arrived and they took over CPR and transported resident to (name of an area hospital) were he later passed from cardiac arrest." The written statement form CNA #2, dated [DATE], indicated: "She went into Resident #A's room with CNA #3, who was an orientee, to give AM care and to get him up. CNA#3 was asked to take Resident #A to the dining room and CNA#2 asked her to get another resident some jello while she was in the dining room. CNA #2 stayed and made the resident's bed and the nurse was giving his roommate medication. CNA #2 proceeded to another resident's room when she was called to by the nurse, from the hall, asking CNA #2 to go to the dining room with her. She started working on Resident #A gave him the Heimlich and we took him to the floor and she started CPR till EMT's the ambulance people got here to work on him too." The written statement from CNA #5, dated [DATE], stated "I was on East hall in room 18 when I heard the nurse and aide panicking. I ran out the room and saw that Resident #A was choking the nurse then took him out of the chair layed him on the floor and started CPR I then called 911 and the nurse gave me the keys to get supplies and I got paper work ready and waited for ambulance and they took over." The written statement from CNA #3, dated [DATE], stated "Me and another CNA got Resident #A up. He was laughing and saying he was hungry for vittles and coffee. The nurse was in room with other resident giving meds. Some how peanut butter and jelly sandwiches came up. I assumed they were talking about giving resident some. I gave him a peanut butter jelly sandwich and bowl of jello to eat. Twenty minutes later we found him unresponsive. We rushed him to his room and got him on floor while nurse performed CNA (sic). The other hall CNA called 911. I must have misunderstood." During an interview with the Administrator and the Director of Nursing on [DATE] at 2:17 p.m., The Administrator indicated all staff were educated on the Heimlich Maneuver by the Director of Nursing and the Corp Nurse Consultant but no documentation was presented. She also indicated that prior to the incident staff were made aware of resident dietary restrictions by information in the CNA assignment sheets and the tray cards. Since the incident, the facility has implemented a double checking system for tray distribution at meal times. The Director of Nursing indicated there were two suction machines in the facility at the time of the incident and staff present during the incident knew how to use the equipment. She further indicated orientee CNA's should not perform any task they have not been signed off on by their preceptor. She acknowledged CNA #3 had not worked during a time where she could participate and be checked off on meal distribution. She also indicated CNA #3 should not have been left unsupervised by her preceptor. "Orientation needs to be looked at and I am". During a tour and interview with the Director of Nursing on [DATE] at 9:00 a.m., the crash cart, consisting of a suction machine and supplies, was observed in the oxygen room. The machine was wrapped in a clear plastic bag with a tag indicating the last time the cart was checked. The tag was dated [DATE]. The Director of Nursing indicated prior to the incident the cart was to be checked by the night nurse but there was no documentation or monitoring of this duty. The second suction machine, with supplies, was located in the dining room, wrapped in a clear plastic bag and tagged as having been checked [DATE]. The Director of Nursing indicated the suction machine had always been in the dining room, even prior to the incident. During a telephone interview, on [DATE] at 8:36 a.m., with Nurse #1, she indicated she told CNA #1 and CNA3# to get Resident #A jello. She stated there was another resident present and she instructed them to provide that resident with a snack as well. She denied any mention of a peanut butter sandwich. Nurse #1 stated that when she saw the resident in the dining room he was blue and she could see he had something in his mouth but she "couldn't get it out." She then indicated she did the Heimlich Maneuver. She indicated she did this for approximately one minute, then checked for a pulse. The resident had no pulse or respirations at this time and she indicated she began performing CPR and told the CNA to call 911. She indicated suction equipment was in the oxygen room and she had sent the CNA to get the crash cart. She indicated when the crash cart arrived she could not find the needed equipment to suction the resident. She also indicated "it took her (CNA) awhile for her to even bring be the crash cart"' She was not aware of the suction machine located in the dining room. When asked if a CNA on orientation could be asked to perform a skill she/he had not been checked off on alone or with out supervision she stated, "yes". During a telephone interview on [DATE] at 8:50 a.m., with CNA #1, she indicated the following: "I had an person I was training. At about 3:45 a.m. I went into Resident #A's room. He wanted up- his back was hurting. I told him I would be back about 4:00 a.m. (15 minutes) to get him up." CNA #1 and CNA #3 (trainee) both came back to Resident #A's room. They got him cleaned up, dressed, and put on his ted hose. CNA #1 and CNA #3 were both in Resident #A's room. While they were in Resident #A's room, another resident was yelling for CNA #1, telling her she wanted a snack. When CNA #1 and CNA #3 finished getting Resident #A ready, CNA #1 looked at CNA #3 and said 'roll him to the dining room.' She then asked CNA#3 'do you know the other resident (the one that was yelling) stating she wanted a snack?'. When CNA #1 asked, CNA #3 indicated at that time she did know the other resident. CNA #1 asked CNA #3 to get the other resident '2 jellos from the fridge'. The nurse was in the room providing care for Resident #A roommate. CNA #1 finished making Resident #A's bed then went down the hall- away from the dining room. CNA #3 had not returned." CNA # 1 indicated the nurse left the room also. CNA #1 then heard the nurse yell for CNA #1 to come on to the dining room. CNA #1 indicated the nurse did the Heimlich on the resident and lowered him to the floor. CPR was started and 911 called. The ambulance arrived and they took over the CPR. CNA #1 indicated she asked CNA #3 to roll the resident to the dining room, not to give him anything. She indicated she had asked CNA #3 to give the other resident 2 jellos. She also indicated did not hear the nurse say anything to the trainee. She indicted the trainee was suppose to come right back to be with her. CNA #1 indicated she learned residents during training by staying with the person training her and learned what the residents looked like and their names. She indicated she always ask about diets before giving a resident liquids or food because this could change. She indicated the nursing staff was very good about communicating changes in diets to the CNAs. She indicated they also have sheets with all resident information provided. CNA#1 could not remember if CNA #3 was in the dining room during CPR. During an interview with the Administrator on [DATE] at 8:31 a.m., the Administrator indicated they did not have a policy for calling 911, code status or CPR. She also indicated there was no documented staff education for CPR, code status or suctioning prior to the incident dated [DATE]. She indicated suctioning and suction equipment was part of the orientation for nurses and part of the nursing orientation check off list. A copy of the Nursing Orientation Check Off List was provided. CNA #3 voluntarily terminated employment immediately after the incident and was not available for interview. Review of the inservice information, dated [DATE], provided by the Administrator on [DATE] at 1:00 p.m., included, but was not limited to, the following: The inservices included information related the differences between mechanical soft and pureed diets, how to prepare pureed foods and dietary compliance. 28 nursing staff members attended the inservice Nurse #1's signature was on the attendance sheet. The inservices included information related to meal service. 38 nursing staff members attended the inservice Nurse #1 and CNA #1's signatures were listed on the attendance sheet. The inservices included information related to code status, when to suction and prompt calling of 911. 26 nursing staff members attended the inservice Nurse #1, CNA #1;and CNA #2's signatures were listed on the attendance sheet. The inservices included information related to choking, Heimlich Maneuver and following dietary orders/plan of care. 48 staff members attended the inservice Nurse #1, and CNA #1's signatures were listed on the attendance sheet. The inservices included information related to CNA orientation. 24 staff members attended the inservice Nurse #1, CNA #1;and CNA #2's signatures were listed on the attendance sheet. The inservices included information related to difficulty swallowing, aspiration choking. 34 staff members attended the inservice Nurse #1, and CNA #1's signatures were listed on the attendance sheet. The inservices included information related to how to use the suction machine and where suction equipments is located. 11 nursing staff members attended the inservice Nurse #1 signatures was listed on the attendance sheet. Review of the current facility policy, provided by the Administrator on [DATE] at 8:52 a.m., titled "Resident Rights", included, but was not limited to the following: "...Quality of Life ...(e) Accommodation of needs A resident has the right to... (1) Reside and receive services in the facility with reasonable accommodations of the individual's needs and preferences, except when the health or safety of the individual or other residents would be endangered..." The immediate jeopardy began on [DATE]. The immediate jeopardy was removed but noncompliance remained at the no actual harm with potential for more than minimal harm that is not immediate jeopardy level, on [DATE] after the facility implemented a systemic plan that included the following actions: 1.) CPR validation of all nurses was checked on [DATE]. 2.) The facility "crash cart" was audited on [DATE] for the availability of all supplies needed. 3.) Dietary manager or designee to monitor diet sheet in pantry and kitchen daily, started [DATE]. 4.) Charge nurse will monitor the daily CNA assignment sheets, started [DATE]. 5.) DoN, Administrator or designee will monitor any new diets or dietary changes and update CNA assignment sheets, started [DATE]. 6.) DoN or designee will check suction machine in dining room and oxygen room to ensure readiness of equipment for emergency use, started [DATE]. This federal tag relates to Complaint IN 878. 3.1 - 45(a)(2)

Based on record review and interview, the facility failed to ensure the nursing staff followed a resident's advanced directives and to perform a full code on the resident. This failure resulted in death for 1 of 5 residents reviewed for following their advanced directives at the time of death in a sample of 7. (Resident #D) This deficient practice resulted in Immediate Jeopardy. This Immediate Jeopardy began on [DATE] when facility staff failed to identify a resident as being a "full code" at the time of his death and failed to initiate cardiopulmonary resuscitation. The Administrator and Director of Nursing were notified of the immediate jeopardy on [DATE]. The Immediate Jeopardy was removed, but noncompliance remained at the no actual harm with potential for more than minimal harm that is not immediate jeopardy level, on [DATE], when the facility developed and had implemented a systemic plan of correction. Findings include: The clinical record for Resident #D was reviewed on [DATE] at 2:35 p.m. [DIAGNOSES REDACTED]. A recapitulation of physician's orders [REDACTED].#D was a "full code". A "CARDIOPULMONARY RESUSCITATION STATUS FORM", dated [DATE], indicated cardiopulmonary resuscitation (C.P.R.) would be initiated for the resident in the event of a [MEDICAL CONDITION]. A current health care plan problem/need, dated [DATE], indicated the resident requested to be a full code. Interventions for this request included, but were not limited to, in the event of [MEDICAL CONDITION] initiate C.P.R., call the paramedics, let the doctor and family know, and transport resident to nearest emergency room for treatment. A nursing note entry, completed by LPN #4, dated [DATE] at 7:10 p.m., indicated "Went to Res (resident) room to assess Res (resident) after Br. (breathing) tx (treatment). Res (resident) sitting up in w/c (wheelchair) RHC (respirations have ceased) no pulse no response no SaO2 (saturated oxygen) no B/P (blood pressure) no AHR (apical heart rate) per ausc (auscultation)". A nursing note entry, completed by LPN #4, dated [DATE] at 7:20 p.m., indicated "Admin (administrator) notified and will notify DON (Director of Nursing). Call placed to (emergency contact #1) left message to call facility. (Emergency contact #2) called x 3 (3 times) busy signal". A nursing note entry, completed by LPN #4, dated [DATE] at 7:40 p.m., indicated "Call received from Admin (administrator)-to call (name of funeral home) for pick-up. MD (medical doctor) made aware". A nursing note entry, completed by LPN #4, dated [DATE] at 7:45 p.m., indicated "(Funeral home) notified and will come to transfer Res (resident)". A nursing note entry, unsigned, dated [DATE] at 9:55 p.m., indicated "Body released to (funeral home)". The Director of Nursing (DoN) was interviewed on [DATE] at 4:27 p.m. Additional information was requested related to the lack of performing CPR of Resident #D following his passing on [DATE]. The DoN indicated LPN #4 called to notify her of Resident #D's death. LPN #4 indicated to the DoN that when she went to check on Resident #D after his breathing treatment he had "already passed". The DoN indicated if C.P.R. was initiated the emergency medical technicians were called. The DoN indicated the emergency medical technicians had not been called for Resident #D. The DoN indicated there was not a policy for when not to perform C.P.R. on a "full code" resident. The DoN indicated LPN #4 was no longer an employee at the facility. LPN #4 had been terminated by the facility and was not available for an interview. The DoN and the Administrator were interviewed on [DATE] at 9:17 a.m. They both indicated no facility investigation had been completed after the death of Resident #D. The DoN and Administrator were interviewed on [DATE] at 7:57 a.m. The DoN and Administrator indicated they had color coded the outside of each resident's chart and each resident's name plate on [DATE] to ensure each resident's code status information was readily available. This information would be monitored daily during rounds by the Administrator. An audit of all resident records was completed on [DATE] to ensure each record contained the correct code status. Code status in the resident's chart would be monitored monthly. In-services began [DATE] for all staff related to code status, CPR, and when to call emergency medical technicians The Administrator was interviewed on [DATE] at 7:37 a.m. She indicated in-services for all staff had been completed on [DATE]. The facility completed CPR validations with the nurses. This information was provided for review. Two LPNs, two QMA/CNAs, and four CNAs over various shifts were interviewed during the survey. All knew where to find a resident's code status information and when to initiate CPR or notify nurse immediately, and call emergency medical technicians. Review of the current facility policy for "CARDIO-PULONARY RESUSCITATION (CPR)", provided by the Director of Nursing on [DATE] at 1:47 p.m., included, but was not limited to, the following: "POLICY: To assist the facility in ensuring that all residents suffering a cardiac or respiratory arrest will receive the treatment of [REDACTED]. ...2. All licensed nurses certified in CPR will know which residents requested Full Code status, and therefore must receive CPR if they arrest...." Review of the current facility policy for "ADVANCED DIRECTIVES RESIDENTS RIGHT TO REFUSE MEDICAL TREATMENT", updated ,[DATE], provided by Social Services Director on [DATE] at 3:45 p.m., included, but was not limited to, the following: "...DEFINITIONS (FOR PURPOSES OF THIS POLICY ONLY) Advanced Directive: A written and signed document which is consistent with applicable law, voluntarily executed by a competent adult to specify his/her wished concerning the withholding or withdrawal of life-sustaining procedures and/or to name a surrogate decision-maker.... ...Do Not Resuscitate (DNR) Order: A written physician's orders [REDACTED]." Review of the current facility policy, provided by the Dietary Manager on [DATE] at 9:02 a.m., titled "Resident Rights", included, but was not limited to the following: "...Quality of Life ...(b) Self-determination and participation The resident has the right to-- ...(3) Make choices about aspects of his or her life in the facility that are significant to the resident...." The immediate jeopardy began on [DATE]. The immediate jeopardy was removed but noncompliance remained at the no actual harm with potential for more than minimal harm that is not immediate jeopardy level, on [DATE] after the facility implemented a systemic plan that included the following actions: 1.) LPN #4 was terminated by the facility. 2.) A house audit of all resident records was completed on [DATE] related to each resident's code status information being readily available. 3.) CPR verification of all nurses was checked and in-services related to code status, cardiopulmonary resuscitation and notifying emergency medical technicians were completed from [DATE] through [DATE]. This federal tag relates to Complaint IN 878. 3XXX,[DATE](a)