Every finding on record at Brownsburg Health Care Center

Based on observation, interview, and record review, the facility failed to assess residents' quarterly smoking assessments and store residents smoking supplies in a safe secure location for 5 of 5 residents reviewed for smoking (Resident K, L, M, N, and O). Findings include: 1. On 7/14/26 at 10:55 a.m., a record review was completed for Resident L. He had the following diagnoses which included, but were not limited to, tobacco use, chronic obstructive pulmonary disease (a progressive and irreversible lung condition that restricts airflow, making it difficult to breathe) (COPD), hypertension, and unsteadiness on feet. Resident L had a smoking assessment completed on 12/15/26. It indicated that Resident L smoked independently. He had a care plan, dated 9/26/25, indicating he had been advised of the smoking policy. The goal indicated he would be compliant with facility smoking policy. An intervention, dated 9/26/25, indicated reassess resident smoking ability quarterly and after reports of unsafe practices. Another invention included to remind resident and family that all cigarettes, lighter, matches and smoking paraphernalia must be kept at nursing station. On 7/15/26 at 11:40 a.m., during an interview and observation Resident L indicated he had his cigarettes in a drawer and a lighter in his pocket. He pointed to his drawer, and it was noted that he had 2 packs of cigarettes in an unlocked black box in his nightstand. He indicated the key was down in the drawer if he wanted to lock it. He indicated when he wanted to smoke, he would go out the front door and walk to the side of the building where the smoking area was located. 2. On 7/14/26 at 10:12 a.m., a record review was completed for Resident K. He had the following diagnoses which included but were not limited to type I n diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal blood sugar levels), hemiplegia and hemiparesis following cerebral infarction (occur when an ischemic stroke or cerebral infarction damages the right hemisphere of the brain), interstitial pulmonary disease (an umbrella term for over 200 disorders that cause progressive inflammation and scarring (fibrosis) in the lungs), and hypertension (high blood pressure). On 7/14/26 at 11:32 a.m., during an interview Resident K indicated he had one cigarette and his lighter on his person. Sometimes he didn't have cigarettes due to a lack of money. He indicated he was an adult and did require supervision. Resident K had a care plan, dated 2/3/26, indicating he smoked and had been advised of the smoking policy. The resident required supervision with smoking. A goal indicated he would be compliant with the facility smoking policy. An intervention, dated 2/3/26, indicated that him and his family will be reminded to keep all cigarettes, lighter, matches, and smoking paraphernalia must be kept at the nursing station. 3. On 7/14/26 10:58 a.m., a record review was completed for Resident M. She had the following diagnoses which included but were not limited to COPD, hypertension, anxiety, and unknown psychosis, an altered state of the brain that creates a loss of contact with reality). On 2/5/26 Resident M had a smoking assessment that indicated she smoked. Resident M had a care plan indicating she smoked and she had been advised of the facility smoking policy. A goal indicated she would be compliant with the facility smoking policy. An intervention, dated 2/5/26, indicated she would have her smoking ability assessed quarterly and after reports of unsafe practices. On 7/15/26 at 11:11 a.m., during an interview Certified Nursing Aide (CNA) 11 indicated Resident M did not have cigarettes and did not smoke. She was on continuous oxygen. CNA 11 indicated if Resident M smoked, she probably did it when her daughter took her out of the facility. 4. On 7/14/26 at 11:10 a.m., a record review was completed for Resident N. He had the following diagnoses which included but were not limited to adult failure to thrive (FTT) (a condition where a child's physical growth falls significantly behind expected standards), limitation of activities due to disability, depression, and diabetes mellitus. On 6/9/26 he had a smoking assessment indicating he did not smoke. Resident N had a care plan, dated 9/17/25, indicating he smoked/vaped and that he had been advised of the facility smoking policy and required supervision with smoking. The goal indicated he would be compliant with the facility smoking policy. An intervention, dated 9/17/25, indicated to remind resident and family that all cigarettes, lighter, matches and smoking paraphernalia must be kept at nursing station. 5. On 7/14/26 at 11:30 a.m., a record review was completed for Resident O. He had the following diagnoses which included, but were not limited to, Alzheimer's disease, dementia, anxiety, fatigue, and interstitial pulmonary disease. On 2/10/26 Resident N had a smoking assessment. It indicated that he smoked. A care plan, dated 5/8/26, indicated Resident O smoked and had been advised of the facility smoking policy. The resident required supervision with smoking. A goal indicated Resident O would be compliant with the smoking policy. An intervention, dated 5/8/26, indicated Resident O would be reassessed on a quarterly basis and as needed after reports of unsafe practices. On 7/15/26 at 11:16 a.m., during an interview with Activity Staff 13. She indicated residents had a smoking schedule and they followed it. She indicated it may only be a few residents at a time. At this time the smoking area was observed. It was a gazebo with smoking receptables on the deck. A policy titled, Smoking by Residents dated 6/2020 indicated, .The interdisciplinary team (IDT) shall create a smoking care plan for the resident. See smoking care plan.All smoking materials will be stored in a secure area to ensure they are kept safe. This citation relates to Intake 3051915. 410 IAC (Indiana Administrative Code) 16.2-3.1-45.

Based on observations, interviews, and record review, the facility failed to ensure Resident R received dementia specific supervision, monitoring, interventions, and protections resulting in repeated attempts by Resident Q to enter Resident R's room for 1 of 3 residents reviewed for dementia care and the deficient practice affected 3 of 3 residents residing on the dementia unit (Residents Q, R, and S).Findings include:On 7/13/26 at 4:15 a.m., Licensed Practical Nurse (LPN) 5 and Certified Nursing Aide (CNA) 6 were observed in the memory care unit indicated they were not aware of any staff to resident, or resident to resident abuse concerns.On 7/13/26 at 7:50 a.m., Resident R was observed in the main dining room as she ate breakfast and enjoyed conversation with a peer. Resident R was observed to have thin, wispy, patches of hair in various stages of regrowth. A large scar was visible on her scalp. Resident R finished her breakfast and agreed to a confidential interview in her room.During an interview 7/13/26 at 8:15 a.m., Resident R indicated Resident Q repeatedly attempted to enter her room since she returned from the hospital after brain surgery. Resident R stated Resident Q disturbed her several times a day and took items from her room. She stated she complained to aides, nurses, and her family, but the targeting continued. On one occasion, Resident Q entered Resident R's room, staff were not available or didn't see her enter, so Resident R grabbed Resident Q by the wrist and yelled for staff, ya'll better come get her! Resident R expressed frustration and indicated she felt like she had no privacy, she was anxious to fall asleep, and was scared about what could happen if Resident Q went off on her.During an interview on 7/14/26 at 9:47 a.m., Qualified Medication Aide (QMA) 12 indicated Resident Q continued to fixate on Resident R's room and on Resident R. Sometimes she went into Resident S's room too. A 24 Hour Shift Report Logs, dated 6/17/26, indicated Resident Q targeted Resident R's room and Resident S's room and attempted to exit the unit. The record lacked documentation that a staff member had been assigned to monitor/shadow Resident Q.A 24 Hour Shift Report Logs, dated 6/23/26, indicated Resident Q refused medications and continued targeting Resident R's room. The record lacked documentation that a staff member had been assigned to monitor/shadow Resident Q.A 24 Hour Shift Report Logs, dated 7/6/26, indicated Resident Q continued Resident R's room. The record lacked documentation that a staff member had been assigned to monitor/shadow Resident Q.On 7/14/26 from 10:00 a.m. to 11:20 a.m., during a continuous observation, Resident Q repeatedly wandered the hallway, approached the front unit door, and moved close to Resident R's room. Four staff members, the Director of Nursing (DON), Medical Records Coordinator (MRC), Certified Nursing Aide (CNA) 10, and Activity Assistant 8, attempted to redirect her. Resident Q was offered a MedPass supplemental drink, a bag of chips, and was asked to take her Jello-shots and get ready for the rodeo. Resident Q resisted redirection, slapped away items offered to distract her, and refused engagement attempts. Resident Q was repeatedly surrounded by the four staff members which caused her to attempt to back away, or get away, by going to the end of the hall and pushing against the locked exit door, which set off the alarm.During an interview at 10:04 a.m., Activity Assistant 8 indicated the staff could not keep Resident Q away from Resident R's room. Activity Assistant 8 stated Resident Q rummaged through Resident R's belongings and took items from her room, and it upset Resident R.During an interview at 10:42 a.m., CNA 10 stated Resident Q attempted to enter Resident R's room daily and targeted Resident R and her belongings.At 11:00 a.m., the DON, MRC, and CNA 10 left the memory care unit. Two staff facilitated activities in the dining/activity room. Resident Q exited her room, walked up the hallway, and approached Resident R's room. She placed her hand on the door handle, noticed she was being observed, and walked away.At 11:07 a.m., Resident Q again approached Resident R's closed door and walked away when she noticed observation.At 11:20 a.m., Resident Q approached Resident R's closed door a third time and walked away when she noticed observation.During an interview on 7/14/26 at 11:24 a.m., CNA 11 stated Resident Q continued making regular attempts to enter Resident R's room and specifically focused on Residents R and S. CNA 11 did not know why Resident Q fixated on those rooms, but it upset Resident R mostly, because Resident S was less aware of her surroundings.During an interview on 7/14/26 at 12:28 p.m., the ED, DON, and Regional Clinical Support (RCS) indicated they were aware of Resident Q's continued targeting of Resident R. They indicated Resident Q was transferred to the facility because of her affection to males. Resident Q couldn't keep her hands off of them. She wanted to touch, she wanted to grab. So the thought was it would be better for Resident Q to be to be on an all female Memory care. Resident Q admitted around the time Resident R returned from a medical procedure that required her head to be shaved. The staff indicated it may have made Resident R appear more masculine, and gained the unwanted attention from Resident Q. The ED and DON confirmed an altercation between Resident Q and CNA 14 had occurred in Resident R's room. Resident Q had wandered into Resident R's room, refused to leave, and became combative during redirection.Cross reference F600.1. On 7/14/26 at 8:50 a.m., Resident Q's record was reviewed. She was a newly admitted resident who resided on the secured memory care unit with a diagnoses which included, but was not limited to, Alzheimer's dementia, generalized anxiety, and other malaise.A nursing progress note, dated 6/13/26 at 1:40 a.m., indicated, Resident Q wandered into another resident's room Resident R. She became agitated and combative with staff when they attempted to redirect her and CNA 14's hand made contact with Resident Q's face.A Social Service progress note, dated 6/15/26 at 11:30 a.m., indicated Interdisciplinary (IDT) post incident. Resident Q's agitation appeared to have been increased by poor de-escalation technique. Resident Q responds well to redirection involving her family photos, her life-like sensory tools and housekeeping tasks.A Medical Practitioner progress note, dated 6/15/26 at 2:12 p.m., indicated Resident Q had an acute behavioral change reported by facility staff over the weekend. Resident Q was observed with increased agitation, characterized by worsening confusion, wandering into other residents' rooms and combative behavior with redirected. The assessment and plan indicated: Continue dementia care interventions, redirection techniques, and structured environment.No new non-pharmacological interventions were discussed or implemented.A nursing progress note, dated 6/15/26 at 2:36 p.m., indicated a new order was received to give Resident Q Trazadone (an anti-depressant medication often prescribed off-label as a non-addictive sedative). The medication was ordered with the indication for use as dementia with agitation/anxiety and scheduled to give 25 milligrams (mg) three times a day.A nursing progress note, dated 6/16/26 at 10:40 a.m., indicated Resident Q continued to wander into another resident's room. She was redirected to come out of the other resident's room and became agitated and combative with staff. Activities offered a babydoll which was effective.Resident Q's comprehensive care plans were reviewed. The care plan lacked implementation and/or revisions to address her history of intrusive wandering and/or that she seemed to target Residents R and S. 2. On 7/14/26 at 9:00 a.m., Resident R's record was reviewed.She was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, traumatic brain injury and dementia.She returned to the facility on 5/12/26 after a medical procedure which required her head to be shaved.Resident R's nursing progress notes were reviewed and revealed no documentation of behavioral concerns related to her peers and no documentation of her repeated complaints about Resident Q wandering into her room.Resident R's comprehensive care plans were reviewed and lacked implementation/revision for her preference to keep others out of her room.On 7/15/26 at 10:19 a.m., the ED provided a copy of current facility policy titled, Behavior - Management, dated 1/2026. The policy indicated, Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing' to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure that Facility Staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implements appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care. The concept of behavior management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors may pose a risk to self or others; Developing individual and practical care strategies based on assessed needs; Implementing the behavior management program; and ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs. The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program. When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.), Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the Attending Physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s). The facility must provide necessary behavioral health care and services which include: Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensuring that all staff interact and communicate in a manner that promotes mental and psychosocial well-being. Providing meaningful activities which promote engagement, and positive relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being. Providing an environment and atmosphere that is conducive to mental and psychosocial wellbeing. Ensuring that pharmacological interventions are only used when non- pharmacological interventions are ineffective or when clinically indicated. The Charge Nurse will assign a staff member(s) to monitor/shadow the resident as needed. Such monitoring is for the protection of the resident as well as all others and is not meant to restrict their movement or mobility.On 7/15/26 at 10:19 a.m., the ED provided a copy of current facility policy titled, Secure Care Neighborhood, dated 8/2020. The policy indicated, The goal of the Secure Care Neighborhood is to meet the individual needs of residents with dementia related illnesses. The Secure Care Neighborhood will provide a safe environment that maximizes independence and provides an activity intensive atmosphere. Resident eligible for admission for the Secure Care Neighborhood should have a cognitive deficit that could include Dementia related illnesses and is high risk for elopement. The IDT can make exceptions to this criteria on occasion and the decision must be specific to the resident safety and the safety of the other residents who reside in the Secure Neighborhood.On 7/15/26 at 10:19 a.m., the ED provided a copy of current facility policy titled, Resident Rights, dated 8/2020. The policy indicated, All residents have a right to a dignified existence, self-determination, and communication with and access to: persons and services inside and outside the facility including those specified in this policy. The 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 will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source.This citation relates to Intakes 3043476 and 3054883.410 IAC (Indiana Administrative Code) 16.2-3.1-37.

Based on observations, interviews, and record review, the facility failed to implement an effective QAPI plan that identified, investigated, analyzed, and corrected persistent dementia related safety concerns on the secured memory care unit. This deficient practice had the potential to affect all 11 of 11 residents residing on the secured memory care unit.Findings include:In January 2026, the facility received an Immediate Jeopardy (IJ) citation for dementia care involving Resident 10 and Resident 29. Review of the prior IJ citation revealed the facility failed to identify escalating behaviors of Resident 10 toward Resident 29, resulting in Resident 29 sustaining a lip laceration, nasal fracture, and rib fractures after Resident 10 pushed her on 11/20/25.The IJ investigation documented: Resident 10 had a known history of delusional thinking, aggression, and fixation on Resident 29, whom she perceived as male. Resident 29 had documented intrusive wandering behaviors. The facility lacked behavior monitoring, failed to update care plans, failed to implement interventions to prevent resident to resident contact, lacked CNA assignment sheet instructions, and had no documented IDT follow up.A document titled Abuse Allegation Timeline and Investigation Summary indicated on 6/12/26 at approximately 9:30 p.m. the charge nurse, Licensed Practical Nurse (LPN) 16, contacted the administrator to report CNA 14 for abusing Resident Q. CNA 14 was immediately removed from the facility. The document included a statement from CNA 18 that indicated CNA 14 was attempting to redirect Resident Q out of another Residents room when Resident Q pulled away and went further into the room. The statement indicated CNA 14 reached for Resident Q again and Resident Q hit CNA 14 with a closed hand in the face once and CNA 14 hit Resident Q in the face with an open hand twice. This action resulted in a scratch on Resident Q's face. The document included a statement from Qualified Medication Aide (QMA) 17 which indicated she was walking down the hall when she heard commotion coming from a Residents room. Upon her arrival to that room she witnessed CNA 14 strike Resident Q in the face twice. The document included a statement from LPN 16 which indicated she was contacted by QMA 17 by phone and was asked to go to the memory care unit. QMA 17 indicated to LPN 16 that CNA 14 hit Resident Q in the face. The document included a statement from CNA 14 which indicated she was attempting to redirect Resident Q out of another Residents room, but Resident Q refused to leave. CNA 14 indicated in her statement that she grabbed Resident Q's hands in an attempt to guide the Resident out of the room. CNA14 initially denied striking Resident Q in her statement but later in questioning she admitted to striking the Resident.Cross reference F600.During an interview, on 7/13/26 at 8:15 a.m., Resident R indicated Resident Q repeatedly attempted to enter her room since she returned from the hospital after brain surgery. Resident R stated Resident Q disturbed her several times a day and took items from her room. She stated she complained to aides, nurses, and her family, but the targeting continued. On one occasion, Resident Q entered Resident R's room, staff were not available or didn't see her enter, so Resident R grabbed Resident Q by the wrist and yelled for staff, ya'll better come get her! Resident R expressed frustration and indicated she felt like she had no privacy, she was anxious to fall asleep, and was scared about what could happen if Resident Q went off on her.During an interview on 7/14/26 at 9:47 a.m., Qualified Medication Aide (QMA) 12 indicated Resident Q continued to fixate on Resident R's room and on Resident R. Sometimes she went into Resident S's room too. A 24 Hour Shift Report Logs, dated 6/17/26, indicated Resident Q targeted Resident R's room and Resident S's room and attempted to exit the unit. The record lacked documentation that a staff member had been assigned to monitor/shadow Resident Q.A 24 Hour Shift Report Logs, dated 6/23/26, indicated Resident Q refused medications and continued targeting Resident R's room. The record lacked documentation that a staff member had been assigned to monitor/shadow Resident Q.A 24 Hour Shift Report Logs, dated 7/6/26, indicated Resident Q continued Resident R's room. The record lacked documentation that a staff member had been assigned to monitor/shadow Resident Q.On 7/14/26 from 10:00 a.m. to 11:20 a.m., during a continuous observation, Resident Q repeatedly wandered the hallway, approached the front unit door, and moved close to Resident R's room. Four staff members, the Director of Nursing (DON), Medical Records Coordinator (MRC), Certified Nursing Aide (CNA) 10, and Activity Assistant 8, attempted to redirect her. Resident Q was offered a MedPass supplemental drink, a bag of chips, and was asked to take her Jello-shots and get ready for the rodeo. Resident Q resisted redirection, slapped away items offered to distract her, and refused engagement attempts. Resident Q was repeatedly surrounded by the four staff members which caused her to attempt to back away, or get away, by going to the end of the hall and pushing against the locked exit door, which set off the alarm.During an interview at 10:04 a.m., Activity Assistant 8 indicated the staff could not keep Resident Q away from Resident R's room. Activity Assistant 8 stated Resident Q rummaged through Resident R's belongings and took items from her room, and it upset Resident R.During an interview at 10:42 a.m., CNA 10 stated Resident Q attempted to enter Resident R's room daily and targeted Resident R and her belongings.Cross reference F585 and F744.During an interview on 7/16/26 at 2:30 p.m., with the DON, ED and RCS present, the DON indicated the facility's QAPI plan for dementia care began in February 2026, had been reviewed monthly, and had been updated to address new concerns on the memory care unit. The DON indicated;The facility provided re educated staff on de escalation during resident agitation.The facility assigned preferred staff to Resident Q, provided her with increased one to one care, monitored her for behavioral triggers, and attempted to eliminate opportunities for escalation.The facility provided feminine hair products to Residents R and S to assist Resident Q in recognizing their gender.On 7/15/26 at 10:20 a.m., the ED provided a copy of the facility's investigation into the Staff to Resident altercation for Resident Q. It included an in-service record and sign-in log of staff who received the training. The In-service was dated 6/13/26 and included the topic of Abuse, Neglect Reporting and Redirecting- Resident Safety Deescalations. According to the in-service record, seven staff members who were observed interacting with Resident Q during the survey period, had not received the in-service on deescalation and resident agitation: LPN 5, CNA 6, QMA 12, Activity Assistant 8, CNA 10, CNA 11, and the Medical Records Coordinator. Upon Resident Q and R's record reviews, the records lacked documentation of assigned preferred staff for Resident Q, (who and when to be utilized) and lacked documentation of one-on-one supervision (when/why it was needed, and how long it was required).Upon review of Resident R and S's records, their plan of care lacked implementation and/or revision to include attempts to help them appear more feminine to avoid escalating behaviors from Resident Q.On 7/16/26 at 2:45 p.m., the ED provided a copy of an undated document titled, QAPI Performance Improvement Project: Ongoing Aggressive Behaviors on Memory Care Unit. The document indicated, The purpose of this QAPI Performance Improvement Project is to reduce ongoing aggressive behaviors on the memory care unit while protecting resident rights, dignity, psychosocial well-being, and safety. The project will focus on consistent identification of triggers, person-centered non-pharmacological interventions, timely care-plan updates, staff education, interdisciplinary communication, and monitoring for sustained improvement. Planned Interventions 1. Behavior tracking: Implement a daily behavior log that captures resident, time, location, trigger, staff response, outcome, injury, and follow-up needed. Care-plan revision: Update care plans within 24 hours after significant events with specific triggers, prevention strategies, staff approach, redirection techniques, and escalation steps. Once improvement is achieved, the facility will continue monthly review of memory care behavior trends through QAPI, maintain behavior tracking for residents with repeated distress, educate new and agency staff before memory care assignment when feasible, and update individualized interventions whenever a resident experiences a significant change in behavior, condition, environment, or medication regimen.This citation relates to Intakes 3043476 and 3054883.410 IAC (Indiana Administrative Code) 16.2-3.1-52.

A. Based on observations, interviews, and record review, the facility failed to ensure that Resident R, who resided on the secured memory care unit, had access to grievance forms or had grievances submitted on her behalf for 1 of 3 residents reviewed for resident rights. This deficient practice had the potential to affect 11 of 11 residents who resided on the secured memory care unit. B. Based on observation, record review, and interview, the facility failed to ensure a grievance related to a resident's mattress causing her discomfort and pain was submitted and investigated for 1 of 3 residents reviewed for resident rights (Resident F). Findings include: A. On 7/13/26 at 8:15 a.m., Resident R stated she had ongoing concerns that Resident Q repeatedly attempted to enter her room and disturb her. She reported the problem began when she returned from the hospital after brain surgery and continued thereafter. Resident R stated she had complained to aides, nurses, and her family members that Resident Q persistently and intrusively wandered into her room. Resident R reported she had seen bright orange grievance forms in the hallway outside the unit, but when she looked for forms after returning to her room, she did not find any available on the unit. Resident R stated she did not know if anyone had submitted a grievance on her behalf and believed none had been filed since Resident Q continued entering her room. These repeated intrusions and the constant worry that Resident Q would enter her room and take her belongings caused Resident R to feel anxious and unsafe. On 7/13/26 at 9:00 a.m., the secured memory care unit was observed. No grievance forms were available. During an interview on 7/14/26 at 9:47 a.m., Qualified Medication Aide (QMA) 12 stated Resident Q continued to fixate on Resident R's room and on Resident R. QMA 12 did not know why Resident Q targeted Resident R but reported the issue had continued since Resident R returned from the hospital after her brain surgery. On 7/14/26, during continuous observation from 10:00 a.m. to 11:20 a.m., Resident Q was observed as she repeatedly wander up and down the hallway. She approached the front unit door and moved close to Resident R's room. Four staff members; the Director of Nursing (DON), Medical Records Coordinator (MRC), Certified Nursing Aide (CNA) 10, and Activity Assistant 9, immediately surrounded her and attempted to redirect her away from Resident R's room. Resident Q resisted redirection and slapped away items offered to distract her, including a supplemental drink and snack chips. Staff also attempted to engage her verbally by asking if she wanted to get ready for the rodeo, but Resident Q continued wandering around the hallway. During an interview at 10:04 a.m., Activity Assistant 8 stated the staff could not keep Resident Q away from Resident R's room and stated Resident Q rummaged through Resident R's personal belongings and took items. During an interview on 7/14/26 at 11:42 a.m., CNA 11 indicated Resident Q continued to make regular attempts to enter Resident R's room. CNA 11 expressed her personal belief that Resident Q may have been focusing specifically on Residents R and S. On 7/14/26 at 11:07 a.m., the Executive Director (ED) provided grievance logs for June and July. There was no documentation showing the facility submitted or investigated any grievance related to Resident R's ongoing concerns about Resident Q entering her room. During an interview on 7/14/26 at 12:28 p.m., with the ED, DON, and Regional Clinical Support (RCS) present, the ED and DON indicated they were aware of the ongoing issue of Resident Q targeting Resident R's room. The ED, DON, and RCS indicated grievance forms should be available for all residents, which included the memory care unit for residents capable of submitting grievances or for families visiting residents. They indicated residents or family members could verbally submit grievances, but all investigations and outcomes should have been documented. Cross reference F744. 2. On 7/14/26 at 10:12 a.m., Resident F was observed lying in her bed. She indicated her current bed was new, and she was thankful to be out of that horrible old bed. She indicated the old bed was a low air loss mattress that inflated and deflated in certain places on the mattress. It caused her to be in great pain. So much pain that she dialed 911 to help her and then went to the emergency room to get her body off that mattress for at least a little bit of time she was gone. She indicated everybody looked at her old bed and nobody knew anything about the operation of the bed. She indicated the mattress settings were at 350 and it was too high, indicating the settings went off of her weight and she was only 250 pounds. The doctor came in on 7/10/26 and ordered her a new mattress. The mattress was finally changed and now she was so much better and could move around in the bed without pain. On 7/14/26 at 1:33 p.m., a record review was completed for Resident F. She had the following diagnoses which included but were not limited to obesity, osteoarthritis of both knees (a degenerative joint disease where the protective cartilage covering the ends of the bones gradually wears away), osteoarthritis of the both hips, spondylosis without myelopathy or radiculopathy, cervical region (spinal osteoarthritis, a degenerative condition caused by age-related wear and tear on the spine), sciatica (a symptom of nerve irritation rather than a standalone medical condition), and other chronic pain. Resident F admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) was 15/15 indicating her cognition was intact on 5/6/26. Resident F had a care plan, dated 5/15/26, indicating she required pain management related to acute/chronic pain related to arthritis, back, and pelvic wound. The goal was not to have an interruption in normal activities due to pain. An intervention, dated 5/15/26, indicated to anticipate Resident F's need for pain relief and respond immediately to any complaint of pain. On 6/28/26 at 1:40 a.m., Resident requested sobbing and complaining of pain. She requested to go to the emergency room. 911 was notified and she was sent to the emergency room. On 7/4/26 at 12:10 a.m., a progress noted indicated resident was crying and stating that she was uncomfortable in the bed and wanted the bed changed. The Director of Nursing (DON) was notified. The resident was informed that her bed was unable to be replaced or changed. On 7/16/26 at 10:15 a.m., during an interview with the Executive Director (ED) she indicated they attempted to try multiple mattresses for Resident F. She indicated she would look into further details related to the resident and her mattress concerns. On 7/15/26 at 10:19 a.m., the ED provided the current facility policy titled, Grievances and Complaints, dated 8/2020. The policy stated, The Facility advises residents and their representatives (including family, legal representatives, and advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints. The disposition of all resident grievances and/or complaints is recorded in the Facility's Resident Grievance/Complaint Log. Any resident, representative, family member, staff, visitor, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, theft of property, etc., without fear of threat or reprisal in any form. Grievances and/or complaints may be submitted orally or in writing and can be made anonymously through the Compliance Hotline. Individuals will use Facility complaint forms or may use Resident Grievance/Complaint Form to submit written grievance reports. Duties and Obligations of Staff. When a Facility Staff member overhears or receives a complaint from a resident, a resident's representative, another interested family member or visitor of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the Facility Staff member is encouraged to advise the resident/concerned party that they may file a complaint or grievance without fear of reprisal or discrimination, and will assist the resident, or person acting on the resident's behalf, in filing a written complaint with the Facility. This Federal tag related to Intake 3049390 and 3054883. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on record reviews and interviews, the facility failed to protect the residents' rights to be free from physical abuse by a Certified Nursing Aide (CNA) and verbal abuse by a Housekeeping Supervisor for 2 of 9 residents reviewed for abuse (Residents Q and H). This deficient practice was corrected on 6/13/26, prior to the start of the survey, and was therefore past noncompliance. Findings include:1. On 7/15/26 at 10:20 a.m. a copy of an investigation into an allegation of staff to resident abuse was provided. A document titled Abuse Allegation Timeline and Investigation Summary indicated on 6/12/26 at approximately 9:30 p.m., Licensed Practical Nurse (LPN) 16, contacted the Administrator to report CNA 14 for abusing Resident Q. CNA 14 was immediately removed from the facility. The document included a statement from CNA 18 that indicated CNA 14 was attempting to redirect Resident Q out of another Residents room when Resident Q pulled away and went further into the room. The statement indicated CNA 14 reached for Resident Q again and Resident Q hit CNA 14 with a closed hand in the face once and CNA 14 hit Resident Q in the face with an open hand twice. This action resulted in a scratch on Resident Q's face. The document included a statement from Qualified Medication Aide (QMA) 17 which indicated she was walking down the hall when she heard commotion coming from a resident's room. Upon her arrival to that room she witnessed CNA 14 struck Resident Q in the face twice. The document included a statement from LPN 16 which indicated she was contacted by QMA 17 by phone and was asked to go to the memory care unit. QMA 17 indicated to LPN 16 that CNA 14 hit Resident Q in the face. The document included a statement from CNA 14 which indicated she was attempting to redirect Resident Q out of another Residents room, but Resident Q refused to leave. CNA 14 indicated in her statement that she grabbed Resident Q's hands in an attempt to guide the Resident out of the room. CNA14 initially denied striking Resident Q in her statement but later in questioning she admitted to striking the Resident. A corrective action form from the Director of Nursing to CNA 14, dated 6/13/26, indicated CNA 14 was terminated as a result of the investigation of alleged abuse. The form indicated CNA 14 had failed to use safe redirection techniques with an agitated resident and had made contact with the Resident causing the situation to escalate. 2. On 7/20/26 a copy of a corrective action form was provided, that form indicated on 2/4/26 the Housekeeping Supervisor was suspended pending the investigation into an allegation of verbal abuse towards Resident H. The form indicated on 2/4/26 the Administrator was made aware that the Housekeeping Supervisor had been overheard speaking to Resident H in an elevated voice and being argumentative with the resident related to white plastic hangers and who owned them. When the Housekeeping Supervisor was interviewed about the incident, she admitted she lost her temper. As a result of the incident the Housekeeping Supervisor received a final warning. On 7/20/26 a copy of a Performance Improvement Plan (PIP), dated 2/20/26, indicated the Housekeeping Supervisor had failed to do multiple facets of her role including, but not limited to, failure to interact with staff, residents, and visitors in a positive, respectful and professional manner. The PIP indicated on 2/4/26 the Housekeeping Supervisor was suspended pending investigation into alleged verbal abuse. The allegation was substantiated, and as a result of that the Housekeeping Supervisor did several customer service trainings and received her final warning. During an interview 7/16/26 at 12:00 p.m. the Administrator indicated when she got here the current Housekeeping Supervisor was not the supervisor. She had stepped down after the verbal altercation with Resident H and a new Housekeeping Supervisor was in orientation when the Administrator started. That new supervisor was hired on 3/3/26 and resigned on 4/11/26. At that time the Administrator asked the Regional Director of Operations why the current Housekeeping Supervisor had stepped down, because she was the Administrator's go to person for any housekeeping. The Administrator indicated she was told it was because the Housekeeping Supervisor was in a verbal altercation with a resident. She indicated she was never told it was an allegation of abuse. The Administrator indicated she was unaware of the PIP and wasn't sure why they chose to bring the current Housekeeping Supervisor back if there was substantiated abuse. During an interview on 7/16/26 at 12:39 p.m. the Administrator indicated the information they gave her was that the Housekeeping Supervisor was suspended pending the investigation, but it appeared to she was brought back because poor customer service was substantiated not abuse. The Administrator indicated she hadn't had any corrective action or grievances submitted about her behavior since the incident. On 7/15/26 at 10:20 a.m. a copy of a current facility policy titled Abuse-Reportable Events, dated 5/2017, was provided. That policy indicated .It is the policy of this home to prohibit resident abuse or neglect in any form. Abuse: The willful infliction of injury,. intimidation,. resulting in physical harm,. This includes. verbal,. or physical abuse. Physical abuse: Physical action within the definition of abuse, including, but not limited to, hitting, slapping,. Verbal abuse: The use of oral,. language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. This deficient practice was corrected by 6/13/26 after the facility implemented a systemic plan that included the following actions: assessment of all memory care residents for injuries of unknown origin, immediate reeducation of abuse prevention for all staff members, corrective action for the CNA and Housekeeping Supervisor involved in the abuse, ongoing in-servicing education to staff related to abuse prevention, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This citation relates to Intakes 3043476, 3044848, 3046310, and 3054883 410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to ensure a resident's discharge was adequately planned and safe for 1 of 5 residents reviewed for discharges (Resident D). Findings include:During an interview, on 7/13/26 at 12:03 p.m., Resident D indicated he was discharged from the facility to an unsafe place because he voiced too many grievances. Resident D indicated the discharge was in retaliation for him voicing so many grievances to the facility. Resident D's record was reviewed on 7/13/26 at 11:55 a.m. Diagnoses on the resident's profile included, but were not limited to, cellulitis (skin infection) of the left lower limb, peripheral vascular disease (progressive blood circulation disorder), non-pressure chronic ulcer (open area) of other part of left lower leg with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with fat layer exposed, and acquired absence of right leg above knee. Census information indicated the resident initially admitted to the facility on [DATE] and was discharged on 7/6/26. Hospital documentation, dated 4/1/26, indicated the resident had been homeless. The resident had a previous substance abuse disorder and was being discharged on this day from an extended care facility to a sober living facility. At the time of the transfer, the resident attempted to get in his ride-share, fell, and was considered too medically complex to go to the sober living facility. He was brought to the emergency room (ER) and required observation related to a lack of safe discharge options. A care plan, initiated on 4/9/26, indicated the resident had a right above knee amputation. An admission Minimum Data Set (MDS) assessment, dated 5/31/26, indicated the resident was cognitively intact, had an overall goal to remain in the facility, and there was no active discharge planning occurring for the resident to return to the community. A review of grievances indicated the resident filed a grievance on 6/4/26, 6/5/26, four times on 6/8/26, 6/15/26, and 6/16/26. A quarterly MDS assessment, dated 6/12/26, indicated the assessment information was obtained for the resident. The resident declined wanting to talk to someone about the possibility of returning to live and receive services in the community and no active discharge planning was occurring for the resident to return to the community. A physician's order, dated 6/12/26, indicated cleanse the left dorsal (top) foot with normal saline soaked gauze, apply calcium alginate (absorbent wound treatment) to open area, secure with foam wound dressing, change three times weekly, and as needed if soiled or dislodged. A physician's order, dated 6/12/26, indicated cleanse the left lateral (outer) lower leg with normal saline, apply collagen (promotes wound healing) to wound bed, cover with bordered gauze, and change daily. A physician's order, dated 6/12/26, indicated apply Santyl (medication to remove dead tissue) to left dorsal foot topically daily. The order lacked documentation if this was for the same wound on the left dorsal foot, and if so, why the other order was three times weekly and not daily. A care plan, initiated on 6/17/26, indicated the resident exhibited attention-seeking behavior. The intervention was staff would anticipate and meet the resident's needs. A care plan, initiated on 6/19/26, indicated the resident exhibited verbal aggression and profane language. Interventions included, but were not limited to, assist the resident in avoiding other residents that may incite outbursts. A progress note, dated 7/1/26, indicated Social Services talked to the resident about his financial liability to the facility. The resident stated he would pay the liability but wanted to talk to the Business Office Manager (BOM). A progress note, dated 7/3/26, indicated the resident was starting to mess with dietary staff. The resident gave the Dietary Manager a selective menu, and the resident was able to choose what he wanted. The resident always indicated he only wanted milk at breakfast and not at lunch or dinner. The prior night, the Dietary Manger received a call from the cook who was very upset because the resident came down to dietary yelling and cursing and asked the cook if she could read because he did not have milk on his tray. The cook told the resident he had not written down milk as a request, but he could have the milk now if he wanted it. The resident called the cook a dumb b----. The resident will, also not put items on his menu purposely and then come and yell he didn't get it. The Dietary Manager educated the resident on selecting his menu options and instructed staff to keep a copy of the menu selections. A progress note, dated 7/6/26 at 9:15 a.m., indicated the resident was verbally aggressive towards another resident when the other resident was asking for soda. The residents were separated with no concerns. The resident was placed on one on one observation, family and physician notified, and the physician gave an order for the resident to be transferred to an inpatient psychiatric facility. The resident refused an inpatient psychiatric facility and indicated he would go to the address given. The physician ordered the resident's discharge, three days of narcotics, and education given to the resident about his wound treatment to be changed three times weekly. The note lacked documentation the resident demonstrated being able to do the treatment himself, who lived at the address given, and if the person who lived there was OK with the resident being discharged there. A progress note, dated 7/6/26 at 11:03 a.m., indicated the resident wanted to discharge and refused in-house services. The resident was educated on the treatment, and the family was notified. The note lacked documentation of why the resident wanted to discharge, or what other options were provided to the resident. A progress note, dated 7/6/26 at 11:50 a.m., indicated the Social Services submitted four referrals to inpatient behavioral/psychiatric facilities due to the resident's behavior towards staff and other residents. No response was received. The resident declined to voluntarily participate in psychiatric services. The note lacked documentation of why referrals were made if the resident actually wanted to voluntarily discharge from the facility. A progress note, dated 7/6/26 at 12:48 p.m., indicated all inpatient psychiatric facilities had declined to admit the resident. The note lacked documentation of why referrals were made if the resident actually wanted to voluntarily discharge from the facility. A nurse practitioner (NP) progress note, dated 7/6/26 at 2:51 p.m. The progress note indicated, .seen today for discharge evaluation and medical management following a skilled nursing facility stay after hospitalization for sepsis [body's extreme, life-threatening response to infection] secondary to left lower extremity cellulitis with wound infections.During his SNF [skilled nursing facility] stay, the resident received ongoing wound care, therapy services, pain management, and management of multiple chronic medical conditions.Despite medical stabilization, the resident has demonstrated repeated behaviors that have significantly disrupted the safe operation of the facility, including verbal threats and threatening behavior directed toward facility staff and other residents. Documentation reflects these behaviors persisted despite interdisciplinary interventions, staff education, behavioral redirection, care planning, and attempts to safely manage his care within the facility. Due to ongoing threats that present a safety risk to others and cannot be safely managed within the current setting, the facility has determined discharge is medically and administratively necessary.Resident is medically stable for discharge. Facility discharge is necessitated by persistent threatening behavior toward staff and fellow residents creating a safety concern despite interdisciplinary interventions and behavioral management efforts. The note lacked documentation the resident's prior homelessness was addressed as a safety barrier for discharge. A progress note, dated 7/6/26 at 4:01 p.m., indicated the resident discharged from the facility to the provided address. The progress note lacked documentation the resident was provided with written discharge instructions. An undated discharge planning review indicated the resident was being discharged home. The document included a section for self-care evaluation and equipment, all were marked non-applicable, including walking, wheelchair use, transfers, bathing, dressing, using the restroom, preparing meals, eating, grocery shopping, housekeeping, performing home maintenance, obtaining transportation, scheduling medical appointments, getting and taking medications, and performing special treatments/procedures. Medications sent with resident indicated, med list, meds, 3 days of narcs [narcotics], tx [treatment supplies]. A section indicated, Indicate whether resident verbalized/demonstrated understanding of instructions, and was left blank. The contact section included an area to document names of providers and who the resident should contact and was left blank. A signature section for resident and staff signatures was left blank. The review lacked documentation a copy was provided to the resident at discharge. A progress note, dated 7/9/26, indicated the resident's preferred hospital wound center was notified, and the representative stated the resident needed to call and make future appointments. The note lacked documentation the preferred provider was notified prior to the resident's discharge or the resident was given information about how and when to contact them. Progress notes lacked documentation the resident's discharge was planned, including documented evidence the resident understood and was able to provide care for his wounds, how and when to take his medications, and how to obtain additional wound care products or medications. During an interview, on 7/13/26 at 11:48 a.m., the Executive Director (ED) indicated the discharge planning review document was what was used to prepare the resident for the discharge. During an interview, on 7/13/26 at 1:46 p.m., the Regional Clinical Support Nurse indicated the recapitulation of stay document was what should have been used for the resident's discharge instructions, and it had not been done. The document should have been reviewed and signed by the resident. During an interview, on 7/14/26 at 11:22 a.m., Certified Nurse Aide (CNA) 15 indicated she took the resident to the address he discharged to. When they arrived at the house, CNA 15 helped the resident get off the facility bus with his belongings. When CNA 15 knocked on the door, no one answered, so the resident was left on the front porch with his belongings. The resident was on the phone with someone and told CNA 15 his friend was on the way to the house. CNA 15 did not talk to the person on the phone, stay with the resident, or notify authorities he was being left alone on a porch. During an interview on 7/14/26 at 12:08 p.m., the Executive Director (ED) indicated the resident told her he was not staying at the facility because he did not want to see psychiatric services. CNA 15 told the ED she had knocked on the door when she dropped the resident off, but no one answered, and the resident was left on the porch. The ED indicated she was not sure where the resident was now and had not followed up with him. The resident was upset about having to pay his liability. During an interview, on 7/14/26 at 12:30 p.m., the Director of Nursing (DON) indicated the resident told them where he wanted to go to [hospital name] wound center for wound care after he discharged from the facility. The resident had not been receiving wound care from the wound center prior to his discharge from the facility. On 7/14/26 at 2:28 p.m., the ED provided a document titled, Transfer and Discharge Planning, last revised in August 2020, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility.Social Services Staff will conduct a Discharge Planning Assessment and will help orient the resident to the impending discharge.Discharge Planning: A. Discharge planning will begin on the residents' admission to the Facility.C. If the IDT [interdisciplinary team] and the Attending Physician determine that the resident may soon be discharged , Social Services Staff will coordinate the discussion of discharge with the IDT team, the resident, and the resident's personal representative.D. Social Services Staff will communicate with Facility Staff, the resident and resident's family members as the time for discharge approaches. E. Social Services Staff will document the discharge planning, preparation, and the resident's post-discharge needs in the electronic health record. i. In preparation for discharge, Social Services will document referrals to local contact agencies, the Ombudsman or other relevant support services and the response of the resident/representative to those referrals. F. Social Services Staff will orient the resident to the impending discharge. G. Social Services Staff will coordinate resident family conferences to discuss discharge needs, plans, and teaching, and will coordinate with other IDT members as appropriate. H. If the resident/representative wishes to be discharged to a setting that does not appear to meet the resident's post-discharge needs or appears unsafe, the Facility will treat this request similarly to a refusal of care.ii. The facility will attempt to determine why the resident/representative is choosing that location.iv.If indicated, the referral to Adult Protective Services.will be made at the time of discharge.Documentation.A copy of the Discharge Summary will be provided to the resident.upon discharge when return is not anticipated. Cross reference F628. This citation relates to Intake 3091378.

Based on interview and record review, the facility failed to ensure a 30-day notice was issued to a resident prior to a facility-initiated discharge for 1 of 5 discharges reviewed (Resident D). Findings include:During an interview, on 7/13/26 at 12:03 p.m., Resident D indicated he was discharged from the facility to an unsafe place because he voiced too many grievances. Resident D indicated the discharge was in retaliation for him voicing so many grievances to the facility. During an interview on 7/14/26 at 12:08 p.m., the Executive Director (ED) indicated the resident told her he was not staying at the facility because he did not want to see psychiatric services. CNA 15 told the ED she had knocked on the door when she dropped the resident off, but no one answered, and the resident was left on the porch. The ED indicated she was not sure where the resident was now and had not followed up with him. The resident was upset about having to pay his liability. The ED indicated she did not give the resident a 30-day notice of transfer or discharge and did not feel it was required. The ED indicated she was aware the NP documented the resident's discharge was facility-initiated. Resident D's record was reviewed on 7/13/26 at 11:55 a.m. Diagnoses on the resident's profile included, but were not limited to, cellulitis (skin infection) of the left lower limb, peripheral vascular disease (progressive blood circulation disorder), non-pressure chronic ulcer (open area) of other part of left lower leg with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with fat layer exposed, and acquired absence of right leg above knee. Census information indicated the resident initially admitted to the facility on [DATE] and was discharged on 7/6/26. Hospital documentation, dated 4/1/26, indicated the resident had been homeless. The resident had a previous substance abuse disorder and was being discharged on this day from an extended care facility to a sober living facility. At the time of the transfer, the resident attempted to get in his ride-share, fell, and was considered too medically complex to go to the sober living facility. He was brought to the emergency room (ER) and required observation related to a lack of safe discharge options. An admission Minimum Data Set (MDS) assessment, dated 5/31/26, indicated the resident was cognitively intact, had an overall goal to remain in the facility, and there was no active discharge planning occurring for the resident to return to the community. A quarterly MDS assessment, dated 6/12/26, indicated the assessment information was obtained for the resident. The resident declined wanting to talk to someone about the possibility of returning to live and receive services in the community and no active discharge planning was occurring for the resident to return to the community. A review of grievances indicated the resident filed a grievance on 6/4/26, 6/5/26, four times on 6/8/26, 6/15/26, and 6/16/26. A progress note, dated 7/1/26, indicated Social Services talked to the resident about his financial liability to the facility. The resident stated he would pay the liability but wanted to talk to the Business Office Manager (BOM). A progress note, dated 7/3/26, indicated the resident was starting to mess with dietary staff. The resident gave the Dietary Manager a selective menu, and the resident was able to choose what he wanted. The resident always indicated he only wanted milk at breakfast and not at lunch or dinner. The prior night, the Dietary Manger received a call from the cook who was very upset because the resident came down to dietary yelling and cursing and asked the cook if she could read because he did not have milk on his tray. The cook told the resident he had not written down milk as a request, but he could have the milk now if he wanted it. The resident called the cook a dumb b****. The resident will, also not put items on his menu purposely and then come and yell he didn't get it. The Dietary Manager educated the resident on selecting his menu options and instructed staff to keep a copy of the menu selections. A progress note, dated 7/6/26 at 9:15 a.m., indicated the resident was verbally aggressive towards another resident when the other resident was asking for soda. The residents were separated with no concerns. The resident was placed on one on one observation, family and physician notified, and the physician gave an order for the resident to be transferred to an inpatient psychiatric facility. The resident refused an inpatient psychiatric facility and indicated he would go to the address given. The physician ordered the resident's discharge, three days of narcotics, and education given to the resident about his wound treatment to be changed three times weekly. The note lacked documentation the resident demonstrated being able to do the treatment himself, who lived at the address given, and if the person who lived there was OK with the resident being discharged there. A progress note, dated 7/6/26 at 11:03 a.m., indicated the resident wanted to discharge and refused in-house services. The resident was educated on the treatment, and the family was notified. The note lacked documentation of why the resident wanted to discharge, or what other options were provided to the resident. A progress note, dated 7/6/26 at 11:50 a.m., indicated the Social Services submitted four referrals to inpatient behavioral/psychiatric facilities due to the resident's behavior towards staff and other residents. No response was received. The resident declined to voluntarily participate in psychiatric services. The note lacked documentation of why referrals were made if the resident actually wanted to voluntarily discharge from the facility. A progress note, dated 7/6/26 at 12:48 p.m., indicated all inpatient psychiatric facilities had declined to admit the resident. The note lacked documentation of why referrals were made if the resident actually wanted to voluntarily discharge from the facility. A nurse practitioner (NP) progress note, dated 7/6/26 at 2:51 p.m. The progress note indicated, .seen today for discharge evaluation and medical management following a skilled nursing facility stay after hospitalization for sepsis [body's extreme, life-threatening response to infection] secondary to left lower extremity cellulitis with wound infections.During his SNF [skilled nursing facility] stay, the resident received ongoing wound care, therapy services, pain management, and management of multiple chronic medical conditions.Despite medical stabilization, the resident has demonstrated repeated behaviors that have significantly disrupted the safe operation of the facility, including verbal threats and threatening behavior directed toward facility staff and other residents. Documentation reflects these behaviors persisted despite interdisciplinary interventions, staff education, behavioral redirection, care planning, and attempts to safely manage his care within the facility. Due to ongoing threats that present a safety risk to others and cannot be safely managed within the current setting, the facility has determined discharge is medically and administratively necessary.Resident is medically stable for discharge. Facility discharge is necessitated by persistent threatening behavior toward staff and fellow residents creating a safety concern despite interdisciplinary interventions and behavioral management efforts. The note lacked documentation the resident's prior homelessness was addressed as a safety barrier for discharge or that a 30-day notice of transfer or discharge was issued before the facility-initiated discharge was initiated. A progress note, dated 7/6/26 at 4:01 p.m., indicated the resident discharged from the facility to the provided address. The note lacked documentation a 30-day notice of transfer or discharge was provided to the resident for the facility-initiated discharge. On 7/14/26 at 2:28 p.m., the ED provided a document titled, Transfer and Discharge, dated 10/24/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Residents are transferred/discharged based on physician order unless they sign themselves out against medical advice.Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of transfer/discharge.Cases in which 30 days' notice is not possible, notice of transfer or discharge should be provided to the resident of his/her responsible party as soon as practicable. Cross reference F627. This citation relates to Intake 3091378.

Based on record review and interview, the facility failed to ensure a resident's change in condition was treated in a timely manner, was effectively monitored, and was communicated accurately to the medical provider for 1 of 10 residents reviewed for quality of care (Resident J). Findings include:Resident J's record was reviewed on 7/13/26 at 2:00 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, mild cognitive impairment. A significant change Minimum Data Set (MDS) assessment, dated 4/22/26, indicated the resident had a moderate cognitive impairment and an indwelling urinary catheter (tube inserted into the bladder). A nutrition assessment, dated 5/29/26, indicated the resident had an estimated need of 1,677 milliliters (ml) of fluid daily. A physician's order, dated 6/11/26, indicated obtain urine sample to rule out UTI, one time only, for worsening confusion. A Medication Administration Record (MAR), dated June 2026, indicated the urine sample collection was scheduled on 6/12/26, but was documented as not completed. The medical record lacked documentation of why the sample was not collected. A progress note, dated 6/25/26, indicated the resident's urine was collected and sent to the laboratory for a urinalysis (UA). The note lacked documentation of why the sample was collected, including if it was related to the missed sample from 6/12/26. The UA and culture and sensitivity (C&S) results were reported on 6/27/26 and indicated greater than 100,000 colony-forming units (CFU)/milliliters (ml) (an amount of bacteria which indicates a UTI) of Enterobacter cloacae (bacteria) and Escherichia coli (bacteria). The results indicated Resident J had a urinary tract infection (UTI). Progress notes, dated 6/27/26 to 6/28/26, lacked documentation the physician was notified of the UA C&S results. A fluid intake report, dated 6/28/26, indicated the resident had 300 ml of fluid that day. A fluid intake report, dated 6/29/26, indicated the resident had 1,070 ml of fluid that day. A Nurse Practitioner (NP) progress note, dated 6/29/26, indicated the resident was being seen due to an acute (current) UTI. The NP reviewed the urine culture results and indicated the resident required antibiotic therapy and ongoing monitoring of an acute complicated UTI related to the Foley catheterization (tube inserted into the bladder) and multiple chronic medical comorbidities. The resident's temperature was 97.6 degrees Fahrenheit (F) blood pressure (B/P) 157/93, heart rate 62 beats per minute (bpm), oxygen saturation (amount of oxygen in blood) on room air 98 percent. The NP's plan was to order nitrofurantoin (antibiotic) 100 milligrams (mg) twice daily for 7 days, monitor closely for fever, worsening suprapubic pain (pain in the lower central part of the abdomen), flank pain (just below rib cage and above waist), altered mental status, decreased urine output, or other evidence of treatment failure or sepsis, and notify the provider of clinical deterioration. A MAR, dated June 2026, indicated the nitrofurantoin was scheduled to be started, on 6/29/26, in the evening, but the dose was not administered. The resident received two doses of nitrofurantoin on 6/30/26. A fluid intake report, dated 6/30/26, indicated the resident had 1,240 ml of fluid that day. A MAR, dated July 2026, indicated the resident received one dose of nitrofurantoin on the morning of 7/1/26, but the evening shift had not administered. A progress note, dated 7/1/26 at 10:50 a.m., indicated the resident was unable to take her medications, and her temperature was 100 degrees F. The note lacked documentation the physician was notified. Text conversation between the resident's nurse and the provider was dated 7/1/26 at 11:51 a.m. The nurse indicated the resident had a temperature of 100.1 degrees F, oxygen saturation of 89 percent, blood pressure 96/66, and pulse 93 bpm. The resident was on nitrofurantoin for UTI for seven days. The nurse requested the medical provider advise. The medical provider responded and indicated give Tylenol stat (immediately), ordered labs, and Rocephin (ceftriaxone) one gram (gm) intramuscularly (IM) for five days for upper respiratory infection (URI), elevated temperature, and hypoxia (low oxygen saturation). The conversation did not indicate the nurse told the on-call provider she felt the resident needed to go to the hospital. A situation, background, assessment, recommendation (SBAR) summary for providers, dated 7/1/26 at 12:09 p.m., indicated the resident's blood pressure was 99/66, pulse 93 bpm, temperature 100.1 degrees F, and oxygen saturation of 89 percent. The provider ordered labs, Rocephin one gm IM daily for five days for URI, and a chest x-ray. The SBAR did not indicate the nurse requested the resident be sent to the hospital. An order change progress note, dated 7/1/26 at 3:25 p.m., indicated the system identified a possible drug allergy for the ceftriaxone injection order. The area to document notification of the provider and responsible party was left blank. The medical record lacked documentation the provider was notified. A MAR, dated July 2026, indicated the ceftriaxone was scheduled to be started on 7/2/26, in the morning, and was not administered on 7/1/26. An undated Emergency Drug Kit (EDK) inventory indicated ceftriaxone 1 gm vials were included in the EDK. A report, dated 7/1/26, indicated there was no ceftriaxone removed from the EDK on 7/1/26. A chest x-ray, dated 7/1/26, was completed at 3:01 p.m. and reported at 6:33 p.m., showed no acute findings. A progress note, dated 7/1/26 at 5:00 p.m., indicated the resident had a temperature of 100.1 degrees F. The nurse spoke with the on-call provider, and they ordered labs, chest x-ray, and Rocephin. The resident's lung sounds were diminished with crackles. The resident had barely eaten that day. The resident was hard to wake up, even for her family member. The note indicated, The resident would benefit from being sent to the ER [emergency room] for eval [evaluation]. [On-call provider name] has not recommended this at this time. The note lacked documentation, the nurse notified the on-call provider the nurse thought the resident would benefit from being sent to the ER. A text conversation between the resident's nurse and the medical provider was dated 7/1/26 at 11:58 p.m. The nurse indicated the resident was not arousable with attempts to give medication. Vital signs were temperature 102 degrees F, pulse 106 bpm, blood pressure 118/76, and oxygen saturation 94 percent. The nurse indicated, .She also has an order for ceftriaxone.to start tomorrow at 9am [9:00 a.m.] and is on nitrofurantoin 100 mg bid [twice daily].only allergy is to penicillin, still want me to give Rocephin now? I think she possibly had a dose today, her pulse is weak, respirations shallow, can't get her to wake up with sternal rub. The physician responded if the nurse was unable to get the resident to wake up, to send her to the emergency room. A fluid intake report, dated 7/1/26, indicated the resident had 840 ml of fluid that day. A progress note, dated 7/2/26, indicated the resident was had an elevated temperature and was unarousable. The resident was sent to the ER. An ER hospital history and physical, dated 7/2/26, indicated the following regarding the resident's condition when she arrived in the ER. -The resident's family member reported the resident sounded gurgly over the last three days and her responsiveness decreased. -The resident was apparently started on Rocephin earlier today, but this evening had an elevated temperature and was not responsive to a sternal rub so she was sent to the ER. -A computed tomography (CT) of the abdomen and pelvis indicated there was occlusive debris (material blocking the airway) in the bronchus intermedius (a short airway in the right lung that connects the upper airway to the middle and lower lobes) and bronchi (the large, branching tubes that air travels down to reach your lungs) to the right lower and upper lobes, and post-obstructive atelectasis (collapsed lung) in the right lower lobe that might be due to aspiration (accidental inhalation of solid or liquid material) or infection, and moderate to large volume colonic stool with rectal wall thickening (large amount of stool in the colon). -The resident was diagnosed with sepsis secondary to aspiration pneumonia, stercoral colitis (a dangerous inflammatory condition of the colon caused by severe fecal impaction),UTI, and possible wound infection. -Aspiration pneumonia with hypoxia, as noted on the CT scan, was suspected to be due to medications and food being given while the resident was obtunded (decreased level of consciousness). The resident was ordered to have strictly nothing by mouth. -The resident was severely dehydrated with a sodium level of 152 milliequivalents (mEq)/liter (L) (normal is 135-145 mEq/L). The resident's family member reported the resident had virtually no intake for at least three days. During an interview, on 7/14/26 at 9:24 a.m., Resident J's family member indicated the resident started acting like she had a UTI, around 6/12/26, and the family member thought the facility was going to check the resident's urine. The resident had been in the intensive care unit (ICU) since she left the facility and was still there. On 7/1/26, the resident's family member was at the facility from around 3:30 p.m. to 8:30 p.m. During that time, she found the resident with food sitting and being held in her mouth while the resident was asleep. She saw the staff feeding the resident dinner, but she did not think the resident was able to swallow it. The resident was not responding to her. The family member returned to the facility around midnight and told them she wanted the resident sent to the hospital. When she returned to the facility at midnight, staff had to help her remove spoonfuls of pudding from the resident's mouth. During an interview, on 7/15/26 at 9:25 a.m., Licensed Practical Nurse (LPN) 19 indicated she was working as a unit manager on 7/1/26. LPN 19 acknowledged she documented that the resident would have benefited from being transferred to the hospital. LPN 19 indicated she asked for the resident to go to the hospital, but Registered Nurse (RN) 20 was in charge and did not think the resident needed to go to the hospital because they had other interventions in place. Later, the resident's family member ended up insisting the resident be sent out to the hospital. The resident was running a fever and was not acting normally. Around 2:00 p.m., on 7/1/26, the resident became less responsive. Antibiotics should have been pulled from the EDK and administered immediately when they were ordered. If an antibiotic was not available in the EDK, it should have been ordered from the back-up pharmacy and administered upon arrival. LPN 19 indicated she received the order for Rocephin for the resident. She had not administered it because, for some reason, the system would not let her schedule the first administration until the following morning. She indicated she was aware of the resident's penicillin allergy, and the physician was also aware. She was not sure if the allergy was the reason why the system would not let her schedule it until the next day. If a resident experienced a change in condition, unless it was life-threatening, the staff was supposed to contact the Director of Nursing (DON) first and then call the physician. LPN 19 indicated she had not discussed the possibility of sending the resident to the hospital with the DON. During an interview, on 7/15/26 at 11:36 a.m., RN 20 indicated she had not taken care of Resident J on 7/1/26. RN 20 indicated she was not aware of any interventions or care Resident J received and had not given any guidance to LPN 19 about whether or not Resident J should have been sent to the hospital. During an interview, on 7/15/26 at 12:21 p.m., the Regional Nurse Consultant indicated labs should have been reviewed by the physician the same day they were reported. The providers were able to access their own labs for review. When the physician ordered an antibiotic it should have been pulled from the EDK and administered. During an interview, on 7/16/26 at 9:21 a.m., Nurse Practitioner (NP) 21 indicated she was familiar with Resident J but was not on call the night she was sent to the hospital. NP 21 indicated if a nurse communicated with the on-call provider that the nurse felt the resident needed to go to the hospital, then the on-call provider most likely would have ordered a hospital transfer. If that information was not effectively communicated to the on-call provider service, then there would have been no way for the on-call provider to know the nurse thought the resident needed to go to the hospital. If an antibiotic was ordered, and available in the EDK, then NP 21 would have expected the nurse to pull the antibiotic from the EDK and administer it soon after it was ordered. During an interview, on 7/16/26 at 9:45 a.m., the Regional Nurse Consultant indicated the NP saw Resident J on 6/29/26, reviewed the positive urine culture, and ordered the nitrofurantoin. The Regional Nurse Consultant indicated the nitrofurantoin was not administered until 6/30/26. She was not sure why the urine culture was not collected, as ordered, on 6/12/26. The Regional Nurse Consultant referenced the text conversations between the nurses and the on-call provider. The Regional Nurse Consultant indicated LPN 19 had not communicated with the on-call provider that the nurse thought the resident needed to be sent to the hospital. The on-call provider was not familiar with the resident. The Regional Nurse Consultant indicated she thought the system had delayed the start time for the Rocephin because of the Penicillin allergy. The nurse should have contacted the on-call provider to ensure they were aware of the allergy and determine if they wanted the medication administered or changed. She was unable to find documentation the on-call provider was notified. On 7/16/26 at 12:35 p.m., the Director of Nursing (DON) provided a document titled, Change of Condition Notification, dated June 2020, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. Policy: Definition: an acute change in condition.is a sudden, clinically important deviation from a patient's baseline physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death.III. Notifying the Attending Physician: A. The Attending Physician will be notified timely with a resident's change in condition. B. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.IV. Reporting Information to the Attending Physician: A. Emergency Situations.If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. On 7/16/26 at 12:46 p.m., the DON provided a document titled, Laboratory, Diagnostic, and Radiology Services, dated January 2026, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that laboratory.services are provided in a timely, safe, and effective manner to meet residents' medical needs.The Facility is responsible for the quality and timeliness of services provided by the laboratory.The ordering practitioner will be notified of results that fall outside of clinical reference or expected 'normal' ranges per the ordering practitioner's order. On 7/16/26 at 12:50 p.m., the DON provided an undated document titled, .Receiving Medications from Pharmacy, and indicated it was the policy currently being used by the facility. The policy indicated, .Medications.are received from the pharmacy supplier on a timely basis. This citation relates to Intake 3069737. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to ensure a urinary tract infection (UTI) was treated timely for 1 of 5 residents reviewed for transfers and discharges (Resident J). Findings include:Resident J's record was reviewed on 7/13/26 at 2:00 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, mild cognitive impairment. A significant change Minimum Data Set (MDS) assessment, dated 4/22/26, indicated the resident had a moderate cognitive impairment and an indwelling urinary catheter (tube inserted into the bladder). A physician's progress note, dated 5/28/26, indicated a urinalysis (UA) culture and sensitivity (C&S) was ordered due to increased lethargy. A lab report, dated 5/29/26, indicated a UA was completed with no C&S. The UA indicated 3+ leukocytes (large, moderate-to-high concentration of white blood cells in the urine, a strong sign that the immune system is actively fighting an infection or significant inflammation in the urinary tract) in the urine. Progress notes, dated 5/29/26 to 5/31/26, lacked documentation the physician was notified of the UA results. A progress note, dated 5/31/26 at 8:39 p.m., indicated the resident had a decreased blood pressure, increased lethargy, and was not eating. The resident was sent to the hospital. A progress note, dated 5/31/26 at 11:58 p.m., indicated the resident was enroute back to the facility from the hospital. The resident was diagnosed with a urinary tract infection (UTI) and yest infection. The resident received Rocephin (antibiotic) in the emergency room (ER), and new orders for Keflex (antibiotic) and Diflucan (anti-fungal) were expected. A physician's progress note, dated 6/1/26, indicated the resident's leukocytosis (elevated white blood cell count which indicates possible infection) identified during the evaluation was likely related to the UTI. The plan was to continue cephalexin (Keflex) 500 milligrams (mg) by mouth every 6 hours for 7 days. The resident had altered mental status/acute metabolic encephalopathy (a sudden, reversible brain dysfunction which can be caused by infections) related to the infection, and it was improving following treatment. The note indicated, Monitor neurological status closely. Progress notes lacked documentation of increased monitoring of the resident's neurological status. A physician's order, dated 6/11/26, indicated obtain urine sample to rule out UTI, one time only, for worsening confusion. A Medication Administration Record (MAR), dated June 2026, indicated the urine sample collection was scheduled on 6/12/26, but was documented as not completed. The medical record lacked documentation of why the sample was not collected. A progress note, dated 6/25/26, indicated the resident's urine was collected and sent to the laboratory for a UA. The note lacked documentation of why the sample was collected, including if it was related to the missed sample from 6/12/26. The UA C&S results were reported on 6/27/26 and indicated greater than 100,000 colony-forming units (CFU)/milliliters (ml) (an amount of bacteria which indicates a UTI) of Enterobacter cloacae (bacteria) and Escherichia coli (bacteria). Progress notes, dated 6/27/26 to 6/28/26, lacked documentation the physician was notified of the UA C&S results. A Nurse Practitioner (NP) progress note, dated 6/29/26, indicated the resident was being seen due to an acute (current) UTI. The NP reviewed the urine culture results and indicated the resident required antibiotic therapy and ongoing monitoring of an acute complicated UTI related to the Foley catheterization (tube inserted into the bladder) and multiple chronic medical comorbidities. The resident's temperature was 97.6 degrees Fahrenheit (F) blood pressure (B/P) 157/93, heart rate 62 beats per minute (bpm), oxygen saturation (amount of oxygen in blood) on room air 98 percent. The NP's plan was to order nitrofurantoin (antibiotic) 100 mg twice daily for 7 days, monitor closely for fever, worsening suprapubic pain (pain in the lower central part of the abdomen), flank pain (just below rib cage and above waist), altered mental status, decreased urine output, or other evidence of treatment failure or sepsis, and notify the provider of clinical deterioration. A MAR, dated June 2026, indicated the nitrofurantoin was scheduled to be started, on 6/29/26, in the evening, but the dose was not administered. The resident received two doses of nitrofurantoin on 6/30/26. A MAR, dated July 2026, indicated the resident received one dose of nitrofurantoin on the morning of 7/1/26, but the evening shift did not administer the dose. A progress note, dated 7/1/26 at 10:50 a.m., indicated the resident was unable to take her medications, and her temperature was 100 degrees F. The note lacked documentation the physician was notified. A situation, background, assessment, recommendation (SBAR) summary for providers, dated 7/1/26 at 12:09 p.m., indicated the resident's blood pressure was 99/66, pulse 93 bpm, temperature 100.1 degrees F, and oxygen saturation of 89 percent. The provider ordered labs, and Rocephin one gram (gm) daily for five days. A progress note, dated 7/2/26, indicated the resident was had an elevated temperature and was unarousable. The resident was sent to the emergency room (ER). An undated emergency drug kit (EDK) inventory sheet indicated there were 12 tablets of nitrofurantoin 100 mg in the facility's EDK. An EDK report, dated 6/29/26 to 7/1/26, indicated there was no nitrofurantoin removed from the EDK on those dates. A hospital history and physical, dated 7/2/26, indicated the resident was septic with several possible concurrent contributing factors, including UTI. During an interview, on 7/14/26 at 9:24 a.m., Resident J's family member indicated the facility told the family member they would check the resident for a UTI around 6/12/26 because the resident was acting like she usually did when she had a UTI. This testing was not done. The resident has been in the intensive care unit since she left the facility. The evening of 7/1/26, the resident's family member was in the facility, from 3:30 p.m. to 8:30 p.m., and then went home. The family member returned to the facility around midnight the same night. The resident was non-responsive and not able to swallow. During an interview, on 7/15/26 at 12:21 p.m., the Regional Nurse Consultant indicated labs should have been reviewed by the physician the same day they were reported. The providers were able to access their own labs for review. When the physician ordered an antibiotic it should have been pulled from the EDK and administered. During an interview on 7/16/26 at 9:45 a.m., the Regional Nurse Consultant indicated she was not sure why the UA C&S was not done on 6/12/26, but it should have been. The NP saw the resident on 6/29/26 and ordered nitrofurantoin, but it was not started until 6/30/26. On 7/16/26 at 12:46 p.m., the Director of Nursing (DON) provided a document titled, Laboratory, Diagnostic, and Radiology Services, dated January 2026, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that laboratory.services are provided in a timely, safe, and effective manner to meet residents' medical needs.The Facility is responsible for the quality and timeliness of services provided by the laboratory.The ordering practitioner will be notified of results that fall outside of clinical reference or expected 'normal' ranges per the ordering practitioner's order. On 7/16/26 at 12:50 p.m., the DON provided an undated document titled, .Receiving Medications from Pharmacy, and indicated it was the policy currently being used by the facility. The policy indicated, .Medications.are received from the pharmacy supplier on a timely basis. Cross reference F684. This citation relates to Intake 3069737. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to have competent and sufficient staff to administer medications and insulin timely to residents as ordered for 5 of 5 residents observed during 1 of 1 medication observation (Residents B, C, E, D, and F). Findings include:On 5/26/26 at 7:08 p.m., Registered Nurse (RN) 6 was observed at the medication cart. He indicated he was passing medications. The electronic medication administration record was on the computer screen for Resident B. He had medications hi-lighted in red indicating they were overdue. RN 6 prepped Resident B's medications and administered them to the resident at 7:22 p.m. RN 6 indicated he had two new admissions and was running behind. When asked if other nursing staff helped him so he wouldn't be late, he indicated he had assistance available. On 5/26/26 at 7:28 p.m., RN 6 indicated he needed to check Resident C's blood sugar that was due at 5:00 p.m. He took out the monitor and checked Resident C's blood sugar. It was 459, outside of his ordered parameters. Per his sliding scale orders, it indicated to notify the physician if blood sugar was greater than 400. RN 6 left the cart to notify the Nurse Practitioner (NP) due to the high blood sugar. The NP ordered 12 units of lispro insulin, and the insulin was administered as ordered. RN 6 indicated he would redo his blood sugar at 9:00 p.m. as ordered and administer the ordered amount of insulin required. On 5/26/26 at 7:45 p.m. RN 6 administered routine ordered morphine to Resident E. He did not sign the morphine out after administering the medication. On 5/26/26 at 7:55 p.m., RN 6 prepped Resident D's medications. He indicated that morphine was out of stock due to using on another resident earlier in the day. He prepped the resident's lorazepam. He did not prep the omeprazole that was ordered. He crushed the lorazepam (an antianxiety) tablet and administered it to the resident. He did not sign the lorazepam out after administering it. On 5/26/26 at 8:10 p.m., The Director of Nursing (DON) indicated she would call the NP to make her aware of RN 6 administering late medications due to admitting new residents. On 5/26/26 at 8:12 p.m., Resident D was yelling out. He had new orders for morphine but there was none available to administer to him. The DON indicated she would call the NP and get a one-time order for oxycodone (a pain medication) for Resident D. On 5/26/26 at 8:15 p.m., the DON walked by the cart with a pill cup and indicated it was oxycodone for Resident D. On 5/26/26 at 8:16 p.m., RN 6 was prepping Resident F's medications. Resident F needed his blood sugar checked at 5:00 p.m. RN 6 checked Resident F's blood sugar and it was 177. He prepared his medications metformin (for blood sugar), atorvastatin (for high cholesterol), and apixaban (a blood thinner) and administered the medications. His ordered insulin Lispro 5 units was not administered as ordered for 5:00 p.m. RN 6 indicated he would talk to the NP about the blood sugar as it was due to be checked again at 9:00 p.m. On 5/27/26 at 11:12 a.m., the Resident's records were reviewed. The records did not contain orders or notes for Resident C, D or F medications being administered late or omitted. Resident D's record lacked an order for the one-time oxycodone that was administered. On 5/27/26 at 2:13 p.m., the DON indicated she would go back and put orders in for the residents. A policy titled, Medication Administration and General Guidelines was provided by the DON on 5/27/26 at 2:41 p.m. It indicated, .Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise). Before or after meals orders are administered precisely as ordered. Unless other specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. This citation relates to Intake 3002927. 410 IAC (Indiana Administrative Code) 16.2-3.1-14(i)

Based on record review and interview, the facility failed to ensure falls were coded on a Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accidents (Resident K). Findings include:Resident K's record was reviewed on 5/26/26 at 10:06 p.m. A quarterly Minimum Data Set (MDS) assessment was dated 3/2/26. A progress note, dated 3/11/26, indicated the resident had a witnessed fall in the dining room and had a laceration to the forehead and back of head. Follow-up progress notes, dated 3/11/26, indicated the resident was sent to the hospital and returned to the facility with three sutures to the left side of her forehead. A progress note, dated 3/30/26, indicated the resident fell in the bathroom and had a bruise on her forehead. A progress note, dated 4/17/26, indicated the resident stood up from the dining room table, tripped, and fell on her right side. There was no visible injury, but the resident was guarding the right lower extremity and would not straighten the leg. A progress note, dated 4/18/26, indicated the resident's power of attorney (POA) requested the resident be sent out to the hospital related to the previous fall. An x-ray report, dated 4/18/26, indicated the resident had a right femur (thighbone) fracture. A discharge, return not anticipated, MDS assessment, dated 4/18/26, indicated the resident had no falls since the prior assessment. During an interview, on 5/27/26 at 11:21 a.m., the Corporate MDS Coordinator indicated she reviewed the discharge MDS assessment, dated 4/18/26, and indicated the resident's falls were not coded on the assessment. The falls should have been included on the MDS assessment. The facility used the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual as the facility policy for MDS assessment accuracy. The CMS MDS RAI manual, version 3.0, dated October 2025, indicated, J1900: Number of Falls Since.Prior Assessment.Coding Instructions for J1900: Determine the number of falls that occurred since.prior assessment.and code the level of fall-related injury for each. Code each fall only once. This citation relates to Intake 3002927. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(c)(1)

Based on record review and interview, the facility failed to ensure a resident received ordered monitoring of orthostatic blood pressures and failed to ensure prompt treatment for a fracture after a fall for 1 of 3 residents reviewed for accidents (Resident K). Findings include:Resident K's record was reviewed on 5/26/26 at 10:06 p.m. Diagnoses on the resident's profile included, but were not limited to, dementia (a decline in mental ability severe enough to interfere with daily life) with mood disturbance and repeated falls. A physician's order, dated 12/8/21, indicated monitor the resident's pain on a scale of 0 to 10 every shift and document non-pharmacological and pharmacological interventions for pain. A physician's order, dated 11/11/22, indicated acetaminophen (pain medication) 325 milligrams (mg), give 2 tablets by mouth every 4 hours as needed for pain. A quarterly Minimum Data Set (MDS) assessment, dated 3/2/26, indicated the resident had a severe cognitive impairment. A progress note, dated 3/11/26, indicated the resident had a witnessed fall in the dining room and had a laceration to the forehead and back of head. Follow-up progress notes, dated 3/11/26, indicated the resident was sent to the hospital and returned to the facility with three sutures to the left side of her forehead. A progress note, dated 3/30/26, indicated the resident fell in the bathroom and had a bruise on her forehead. An IDT progress note, dated 3/31/26, indicated the IDT reviewed the resident's witnessed fall. The resident was found on the bathroom floor in front of the toilet. The resident had a skin tear to the right knee and a bruise to the forehead. The resident was ambulatory and unable to give an explanation of what happened. Immediate interventions included obtain vital signs, assess for pain and injury, and cleanse the skin tear to the right knee. The Nurse Practitioner (NP) was notified and ordered orthostatic blood pressures (measurement of blood pressure while lying, sitting, standing) for three days. A Treatment Administration Record (TAR), dated 3/31/26, indicated the resident's orthostatic blood pressure was scheduled to be checked on day, evening, and night shift. The TAR included an area to document lying, sitting, and standing blood pressures; however, the areas only included one number and did not include a blood pressure value. There was one blood pressure recorded each shift. The TAR lacked documentation orthostatic blood pressures were completed. A TAR, dated 4/1/26 and 4/2/26, indicated the same schedule for the resident's orthostatic blood pressures. On 4/1/26, day and evening shift, the orthostatic blood pressure documentation was left blank and lacked documentation vital signs were completed. On 4/1/26, night shift, the documentation included one blood pressure, but lacked documentation orthostatic blood pressures were completed. On 4/2/26, the documentation included one blood pressure and lacked documentation the orthostatic blood pressures were completed. Progress notes, dated 4/2/26 to 4/17/26, lacked documentation the NP was notified regarding the orthostatic blood pressures. A progress note, dated 4/17/26 at 5:30 p.m., indicated the staff witnessed the resident stand up from the dining room table to ambulate with the walker. The resident tripped, fell, and landed on her right side. The resident was assessed with no visible injuries but was guarding the right lower extremity and would not straighten the leg. The Nurse Practitioner (NP) was notified and ordered an x-ray of the right lower extremity. The resident was assisted to bed by staff, and as needed pain medication was administered. A progress note, dated 4/17/26 at 11:13 p.m., indicated the mobile x-ray company called and stated the earliest they were able to complete the resident's x-ray was the following day (4/18/26), in the afternoon. The nurse was awaiting a return call from the NP, and the resident continued to complain of pain guarded the right lower extremity and was unable to extend the leg. Progress notes lacked documentation of further follow-up with the NP regarding the delay in the resident's x-ray. A physician's order, dated 4/18/26 at 8:42 a.m., indicated oxycodone (an opioid pain medication) 5 mg every 4 hours as needed for right hip pain. A progress note, dated 4/18/26, indicated the resident's power of attorney (POA) requested the resident be sent out to the hospital related to the previous fall. An x-ray report, dated 4/18/26, indicated the resident had a right femur (thighbone) fracture. A Medication Administration Record (MAR), dated April 2026, indicated the resident's pain was assessed every shift. The assessments indicated the resident had no pain until the night shift of 4/17/26, when a pain assessment of 4 out of 10 was documented. The resident was administered acetaminophen, on 4/17/26 at 6:59 p.m., for pain at 6 out of 10 which was effective. The resident was administered oxycodone, on 4/18/26 at 8:45 a.m., for pain at 8 out of 10 which was effective. The MAR lacked documentation the resident received pain medication between, 6:59 p.m. on 4/17/26 and 8:45 a.m. on 4/18/26, despite the resident having pain assessed at a 4 out of 10 on night shift. A hospital history and physical, dated 4/18/26, indicated the resident was admitted to the hospital for evaluation of hip pain following a fall. The resident's family member stated they were notified at 10:30 p.m. the previous night that the resident fell and completed of hip pain. An x-ray was ordered, but no results were communicated with the family overnight. The family arrived at the facility the following morning, at 7:30 a.m., and found the resident in bed experiencing significant pain, with only acetaminophen available. The x-ray company had not yet arrived at the facility to complete the x-ray. The family requested additional pain medication, and arrangements were made to send the resident to the hospital. The physician discussed risks and benefits of surgery for the fracture. The family chose comfort care and would pursue hospice care. A progress note, dated 4/19/26, indicated the resident's POA notified the facility the resident was being moved to a hospice facility. During an interview, on 5/27/26 at 10:03 a.m., Licensed Practical Nurse (LPN) 13 indicated an intervention should have been put in place immediately to prevent further falls. When a resident fell, the nurse assessed the resident while they were still on the floor. If there was a potential hip fracture, such as guarding or not extending the leg, and pain, the resident should not have been moved off the floor and should have been sent to the hospital immediately. During an interview, on 5/27/26 at 10:35 a.m., the Registered Nurse (RN) Corporate Consultant indicated if a resident fell and was guarding or not extending their leg and complaining of pain, then they should not have been moved from the floor and been sent out to the hospital. During an interview, on 5/27/26 at 2:18 p.m., the Registered Nurse (RN) Corporate Consultant indicated she reviewed the resident's orthostatic blood pressure documentation. She was not sure why a single number was all that was documented on the TAR instead of the full blood pressure. During an interview, on 5/27/26 at 2:40 p.m., the RN Corporate Consultant indicated she was not able to find documentation the NP was notified regarding the orthostatic blood pressures. The RN Corporate Consultant indicated she talked to the NP, and the NP had not remembered regarding Resident K specifically, but things like that were normally reviewed at the next NP visit. On 5/27/26 at 12:23 p.m., the Executive Director (ED) provided a document titled, Fall Evaluation and Prevention, last revised August 2020, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention.The IDT team will review the plan of care and update the interventions as appropriate. The policy also indicated, .Procedure.Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition. This citation relates to Intake 3002927. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation and interview, the facility failed to effectively cleanse a glucometer (used to check blood sugar) after its usage for 1 of 1 glucometer observed (Residents B and G).Findings include:On 5/26/26 at 7:45 p.m., RN 6 had just finished checking Resident B's blood sugar. He brought the monitor to the cart and pulled out an alcohol prep pad with an ungloved hand and wiped down the strip insertion area for a couple of seconds. Then he left the monitor sitting on the medication cart and continued passing medications to the resident.When asked about cleaning procedures, RN 6 indicated he was out of the wipes they usually used to clean the machine.On 5/26/26 at 8:10 p.m., the Director of Nursing (DON) arrived and provided a tub of purple top wipes to cleanse the glucometer machine with. RN 6 placed the wipes in the bottom drawer of the medication cart.On 5/26/26 at 8:15 p.m., RN 6 went to Resident G to check his blood sugar without cleaning the monitor with the purple top wipes. RN 6 returned to the medication cart after checking Resident 6's blood sugar and pulled out the tub of wipes. He pulled out a wipe and rubbed it with an ungloved hand onto the glucometer monitor for approximately 20 seconds, then placed the wipe in the trash and left the monitor on top of the medication cart.Per the manufacturer of the Even Care glucometer machine, Medline, they recommend cleaning and disinfecting using a EPA-registered (U.S. Environmental Protection Agency) disinfecting wipes. The purple top wipes were PDI wipes (Professional Disposables International). The tub contained directions indicating .Contact Time: Allow surface to remain wet for 1 full minute.A policy titled Blood Glucose Monitoring was provided by the DON on 5/27/26 at 2:41 p.m. It indicated, .If the blood glucose monitor is multi-patient use: A. clean and disinfect the blood glucose machine according to manufacturer's directions with an appropriate cleaning product. The disinfection solvent should be effective against HIV (Human Immunodeficiency Virus), Hepatitis C, and Hepatitis B virus. Note that 70% of ethanol solutions are not effective against viral blood borne pathogens. B. If the manufacturer of the device in use does not specify how the device should be cleaned and disinfected, then it should not be shared or reused with a different resident. C. [NAME] gloves prior to cleaning the blood glucose monitor. D. Following the cleaning, remove gloves and wash hands.This citation relates to Intake 3002927.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on interview and record review, the facility failed to administer narcotic medication in accordance with physician's orders and manufactures instructions resulting in lethargy and increased tiredness for 1 of 3 residents reviewed for medication administration (Resident C).Findings include:During an interview on 3/31/26 at 3:15 p.m., Resident C and her daughter felt Resident C received her medication too close together causing her to be overmedicated. The resident indicated she sometimes could barely keep her eyes open and felt very fatigued. This happened off and on, but not everyday. The resident indicated her doses were not administered on time regularly, and sometimes were very late. She had spoken to the nursing staff about it, but it continued to happen sometimes. A record review for Resident C was completed on 3/31/26 at 1:38 p.m. Diagnoses included stage 3 hypertensive chronic kidney disease, polymyalgia rheumatica (an inflammatory rheumatic disease), lumbago with sciatica (low back pain (lumbago) paired with radiating pain, numbness, or tingling that travels down the leg, usually caused by irritation of the sciatic nerve from a herniated disc, bone spur, or muscle spasms), and gout.A quarterly Minimum Data Set (MDS) assessment, dated 12/12/25, indicated the resident was cognitively intact. She was able to make herself understood and was able to understand others. She used a motorized wheelchair for mobility. She was dependent on staff for toileting and bathing. She required substantial/maximum assistance from staff for transfers.A current, as of 3/19/26, health care plan indicated resident was on pain medication therapy related to osteoarthritis, lumbago, GERD, neuropathy, hammer toes, gout, and general discomfort and required the use of pain medication (tramadol). Interventions included administering pain medications as ordered by the physician.A current physicians order, dated 1/22/20, indicated to administer tramadol hydrochloride (an opioid pain medication) 50 mg (milligram) five times per day for pain related to polymyalgia rheumatic. Administration times were 1:00 a.m., 6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.A review of Resident C's electronic Medication Administration Record (eMAR) indicated the tramadol was administered as follows:a) On 3/2/26, the medication was administered at 1:10 p.m., two hours and 10 minutes past the ordered time of 11:00 a.m.b) On 3/9/26, the medication was administered at 2:02 p.m.; three hours and two minutes past the ordered time of 11:00 a.m. The medication was next administered at 4:39 p.m.; two hours and 37 minutes after the previous dose administration.c) On 3/15/26, the medication was administered at 1:23 p.m.; two hours and 23 minutes past the ordered time of 11:00 a.m.d) On 3/23/26, two doses of the medication were administered at 7:48 a.m.; six hours and 48 minutes past the ordered time of 1:00 a.m., and one hour and 48 minutes after the ordered time 6:00 a.m.e) On 3/27/26, the medication was administered at 12:41 p.m.; one hour and 41 minutes past the ordered time of 11:00 a.m. The following administration was at 7:52 p.m.; three hours and 52 minutes past the ordered time of 4:00 p.m. A nurse practitioner progress note, dated 3/12/26, included Resident C reported increased fatigue over the past several days, but denied pain, shortness of breath, chest discomfort, dizziness, or gastrointestinal symptoms. She remained alert, oriented, and able to participate in conversation and follow commands appropriately.During an interview on 4/1/26 at 4:49 p.m., the DON indicated the medication was documented as being provided outside the policy time parameters for Resident C. The opioid medication the resident received should be given timely.A current facility policy, undated, titled, Liberalized Medication Pass Times, provided by the DON on 3/31/26 at 11:15 a.m., indicated the following: Policy: It is the policy of the company to administer medications to residents in a safe manner that coincides with their daily activities and normal schedule.Administration window will be one hour prior to scheduled dose and one hour post scheduled dose.*Any physician orders for specific medication times will supersede facility policy for liberalized medication pass times.*.A current facility policy, undated, titled, Medication - Administration, provided by the DON on 4/1/26 at 3:48 p.m., included the following: Purpose To provide practice standards for safe administration of medications for residents in the Facility. Policy.V. Medications may be administered one hour before or after the scheduled medication administration time.This citation relates to Intake 2744198.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to maintain sanitary conditions for catheter collection bags and tubing to prevent contamination for 2 of 2 residents reviewed for quality of care (Residents B and E).Findings include: 1. During an observation on 3/31/26 at 3:19 p.m., accompanied by QMA 2, Resident B's catheter bag and tubing were observed. The resident was in bed lying on his left side. His catheter bag was covered in a pillowcase, tied at the top of the bag around the tubing, lying on the floor. The tubing was lying on the floor and rising to, and under the sheet. During the observation, QMA 2 indicated that the catheter bag and tubing should not be on the floor due to risk of contamination. She indicated the catheter bag should be secured to the bed frame, and the tubing and the bag should be off the floor.The clinical record for Resident B was completed on 3/31/26 at 11:42 a.m. Diagnoses included urinary tract infection, obstructive and reflux uropathy (urinary blockage), urinary retention, hydronephrosis (swelling of one or both kidneys caused by a backup of urine).A current health care plan, revised on 1/13/26, indicated Resident B had a suprapubic catheter to his right lower abdomen. Interventions included checking the tubing for kinks and maintaining the drainage bag off the floor.An acute care hospital Discharge summary, dated [DATE], completed prior to Resident B's re-admission to the facility, included that the resident had a diagnoses of urinary tract infection and sepsis. Resident to be given methenamin hippurate, (a non-antibiotic antiseptic used to prevent recurring urinary tract infections by acidifying urine) 1 g (gram), twice daily for 30 days. 2. During an observation at 10:35 a.m., Resident E was observed down the hallway in his wheelchair. He was being assisted down the hallway by staff. His catheter bag was attached to the bottom of the wheelchair and the full bottom, approximately one quarter of the bag, was dragging across the floor. During an observation on 3/31/26 at 11:55 a.m., Resident E was seated across from the nurses' station with other residents. His catheter bag was observed hanging from the bottom of his wheelchair with the bottom of the bag resting on the floor and part of tubing was touching the floor.The clinical record for Resident E was completed 4/1/26 at 10:25 a.m. Diagnoses included kidney stones, obstructive and reflux uropathy, mild cognitive impairment, acute kidney failure, and bladder cancer.A nurse practitioner's note, dated 3/24/26, indicated the resident had admitted following a hospital stay for urinary retention and obstruction.A progress note, dated 3/31/26, indicated the resident's foley catheter bag was clamped off to collect a urine specimen for a urinalysis with culture and sensitivity.A Medication Administration Note, dated 3/31/26, indicated to administer phenazopyridine hydrochloride (a urinary tract analgesic used to relieve pain, burning, and urgency caused by infections) 100 mg (milligram) every 12 hours as needed for urinary discomfort.The clinical record lacked a care plan entry for the resident's urinary catheter.During an interview on 4/1/26 at 4:49 p.m., the Regional Nurse Consultant indicated resident catheter bags and tubing should not be placed or rested on the floor and should be handled in a sanitary manner to avoid infection.A current facility policy, revised 6/2020, titled, Catheter-Care of, provided by the DON on 4/1/26 at 3:48 p.m., included the following: Purpose To prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary.Procedure.III. Proper Techniques for Urinary Catheter Maintenance.F. Collection Bags- i. Take care to ensure the collection bag does not touch the floor at any time.This citation relates to Intake 2801884.410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)

Based on observations, interviews, and record reviews, the facility failed to prevent physical abuse between two dementia residents resulting in Resident D obtaining a laceration to the upper lip, nasal fracture, fractures to the 6th, 7th, and 8th ribs, and subsequent change in condition related to weakness from her hospitalization where she is no longer able to walk independently and requires staff assistance to be transported in a wheelchair (Residents D and E) for 1 of 6 residents reviewed for abuse. In addition to the residents in immediate jeopardy, the facility failed to implement effective supervision and interventions to prevent resident-to-resident sexual abuse when a cognitively impaired male resident, (Resident G) entered a cognitively impaired female resident's room (Resident F) removed her pants and briefs and began to masturbate while touching her. This resulted in harm that is not immediate jeopardy for 1 of 6 residents reviewed for abuse when Resident F was documented to have increased anxiety, reduced engagement, and a departure from her previously consistently happy demeanor. The immediate jeopardy began on 11/20/25 when Resident D, who resided on the secured memory care unit, wandered near the doorway of Resident E. Resident E purposely pushed Resident D, who lost her balance and fell, hitting her face on the handrail. Upon immediate assessment, Resident D sustained a laceration to her upper lip, had a nosebleed, and skin tears to the left hand. She was sent to the hospital for treatment where she was found to have a lip laceration, nasal fracture, and fractures of the 6th, 7th, and 8th ribs. Upon return to the facility, she declined from walking independently to requiring total dependence on staff for transfers and ambulation by staff in a wheelchair. Per staff interviews and resident medical record reviews, Resident E had a history of psychosis, delusional thinking, and aggressive behaviors, specifically targeted at Resident D, prior to the incident. Per staff interviews and resident medical record reviews, Resident D frequently paced the hall and intrusively wandered into other resident's rooms. Residents D's and E's records lack documentation of the targeting of Resident D by Resident E or interventions to prevent harm to either resident. Observations during the survey have found Resident D and Resident E to be left alone in common areas without staff supervision. The Administrator (ADM), the Director of Nursing (DON), and the Regional Nurse Consultant (RNC) were notified of the Immediate Jeopardy on 1/7/26 at 4:54 p.m. The immediate jeopardy was removed on 1/9/26 at 12:20 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:1. An Indiana Department of Health facility incident report, dated 11/20/25, indicated Resident E was involved in a resident-to-resident altercation. Resident D was intrusively wandering into Resident E's room when Resident E made open hand and extended arm contact with Resident D resulting in her losing her balance causing her to hit her mouth on the handrail as she fell. Resident D was assessed and noted to have a deep laceration to upper lip, nosebleed, skin tears to top of left hand and 2nd knuckle. The NP ordered to send Resident D to the hospital for evaluation and treatment. On 1/5/26 at 10:35 a.m., upon initial observation of the secured memory care unit, no staff were present in the main dining/activity room. Resident E was seated in a chair at a table and Resident D was seated in her wheelchair at a separate table with her back to Resident E. On 1/5/26 at 10:40 a.m., Qualified Medication Aide (QMA) 13 entered the unit in a hurry and indicated in general to the gathered residents in the dining room, let's see what they have going on for you guys. I have no idea, and stated she was just going to wing it, indicating she had been pulled to multiple assignments that morning. On 1/6/26 at 8:53 a.m., Certified Nursing Assistant (CNA) 15 indicated she did not normally work in the memory care unit, she had been pulled to help cover the previous day and was not familiar with the residents. On 1/6/26 at 9:00 a.m., the main dining/activity room of the secured memory care unit was observed. There were seven residents present, the TV was on, and an unidentified housekeeper was observed cleaning the floors. There were no direct care staff present. Resident D was seated in her wheelchair at a table with three peers. On 1/6/26 at 9:22 a.m., Resident E was observed at a table in the main dining room area. She was lightly engaged in a coloring activity. She only participated when encouraged and stopped her activity to watch the other residents. Resident D was seated at a separate table, not engaged in the activity. During this activity, staff were in and out of the dining room, as the nurse passed medications and the CNA provided incontinent/ADL care. On 1/7/26 at 8:42 a.m., Licensed Practical Nurse (LPN) 16 indicated she was assigned to the memory care unit that morning. She did not usually work on the unit and was not sure about the residents' routines, preferences, or behaviors. On 1/7/26 at 11:27 a.m., no staff were present in the main dining/activity room, where residents were seated with the Daily Chronicle and coloring materials. Resident D was seated in her wheelchair at a table with one peer. On 1/7/26 at 2:43 p.m., Resident E was observed unsupervised as she independently ambulated from her room, across the hall, into another resident's room, then walked into the dining room and asked when it was mealtime. During an interview on 1/6/26 at 10:40 a.m., Resident D's family member indicated Resident D had experienced three falls during the previous year, the most serious fall was a result of being pushed down by another resident. The family member indicated the other resident apparently didn't like Resident D and pushed her which caused her to fall and strike a rail. This incident resulted in a busted lip that required stitches. The family member indicated Resident D had been walking independently prior to the incident but became weak following the hospitalization and was no longer safe to walk independently. The family member confirmed Resident D sustained facial and rib fractures from the incident and expressed concern that Resident D was not protected from harm. During an interview on 1/7/26 at 12:15 p.m., CNA 14 indicated Resident E appeared to target Resident D more than the other residents. Resident E had a history of aggressive behaviors, particularly when residents wandered into her room, it made her mad. During an interview on 1/7/26 at 12:18 p.m., the Admissions Coordinator indicated she also helped as an activity aide on the memory care unit. She was not employed at the time of the incident between Resident D and E, but was later informed that Resident E had a history of delusional thinking and aggressive behavior. Resident E perceived Resident D as threat and often expressed more aggressive behaviors towards her because she thought Resident D was a man. Since the Admissions Coordinator started working on the memory care unit as an activity assistant, she had not seen or been made aware of specific interventions to prevent future altercations between Resident D and E and/or interventions to prevent other residents from wandering into Resident E's room. During an interview on 1/7/26 at 3:17 p.m., the Assistant Director of Nursing (ADON) was working as the nurse on the floor in the secured memory care unit. He indicated it was not his usual assignment to be in the memory care unit and he was not familiar with the residents. He could not speak to Resident D or Resident E's routines, preferences, behaviors and/or potential for altercations. During an interview on 1/7/26 at 3:20 p.m., CNA 18 demonstrated a significant language barrier and was unable to understand or respond to questions regarding resident behaviors and safety concerns. During a follow up interview on 1/7/26 at 3:23 p.m., QMA 14 reiterated, it was well known that Resident E did not like residents, particularly Resident D to enter her room. Resident D repeatedly intrusively wandered into Resident E's room, and on the day of the incident, Resident D had been walking by Resident E's room, when Resident E saw her in the frame of her doorway and shoved Resident D down, yelling at her, Get out of my room! QMA 14 was too far away to prevent the push/fall, but witnessed the incident. She immediately called for help and stayed with Resident D until the nurse came. QMA 14 indicated Resident D had blood coming from her nose and lip and lost a tooth at the time of the fall. During an interview on 1/7/26 at 3:30 p.m., QMA 19 indicated she had worked in the memory care unit before and knew that Resident E did not like when other residents came into her room. It made the resident mad and she would yell and scream for them to get out. QMA 19 indicated she had been working in the memory care unit on the day of the incident. At that time, she was next door helping another resident with a meal when she witnessed Resident D pass the room she was in, walking down the hall per her routine. Then QMA 19 heard a loud bang/crash. She rushed to see what happened and saw Resident D on the floor with blood around her nose and mouth. During an interview on 1/7/26 at 3:38 p.m., Activity Assistant 20 indicated she helped out in the memory care unit on a regular basis. She indicated it was well known that Resident E did not like other residents coming into her room and particularly did not like Resident D because she thought Resident D looked like a man, and perceived her as a threat. During an interview on 1/7/26 at 3:43 p.m., the Director of Nursing (DON) indicated she assumed the DON position in May 2025. The DON described Resident E as feisty and while she mostly had a history of being verbally aggressive, there had been one or two incidents of physical aggression towards her peers prior to the incident with Resident D. The DON indicated Resident D used to wear a hair piece, but when she stopped wearing it Resident E began to perceive Resident D as a man and remained fixated on her due to Resident D's appearance. a. Resident E's record was reviewed on 1/7/26 at 11:28 a.m. She was a long term care resident who resided in the secured memory care unit and had diagnoses which included, but were not limited to, vascular dementia, delusional disorder, and generalized anxiety disorder. A quarterly Minimum Data Set (MDS) assessment, dated 10/29/25, indicated Resident E was moderately cognitively impaired and there were no behaviors coded for the look back period. A Psychiatric progress note, dated 8/22/25, indicated Resident E had a prior psychiatric history of major depression, dementia, psychotic/delusional disorder. History of hallucinations ordelusions. History of inpatient psychiatric hospitalization. A summary of the visit indicated Resident E complained about a fellow resident who wandered into other rooms and touches her while laughing, Resident E cussed at her and demanded they should put her in jail. Staff were able to confirmed that Resident D did intrusively wander into other's rooms. Staff also reported that Resident E had been more anxious lately. The record lacked documentation of follow up, interventions and/or care plan revisions to address the resident's complaints about an intrusive peer and her increased anxiety. A Psychiatric progress note, dated 9/19/25, indicated Resident E required an emergent telehealth visit, due to a situation between [two] residents and was currently on 15 minute checks for safety. During the call, Resident E was calm and did not recall the incident from last night with another resident. She did not show signs of agitation, aggression or distress, and was determined appropriate to come off safety checks. The record lacked documentation of any incident between Resident E and another peer and/or follow up, interventions and/or care plan revisions to address to alleged incident. Resident E's progress notes were reviewed and lacked routine behavior monitoring and/or behavior documentation if occurred. The progress notes lacked documentation of Resident E's resident to resident concerns/fixation towards Resident D. A nursing progress note, dated 11/20/25 at 7:15 p.m., indicated Resident E had an altercation with another resident, [Resident D] was entering her doorway intrusively wandering into her room. With open hands and extended arms, Resident E made contact with Resident D which resulted in Resident D losing her balance and hitting her face on handrail as she fell. Resident D was sent to the emergency room for evaluation and treatment. Resident E was subsequently sent to an in-patient psychiatric hospital for evaluation. Resident E's comprehensive care plans were reviewed and lacked implementation/revision to include her concerns/fixation towards Resident D and or her preferences to keep peers out of her room. Her physician's orders were reviewed and did not include any behavior monitoring. A current CNA assignment sheet was provided by the DON on 1/7/26 at 3:47 p.m. The notes section for Resident E was blank. It did not include person-centered interventions for history of aggression and/or preferences to keep other residents out of her room. During an interview on 1/7/26 at 3:43 p.m., three psychiatric progress notes (noted above for the following dates 8/22/25, 9/17/25 and 9/26/25) were reviewed with the DON, who indicated she was unaware of the events leading up to these encounters and would look further into the records. During an interview on 1/7/26 at 4:25 p.m., the DON indicated she had not been able to locate or find additional information or documentation related to the three psychiatric progress notes from 8/22/25, 9/17/25, and 9/26/25. Throughout the survey observation period, no visual interventions were observed on or near Resident E's room to discourage her peers from intrusively wandering. b. On 1/7/26 at 2:51 p.m., Resident D's record was reviewed. She was a long term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, unspecified dementia, mild cognitive impairment, and unsteadiness on feet. A quarterly MDS, dated [DATE], indicated Resident D was severely cognitively impaired but was able to eat independently and walk up to 150 feet independently or with only minimal set up assistance. Resident D's progress notes were reviewed and lacked routine behavior monitoring and/or behavior documentation related to her repeated intrusive wandering. Resident D's comprehensive care plans were reviewed. She had a care plan that was not initiated until 11/16/25 which indicated she had behavior of wandering into other resident's rooms. An intervention for this plan of care included, Intervene as necessary to protect the rights and safety of others. Resident D's care plan lacked implementation/revision that she was often perceived by other residents as a man due to her appearance or that she was targeted because of her peers perceived threat. A nursing progress note, dated 11/20/25 at 7:26 p.m., indicated Resident D was involved in a resident-to-resident altercation at 5:42 p.m. Resident D was intrusively wandering into another resident's room when the other resident made open hands and extended arms contact with her resulting in her losing her balance causing her to hit her mouth on the handrail as she fell. At the time of the fall Resident D was assessed and found to have sustained, a deep laceration from her upper lip to her nose, skin tears to top of her left hand and 2nd knuckle. A hospital Discharge summary, dated [DATE], indicated Resident D was sent to the emergency room for evaluation and treatment and was subsequently found to have sustained a laceration to her upper lip which required sutures, a nasal bone fracture, and fractures of her 6th, 7th and 8th ribs. A significant change MDS, dated [DATE], was initiated upon her return from the hospital which indicated a decline in her ability to eat and walk. She required maximum assistance to eat, and maximum assistance to ambulate. A current CNA assignment sheet was provided by the DON on 1/7/26 at 3:47 p.m. The notes section for Resident D was not revised to change her ambulation status from walking to wheelchair and did not include person-centered interventions/approaches to address her peers often mistaking her for a man, due to her appearance. On 1/8/26 at 10:54 a.m., a copy of the incident investigation documentation was provided by the Administrator (ADM). The investigation was conducted by the DON but did not include a date the investigation was initiated or finalized. A Witness Statement from QMA 14 indicated, .I saw [Resident E] push [Resident D] right in front of her door . [Resident D] fell on her face flat, she had an upper lip split and was bleeding, she also had skin tear on her left hand. A description of the incident indicated Resident E and Resident D were involved in a resident-to-resident altercation. Resident D was intrusively wandering into Resident E's room when Resident E made open hand contact with extended arms resulting in Resident D losing her balance, falling, and hitting her face on the handrail. The residents were immediately separated and safety for all residents assured. The residents were assessed, and Resident D was noted to have a deep laceration to upper lip and skin tears to top of left hand and 2nd knuckle of left hand. Resident D showed no non-verbal signs of pain or distress. The spouse of Resident D was notified as well as Administrator and on call NP. Messages were left for family of Resident E. The NP ordered to send Resident D to the ER for evaluation and treatment. 911 called. Labs and urine were ordered for Resident E along with a psychiatric (psych) eval. Resident E was placed on one-to-one supervision until placement with psych confirmed. The investigation documents indicated the following recommendations: Resident D would be closely monitored for signs and symptoms of infection regarding stitches to upper lip. Lab monitoring in place. Resident D placed on therapy case load. Activities would meet with the resident and assess activity needs. Resident E was on one-to-one supervision and sent to psych for eval. The IDT [interdisciplinary team] would review care of residents. Education provided on resident safety. Both residents' care plans were updated. Resident D's record lacked documentation that monitoring of Resident D's lip for infection was implemented. Throughout the survey period, no visual interventions were observed in place such as a picture of Resident D, or her name in large letters on her door to help her identify her own room. Neither Resident E or D were reviewed by Activities nor were care plans for activities revised. No IDT notes were noted in the either residents' charts Neither Residents care plans were updated. On 1/5/26 at 10:00 a.m., the Administrator provided a copy of the facility current Abuse Prevention and Prohibition, dated 8/2020. The policy indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. the facility is committed to protecting residents from abuse by anyone, including, but not limited to Facility staff, other residents. The immediate jeopardy that began on 11/20/25 was removed on 1/9/26 at 12:20 p.m., when the facility ensured a systemic plan to include staff education and monitoring of residents to ensure staff provided supervision. Resident D was moved to a new unit to ensure residents would not be in common areas together. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. 2. An Indiana Department of Health facility incident report, dated 7/27/25, indicated Resident G entered Resident F's room and started behaving socially inappropriately. Staff reported Resident G's pants were open. Staff redirected Resident G out of the room. Resident F did not recall anything happening or being fearful and denied knowing anything that happened. Resident safety was assured. Staff and neighborhood interviews were started. Resident G was placed on direct observation for 48 hours. The Police Department was notified. On 1/5/26 at 10:40 a.m., Resident F was initially observed. She was seated in a wheelchair in the main dining/activity room. She appeared to be watching the T.V. She smiled pleasantly, but did not engage in meaningful conversation. During the survey period, Resident G was observed on multiple occasions independently ambulating through the halls. During an interview on 1/6/26 at 11:06 a.m., Resident F's husband indicated, back in the summer, he was notified that another male resident had been found in her room and had removed her pants. He was not informed of any additional actions or outcomes from the incident which made him upset. He began to cry and indicated he felt helpless and that he had failed his wife and let her down. He indicated Resident F was confused and unable to understand or express what had occurred, and she was subsequently moved to the secured memory care unit following the assault. He expressed emotional distress while recalling the incident and Resident F was unable to communicate her feelings or distress related to the sexual assault. On 1/7/26 at 2:14 p.m., Resident G was observed in his room. He was seated in a recliner chair and watched TV. Resident G denied having a girlfriend in the facility and did not recall taking liberties, or having private time with another female resident. Resident G indicated he spent most of his time in his room, but sometimes like to walk through the facility to check things out, and go to the front to step outside and feel the weather. During an interview on 1/7/26 at 2:16 p.m., Qualified Medication Aide (QMA) 10 indicated Resident G was independently ambulatory, and that while he spent most of his time in his room, he would still walk through the building at his leisure. During an interview on 1/8/26 at 12:30 p.m., the Director of nursing indicated she was on vacation at the time of the incident, the Administrator (ADM) at the time had come in to address the situation. The DON had not conducted any additional or ongoing assessments or interventions upon her return as she was under the impression the ADM had taken care of it all. During a follow up interview on 1/8/26 at 1:13 p.m., the DON indicated after the sexual abuse between Resident F and G, Resident G had been placed on 15-minute checks, he had a psychotic consult and was placed on 48-hour close observation. Other than the psychotic consultation, the DON could not provide evidence of additional follow up. During an interview on 1/8/26 at 1:16 p.m., Certified Nursing Aide (CNA) 23 indicated, she had not been employed at the time of the incident, and no one had told her about Resident G's history of sexually inappropriate behavior. She did not know and had not been informed to be aware of this potential behavior as he continued to be able to and liked to walk through the building.' During an interview on 1/8/26 at 1:17 p.m., CNA 15 indicated, she had not been working the day of the abuse, but when she came back to work and found out about it, she was shocked to learn it had been Resident G because he was such a sweet guy. CNA 15 indicated there was no education or in-service after the incident, and since it was so out of character for Resident G, no one really considered monitoring him for it because it was so unlike him. CNA 15 indicated he did still walk through the facility as he pleased and she had never witnessed behavior like that from him. During an interview on 1/9/26 at 12:59 p.m., QMA 22 indicated she was the only witness to what happened between Resident F and G. She indicated it was around 3:30 p.m. when she realized she had not seen Resident F, which was unusual, as Resident F liked to be out of her room and attended activities. She decided to go check on Resident F and when she opened Resident F's door, she saw Resident G seated in a chair with his pants and underwear pulled down to his thighs, while Resident F was naked from the waist down and stood in front of Resident G. Resident G was masturbating with one hand, while his other hand was between Resident F's legs. QMA 22 indicated she immediately walked in and told Resident G to stop and pull his pants up. She removed Resident G from Resident F's room and went to get the nurse. The nurse immediately came and went to assess Resident F. QMA 22 stayed with Resident G who admitted to touching himself and Resident G, but he thought it was ok because she did not tell him to stop. During an interview on 1/9/26 at 1:29 p.m., Licensed Practice Nurse (LPN) 24 indicated she had been working on the secured memory care unit with QMA 22 came to her and explained what she saw. LPN 24 immediately went to assess Resident F, but Resident F was unable to recall what happened. LPN 24 conducted a skin and pain assessment and notified the ADM and the police were called. The ADM came right away and Resident G was moved to a new room. LPN and QMA gave their witness statements to the police. During an interview on 1/9/26 at 1:43 p.m., the Receptionist indicated Resident G liked to come up and get money out every now and then, he would come to the front desk to ask about weather and liked to step outside to check it out. Sometimes he sat in the lobby and other common areas. a. On 1/7/26 at 8:15 a.m., Resident F's record was reviewed. She was a long-term care resident who resided on the secured memory care unit at the time of the review. She was admitted in November of 2024 and had diagnoses which included, but were not limited to, unspecified dementia, recurrent major depressive disorder, and cognitive impairment. A quarterly minimum data set (MDS) assessment dated , 5/19/25, current at the time of the following incident, indicated Resident F was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. A care plan progress note, dated 2/11/25 at 12:19 p.m., (and repeated throughout the record) indicated, she was followed by a psychiatric provider and had a history of sexual trauma, molested by brother when she was young. A review of Resident F's psychiatric consult progress notes revealed the following: From her admission on [DATE] through 7/10/25, she was routinely assessed as psychiatrically stable, alert and pleasant at baseline, with no documented increase in anxiety, agitation, or behavioral symptoms. Psychiatric progress notes dated 11/7/24, 11/14/24, 12/5/24, 12/26/24, 3/6/25, 5/15/25, and 7/10/25 repeatedly documented no significant changes in mood, sleep, appetite, or behavior, and an interdisciplinary team (IDT) approved gradual dose reduction of sertraline in May 2025 which further reflected clinical stability prior to July. A psychiatric consult, dated 7/11/25, indicated Resident F had allowed another resident into her room without supervision, during which the resident cut her hair. Resident F did not object at the time, but later expressed regret and distress, demonstrating impaired judgment and delayed emotional processing. The psychiatric note indicated, .during the session resident was cooperative and presented as upset, with incongruent. Resident described this as 'being okay' while touching her hair constantly. Resident was observed with a new haircut and when asked about it, resident referred 'hating her hair' and regretting the decision to cut her hair. Per SSD [Social Service Director] resident let a fellow resident cut her hair, although neither of them remember the full event . she was moved to another room to prevent further incidents. Resident F's assessments, nursing progress notes and care plan lacked documentation, follow up and/or interventions to address and prevent any further resident-to-resident incidents after she allowed her hair to be cut. Following the July 2025 sexual assault, psychiatric documentation, dated 7/27/25 and 7/31/25, identified a change in her psychiatric status, with providers noting new or increased anxiety, reduced engagement, and a departure from her previously consistently happy demeanor, which resulted in an increase in psychotropic medication. Resident F's record lacked physician notification and/or orders of increased behavior monitoring, such as additional supervisor related to poor decision making. Resident F's record lacked nursing IDT follow up for the hair cutting incident and the sexual assault incident to address the root cause of these behaviors and to implement new interventions to protect her from future incidents. Resident F's record lacked comprehensive care plans to address her history of sexual trauma endured in her youth, poor judgement and decision making related to allowing a peer to cut her hair, and poor judgement/decision making and not being able to stop another resident from sexually assaulting her. b. On 1/7/26 at 9:15 a.m., Resident G's record was reviewed. He was a long-term care resident who resided on the 400-hall at the time of the review. He was admitted to the facility on [DATE] and had diagnoses which included, but were not limited to, unspecified dementia. A quarterly MDS assessment, dated 5/16/26, indicated Resident G was moderately cognitively impaired with a BIMS score of 11 out of 15. A nursing progress note, dated 7/27/25 at 5:45 p.m., indicated Resident G was found to be socially inappropriate in another resident's room, and requiring staff to remove him for Resident F's safety. A Psychiatric progress note, dated 7/27/25, indicated nursing staff found Resident G had entered a female resident's room and began masturbating. Nursing staff redirected Resident G and provided education regarding facility policy and appropriate behaviors with other residents. During the psychiatric consultation, Resident G became agitated and did not understand why the behavior was inappropriate. Nursing staff reported this was believed to be the first incident of this nature and requested psychiatric involvement. On 8/01/25, a follow-up psychiatric services visit for Resident G was conducted at the request of the SSD, due to an inappropriate sexual incident involving a female resident, which resulted in Resident G being moved to another hall. Per Social Services recommendation, the incident was not explicitly discussed during the session, as Resident G had previously discussed the incident with other providers, expressed feelings of shame, and had demonstrated agitation when the topic was revisited. During the session, Resident G was cooperative, presented as neutral with congruent affect, and denied major concerns with mood, sleep, or appetite. When asked about the room change, Resident G stated he did not know why he was moved but reported being okay with the change. Resident G's record lacked physician notification and/or orders of increased behavior monitoring, such as additional supervisor related to sexually explicit behaviors. Resident G's record lacked nursing IDT follow up for the resident-to-resident sexual assault to discuss and address the root cause of the behavior and prevent future occurrences. Resident G's record lacked comprehensive care plans to address his history of or new behavior sexually explicit actions towards his peer, and lacked implementations to prevent future incidents. On 1/5/26 at 10:00 a.m., the Administrator provided a copy of the facility current Abuse Prevention and Prohibition, dated 8/2020. The policy indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. the facility is committed to protecting residents from abuse by anyone, including, but not limited to Facility staff, other residents. This citation relates to Intake 2711282. 3.1-27(a)

Based on observation, interview, and record reviews, the facility failed to provide RN coverage per the facility assessment, failed to ensure adequate staffing on the memory care (dementia) unit, and failed to ensure adequate staffing to answer call lights and provide showers. This deficient practice had the potential to affect 78 of 78 residents residing in the facility. Findings include:1. Upon the survey entrance on 1/5/26 at 10:00 a.m., the Executive Director (ED) provided a copy of the Facility Assessment. Per the assessment, the facility required a minimum PPD (how many hours are spent with a patient per day) for Registered Nurses (RN) of 0.54 hours daily. A copy of the schedules requested were provided by the Executive Director (ED) on 1/5/26 at 10:33 a.m. Upon reviewing the nursing staffing schedules, the facility did not meet its minimum RN coverage PPD on the following dates: 7/27/25, 11/20/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 1/5/26, 1/6/26, 1/7/26, 1/8/26, and 1/9/26. On 1/12/26 at 1:42 p.m. The Regional Nurse Consultant (RNC) indicated there should be at least two staff members on the memory care unit at night. Upon review of the nursing staffing schedules, the facility did not staff the memory care unit with an adequate number of staff for night shift by using one Certified Nursing Assistant (CNA) or one Qualified Nursing Assistant (QMA) on the following dates: 7/27/25, 11/20/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 1/5/26, 1/6/26, 1/7/26, 1/8/26, 1/9/26. This staff member was to provide nursing and nursing assistant duties to a total of 14 residents on the night shift. 2. On 1/5/26 at 10:35 a.m., upon initial observation of the secured memory care unit, no staff were present in the main dining/activity room. Resident E was seated in a chair at a table and Resident D was seated in her wheelchair at a separate table with her back to Resident E. On 1/5/26 at 10:40 a.m., Qualified Medication Aide (QMA) 13 entered the unit in a hurry and indicated in general to the gathered residents in the dining room, let's see what they have going on for you guys. I have no idea, and stated she was just going to wing it, indicating she had been pulled to multiple assignments that morning. During an interview on 1/5/26 at 10:45 a.m., QMA 13 indicated she worked all over the building and sometimes helped out in memory care. She indicated they were short staffed that morning so she was pulled in a thousand different directions but had been asked to help with activities in the memory care unit. On 1/6/26 at 8:53 a.m., Certified Nursing Aide (CNA) 15 was observed working on the memory care hall. She indicated, usually helped with weights, for the long-term care halls, and had never worked in the memory care unit. She indicated she was pulled to help but was not provided a CNA assignment sheet, so she would just ask the nurse about the resident's as needed. On 1/6/26 at 9:00 a.m., the main dining/activity room of the secured memory care unit was observed. There were seven residents present, the TV was on, and an unidentified housekeeper was observed cleaning the floors. There were no direct care staff present. Resident D was seated in her wheelchair at a table with three peers. On 1/6/26 at 9:22 a.m., Resident E was observed at a table in the main dining room area. She was lightly engaged in a coloring activity. She only participated when encouraged and stopped her activity to watch the other residents. Resident D was seated at a separate table, not engaged in the activity. During this activity, staff were in and out of the dining room, as the nurse passed medications and the CNA provided incontinent/ADL care. During an interview on 1/6/26 at 10:40 a.m., Resident D's family member indicated Resident D had experienced three falls during the previous year, the most serious fall was a result of being pushed down by another resident. The family member indicated the other resident apparently didn't like Resident D and pushed her which caused her to fall and strike a rail. This incident resulted in a busted lip that required stitches. The family member indicated Resident D had been walking independently prior to the incident but became weak following the hospitalization and was no longer safe to walk independently. The family member confirmed Resident D sustained facial and rib fractures from the incident and expressed concern that Resident D was not protected from harm. On 1/7/26 at 8:42 a.m., Licensed Practical Nurse (LPN) 16 indicated she was assigned to the memory care unit that morning. She did not usually work on the unit and was not sure about the residents' routines, preferences, or behaviors. On 1/7/26 at 11:27 a.m., no staff were present in the main dining/activity room, where residents were seated with the Daily Chronicle and coloring materials. Resident D was seated in her wheelchair at a table with one peer. On 1/7/26 at 2:43 p.m., Resident E was observed unsupervised as she independently ambulated from her room, across the hall, into another resident's room, then walked into the dining room and asked when it was mealtime. During an interview on 1/7/26 at 3:17 p.m., the Assistant Director of Nursing (ADON) was working as the nurse on the floor in the secured memory care unit. He indicated it was not his usual assignment to be in the memory care unit and he was not familiar with the residents. He could not speak to Resident D or Resident E's routines, preferences, behaviors and/or potential for altercations. During an interview on 1/7/26 at 3:20 p.m., CNA 18 demonstrated a significant language barrier and was unable to understand or respond to questions regarding resident behaviors and safety concerns. During an interview on 1/8/25 at 9:25 a.m., LPN 27 indicated there was usually only one Nurse or QMA in the memory care unit to pass medication, and only one CNA. She thought it would be helpful to have at least 2 CNAs and an activity aide. On 1/9/26 at 9:35 a.m., LPN 27 was observed repeatedly leaving her medication administration tasks to monitor residents in the dining room due to lack of staff supervision. On 1/9/226 at 10:58 a.m., Resident F indicated she needed to use the bathroom. LPN 27 was the only staff member on the unit and told her she would have to wait for someone else to come back to the unit to supervise the dining/activity room because staff could not leave the dining room unattended. Cross Reference F600 and F744. 3. A review of grievances, dated July 2025 through December 2025, revealed multiple repeated complaints across residents demonstrating a pattern of unresolved systemic issues which included, but were not limited to: Call light response time and staff attitude, missed or delayed showers and complaints about ADL (activities of daily living) care, and short staffing or staffing concerns. Fourteen of the twenty-three grievances reviewed were direct complaints about call lights response time and/or staff attitude. Grievances filed on 8/19/25, 8/28/25, 9/5/25, 9/13/25, 9/22/25, 9/27/25, and 10/22/25 alleged showers were not received, staff refused to give them showers, shower days were missed, or residents were told the facility was too short staffed to give the shower at the scheduled time. Grievances filed on 8/28/25, 9/9/25, 9/18/25, 9/30/25, 10/22/25, and 11/12/25 identified ongoing concerns related to inadequate staffing, including statements that staff were unavailable, residents were told staff were too busy to assist, or care could not be provided as scheduled. These grievances were accompanied by repeated reports of missed or delayed ADL care, including bathing and toileting assistance, as well as prolonged call light response times. Cross reference F656. A policy titled, Secure Care Neighborhood with a revision date of 7/24 was provided by the Executive Director (ED) on 1/9/26 at 3:05 p.m. It indicated, .The secure care neighborhood will be staffed to meet the needs of the residents residing in the neighborhood.The facility who has a secure neighborhood (secure unit) will provide therapeutic staffing to meet the needs of the residents who reside in the secured area. A policy titled, Nursing Department-Staffing, Scheduling and Postings with a revision date of 1/25 was provided by the ED on 1/9/26 at 3:05 p.m. It indicated, .In staffing, an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs and will account for the number, acuity, and diagnoses the facilities resident populations. This citation relates to Intake 2611908. 3.1-17(a) 3.1-17(b)(1)

Based on interview and record review, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic quality and safety issues. This failure resulted in the facility's inability to prevent recurrence of known problems and contributed to harm-level and Immediate Jeopardy deficiencies. This deficient practice had the potential to affect 78 of 78 residents who resided in the facility. Findings include:During interview on 1/12/26 at 11:21 a.m., the Regional Director of Operation (RDO) and the Regional Nurse Consultant, (RNC) indicated the faculty had failed to effectively incorporate a QAPI program to help mitigate deficiencies that were identified during the survey period. The Regional Director of Operation (RDO) and the Regional Nurse Consultant, (RNC) acknowledged that under the prior administration, required corporate and facility processes for incident reporting, investigation, and interdisciplinary team (IDT) oversight were not followed. They confirmed that adverse incidents and reportable events were frequently managed in a vacuum, without IDT involvement, administrative awareness, or appropriate investigation, tracking, or follow-up. Leadership stated that the facility failed to utilize the corporate Adverse Incident Reporting (AIR) process, resulting in incidents not being reported, tracked, or reviewed through required quality assurance mechanisms. During the previous administrator's employment, there had been increased leadership turnover and administrative leave without effective transition plans or delegation of responsibilities put into place to ensure continuity of oversight. Incoming administrative and clinical leaders reported they were unaware of ongoing incidents, investigations, or regulatory requirements until after survey activity occurred. Leadership acknowledged that previous training, onboarding, and supervision of key personnel, including the Director of Nursing and Administrator, had been insufficient, and moving forward both the RDO and RNC would be working closely with IDT to correct these deficiencies. The RDO and RNC indicated that these administrative failures resulted in a lack of timely investigations, inadequate care planning, insufficient staff education, and failure to identify and correct systemic issues related to abuse allegations, staffing concerns, pressure injuries, and resident-to-resident altercations. During interview on 1/12/26 at 1:46 p.m., the Administrator (ADM) indicated he was interim and had only been in the building about a week prior to survey. He had the opportunity to briefly review the QAPI documentation and although QAPI meetings were convened on a regular basis, he was unable to identify effective actions to mitigate many concerns that had been identified during the survey period. Ad hoc quality reviews had recently been initiated (e.g., boiler safety, resident smoking practices, medication storage, housekeeping concerns), but these reviews were reactive, limited in scope, and not part of a comprehensive, data-driven QAPI program. The Administrator confirmed that identified concerns were not consistently subjected to formal root cause analysis, measurable action plans, or ongoing effectiveness monitoring prior to survey involvement. The Administrator indicated grievances related to staffing, call light response times, staff attitude, showers, and basic care needs had been recurring but were not consistently trended, analyzed, or incorporated into QAPI for systemic correction and that the facility failed to utilize its QAPI program to proactively identify, prioritize, and correct systemic issues, resulting in repeated deficiencies. During a follow up interview on 1/13/26 at 9:38 a.m., the Administrator (ADM) acknowledged that despite staffing concerns being identified at least three times within the previous 12 months, no formal action plan or Performance Improvement Project (PIP) had been initiated. During the survey entrance conference on 1/5/26 at 10:00 a.m., the ADM provided a current copy blank QAPI documents as an example of how potential issues were identified and addressed. He indicated that the facility policy was for each department to reflect on its services and programming to identify potential issues that would require proactive action plans to help identify and prevent deficient practices. 3.1-52

Based on observations, interviews, and record reviews, the facility failed to ensure residents were treated with respect and dignity by allowing staff to refer to residents using demeaning and task-oriented labels ( feeds/feeders) during meal service and failed to ensure residents were provided the opportunity to accept or decline entry into their rooms when staff walked in without knocking or waiting for a reply. This deficient practice had the potential to affect 4 of 5 residents reviewed for dignity (Residents D, 48, 53, and 37). Findings include:1. During a dining observation on 1/5/26 at 11:59 p.m., a rolling lunch cart was brought to the secured memory care unit and Licensed Practical Nurse (LPN) 25 and Certified Nursing Aide (CNA) 15 began to pass lunch trays. As they began to pass trays out, CNA 15 asked, are there any feeds back here? LPN 25 indicated, there are three feeds, and pointed to Residents D, 48 and 53. All residents' meals were served on their plastic trays. The lunch plates, cups, and utensils were not removed and from the tray to be more homelike and less institutional. During an interview on 1/5/26 at 12:05 p.m., CNA 15 indicated, she had never worked in memory care and asked about feeds because she doesn't know the residents' names. On 1/9/26 at 3:05 p.m., the Administrator (ADM) provided a copy of current facility policy titled, Resident Rights, dated/revised 2/2025. The policy indicated, residents have the right to be treated with dignity, respect, and individuality at all times, including being free from degrading, demeaning, or disrespectful language and treatment by staff. On 1/9/26 at 3:05 p.m., the ADM provided a copy of current facility policy titled, Secure Care Neighborhood, dated/revised 7/2024. The policy indicated residents residing on the dementia unit are to receive person-centered care that preserves dignity, utilizes respectful communication, and prohibits labeling, stigmatizing, or dehumanizing language regardless of cognitive status. 2. During an interview on 1/5/26 at 11:00 a.m. Resident H indicated staff regularly barged into their room without knocking, or if they did knock, they came in right after knocking instead of waiting for the resident to invite them into the room. As the resident voiced their concerns, an unidentified staff member knocked twice and then proceeded to come into the room without waiting for a reply and invitation into the room from the resident. The staff member quickly set the resident's lunch tray down, apologized and walked out of the room. 3. During an interview with Resident K and the Ombudsman on 1/8/26 at 1:08 p.m. an unidentified staff member knocked twice and then proceeded to open the door without waiting for a reply and invitation into the room from the resident. The staff member quickly apologized and closed the door. The Ombudsman indicated since she had been in the room talking with Resident K, three different staff members had also done what that unidentified staff member did. On 1/13/26 at 11:57 a.m. a copy of a current facility policy titled, Privacy and Dignity dated 6/2020 was provided. That policy indicated, .Purpose [of this policy is] To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of life. The Facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect. V. The Facility promotes independence and dignity in dining. VI. The Facility respects the resident's private space and property. IX. The following rights to privacy are a part of the admission agreement and the resident is informed of these rights during the admission process A. Residents are afforded a right to privacy. 3.1-3(t) 3.1-32(a)

Based on record review and interview, the facility failed to identify repeated grievances and implement effective corrective actions to alleviate ongoing resident complaints related to personal care services, responsiveness to call lights, hygiene care, and staff interactions which demonstrated that corrective measures were ineffective and systemic issues were not addressed for 6 of 6 months of grievances reviewed. Findings include: On 1/9/26 at 1:14 p.m. the Director of Nursing provided copies of the previous 6 months of grievances. A review of grievances, dated July 2025 through December 2025, revealed multiple repeated complaints across residents demonstrating a pattern of unresolved systemic issues which included, but were not limited to: Call light response time and staff attitude, missed or delayed showers and complaints about ADL (activities of daily living) care, and short staffing or staffing concerns. 1. Call light response time and staff attitude. 14 of the 23 grievances were direct complaints about call lights response time and/or staff attitude. Grievances used for example included, but were not limited to the following: a. On 7/9/25 a resident complained that he had asked his morning shift aide to let the nurse know he was ready for his tube feed around 2:00 p.m. The Nurse never came. The resident asked the second time when his evening shift aide came on duty. The nurse never came. The resident resorted to calling a family member who came to the facility to help get him assistance. b. On 9/16/25 a family member complained on behalf of a resident that there was a long wait time for staff to check on the resident and help her to the bathroom and some staff had poor attitudes and would leave the resident on the toilet.c. On 9/25/25 a resident complained that she could not get help from her caregiver and wound up soaked. The aide would come in to clear the call light, say she would be right back, but never came back. d. On 11/6/25 a resident complained that her aide yelled at her and told her she had just been changed and she wasn't going to change her again that soon.e. On 11/13/25 a resident complained that at approximately 5:00 a.m., they pressed the call button to change their [brief]. The CNA responded and immediately started in yelling at me and accused the resident of knocking towels and pillows onto the floor. She said, she wasn't here to clean up my mess and then got louder by the minute and I feared for my safety and she accused the resident of pointing her finger in the CNA's face but I was just shielding myself. She went on and on and got louder about the resident's finger in her face. I could not get her to calm down. All I wanted was a [brief] change because I was soaking wet and freezing due to no heat. I was very fearful of her. Responses to these grievances redundantly referenced staff member was disciplined but did not include the documentation of alleged discipline and there was no evidence of monitoring or sustained measures for corrective action. 2. Grievances filed on 8/19/25, 8/28/25, 9/5/25, 9/13/25, 9/22/25, 9/27/25, and 10/22/25 alleged showers were not received, staff refused to give them showers, shower days were missed, or residents were told the facility was too short staffed to give the shower at the scheduled time. Responses to these grievances redundantly referenced education provided to staff without evidence of monitoring or sustained measures for corrective action. 3. Grievances filed on 8/28/25, 9/9/25, 9/18/25, 9/30/25, 10/22/25, and 11/12/25 identified ongoing concerns related to inadequate staffing, including statements that staff were unavailable, residents were told staff were too busy to assist, or care could not be provided as scheduled. These grievances were accompanied by repeated reports of missed or delayed ADL care, including bathing and toileting assistance, as well as prolonged call light response times, as noted above. The recurrence of delayed ADL care and call light response issues across multiple grievances served as indicators that staffing levels were insufficient to meet residents' needs. During an interview on 1/12/26 at 1:46 p.m., the Administrator (ADM) indicated the facility had experienced repeated grievance concerns related to staffing, staff attitude, delayed call light response times, missed showers, and unmet ADL care. He stated that these concerns had not yet been fully trended or systematically addressed due to recent turnover and his short tenure but acknowledged the need to incorporate grievances and staffing issues into the facility's QAPI process. The ADM indicated the facility must implement systemic corrective actions, including root cause analysis, tracking and trending of grievances, staffing oversight, and ongoing monitoring to ensure concerns are effectively addressed and do not continue to recur. On 1/9/26 at 2:30 p.m., the ADM provided a copy of current facility policy titled, Grievance/Complaints dated/revised 4/2017. The policy requires that all grievances be promptly investigated, documented in writing, reviewed by the Administrator, and that corrective actions be implemented to prevent further violations of resident rights. The policy further requires the facility to take immediate action to prevent ongoing concerns, communicate findings and actions to residents or representatives, and maintain grievance records for tracking and accountability. Had the facility adhered to this policy by trending grievances, performing root cause analysis, implementing effective corrective actions, and monitoring outcomes, repeated concerns related to staffing, delayed call light response, missed ADL care, and staff behavior may have been identified and addressed before recurring. This citation relates to Intake 2595596. 3.1-7(a)(2)

Based on observation, interview, and record review, the facility failed ensure residents were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. On 6/29/21 at 10:30 a.m., the medical record was reviewed for Resident B. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) annual assessment, dated 4/16/21, indicated Resident B had a Brief Interview for Mental Status (BIM) score of 4 out of 15, which indicated severe cognitive impairment. Resident B had resided on the Memory Care. A Fall Risk Screen, dated 3/1/21, indicated Resident B scored 10, with a score of 10 or greater considered high risk for falls. A care plan, revised on 5/7/21, indicated Resident B was a high risk for falls. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/30/21 at 4:23 p.m., a progress note indicated, Resident was seen on the floor in outside courtyard area. Upon assessment, Resident was complaining of pain in the right hip. MD [Medical Doctor] notified and POA [Power of Attorney] also alerted. WS [sic]initiated. Resident started on neuro checks [assessment for head injury] and skin assessment was completed, no abrasions or cuts noted. Resident currently in dining area. X-ray ordered. On 5/30/21 at 7:30 p.m., the vital sign record indicated pain assessments were recorded as 0 for scale of 1-10. On 5/30/21 at 9:17 p.m., a progress note indicated a new order was obtained for [MEDICATION(S)] (mild pain medication) for complaint of right hip pain. On 5/30/21 at 10:23 p.m., a progress note indicated Resident B's family requested something stronger for pain. The Nurse Practitioner was contacted, and a new order was received for [MEDICATION(S)] (non-narcotic pain medication) one 50 milligram (mg) tablet by mouth 3 times a day for pain. A review of Resident B's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/29/21 at 1:56 p.m., during an interview the Director of Nursing (DON) indicated if a signature box was blank on the MAR, it indicated not given. The n meant no or none when documented in the non-pharmacy interventions. Resident B's pain score on the MAR, for 5/30/21, was documented as 0/10 at 2:00 p.m., and 10:00 p.m. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The neuro check assessment record had a check mark under pain at each scheduled assessment. No description of pain was identified. On 5/31/21 at 1:23 a.m. a progress note indicated, resident had a fall on patio right before dinner, she is alert to self and unable to state what happened , her speech is clear, no visible bruises or abrasions but c/o [complained of] r [right] hip pain, not wanting to bare wt [weight], guarding her r hip and groin, assisted into bed with two staff and monitored with neuros [neuro checks], [Name of Medical Doctor] and family notified, orders obtained for stat [immediate] x ray, prn [as needed] [MEDICATION(S)] was given and resident still guarding and holding right leg up so prn [MEDICATION(S)] was then also ordered and given, family here and concerned about her not being able to toilet herself and not being used to being immobile and feared she might try to get up and also deciding on what they would want to do should x ray come back with injury, official results not in for x ray but did make call to [Name of imaging company] for them to ask for a verbal report which they stated x ray could not rule out conclusively a fracture per verbal report at this point so family opted to go ahead and send her out to [Name of Hospital] ER [emergency room ], notified MD and 911 out, report given to ER nurse. During an interview on 6/29/21 at 1:10 p.m., Resident B's daughter indicated on 5/30/21 the facility had left a message on her brother's (POA) voice mail. The message indicated Resident B had fallen on the patio and was ok but she might need to get an x-ray of her head because they had not seen her fall and didn't know if she had hit her head. The son informed his 2 sisters of the message. The daughter called the facility and was told they had got the resident up and moved her to her room. She was not having much pain, just a little hip pain. The daughter agreed to wait on results of the x-ray, as long as there wasn't a lot of pain. The facility reported they expected to have the x-ray report by 8 p.m. because there was a 4 hour agreement with the imaging company. At 9:30 p.m., they had received no report of the x-ray. The resident's other daughter and husband went to the facility. Upon walking down the hall they could hear Resident B crying and screaming out for someone to help her. The room was dark, and the door was cracked. She had been moved to a different room. Two staff members, at the nurses' station told the family members they put her closer because they were afraid she might try to get up. The x-ray had just been done. She was called by the family members at the facility and informed her of the situation. She could hear her mother crying and screaming. There had been no staff member in the room to comfort her. She hurried to the facility and arrived about 9:40 p.m. There they waited for the x-ray report. The nurse told them Resident B had received her scheduled dose of Tylenol that evening when they asked about pain medication. Resident B was continuously crying and would scream out if anyone touched her. They requested the doctor be called again. At 10:30 p.m. they were still unable to get a report for the x-ray, the family requested she be sent to the emergency room . At the hospital the resident was diagnosed with a fractured upper femur and hip. There was an orthopedic consult on Monday (5/31/21) and she had surgery on Tuesday (6/1/21). Resident B passed away on 6/4/21, in the hospital. 2. On 6/30/21 at 10:00 a.m., the closed medical record was reviewed for Resident C. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment, dated 4/28/21, indicated Resident C had a Brief Interview for Mental Status (BIM) score of 1 out of 15, which indicated severe cognitive impairment. A Fall Risk Screen, dated 5/7/21, indicated Resident C scored 21, with a score of 10 or greater and was considered a high risk for falls. On 6/15/21 at 9:14 a.m., a progress note indicated, cna [Certified Nurse Aid] walked out of DR [dining room] and res. [resident] stood up and fell on left hip, although he has R.O.M [range of motion] and on palpitation, can't feel any dislocation, have called and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 at 9:32 p.m., a progress note indicated, ordered Xray and called daughter [Name]. On 6/15/21 at 12:40 p.m., a progress note indicated, fed res. [resident] and ate over 50% and then started to pull food out of mouth. Then changed res. with 3 people to hold leg, even with body. Res screamed but CNAs stated its hard to tell, r/t [related to] him screaming all the time when gets changed. Didn't attempt to put long pants on him r/t discomfort and having to move left leg anymore than possible. On 6/15/21 at 2:57 p.m., a progress note indicated, N.P [Nurse Practitioner here to check on res. and told her that undersigned has tried 3 times since this A.M. to get pain meds [medication] out for resident r/t pain, she immediately called [Name] pharmacy and wanted to talk to supervisor. [Name of NP] gave me verbal order to get 2 [MEDICATION(S)] [narcotic pain medication] out of [Name of drug dispense machine] for transport., and xray report came with finding of fracture and to send to [Name of Hospital] ER. Daughter [Name] called and informed. On 6/15/21 at 3:30 p.m. a new medication order was entered on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C's pain score, on the MAR, for 6/15/21 at 3:30 p.m., was document as 10/10 (with 10 being the worst pain of his life). The neuro check assessments, post fall indicated pain YES. The last scheduled neuro check assessment was at 2:00 p.m., then at the scheduled 6:00 p.m. assessment it indicated out to the hospital. The time the resident left the building was not documented. On 6/17/21 at 5:11 p.m., a progress note indicated Resident C returned to the facility from the hospital. He was placed on hospice services. The re-admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/17/21 a care plan indicated Resident C's daughter had declined surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/25/21 at 10:15 a.m., Resident C passed away at the facility. On 6/30/21 at 10:11 a.m., the DON provided a current policy, dated March 2020, titled Pain Assessment and Management. This Policy indicated .The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Pain management is a multidisciplinary care process that includes .assessing .recognizing .identifying .addressing .monitoring .Acute pain .should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained .Behavioral signs of pain .verbal expressions such as groaning, crying or screaming .Behavior such as resisting care .guarding, rubbing or favoring a particular body part .difficulty eating or loss of appetite .Review the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] This Federal tag relates to Complaint IN 539. 3.1-37(a)

Based on record review and interview, the facility failed to follow CDC guidance during a pandemic and ensure infection control practices for COVID-19 were implemented for residents with symptoms of COVID-19 (Resident F and Resident C) who resided with asymptomatic roommates (Resident L and Resident K), and another resident with symptoms of COVID-19 who was not placed on isolation precautions (Resident B), resulting in potential exposure of other residents and staff to COVID-19, for 5 of 10 residents reviewed for infection control, and who resided on the 400 hall, which housed 12 residents as of [DATE] The Immediate Jeopardy began on [DATE], on the 400 hall, when Resident F was having symptoms of COVID-19, including congestion, wheezing, and low oxygen saturation (O2) at 75 percent (%) with no isolation precautions (special precautions to prevent the spread of germs) put into place. The resident remained in a room with Resident L who lacked documentation of symptoms of COVID-19. Resident C was found to have symptoms of COVID-19 and remained in a room with Resident K, who lacked documentation of symptoms of COVID-19. Resident B had symptoms of COVID-19 and was not placed on isolation precautions. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy at 4:45 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1a. Resident F's record was reviewed on [DATE] at 4:32 p.m. [DIAGNOSES REDACTED]. A progress note, dated [DATE] at 8:37 p.m., indicated the resident had wheezed and was congested. O2 saturations (the amount of oxygen in the blood - normal is greater than 90%) at 75% on 2 liters per minute (LPM) of oxygen via nasal cannula. The O2 was increased to 3 LPM, and O2 saturations remained in low 80's. The Nurse Practitioner (NP) was notified and new orders were received to obtain labs and chest x-ray the next day. The progress note lacked documentation the resident was placed on isolation precautions. A review of physician's orders [REDACTED].>A daily census form, dated [DATE], indicated Resident F was in a semiprivate room and had a roommate, Resident L. A respiratory surveillance line list, onset date [DATE], indicated the resident had a cough. A progress note, dated [DATE] at 10:13 a.m., indicated the Nurse Practitioner (NP) requested a COVID-19 test, and the resident was moved to an isolation room. A progress note, dated [DATE] at 3:28 a.m., indicated the resident had deceased . A progress note, dated [DATE] at 1:23 p.m., indicated the resident's wife had been notified the COVID-19 test was positive. 1b. Resident L's record was reviewed on [DATE] at 4:28 p.m. [DIAGNOSES REDACTED]. The resident's record, dated [DATE] to [DATE], lacked documentation the resident had been placed on isolation precautions, after being exposed to the resident's roommate, Resident F, who was having symptoms of COVID-19 beginning on [DATE]. A vitals summary, dated [DATE] at 1:16 p.m., indicated the resident had a temperature of 101.1 degrees Fahrenheit. During an interview, on [DATE] at 2:25 p.m., the DON indicated Resident F had symptoms documented [DATE] and was moved into isolation the next day. They had felt the resident had aspirated and did not have symptoms of COVID. The DON indicated per the daily census, on [DATE], Resident F resided in a room with Resident L. On [DATE] the 400 unit hall was placed on isolation precautions, on [DATE] Resident L was tested for COVID-19, and results had not been received at this time. During an interview, on [DATE] at 1:20 p.m., the Regional Director indicated Resident F was not moved to a single room immediately because the facility had to obtain permission from the family and a room had to be deep cleaned. Resident F's wife had not wanted the resident moved because he had the same roommate for a long time and did not want the resident alone. Confidential interviews were conducted during the course of the survey. The interviewee indicated Resident F had low oxygen saturations and wheezing on [DATE]. The resident was placed on isolation precautions on [DATE]. The resident resided in a room with Resident L and was Resident L was not placed on isolation precautions, only gloves and masks were used for Resident L. The DON had indicated not to move Resident F into a private room. There were no standing orders in place for isolation precautions when a resident was symptomatic of COVID-19. The staff would contact the DON if a resident was symptomatic and needed placed in isolation precautions. Confidential interviews were conducted during the course of the survey. The interviewee indicated there were no standing orders in place for isolation precautions when a resident was symptomatic of COVID-19. 2. Resident B's record was reviewed on [DATE] at 1:23 p.m. [DIAGNOSES REDACTED]. A progress note, dated [DATE] at 6:21 p.m., indicated the resident had vomited and then felt better. The resident's temperature was obtained and was 100.9 degrees Fahrenheit, and a few minutes later temperature was retaken and at 101.1 degrees Fahrenheit. The resident was administered two tablets of Tylenol. The record lacked documentation the resident was placed on isolation precautions. A progress note, dated [DATE] at 8:04 p.m., indicated the resident had vomited before he ate pizza and he felt fine. Resident's family member was called and family member requested the resident be tested for COVID-19. A respiratory surveillance line list, onset date [DATE], indicated the resident had a fever and nausea. A review of physician's orders [REDACTED]. A physician note, dated [DATE] at 10:10 a.m., indicated the resident visit had been requested by the resident's family. Resident was seen for vomiting two days over the past three days. Upon exam, the resident appeared to feel unwell with mild noted pallor but per resident had been feeling better. Resident had increased fatigue and confusion the last two days. Low grade temperature was treated on [DATE]. The note indicated the resident would be monitored closely with respiratory evaluation and temperature monitoring frequently throughout the day. A progress note, dated [DATE] at 12:59 p.m., indicated the writer had spoken with daughter and per her request the resident had been tested for COVID-19. A progress note, dated [DATE] at 5:00 p.m., indicated the resident reported being cold and nauseated. Temperature was 101.8 degrees Fahrenheit. The NP was notified and nurse was instructed to call family and ask which hospital to send resident to. Resident was transported to hospital and admitted . A progress note, dated [DATE] at 4:39 a.m., indicated the daughter called to inform the facility her father had passed away. A laboratory document, dated [DATE], indicated the COVID-19 specimen, collected on [DATE], was pending. During an interview, on [DATE] at 10:52 a.m., Resident B's family member indicated the resident had a fever on [DATE] and on [DATE] had a fever and vomited. The resident was sent to the hospital on [DATE] and a COVID-19 test was obtained and came back positive. He was placed on a ventilator on [DATE] and passed away on [DATE]. During an interview, on [DATE] at 2:06 p.m., the DON indicated Resident B had vomited on [DATE], and the resident had indicated he felt it was from lunch he had eaten at the facility and pizza brought in by family that upset his stomach. The resident later spiked a temperature and was treated with Tylenol and resolved. The resident had no other symptoms. The facility had not felt he required isolation precautions at that time. No other symptoms were noted until [DATE] and the resident was sent to the hospital. She was unsure if the policy specified when a resident had signs or symptoms of COVID-19 when the resident should be placed on isolation precautions. 3a. Resident C's record was reviewed on [DATE] at 3:14 p.m. [DIAGNOSES REDACTED]. A progress note, dated [DATE] at 1:20 p.m., indicated the resident had a fever of 100.3 degrees Fahrenheit and malaise. The Nurse Practitioner was notified and new orders for chest x-ray and COVID-19 testing were received. A daily census form, dated [DATE], indicated Resident C was in a semiprivate room and had a roommate, Resident K. A progress note, dated [DATE] at 6:32 a.m., indicated per policy the resident would be moved to a separate room today. 3b. Resident K's record was reviewed, on [DATE] at 2:32 p.m. A progress note, dated [DATE] at 1:16 a.m., indicated the resident had not eaten or drank well, was more confused, and had a temperature of 102.5 degrees Fahrenheit. The resident resided in a secured location with isolation precautions in place. A COVID-19 test was pending. During an interview, on [DATE] at 2:25 p.m., the DON indicated Resident C had developed symptoms on [DATE] and was not moved to a private room until [DATE] because they had to wait for a private room to be deep cleaned. Resident C's roommate (Resident K) was asymptomatic on [DATE]. She indicated 81 residents had been tested for COVID-19 on [DATE]. During an interview, on [DATE] at 1:06 p.m., Certified Nursing Assistant (CNA) 5 indicated the staff used standard precautions with all residents and wore masks. If a resident had symptoms of COVID-19 or had tested positive, the resident would be placed on droplet isolation precautions and would be placed in a private room. Personal Protective Equipment (PPE) for suspected or confirmed COVID-19 consisted of gloves, mask, gown, and a shield or goggles. PPE equipment would be placed outside of a resident's room and the staff would be made aware if a resident was on isolation precautions for COVID-19. During an interview, on [DATE] at 2:25 p.m., the DON indicated staff were only wearing face masks and gloves in the residents' rooms until the residents were placed on droplet isolation. The DON indicated the entire 400 unit hall was placed on isolation precautions on [DATE]. The DON did not indicate there were standing order sets from the physician for isolation. The DON did not indicate Residents F, L, C, K, or B were placed on isolation utilizing the standing order sets for isolation. On [DATE] at 4:45 p.m., the Administrator and DON were informed of the immediate jeopardy. The DON and the Administrator did not indicate there were standing order sets from the physician for isolation. They did not indicate Residents F, L, C, K, or B were placed on isolation utilizing the standing order sets for isolation. During an interview, on [DATE] at 2:44 p.m., the DON provided standing orders for isolation for residents with symptoms of COVID- 19. The DON indicated they had standing orders in place and all residents if symptomatic for COVID-19 were placed on isolation precautions. She had forgotten to mention these orders on [DATE]. A signed document from (name of physician's office), with date of [DATE], indicated, Standing Protocol Order for Covid Signs and Symptoms: 1) Any resident with respiratory, or Covid signs and symptoms are to be placed in droplet isolation .4) Contact provider for notification of initiation of protocol, additional orders, or changes in status. On [DATE] at 4:21 p.m., the Administrator provided a document titled, Disaster Preparedness, and indicated it was the policy currently being used by the facility. The policy indicated, .37. The facility will co-hort residents per the CDC isolation criteria. Residents exhibiting new onset of respiratory illness are isolated until the medical [DIAGNOSES REDACTED]. Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance On [DATE] at 4:21 p.m., the Administrator provided a document titled, Indiana Nursing Home Infection Prevention Assessment Tool for COVID-19, and indicated it was the policy currently being used by the facility. The policy indicated, The following infection prevention and control assessment tool should be used to assist nursing homes with preparing to care for residents with COVID-19 .Identify infections early: actively screen all residents at least daily for fever and respiratory symptoms; immediately isolate anyone who is symptomatic. Long-term care residents with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. Atypical symptoms may include: new or worsening malaise, diarrhea, or sore throat. Identification of these symptoms should prompt isolation and further evaluation for COVID-19 if it is widespread in the community The ISDH Guidance for out-of-hospital facilities, dated [DATE], indicated, The following is guidance for out of hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles: 1. Placement of patient /resident in contact-droplet precautions with proper PPE, including gown, glove, and mask with face shield or eye protection. 2. Proper donning and doffing of personal protection equipment when in contact with COVID-19 residents Reduce the movement of staff between patients with and without COVID-19 precautions with proper PPE- gown, glove, and mask with face shield or eye protection .Patients/residents with known or suspected COVID-19 should be cared for in a single-person (private) room with the door closed. Airborne infection isolation rooms (AIIR) are not required. Patients/residents with known or suspected COVID-19 should not share bathrooms with other patients/residents. All patients/residents returning from the hospital with suspected or confirmed COVID-19 should be cared for in a private room, or Cohorted with other patients of the same status in the same unit, wing, hallway, or building. Patients with close contact with a confirmed COVID-19 patient (e.g., roommate or infected staff without wearing PPE) should be isolated and follow 14 day self-monitoring guidelines. If they develop symptoms, and are confirmed or suspected to have COVID-19, they should remain in isolation until at least 7 days after symptom onset and 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms (e.g., cough), whichever is longer . The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, indicated, If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario. Public health authorities can assist with decisions about resident placement .If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected [DIAGNOSES REDACTED].g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident . The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility reviewed all residents and residents with symptoms/known exposure and/or positive results were placed in isolation with appropriate door signage and orders for isolation. Staff were reeducated on the isolation policies and procedures, and a plan was created to monitor for isolation procedures for residents with symptoms/pending tests or known exposures. The noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 598. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to protect a resident from receiving another resident's medication resulting in a significant medication error and harm when an overdose of benzodiazepine (hypnotic, sedative medication that acts rapidly) occurred, the resident presented with altered mental status (changes in brain function), was sent to the emergency room , and admitted to the hospital for 1 of 3 residents reviewed for medication errors (Resident E). Findings include: During an interview, on 5/22/19 at 11:01 a.m., the Director of Nursing (DON) indicated, on 5/14/19, Resident [NAME] was administered a benzodiazepine (hypnotic, sedative medication that acts rapidly) medication instead of a narcotic pain medication. The resident had a routine order for the benzodiazepine, and an as needed order for pain medication. It was found during the medication error investigation the resident received another resident's benzodiazepine medication. The 6 rights of medication administration should have been used during the medication administration. During an interview, on 5/22/19 at 11:36 a.m., Licensed Practical Nurse (LPN) 10 indicated, on 5/14/19 at approximately 11:30 a.m., Resident [NAME] had reported pain. At that time, LPN 10 prepared the resident's pain medication to administer. She thought she had the resident's [MEDICATION NAME] (pain medication) 5-325 milligrams (mg), 2 tablets, but in error grabbed another resident's medication card. She believed this happened because the cards were stuck together. The medication prepared was [MEDICATION NAME] (benzodiazepine) 2 mg, 2 tablets. She then administered the [MEDICATION NAME] 2 mg, 2 tablets by mouth to Resident E. She had not realized a medication error occurred until the end of her shift at 3 p.m. During that time, the resident's family reported the resident was sleepy and would not respond to them. She assessed the resident and found the resident to be lethargic and hard to wake, but did respond. The physician was notified and orders received to let resident sleep and give fluids. The family then requested the resident be sent to the hospital and the resident was sent by 911 to the emergency department. She should have followed the 6 rights of medication administration by checking for the right resident, right medication, right dose, right route, right time, and right documentation/order. Resident E's record was reviewed on 5/22/19 at 10:24 a.m. The resident was admitted to the facility on [DATE]. A brief interview for mental status (BIMS), signed 5/15/19, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. A medication error report, dated 5/14/19, indicated the resident was given [MEDICATION NAME] 2 mg, 2 tablets by mouth, on 5/14/19 at 11:00 a.m. The reason for error: the wrong card was picked up when preparing the medication. The actual effect of the error on the resident: resident was lethargic and confused. The error was discovered during shift change count of controlled medications. A progress note, dated 5/14/19 at 3:32 p.m., indicated the resident had received the wrong medication during that shift. The resident received [MEDICATION NAME] 2 milligrams (mg) instead of [MEDICATION NAME] (pain medication) 5-325 mg. The resident was very lethargic and hard to wake. The physician was notified and orders were received to give fluids and let resident sleep. A progress note, dated 5/14/19 at 4:15 p.m., indicated the family requested 911 be called and the resident was sent to the emergency room for evaluation. A hospital summary, dated 5/14/19, indicated the resident presented to the emergency department (ED) from a long term care (LTC) facility and was lethargic. The resident was found by family at approximately 2:30 p.m., at the LTC facility to be drowsy and minimally responsive. Family questioned the staff at the facility and it was discovered a medication error had occurred and the resident was given [MEDICATION NAME] 2 mg or possibly 2.5 mg. The resident was admitted to the hospital for continued monitoring with the expectation she would metabolize the medication and her neurological function/mental status would return to her baseline. The admitting [DIAGNOSES REDACTED]. The resident was discharged from the hospital on [DATE] to another LTC facility. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Medication Administration Record [REDACTED] On 5/23/19 at 9:15 a.m., the Administrator provided a document, revised 12/2012, and titled, Administering Medications, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .3. Medications must be administered in accordance with the orders, including any required time frame .7. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .23. Medications ordered for a particular resident may not be administered to another resident On 5/23/19 at 9:15 a.m., the Administrator provided a document, revised 10/2010, and titled, Administering Oral Medications, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation: 1. Verify that there is a physician's medication order for this procedure .Steps in the Procedure: .3. Place the MAR indicated [REDACTED]. 6. Check the label on the medication and confirm the medication name and dose with the MAR .8. Check the medication dose. Re-check to confirm the proper dose. 9. Prepare the correct dose of medication: .b. For narcotics. Check the narcotic record for the previous drug count and compare with the supply on hand. Report any discrepancies to the nurse supervisor On 5/23/19 at 9:15 a.m., the Administrator provided a document, revised 12/2014, and titled, Adverse Consequences and Medication Errors, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: .Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Policy Interpretation and Implementation: 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported .3. An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug and is different from the therapeutic and helpful effects of the drug. An ADR is any noxious and unintended response to a drug .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED].unauthorized drug- a drug is administered without a physician's orders [REDACTED].f. wrong drug This Federal tag relates to Complaint IN 474. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with residents' written plans of care to prevent injuries and/or falls for 3 of 5 residents reviewed for falls/injuries (Resident #44, #25, and #1) and failed to ensure medications were administered per physician's orders [REDACTED].# 33). Findings include: 1. Resident #44's record was reviewed on 3/11/2013 at 8:55 A.M. Her [DIAGNOSES REDACTED]. Resident #44 was a limited assist of one person for bed mobility, an extensive assistance of one person for transfers, and had short and long term memory problems, not being able to recall information after five minutes. A nurse's note dated 3/1/2012-11:10 P.M., indicated, "Writer and QMA (Qualified Medication Aide) heard yelling. Went down hallway found res lying on right side. Res lifted head noted lg (large) amount of blood on floor. Upon further assessment re noted to have laceration upon right eye. Noted bruising to right eye as well. Res c/o right hip pain upon palpation. Applied light pressure to laceration and informed res that we were going to call Dr (doctor) to see if we could send her to E.R. (emergency room ) for right hip pain and laceration. Res left on floor. Another nurse called POA (power of attorney (POA named) and informed her of res fall. Stated, 'Send to (hospital named). 911 called at this time." A hospital note, dated 3/3/2013, indicated, Resident #44 was seen in the emergency room for a facial laceration which required seven sutures and a contusion to her right hip from a fall. During a telephone interview on 3/13/2013 at 10:53 A.M., LPN #4 indicated the pressure alarm was not working when Resident #44 fell out of bed on 3/1/2013. " During a telephone interview on 3/13/2013 at 1:15 P.M., CNA/QMA #3 indicated the bed was not in the low position. She further indicated she was aware Resident #44 could raise the bed herself and confirmed the alarm was not working when she fell out of bed on 3/1/2013. A current care plan, originally dated 8/4/2012, and reviewed on 3/5/2013, indicated Resident #44 was a high risk for falls related to the following: history of fall with fracture, history of falls, medications, use of wheelchair for mobility, [DIAGNOSES REDACTED]. A current goal listed was for Resident #44 to be free from fall related injuries. Interventions included to meet this goal included, but were not limited to: explain call light and assess resident's ability to use, frequently remind her to call for staff and wait for staff assistance, keep articles of need within reach, toilet her with AM/PM care, after lunch, in the evening as needed, offer to toilet every two hours, and after supper, pressure alarm in bed,, and use of a low bed. A current care plan originally dated 8/14/2012, and last reviewed/updated on 2/2/12, indicated, Resident #44 had long and short term memory deficits with difficulty making decision. She could not remember after five minutes. She could not state the details of her life information such as the town she had lived in for nearly [AGE] years. She had poor decision making as evidenced by her lack of safety awareness. Resident #44 was observed on the following dates and times: Resident #44 was observed on 3/5/2013 at 10:00 A.M. She had bruising to most of the right side of her face and sutures to her right forehead. 3/12/2013-8:50 A.M.,11:10 A.M., and, 11:20 A.M. sitting in a wheel chair (w/c), in her room. The call light was positioned in the middle of the low bed and was not within reach of Resident #44. On 3/12/2013, from 11:10 A.M. to 1:15 P.M. (during constant observation), staff entered her room twice to provide fluids to her room mate but did not offer to take Resident #44 to the restroom or ensure the call light was in reach. At 11:49 A.M., staff pushed her down the hall to the dining area. At 11:50 A.M., she was positioned at the dining room table. At 12:34 P.M., Resident #44 was served lunch. From 12:34 p.m. to 1:15 p.m., Resident #44 was observed at the dining room table eating lunch. Review of a Bowel and Bladder assessment dated [DATE], indicated Resident #44 was to be on a every two hour toileting schedule. Review of the CNA assignment sheet indicated Resident #44 should be taken to the bathroom every two hours. During an interview on 3/12/2013 at 12:33 P.M., CNA #2 was asked how she knew what care the residents were to be provided. She replied, "Well, I've worked her for a long time but I do move around." She pulled out her assignment sheet and indicated it should be on the assignment sheet and if it wasn't she would ask someone. The CNA assignment sheet failed to reflect Resident #44's current toileting schedule. During an interview on 3/12/2013 at 12:45 P.M., CNA #2 was asked when Resident #44 was last taken to the bathroom. She stated, "I took her after breakfast at 10:00 A.M. I know I am late. She will stay continent most of the time during the day if you take her to the bathroom." 2. On 3/5/12 at 10:00 A.M., an ISDH (Indiana State Department of Health) facility self reported incident, dated 10/29/12, included, but was not limited to, "Date of Alleged (incident): 10/25/12... Brief Description of Incident: Resident (#25) noted by CNA (Certified Nursing Assistant) #23 to have laceration on back of right calf... Type of Injury: Back of right calf laceration 7.5 cm long by 1/2 inches deep (received 15 stitches in ER (emergency room ))... Immediate Action Taken: Resident assessed... MD (medical doctor) and family notified... Resident sent to ER for evaluation... Preventive Measures Taken: Monitor stitches for s/s (signs and symptoms) of infection... Remove per orders... Ensure no sharp edges on chair, bed, etc..." On 3/12/13 at 10:29 A.M., Resident #25's record was reviewed. [DIAGNOSES REDACTED]. A "Focus Charting" dated 10-9-12 through 10-15-12, included, but was not limited to, "Activities of Daily Living... Transfers: Extensive assistance of 2 or more staff... A "Case Mix ADL Data Collection" dated 10/1/12 through 10/31/12, indicated Resident #25 required extensive assistance with transfers of 2 or more persons. A "Nurse's Notes" dated 10/25/12 at 8:15 P.M., included, but was not limited to, "Called to room by CNA (#23)... had just laid patient (Resident #25) down... noted 7.5 centimeter deep laceration to right lower lateral leg... transferred to ER..." A care plan, dated 10/25/12, included, but was not limited to, "History of skin laceration of unknown etiology... Current laceration right lower leg... Patient (Resident #25) will be free from lacerations... Remind staff to carefully monitor patient during movements/transfers... Monitor skin every shift..." On 3/12/13 at 11:30 A.M., the DoN (Director of Nursing) provided the facility's investigation of Resident #25's skin laceration. The investigation included, but was not limited to, "Incident Date; 10/25/12... Staff Involved: CNA #23 and Registered Nurse (RN) #24....Brief Description of Incident: CNA (#23) called nurse (RN #24) to room to report laceration on back of right calf... CNA (#23) was putting resident to bed and noted laceration... Patient (Resident #25) was being transferred from wheelchair to bed and laid down by CNA (#23)..." On 3/12/13 at 11:35 A.M., in an interview, the DoN indicated the facility was unable to find any sharp edges on Resident #25's personal care equipment. She indicated physical therapy checked her wheelchair and did not find any abnormalities (sharp edges). On 3/12/13 at 2:30 P.M., in an interview, CNA #23 indicated she was the only staff member transferring Resident #25 at the time of the incident on 10/25/12. CNA #23 indicated as soon as she assisted Resident #25 to a standing position, Resident #25 said, "My leg, my leg." At that time, CNA #23 indicated she observed a cut on Resident #25's right leg and called for assistance from RN #24. CNA #23 indicated she was not aware that Resident #25 was a 2 person assist with transfers. On 3/12/13 at 2:50 P.M., in an interview, CNA #25 indicated she provided care to Resident #25. She indicated Resident #25 required 2 staff members for all transfers. 3. Resident #1 was observed without fall interventions (non-skid socks and call light within reach) on the following days: On 3/7/13 at 1:57 P.M., Resident #1 was observed at the bedside without non-skid socks. At that time, in an interview, CNA #26 indicated Resident #1 does try to ambulate without calling for assistance. On 3/11/13 at 3:00 P.M., Resident #1 was observed laying in bed. Resident #1 was easily awakened. She was observed without non-skid socks. On 3/12/13 at 2:55 P.M., Resident #1 was easily awakened while laying in bed. At that time, her call light was observed hanging on the wall. Resident #1 indicated she did not know where the call light was and could not find it. Resident #1 was observed without non-skid socks. On 3/11/13 at 2:37 P.M., Resident #1's record was reviewed. [DIAGNOSES REDACTED]. A "Fall Care Plan Addendum" included, but was not limited to, "7/5/12 at 6:40 P.M.... Found on floor started to sit and chair moved and landed on floor... Chair removed and encouraged resident (Resident #1) to call for assistance... Encouraged to always use walker... 7/28/12 at 9:30 A.M.... Found on floor... trying to reach for closet when lost balance... 8/27/12 at 9:45 P.M.... (Resident #1)Stated was sitting on side of bed and reached for slippers on table and slid to floor... 9/29/12 at 6:45 P.M.... Staff heard resident (Resident #1) calling for help and found sitting on floor between bed and overbed table.... 1.5 cm skin tear to right parietal area and hematoma to same area... (bed at lowest position) 12/5/12 at 3:00 P.M.... Found on floor... slid off bed... 12/9/12 at 10:30 P.M.... Found on bathroom floor laying on her back, said she was trying to use the bathroom and slipped and fell in urine... Assisted to bed, put on non-skid socks... 1/26/13, no time... Resident (#1) was ambulating out of her room with walker and tipped her walker over sideways falling to the ground... 5 cm skin tear to left elbow... 2/7/13, no time... Found sitting on floor, she stated she was going to br (bathroom) and fell and hit her head... Has a bruise to right parietal area and skin tear to right elbow..." A fall care plan, dated 12/12/12, included, but was not limited to, "At risk for falls r/t (related to) medications, osteroarthritis, history of [MEDICAL CONDITION], history of [MEDICAL CONDITIONS], decrease in vision, pain, overall decline in activities of daily living, dementia, and history of falls... Will be free of fall related injury... Continue to encourage to ask for assistance... 7/10/12: Non-skid socks... 12/9/12: Pressure alarm in bed and chair... 8/28/12: Resident to wear non-skid footwear at all times..." 4. On 3/8/13 at 11:30 A.M., Resident #33's record was reviewed. [DIAGNOSES REDACTED]. A "Monthly Vital Sign Record" indicated on 12/3/12, Resident #33's blood pressure was 97/62. A "History and Physical/MD Assessment" dated 12/19/12, indicated Resident #33's had a [DIAGNOSES REDACTED]. A "physician's orders [REDACTED]. The "Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, the MAR indicated [REDACTED]. There was no documentation in Resident #33's record of a physician's orders [REDACTED]. On 3/8/13 at 12:00 P.M., a current medication order ([MEDICATION NAME]) was requested for Resident #33. On 3/8/13 at 1:55 P.M. in an interview, the DoN indicated it was her nurse's (LPN #27) error. The DoN indicated that when LPN #27 didn't find the [MEDICATION NAME] in the medication drawer, she called the pharmacy and re-ordered it without checking for a current order. At that time, the DoN provided a "Medication Error Report" dated 3/8/13. The report included, but was not limited to, "What was physician's orders [REDACTED].. Medication was discontinued 12/22/12, not given in January 2013, given in February 2013 when re-write done (sic) incorrectly and sent to pharmacy... Could the error have endangered the life or welfare of the patient... Per the Nurse Practitioner... Blood pressure low and in normal range so discontinued medication... Blood pressure not low enough to endanger (Resident #33)... What precautions can you take to prevent similar error... Re-education of nurse (LPN #27) making error..." 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents reviewed for accidents (Resident #44, #25, and #1). Findings include: 1. Resident #44's record was reviewed on 3/11/2013 at 8:55 A.M. Her [DIAGNOSES REDACTED]. Resident #44 was a limited assist of one person for bed mobility, an extensive assistance of one person for transfers, and had short and long term memory problems, not being able to recall information after five minutes. A current care plan, originally dated 8/4/2012, and reviewed on 3/5/2013, indicated Resident #44 was a high risk for falls related to the following: history of fall with fracture, history of falls, medications, use of wheelchair for mobility, [DIAGNOSES REDACTED]. A current goal listed was for Resident #44 to be free from fall related injuries. Interventions included to meet this goal included, but were not limited to: explain call light and assess resident's ability to use, frequently remind her to call for staff and wait for staff assistance, keep articles of need within reach, toilet her with AM/PM care, after lunch, in the evening as needed, offer to toilet every two hours, and after supper, pressure alarm in bed,, and use of a low bed. A current care plan originally dated 8/14/2012, and last reviewed/updated on 2/2/12, indicated, Resident #44 had long and short term memory deficits with difficulty making decision. She could not remember after five minutes. She could not state the details of her life information such as the town she had lived in for nearly [AGE] years. She had poor decision making as evidenced by her lack of safety awareness. A nurse's note dated 12/20/12 -10:30 P.M., indicated, "Resident was found sitting on floor in middle of room. Stated she was trying to get to w/c to go to bathroom....Has abrasion on left elbow. Cleansed with NS (normal saline) and bandage applied. Had c/o (complained) of pain while abrasion was being applied. Back is slightly red on right side. Stated, 'I hit my head a little bit.' MD notified. Family is aware. Resident is resting in bed at present time. Will be f/u (follow up) fall with neuros (neurological) for next 72 hours." Documentation was lacking which indicated the facility immediately revised and implemented fall prevention interventions. On 12/21/2013, Resident #44's fall care plan indicated due to the fall on 12/20/2012, an intervention was added to prevent her from sustaining fall related injuries. This intervention was for staff to toilet her with AM/PM care, after lunch, in the evening as needed, offer to toilet every two hours, and after supper. A nurse's note dated 12/28/2013 -1:30 A.M., indicated, "Resident was found on the floor at her bedside by staff. Res (resident) stated, 'I was trying to get up to go to the bathroom.' Res. denies hitting her head and denies pain r/t (related to) fall. She said, 'I slid out of my bed.' V/S (vitals)-B/P (blood pressure) 152/79, P 87, R 20, Neuros WNL. Res was helped by staff back into bed. Reminded res to use call light when needing help. Call light within reach. MD faxed. Will notify family in A.M. Neuro (neurological) sheet started. Will cont. to observe." The record lacked documentation Resident #44 was taken to the bathroom and did not indicate interventions other than reminding the resident with short/long term memory deficits to use her call light. A nurse's note dated 12/28/2012-9:15 A.M., indicated, the family was notified of the fall and the family suggested using an alarm. The DON was notified of the request. A pressure alarm to the bed to alert staff of unsafe movement and a mat at the bedside were added as interventions to Resident #44's fall care plan to meet the goal of preventing her from having fall-related injuries. A nurse's note dated 12/9/2013-3:00 A.M., indicated, "Found resident laying on floor next to bed wedged between w/c (wheelchair) and bed laying on her right side, (had recently been toileted) when asked what happened she stated she was trying to get herself out of bed (she has a hx (history) of this behavior). Right shoulder 1 cm (centimeter) X 1 CM, faint blue bruise, zero swelling, ROM (range of motion) WNL (within normal limits), MAE (moves all extremities), PERRL (sic) (Pupils equal and reactive to light). Notified MD (medical doctor), 151/80 (blood pressure), P (pulse) 86, R (respirations) 16, T (temperature) 97.7, O2 (oxygen saturation) 96%, speech clear; reminded to use call light. Moved w/c. Will cont. (continue) to monitor." The record indicated interventions of encouraging the resident to ask for assistance and use the call light were added to the care plan after a fall with injury on 12/9/2012. The record indicated the resident had been assessed to have/short/long term memory deficits. Documentation was lacking which indicated the facility immediately revised and implemented appropriate fall prevention interventions. A nurse's note dated 3/1/2012-11:10 P.M., indicated, "Writer and QMA (Qualified Medication Aide) heard yelling. Went down hallway found res (resident) lying on right side. Res lifted head noted lg (large) amount of blood on floor. Upon further assessment noted to have laceration upon right eye. Noted bruising to right eye as well. Res c/o right hip pain upon palpation. Applied light pressure to laceration and informed res that we were going to call Dr (doctor) to see if we could send her to E.R. (emergency room ) for right hip pain and laceration. Res left on floor. Another nurse called POA (power of attorney (POA named) and informed her of res fall. Stated, 'Send to (hospital named). 911 called at this time." A hospital note, dated 3/3/2013, indicated, Resident #44 was seen in the emergency room for a facial laceration which required seven sutures and a contusion to her right hip from a fall. During a telephone interview on 3/13/2013 at 10:53 A.M., LPN #4 indicated the pressure alarm was not working when Resident #44 fell out of bed on 3/1/2013. " During a telephone interview on 3/13/2013 at 11:11 A.M., LPN #4 indicated, "I don't remember if the bed was in the low position because I was focused on her and the blood on the floor." During a telephone interview on 3/13/2013 at 1:15 P.M., CNA/QMA #3 indicated, Resident #44 could raise her bed from the low position. She further indicated the bed was not in the low position and the alarm was not working at the time of the fall on 3/1/2013. During an interview on 3/13/2013 at 12:28 P.M., the DON indicated Resident #44 was in a regular bed and had orders to keep the bed in the lowest position. The DON indicated Resident #44 was capable of raising the bed from the low position. She indicated an intervention of a stationary low bed had not been added to the care plan and had not been implemented prior to the fall with injury on 3/1/2013. Resident #44 was observed on the following dates and times: Resident #44 was observed on 3/5/2013 at 10:00 A.M. She had bruising to most of the right side of her face and sutures to her right forehead. 3/12/2013-8:50 A.M.,11:10 A.M., and, 11:20 A.M. sitting in a wheel chair (w/c), in her room. The call light was positioned in the middle of the low bed and was not within reach of Resident #44. On 3/12/2013, from 11:10 A.M. to 1:15 P.M. (during constant observation), staff entered her room twice to provide fluids to her room mate but did not offer to take Resident #44 to the restroom or ensure the call light was in reach. At 11:49 A.M., staff pushed her down the hall to the dining area. At 11:50 A.M., she was positioned at the dining room table. At 12:34 P.M., Resident #44 was served lunch. From 12:34 p.m. to 1:15 p.m., Resident #44 was observed at the dining room table eating lunch. Review of a Bowel and Bladder assessment dated [DATE], indicated Resident #44 was to be on a every two hour toileting schedule. Review of the CNA assignment sheet indicated Resident #44 should have been taken to the bathroom every two hours. During an interview on 3/12/2013 at 12:33 P.M., CNA #2 was asked how she knew what care the residents were to be provided. She replied, "Well, I've worked her for a long time but I do move around." She pulled out her assignment sheet and indicated it should be on the assignment sheet and if it wasn't she would ask someone. The CNA assignment sheet failed to reflect Resident #44's current toileting schedule. During an interview on 3/12/2013 at 12:45 P.M., CNA #2 was asked when Resident #44 was last taken to the bathroom. She stated, "I took her after breakfast at 10:00 A.M. I know I am late. She will stay continent most of the time during the day if you take her to the bathroom." During an interview on 3/13/2013 at 11:38 A.M., the Administrator was asked to provided the facility's current policies related to falls. A policy titled, "Fall Follow-Up" dated 10-13-2004, indicated, "Purpose: To investigate falls in an effort to define the etiology of the fall and to see that appropriate interventions are in place to remove or control the causative factors as much as possible." 2. On 3/5/12 at 10:00 A.M., an ISDH (Indiana State Department of Health) facility self reported incident, dated 10/29/12, included, but was not limited to, "Date of Alleged (incident): 10/25/12... Brief Description of Incident: Resident (#25) noted by CNA (Certified Nursing Assistant) #23 to have laceration on back of right calf... Type of Injury: Back of right calf laceration 7.5 cm long by 1/2 inches deep (received 15 stitches in ER (emergency room ))... Immediate Action Taken: Resident assessed... MD (medical doctor) and family notified... Resident sent to ER for evaluation... Preventive Measures Taken: Monitor stitches for s/s (signs and symptoms) of infection... Remove per orders... Ensure no sharp edges on chair, bed, etc..." On 3/12/13 at 10:29 A.M., Resident #25's record was reviewed. [DIAGNOSES REDACTED]. A "Focus Charting" dated 10-9-12 through 10-15-12, included, but was not limited to, "Activities of Daily Living... Transfers: Extensive assistance of 2 or more staff... A "Case Mix ADL Data Collection" dated 10/1/12 through 10/31/12, indicated Resident #25 required extensive assistance with transfers of 2 or more persons. A "Nurse's Notes" dated 10/25/12 at 8:15 P.M., included, but was not limited to, "Called to room by CNA (#23)... had just laid patient (Resident #25) down... noted 7.5 centimeter deep laceration to right lower lateral leg... transferred to ER..." A care plan, dated 10/25/12, included, but was not limited to, "History of skin laceration of unknown etiology... Current laceration right lower leg... Patient (Resident #25) will be free from lacerations... Remind staff to carefully monitor patient during movements/transfers... Monitor skin every shift..." On 3/12/13 at 11:30 A.M., the DoN (Director of Nursing) provided the facility's investigation of Resident #25's skin laceration. The investigation included, but was not limited to, "Incident Date; 10/25/12... Staff Involved: CNA #23 and Registered Nurse (RN) #24....Brief Description of Incident: CNA (#23) called nurse (RN #24) to room to report laceration on back of right calf... CNA (#23) was putting resident to bed and noted laceration... Patient (Resident #25) was being transferred from wheelchair to bed and laid down by CNA (#23)..." On 3/12/13 at 11:35 A.M., in an interview, the DoN indicated the facility was unable to find any sharp edges on Resident #25's personal care equipment. She indicated physical therapy checked her wheelchair and did not find any abnormalities (sharp edges). On 3/12/13 at 2:30 P.M., in an interview, CNA #23 indicated she was the only staff member transferring Resident #25 at the time of the incident on 10/25/12. CNA #23 indicated as soon as she assisted Resident #25 to a standing position, Resident #25 said, "My leg, my leg." At that time, CNA #23 indicated she observed a cut on Resident #25's right leg and called for assistance from RN #24. CNA #23 indicated she was not aware that Resident #25 was a 2 person assist with transfers. On 3/12/13 at 2:50 P.M., in an interview, CNA #25 indicated she provided care to Resident #25. She indicated Resident #25 required 2 staff members for all transfers. 3. Resident #1 was observed without fall interventions (non-skid socks and call light within reach) on the following days: On 3/7/13 at 1:57 P.M., Resident #1 was observed at the bedside without non-skid socks. At that time, in an interview, CNA #26 indicated Resident #1 does try to ambulate without calling for assistance. On 3/11/13 at 3:00 P.M., Resident #1 was observed laying in bed. Resident #1 was easily awakened. She was observed without non-skid socks. On 3/12/13 at 2:55 P.M., Resident #1 was easily awakened while laying in bed. At that time, her call light was observed hanging on the wall. Resident #1 indicated she did not know where the call light was and could not find it. Resident #1 was observed without non-skid socks. On 3/11/13 at 2:37 P.M., Resident #1's record was reviewed. [DIAGNOSES REDACTED]. A "Fall Care Plan Addendum" included, but was not limited to, "7/5/12 at 6:40 P.M.... Found on floor started to sit and chair moved and landed on floor... Chair removed and encouraged resident (Resident #1) to call for assistance... Encouraged to always use walker... 7/28/12 at 9:30 A.M.... Found on floor... trying to reach for closet when lost balance... 8/27/12 at 9:45 P.M.... (Resident #1)Stated was sitting on side of bed and reached for slippers on table and slid to floor... 9/29/12 at 6:45 P.M.... Staff heard resident (Resident #1) calling for help and found sitting on floor between bed and overbed table.... 1.5 cm skin tear to right parietal area and hematoma to same area... (bed at lowest position) 12/5/12 at 3:00 P.M.... Found on floor... slid off bed... 12/9/12 at 10:30 P.M.... Found on bathroom floor laying on her back, said she was trying to use the bathroom and slipped and fell in urine... Assisted to bed, put on non-skid socks... 1/26/13, no time... Resident (#1) was ambulating out of her room with walker and tipped her walker over sideways falling to the ground... 5 cm skin tear to left elbow... 2/7/13, no time... Found sitting on floor, she stated she was going to br (bathroom) and fell and hit her head... Has a bruise to right parietal area and skin tear to right elbow..." A fall care plan, dated 12/12/12, included, but was not limited to, "At risk for falls r/t (related to) medications, osteroarthritis, history of seizure, history of cerebral vascular accident, syncope, decrease in vision, pain, overall decline in activities of daily living, dementia, and history of falls... Will be free of fall related injury... Continue to encourage to ask for assistance... 7/10/12: Non-skid socks... 12/9/12: Pressure alarm in bed and chair... 8/28/12: Resident to wear non-skid footwear at all times..." 3.1-45(a)(1)

Based on observation, record review and interview, the facility failed to ensure the safety of 1 of 5 residents reviewed for accidents in the sample of 5 in that, although he was assessed as unable to bear weight, he was transferred via a stand-up lift per instructions on the nurse aide information sheet which were in conflict with the official care plan of record. This resulted in fractures of his upper arm and collarbone. (Resident G) Findings include: During the orientation tour of 6/23/11 at 10:30 a.m., Unit Manager #2 indicated Resident G had fractured his clavicle/collarbone while being transferred out of bed with a stand-up lift. She indicated he also had left [DIAGNOSES REDACTED] and was full care. She indicated he was interviewable but it would be extremely difficult because he spoke a Slavic language. Review of Resident G's clinical record was completed on 6/24/11 at 12:05 p.m. His [DIAGNOSES REDACTED]. His 6/8/11 five-day Resident Assessment Instrument indicated he was completely alert and oriented and his speech was clear. It indicated he was dependent on staff for all care except eating and had transferred only twice within the 7-day assessment period. To be noted, Resident G's weight was 284 pounds. The nursing note on Sunday 5/29/11 at 4:15 p.m. indicated Resident G "...screaming stating, 'I want to go to the hospital. L (left) shoulder and L chest pain.' (sic)" The M.D. service was notified and responded at 4:40 p.m. Resident G was transferred via ambulance to the emergency room at 5:30 p.m. where he was subsequently admitted to treat fractures of his clavicle and humerus. During interview with Resident G on 6/24/11 at 12 noon, he said, "Two aides had me in a contraption and I couldn't hold on. I kept telling them, but they just kept telling me to hold on. Well, I couldn't--it was hurting too much and I'm not so strong anymore. I leaned toward the chair and that's when the bad pain started." He also stated, "I haven't been able to stand up on my legs for a long time--since the stroke." Interview of Certified Nurse Aide #1 on 6/24/11 at 2:20 p.m. indicated she answered Resident G's call light to find he had raised the head of his bed to a 90 degree angle and it had stuck there. The resident had an involuntary stool and needed incontinence care, but they couldn't do it with his bed in that position. "We thought and thought and thought and decided to put him in the stand-up lift and clean him there...He agreed to it...He'd been using the stand-up for transfers to and from the wheelchair. He could do it. He used his arms and shoulders." She indicated she didn't see a difference between holding himself on the stand-up for a few seconds during a regular transfer and the several minutes it would take to clean him of an involuntary stool. She indicated they had decided against using the unoccupied bed in the room or other options. She indicated, "He was moaning and telling us he couldn't hold on, but we knew he could do it. We told him we were almost done and he kept saying he couldn't hold on anymore and then he just let go...He could have done it but he didn't want to...He'd been doing just fine." She indicated she and CNA #2 had not conferred with the charge nurse before making this decision. She indicated the nurse aide information/assignment sheets said to use the stand-up lift. She indicated Resident G had not fallen, only slumped down in the straps of the lift leaning toward the bedside chair. Interview with the Director of Nursing 6/24/11 at 1:45 p.m. indicated she was now aware the nurse aide assignment/information sheet which was in effect on 5/29/11 did indicate both pieces of information: Resident G could not bear weight and to use the stand-up lift for transfers. She agreed this was contradictory and had become aware of it only after this event occurred. She had tried to explain how unacceptable this was, but staff "kept repeating" to her that "he could do it...he did it before..he just didn't want to." Review of the current nurse aide assignment/information sheet for Resident G indicated it did state he could not bear weight, but it did not direct staff as to how to transfer him. The current care plan addressed the issue of fall risk and indicated with an intervention added 4/19/11 as "hoyer lift transfer-use 2 people." This federal tag relates to complaint number IN 302. 3.1-45(a)(1)