Every finding on record at Cardinal Care Strategies

Based on interview and record review, the facility failed to ensure actions were taken to prevent further abuse, when a staff member left a resident with the alleged perpetrator after witnessing an alleged act of resident to resident abuse (Residents B and C) and failed to complete a thorough investigation according to the facility's policy following an allegation of resident to resident sexual abuse for 1 of 2 incidents reviewed for abuse. (Residents B and C)Findings include:On 5/12/26 at 11:31 a.m., Resident B sat in her wheelchair in her room with her television on. She indicated, a few days ago, she invited Resident C to her room to talk as friends. He came into her room, shut her door, removed her incontinence brief, and put his finger in her vagina. She was not comfortable with his actions. She yelled out for him to stop and one of the staff members came into her room. She did not want him to do that to her. She felt safe in the facility.A facility investigation file, observed on the conference room table on 5/12/26 at 11:49 a.m., contained Resident B's face sheet, orders, care plans, a Trauma Informed Care Review dated 5/10/26, a social service progress note dated 5/11/26 at 11:45 a.m., and Resident C's face sheet, care plan, and orders. The folder included two witness statements as follows: An undated written statement, signed by CNA 6, indicating around 7:20 p.m., CNA 6 opened Resident B's door to her room to bring in supplies. The privacy curtain was pulled, and she heard Resident B saying no and stop, which made CNA 6 pause. Then Resident B said it again. CNA 6 looked around the curtain and saw Resident C standing over Resident B with his pants down and forcing his fingers inside her vagina. Resident B's brief was hanging on the side of the bed. CNA 6 ran and got the QMA and the Nurse. As they all approached the room, Resident C was still forcing his finger inside Resident B's vagina and Resident B said no stop once again. QMA 7 removed Resident C from the room. A written statement, dated 5/10/26 and signed by CNA 42, indicating that she did not witness the incident but went later to check on Resident B. Resident B indicated to CNA 42 that she unstrapped one side of her brief and Resident C undid the other side. She also indicated that she told him no three times and he didn't stop when she told him to stop. A social service note, dated 5/11/26 at 11:45 a.m., indicated the social service designee met with Resident B regarding the incident on 5/10/26. Resident B indicated that she asked another resident to come to her room to talk. The resident took her pants and brief off and touched her while she was saying no. A CNA entered her room and he stopped. The police were notified; Resident B was interviewed and provided a statement. Victims' rights were reviewed with Resident B, and she indicated that she understood. Resident B indicated she was fine and did not appear upset. She was calm with no signs of psychosocial distress. Ongoing psychiatric/social observation would continue as needed and trauma screening was completed.The facility investigation lacked interviews of residents and other staff members to determine if there were other witnesses or additional allegations related to the incident.Resident B's clinical record was reviewed on 5/12/26 at 10:02 a.m. Diagnoses included major depressive disorder, recurrent severe without psychotic features, unspecified psychosis not due to a substance or known physiological condition, unspecified disorder of adult personality and behavior, unspecified symptoms and signs involving cognitive functions and awareness, and other sexual disorders.A 2/26/26 admission MDS (Minimum Data Set) assessment indicated she was cognitively intact and no maladaptive behaviors were exhibited. The resident required a mechanical lift for transfers.Resident B's clinical record lacked a physical assessment completed following the incident with Resident C.Resident C's clinical record was reviewed on 5/12/26 at 10:26 a.m. Diagnoses included unspecified dementia, moderate, with other behavioral disturbance, generalized anxiety disorder, and mood disorder due to known physiological condition with manic features.A 2/11/26 admission MDS assessment indicated he was cognitively intact and no maladaptive behaviors were exhibited. A 4/15/26 revised care plan indicated that he exhibited sexually inappropriate behaviors as example by making sexually inappropriate remarks to staff, attempting to kiss staff, attempting to touch staff, etc. Interventions included encouraging him to express why he made statements/comments/remarks (2/4/26), explain/educate that the behavior was not appropriate (2/4/26), let him know what kind of behavior was expected and what would be tolerated (2/4/26), talk to him about feelings and the rights of others who were exposed to acting out (2/4/26), and try to find a cause of the behavior (2/4/26).A 5/11/26 discharge assessment indicated Resident C requested to move to a sister facility.During an interview, on 5/12/26 at 12:33 p.m., with the DON, ADON and the Administrator, the DON indicated no other residents were assessed after the incident regarding Resident B and Resident C. During an interview, on 5/12/26 at 12:48 p.m., the Administrator indicated they had not interviewed other residents related to the incident regarding Resident B and Resident C. During an interview, on 5/13/26 at 11:07 a.m. CNA 39 indicated if she witnessed suspected resident to resident abuse, she would immediately separate the residents and report what she observed to the Administrator or the DON. During an interview, on 5/13/26 at 11:34 a.m., CNA 33 indicated if she witnessed alleged abuse she would scream for the nurse, make sure the residents were safe, and would not leave the residents.During an interview, on 5/13/26 at 1:56 p.m., QMA 7 indicated that she and RN 13 were walking in the hall near the dining room, CNA 6 ran from around the corner of Resident B's hall towards them at the Freedom Hall nurse's station and asking them to come with her quickly. The door to Resident B's room was open, QMA 7 entered Resident B's room, the privacy curtain was pulled, and she heard Resident B saying no and stop. QMA 7 pulled the curtain back, Resident B was lying in bed with her brief open and under her. Resident C was standing beside Resident B's bed with his pants down and his fingers in Resident B's vagina. QMA 7 asked Resident C what he was doing, to stop, and get out of the room. QMA 7 called the Administrator to report what she observed.During an interview, on 5/13/26 at 3:41 p.m., with the Administrator and DON, the DON indicated the nurse on duty was responsible for completing, as soon as possible, an incident report and a progress note including a skin assessment. The nurse would also immediately call the Administrator, notify the nurse practitioner, and obtain witness statements from the staff. Either the Administrator, DON, or Social Services designee would interview other staff members and residents. The Administrator indicated when staff observed abuse, they should immediately separate the residents and make sure they were safe, then notify the Administrator right away. There were no facility policies available related to abuse and immediately separating the residents.A current facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, provided by the DON on 5/13/26 at 3:55 p.m. indicated the following: .Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations.7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident.e. interviews any witnesses to the incident; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors.k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly.This citation relates to Intake 3009932.410 IAC (Indiana Administrative Code) 16.2-3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure a physical assessment was completed for a resident following an allegation of resident to resident sexual abuse for 1 of 4 residents reviewed for abuse. (Resident B)Findings include:On 5/12/26 at 10:44 a.m., Resident B was observed participating in an activity in the activity room.On 5/12/26 at 11:31 a.m., Resident B sat in her wheelchair in her room with her television on. She indicated, a few days ago, she invited Resident C to her room to talk as friends. He came into her room, shut her door, removed her incontinence brief, and put his finger in her vagina. She was not comfortable with his actions. She yelled out for him to stop and one of the staff members came into her room. She did not want him to do that to her. She felt safe in the facility.A facility investigation file, observed on the conference room table on 5/12/26 at 11:49 a.m., included Resident B's face sheet, orders, care plans, a social service progress note dated 5/11/26 at 11:45 a.m., and Resident C's face sheet, care plan, and orders. The folder included two witness statements as follows: An undated written statement, signed by CNA 6, indicating around 7:20 p.m., CNA 6 opened Resident B's door to her room to bring in supplies. The privacy curtain was pulled, and she heard Resident B saying no and stop, which made CNA 6 pause. Then Resident B said it again. CNA 6 looked around the curtain and saw Resident C standing over Resident B with his pants down and forcing his fingers inside her vagina. Resident B's brief was hanging on the side of the bed. CNA 6 ran and got the QMA and the Nurse. A social service note, dated 5/11/26 at 11:45 a.m., indicated the social service designee met with Resident B regarding the incident on 5/10/26. Resident B indicated that she asked another resident to come to her room to talk. The resident took her pants and brief off and touched her while she was saying no. A CNA entered her room and he stopped. Resident B indicated she was fine and did not appear upset. She was calm with no signs of psychosocial distress. Resident B's clinical record was reviewed on 5/12/26 at 10:02 a.m. Diagnoses included major depressive disorder, recurrent severe without psychotic features, unspecified psychosis not due to a substance or known physiological condition, unspecified disorder of adult personality and behavior, unspecified symptoms and signs involving cognitive functions and awareness, and other sexual disorders.A 2/26/26 admission MDS (Minimum Data Set) assessment indicated she was cognitively intact and no maladaptive behaviors were exhibited. The resident required a mechanical lift for transfers.Resident B's clinical record lacked a physical assessment completed following the incident with Resident C.Resident C's clinical record was reviewed on 5/12/26 at 10:26 a.m. Diagnoses included unspecified dementia, moderate, with other behavioral disturbance, generalized anxiety disorder, and mood disorder due to known physiological condition with manic features.A 2/11/26 admission MDS assessment indicated he was cognitively intact and no maladaptive behaviors were exhibited. During an interview, on 5/12/26 at 12:33 p.m., with the DON, ADON and the Administrator, the DON indicated no other residents were assessed after the incident regarding Resident B and Resident C. During an interview, on 5/13/26 at 1:56 p.m., QMA 7 indicated that she and RN 13 were walking in the hall near the dining room, CNA 6 ran from around the corner of Resident B's hall towards them at the Freedom Hall nurse's station and asking them to come with her quickly. The door to Resident B's room was open, QMA 7 entered Resident B's room, the privacy curtain was pulled, and she heard Resident B saying no and stop. QMA 7 pulled the curtain back, Resident B was lying in bed with her brief open and under her. Resident C was standing beside Resident B's bed with his pants down and his fingers in Resident B's vagina. QMA 7 asked Resident C what he was doing, to stop, and get out of the room. QMA 7 called the Administrator to report what she observed.During an interview, on 5/13/26 at 3:41 p.m., with the Administrator and DON, the DON indicated the nurse on duty was responsible for completing, as soon as possible, an incident report and a progress note including a skin assessment. A current facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, provided by the DON on 5/13/26 at 3:55 p.m. indicated the following: .Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations.7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident.This citation relates to Intake 3009932.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion when two units were locked and secured (200 and 300 halls) without authorization from the State Agency (Indiana Department of Health) and failed to identify individual needs for specialized programming requiring a secured unit for 4 of 4 residents reviewed for involuntary seclusion. (Residents C, D, G, and J) Findings include:During a random observation, on 4/20/26 at 10:15 a.m., the double doors at the entrance to the 200 Hall were closed and locked. The door was locked in a manner requiring a code to be entered in order to enter or leave the unit. A keypad lock was located on the wall beside the doors. The keypad would unlock the door when a code was entered. The entrance code was not posted near the doors. There were no other unlocked doors allowing access to the 200 Hall unit. Inside the 200 Hall was a nursing station and lounge. Adjoining the lounge was a closed unlocked set of double doors which allowed entrance to the 300 Hall unit (Swan). The 300 hall did not have any other unlocked doors to allow access to the unit. Entrance and exit from the 300 Hall Swan Unit required the individual to enter a code and pass through the locked 200 Hall doors. During random observations, the 200 Hall doors were locked requiring a code for entrance and exit on both 4/20/26 from 10:15 a.m. to 3:30 p.m. and 4/21/26 from 9:15 a.m. to 4:20 p.m.During a phone interview with the Chief Operating Officer (COO) and Nursing Officer for Care Strategies, on 4/21/26 at 10:21 a.m., the COO indicated dementia disclosure had been sent to the State. He believed an FSSA (Indiana Family and Social Services Administration) dementia disclosure form met requirements for a secured unit. He was unaware that the Indiana Department of Health (IDOH) did not license or provide authorization for dementia units. He indicated LSC (Life Safety Code) had allowed them to have the units secured in the past, as had the LTC (Long Term Care) survey teams. He had no information regarding communication with IDOH Division of Long Term care about the 200 or 300 Unit having been approved as a secured unit and being issued an authorization for occupancy for the secured units.1. Resident C's clinical record was reviewed on 4/20/26 at 12:46 p.m. Current diagnoses included bipolar disorder-depression-severe with psychotic features, borderline personality disorder, and anxiety. The resident had a current, 11/12/25, physician's order for Resident my reside on secured unit-No directions specified for order. The resident's record lacked the following: an assessment/evaluation to identify the resident's medical diagnoses, symptom, and/or behavioral symptom being treated by a locked secured unit. The resident had resided on the 200 hall since February 2026. A 1/26/26, quarterly, Minimum Data Set (MDS) Assessment indicated the resident was cognitively intact, had mild depression symptoms, and had displayed no maladaptive behaviors during the assessment period, to include wandering/elopement attempts.2. Resident D's clinical record was reviewed on 4/21/26 at 11:17 a.m. Current diagnoses included paranoid schizophrenia, bipolar disorder, and unspecified intellectual disabilities. The resident had a current physician's order for May reside on secured unit. The resident's record lacked the following: an assessment/evaluation to identify the resident's medical diagnosis, symptom, and/or behavioral symptom being treated by a locked secured unit or a care plan regarding the need for a secured unit. The resident had resided on the 200 hall since March 2026. The resident had resided on the 300 hall from December 2025 to March 2026.A 12/27/25, admission, MDS assessment indicated the resident was severely cognitively impaired. A 3/12/26, significant change, MDS assessment indicated the facility had chosen not to assess the resident's cognitive status or symptoms of depression, and the resident had displayed only one maladaptive behavior during the assessment period in the form of rejected care 1 to 3 times during the assessment period.3. Resident G's clinical record was reviewed on 4/21/26 at 2:10 p.m. Current diagnoses included dementia, chronic post-traumatic stress disorder, depression, and anxiety. The resident had a current, 3/30/26, physician's order for May reside in secured unit-No directions specified for order. The resident's record lacked the following: a care plan regarding the need for a secured unit. The resident had resided on the 300 hall since March 2026.A 4/3/26, admission, MDS assessment, indicated the resident was severely cognitively impaired, and displayed no maladaptive behaviors during the assessment period, including wandering. 4. Resident J's clinical record was reviewed on 4/21/26 at 3:00 p.m. Current diagnoses included Alzheimer's disease, anxiety, depression, and delusional disorder. The resident had a current ,10/20/25, physician's for May reside in secured unit-No directions specified for order. The resident's record lacked the following: an assessment/ evaluation to identify the resident's medical and/or behavioral symptom being treated by a locked secured unit.A 4/13/26, significant change, MDS assessment indicated the resident had both long- and short-term memory loss and wandered 1 to 3 days of the assessment period.During an interview, on 4/21/26 at 9:15 a.m., both the Administrator and DON indicated the following:The facility had no criteria, policy, or program related to the secured units. When they both recently began employment at the facility (in 2026), they both had been of the understanding that the 300 Hall/Swan unit was an approved secured dementia unit, and the 200 Hall was a [approved] secured behavioral unit. They both were also under the understanding that the corporation and previous ownership had completed all the necessary requirements for dedicated secured units.Resident G was admitted to the 300 Hall/[NAME] unit because he had a diagnosis of dementia and required dementia services. He did not have a care plan for the need for a secured dementia unit prior to 4/21/26. He had no documented attempts or statements regarding elopement.Resident J resided on the 300 Hall Unit/[NAME] Unit due to advanced dementia. The resident had no assessment or evaluation prior to his admission to the secured unit. The facility was of the understanding that he did have a history of behaviors and exit seeking prior to his admission to the secured unit. He had made no elopement attempts in the past 90 days.Resident D resided on the 200 Unit for behavior management needs. He had resided on the 300 Unit and had been moved to the 200 Unit when the family made an informed effort to separate the residents in the two units by diagnosis and need. He did not have an evaluation or assessment prior to residing on the secured unit. He did have a history of behaviors and a mental health diagnosis. In February 2026, he followed a staff member off the unit as they were leaving. Staff had to accompany him into the other area of the facility, and a great deal of effort was required to convince him to return to the unit. He did not have a care plan regarding his need for a secured unit prior to 4/20/26.Resident C did not have an assessment/evaluation prior to her placement on the secured unit. She did have a mental health diagnosis, and a history of behavioral concerns include statements of elopement. Review of IDOH licensing records indicated a lack of authorization to occupy for any secured unit within the facility, to ensure inspections had been completed to for compliance with safety regulations. A current, undated, facility policy titled, Care Strategies Abuse and Prevention Policy, provided by the DON via email on 4/20/26 at 10:48 a.m., indicated the following: .Examples of abuse:.involuntary seclusion. A current, undated, facility policy titled Your Rights and Protection as a Nursing Home Resident provided by the Administrator via email on 4/22/26, indicated the following: .Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual,physical, and mental abuse. Nursing homes can't keep you apart from everyone else against your will. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(l)(4)

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse from a staff member in the form of threats of physical violence for 1 of 4 residents reviewed for abuse. (Resident C) Findings include: Resident C's clinical record was reviewed on 4/20/26 at 12:46 p.m. Current diagnoses included bipolar disorder-depression-severe with psychotic features, borderline personality disorder, and anxiety. A 1/26/26, quarterly, Minimum Data Set (MDS) Assessment indicated the resident was cognitively intact, had mild depression symptoms, and had displayed no maladaptive behaviors during the assessment period, which included wandering/elopement attempts.The resident had a current, 3/23/26, care plan problem/need regarding exhibits behavior indicators as evidence by demanding staff. Approaches to this need included address wants and needs in a timely manner and Provide resident with support and reassurance. The resident had a current, 11/25/25, care plan problem/need of being at risk for decline in psychosocial wellbeing secondary to past sexual assaults which has contributed to some of the following mood and behaviors. Approaches to this need included staff to allow resident to vent appropriately and validate feelings as necessary and staff to encourage resident to use healthy coping mechanisms such as going for a small ride around the facility, sitting with a staff member on the porch and getting fresh air, speaking to a positive support person, calling a friend, or looking at old photos that make resident happy. During an interview, on 4/21/26 at 9:15 a.m., the Administrator and DON both indicated they had received an allegation of verbal abuse regarding a threat of physical violence. Resident C had alleged QMA 5 threatened to hit her if the resident hit her first and they would both go to jail. During the course of the facility investigation, QMA 5 confessed to making the statement. QMA 5's employment was terminated in response to her verbal threat.A 3/18/26 written facility investigation statement by LPN 4, provided by the Administrator on 4/20/26, following the entrance conference, indicated the following: [Resident C] stated to me that [QMA 5] said to her 'I will kick you're a--' [Resident C] did have behaviors over receiving her medications early. [QMA 5] was at nurses station while I was entering incident reports due to another incident. [QMA 5's] shift was over and she left. While [LPN 5] was at the desk, she [QMA 5] said 'I wish they would fire me.' A, 3/19/26, written resident interview with Resident C, provided by the Administrator on 4/20/26, following the entrance conference, indicated the following: [QMA 5] played a recording of me on her phone when I was in psychosis and was laughing at the recording. I told her to turn it off she grabbed the baby gate and pushed it toward my knee and hit my knee. I told her I was going to hit her with the gate and she said I am going to slap you if you do 'I picked up the gate and threw it on the ground'. A, 3/19/26, written statement of a phone interview, signed by the Administrator and DON, provided by the Administrator on 4/20/26 following the entrance conference, indicated the following: .Interview with [QMA 5]- [QMA 5] indicated she made said statement. [QMA 5] did state that she did tell resident 'If you hit me, I am going to hit you and we both go to jail.' A written email from QMA 5, dated 3/19/26 at 3:30 p.m., and provided by the Administrator on 4/20/26, following the entrance conference, indicated the following: On Wednesday 18th of 2026, at approximately 6:00PM, I was giving report to my co-worker when a resident [Resident C] approached and involved herself in the conversation. The resident became upset and began making threatening statements towards me, including stating that she would hit me with the gate. && (sic) she stated she would hit me like she did [another employee's name]. She also kept saying she was going to get me fired! During the interaction, I responded that if she hit me, I would defend myself and stated the situation would result in both of us going to jail. The resident then forcefully grabbed and removed the door from the gate area in an aggressive manner. No physical altercation occurred. A current, undated, facility policy titled, Care Strategies Abuse and Prevention Policy, provided by the DON via email on 4/20/26 at 10:48 a.m., indicated Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms.Examples: .are not limited to: threats of harm. A current, undated, facility policy titled Your Rights and Protection as a Nursing Home Resident provided by the Administrator via email on 4/22/26, indicated Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse. Nursing homes can't keep you apart from everyone else against your will. This citation relates to Intakes 2970583 and 2808587. 410 IAC (Indiana Administrative Code) 16.2-3.1 - 27 (a)410 IAC 16.2-3.1-27(b)

Based on observation, intervew, and record review, the facility failed to ensure menus were followed in order to ensure accurate portion size for entrees served. This deficient practice had the potential to impact 81 of 81 residents, who recieved meals prepared by the facility. Findings include: During a lunch meal service observation on 1/5/26 from 11:25 a.m. to 11:37 a.m., [NAME] 16 was observed scooping a 4-ounce portion of beef and noodles and placing it on nine meal trays. During an interview on 1/05/2026 at11:37 a.m., [NAME] 16 indicated the nine resident meal trays she had served, and the staff had placed on the meal cart, were ready for meal service and no additional items were needed for service. She indicated she had served 4 ounces of beef and noodles on each of the meal trays. During an observation and interview with the Dietary Manager on 1/5/2026 at 11:38 a.m., the Dietary Manager reviewed the menu and portion size guide and indicated all resident should have been served an 8-ounce (1 cup) serving of beef and noodles. She indicated an additional 4 ounces of beef and noodles would need to be added to the nine already prepared resident meal plates before they would be served. During an interview on 1/9/26 at 2:00 p.m., the ADON indicated all 81 residents ate meals prepared by the facility kitchen. A current, 9/19/25, facility menu for the 1/5/26 lunch meal, provided by the Administrator on 1/5/26 at 11:46 a.m., indicated the portion size for beef and noodles was 8 ounces for every diet type served. A current, 6/7/21, policy titled, Dietary, provided by the Administrator on 1/6/26 at 1:02 p.m., indicated Every effort will be made to serve the items on the posted menu . 1.3-20(i)

Based on interview and record review, the facility failed to provide a surety bond which covered the total amount of resident funds. This deficient practice had the potential to impact 71 of 71 residents who had their funds managed by the facility. Findings include:During a review of resident funds with the Business Office Manager (BOM) on 1/9/26 at 9:27 a.m., she provided a list of residents for whom the facility managed funds, the last months bank statement, and a copy of the surety bond.The 1/8/26, Trial Balance report provided by the BOM on 11/9/26 at 9:27 a.m., indicated the facility managed resident funds for 71 residents.The current, 1/4/22, Surety Bond policy, provided by the BOM on 1/9/26 at 9:27 a.m., indicated the resident funds account was ensured for $80,000.00 (eighty thousand dollars). The Business Checking With Interest Account Statement, for the period of 11/29/25 to 12/31/25, provided by the BOM on 1/9/26 at 9:27 a.m., indicated the ledger balance on three occasions exceeded $80,000.00 dollars as follows:12/3/25 $116,270.81 ($36,270.81 an excess of $80,000)12/4/25 $115,892.81 ($35,892.81 an excess of $80,000)12/5/25 $115,657.81 ($35,657.81 an excess of $80,000) The Business Checking With Interest Account Statement, for the period of 11/01/25 to 11/28/25, provided by the Administrator on 1/9/26 at 2:00 p.m., indicated the ledger balance on two occasions exceeded $80,000.00 dollars as follows:11/3/25 $80,669.58 (an excess of $669.58)11/4/25 $80,327.58 (an excess of $327.58) The Business Checking With Interest Account Statement, for the period of 10/01/25 to 10/31/25, provided by the Administrator on 1/9/26 at 2:00 p.m., indicated the ledger balance on fourteen occasions exceeded $80,000.00 dollars as follows:10/1/25 $158,187.52 (an excess of $78,187.52)10/2/25 $156,009.52 (an excess of $76,009.52)10/3/25 $195,004.68 (an excess of $115,004.68)10/6/25 $155,466.19 (an excess of $75,466.19)10/7/25 $156,048.19 (an excess of $76,048.19)10/8/25 $163,281.37 (an excess of $83,281.37)10/9/25 $156,235.37 (an excess of $76,235.37)10/10/25 $155,432.11 (an excess of $75,432.11)10/14/25 $152,695.14 (an excess of $72,695.14)10/15/25 $152,056.54 (an excess of $72,056.54)10/16/25 $151,873.54 (an excess of $71,873.54)10/17/25 $152,052.54 (an excess of $72,052.54)10/20/25 $151,580.00 (an excess of $71,580.00)10/21/25 $151,474.00 (an excess of $71,474.00) During an interview on 1/9/26 at 2:30 p.m., the Administrator indicated the facility had balances in excess of $80,000.00. The corporation did review balances each business day. The corporation believed since the removal of resident liability took the balance down below $80,000.00, they didn't need to ensure the excess amounts. A policy and procedure was requested on 1/9/26 a 2:30 p.m., but was not provided by the time of exit on 1/9/26.3.1-6(i)

Based on observation and interview, the facility failed to ensure medications were stored securely without loose pills for 2 of 4 medication carts reviewed. (100 East and 100 West) Findings include:During an observation of the 100 East medication cart with QMA 10 on 1/7/26 at 8:43 a.m., one yellow ovate pill inscribed with H125 and one white ovate pill inscribed with L612 were found in the 3rd drawer on the right-hand side. A white circle pill with no visible marking was found in the 2nd drawer on the right-hand side. During a concurrent interview QMA 10 indicated no loose pills should have been found in the medication cart. During an observation of the 100 [NAME] medication cart with LPN 9 on 1/8/26 at 8:23 a.m., one white circular pill inscribed with RE22 was found in the 2nd drawer on the right-hand side. Two yellow circular pills inscribed with L20 were found in the 3rd drawer on the right-hand side. During an interview at the time of the observation, LPN 9 indicated no loose pills should have been found in the medication cart. Any loose pills found should have been discarded appropriately. During an interview on 1/9/26 at 10:33 a.m., the ADON indicated no loose pills should have been found in the medication carts. Unit managers performed weekly storage audits on the medication carts. The pharmacy also came to the facility monthly and performed medication cart audits. During an interview on 1/9/26 at 4:27 p.m., the ADON indicated no medication cart audits had been performed since 12/18/25. A current facility policy revised October 2024, titled Medication Labeling and Storage, provided by the ADON on 1/9/26 at 11:27 a.m. indicated the following: .1. Medication and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. W. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 3.1-25(m)

Based on interview and record review, the facility failed to provide notice of a roommate change to the resident prior to receiving a new roommate for 1 of 3 residents reviewed for resident rights. (Resident B) Finding includes:Resident B's clinical record was reviewed on 1/7/26 at 2:51 p.m. Diagnoses included opioid abuse, alcohol use, chronic pain, major depressive disorder, and anxiety disorder. A 10/9/25, significant change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident required set-up assistance for all activities of daily living. During an interview on 1/7/26 at 3:18 p.m., Resident B indicated he did not currently have a roommate. In December, approximately 3 weeks ago, the facility brought a new roommate into his room. Resident B had been out of his room and did not know he had a roommate until he returned to his room, and the new roommate was already there. The clinical record lacked a notification to Resident B prior to receiving a roommate (on 12/17/25). During an interview, on 1/8/26 at 3:42 p.m., the ADON indicated the Social Service Director (SSD) was the staff member who gave notices to the residents when they were going to receive a roommate. On 1/8/26 at 3:46 p.m., the SSD indicated Resident B received a new roommate on 12/17/25 due to a previous roommate incompatibility. This corporation did not have a room transfer notification form. She notified residents verbally when they were going to get a roommate and typically made a progress note indicating when she notified them. The SSD indicated she was unable to provide evidence to indicate Resident B was notified prior to receiving a roommate on 12/17/25. Resident B would be able to accurately indicate whether he had been notified or not. On 1/9/26 at 2:06 p.m., the Corporate Nurse Consultant indicated residents had the right to be notified prior to receiving a new roommate. A current document, undated, titled Your Rights and Protections as a Nursing Home Resident, provided by the ADON on 1/9/26 at 9:04 a.m., indicated the following: .As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the right to be informed. At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. You have the right too: . Get Proper Privacy, Property, and Living Arrangements: . The nursing home has to notify you before your room or your roommate is changed and should take your preferences into account. This citation relates to Intake 2697288. 3.1-3(v)(2)

Based on record review and interview, the facility failed to provide the appropriate Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) for residents discharged from Medicare A skilled services for 2 of 2 residents reviewed for Beneficiary Notifications. (Residents 3 and 43) Findings include:On 1/8/26 at 1:31 p.m., the facility's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Forms were reviewed, and indicated the following:1.Resident 3 was admitted to Medicare A Skilled Services on 12/3/25. The last covered day was 12/17/25. The SNF Notice of Medicare Non-Coverage (NONMC) was reviewed with the resident and/or resident representative and signed on 12/15/25. The SNF NONMC indicated the resident was discharged from therapy. The clinical record lacked a SNF ABN. 2. Resident 43 was admitted to Medicare A Skilled Services on 11/27/25. The last covered day was 12/5/25. The SNF NONMC was reviewed with the resident and/or resident representatives and signed on 12/3/25. The SNF NONMC indicated the resident discharged from therapy. The clinical record lacked a SNF ABN. During an interview, on 1/8/26 at 1:45 p.m., the BOM and Therapy Director indicated they completed the SNF NONMC paperwork together after a resident was discharged from Medicare A services. They thought the SNF NONMC and the SNF ABN form was the same form. Residents 3 and 43 only received the SNF NONMC form. They indicated they had not received training on the proper use of the SNF ABN form. During an interview, on 1/8/25 at 4:25 p.m., the Corporate Nurse Consultant indicated the facility did not have a policy related to Beneficiary Notifications. According to the Centers for Medicare and Medicaid Services (CMS) website page Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN), located at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/snfabn-instructionsv508_clean-111517.docx, retrieved on 1/12/25 at 12:47 p.m., indicated .These abbreviated instructions explain when and how the SNF ABN must be delivered .Medicare requires Skilled Nursing Facilities (SNFs) to issue the SNF ABN to Original Medicare . patients prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. The SNF ABN provides information to the patient so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility . 3.1-4(f)(3)

Based on record review and interview, the facility failed to prevent resident-to-resident abuse from a resident known to have a history of a resident-to-resident altercation and anger outbursts (Resident B) to a cognitively dependent resident for 1 of 3 residents reviewed for abuse. (Resident 76) Findings include:Resident B's clinical record was reviewed on 1/7/26 at 2:51 p.m. Diagnoses included opioid abuse, alcohol use with intoxication, chronic pain, major depressive disorder, and anxiety disorder. A 10/9/25, significant change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident required set-up assistance for all activities of daily living. He used a motorized wheelchair for mobility. The resident's preferences indicated it was very important to take care of his personal belongings and somewhat important to have a place to keep his personal belongings safe. Resident B's current care plans indicated the following: An 8/7/25, care plan for risk of psychosocial distress related to anxiety disorder and major depressive disorder. The resident had the potential to exhibit the following behaviors: increased agitation, verbal outbursts, cursing/profane language, self-isolation, and negative statements. Interventions included: request assistance from administration, DON, or Social Services in answering questions or concerns the resident might have that cannot be easily addressed by nursing staff (8/7/25). A 9/11/25, care plan related to mental illness related to generalized anxiety disorder, major depressive disorder, alcohol use, alcohol withdrawal, and opioid abuse without specialized services was in place. Interventions included supportive counseling from nursing facility staff (9/11/25) and a behaviorally based treatment plan (9/11/25). A 12/19/25, care plan for the potential to be physically aggressive related to anger. Resident B was physically aggressive toward another resident by pushing. Interventions included administer medications as ordered (12/19/25), psychiatric consultation as indicated (12/19/25), intervene before agitation escalates when the resident becomes agitated, guide away from the source of distress, and engage calmy in conversation (12/19/25). The care plan lacked a care plan related to a previous resident-to-resident physical altercation with resident specific interventions to prevent further altercations. Progress notes indicated the following: On 8/26/25, Resident B had a behavior during smoking break. The resident indicated he let his anger get the best of him. On 10/21/25, Resident B was in a resident-to-resident physical altercation and hit another resident. On 12/18/25 at 9:03 p.m., the progress note indicated Resident B was in an incident involving a male roommate. Resident B stated his roommate was going through his closet. Resident B was observed by staff holding his roommate pushed up against the closet door. The roommate did not deny being held against the door. Resident B was visibly upset and demanded to have his roommate removed. Resident B did not deny he pushed his roommate against the closet door. Resident B indicated neither of the residents used their hands to hit each other. The DON and Administration were notified of the incident. On 12/18/25 at 9:37 p.m., no new skin issues were identified for Resident B. During an interview on 1/7/26 at 3:18 p.m., Resident B indicated he did not currently have a roommate. In December, approximately 3 weeks ago, the facility brought a new roommate, Resident 76, into his room without prior notification. Within the first 24 hours of getting his new roommate, he returned to his room when he went to smoke break and found Resident 76 going through his closet. He yelled at Resident 76 and told him to get out of his closet and Resident 76 came at Resident B swinging, so Resident B pushed Resident 76's hands away. Resident B then went out to the hallway and yelled for someone to get Resident 76 out of Resident B's room. Staff came into the room and the residents were still arguing. Resident B did not see Resident 76 take any items from Resident B's closet. Resident B indicated staff interviewed him about what happened, though he was uncertain which staff it was. Resident 76 was immediately removed from his room by staff and moved to a different room. Resident B wished he was introduced to his roommate and informed what he might expect from his new roommate. The clinical record lacked indication of a notification to Resident B prior to receiving a new roommate on 12/17/25. On 1/7/25 at 4:25 p.m., the Corporate Nurse Consultant was requested to provide a copy of the facility's entire investigation of the resident-to-resident altercation between Resident B and Resident 76 that occurred in the evening on 12/18/25. During an interview on 1/7/25 at 4:27 p.m., the DON indicated in the evening on 12/18/25, she was not at the facility, but she was notified by an unknown CNA of an altercation between Resident B and Resident 76. The unidentified CNA told her the nurse was busy and asked the unidentified CNA to contact the DON. The unidentified CNA had gone into the resident's room after an altercation and found Resident 76 near the closet and Resident B had pushed Resident 76 back and was yelling at Resident 76. There were three CNAs of unknown identity that the DON spoke with individually over the phone the night of 12/18/25 and obtained detailed descriptions from each of them. The DON could not remember the names of the staff or the times she spoke with them and she could not find the times in her telephone history. The details were included in the facility investigation provided by the Corporate Nurse Consultant per the DON. The aides had recently bathed Resident 76 prior to Resident B returning to his room, when the incident occurred. Resident 76 had a shirt in his hand and Resident B ripped the shirt out of Resident 76's hand and was yelling at Resident 76. The residents were immediately separated prior to the DON receiving notification. Resident 76 had been known to have some Sundower's Syndrome symptoms (increased confusion) in the evenings. As a result, Resident 76 was excited by what had occurred and had to be convinced to leave the room. He was taken to the common area and then moved to a new room. Resident B was upset and screamed at all the staff. Later, she spoke with LPN 11 and ensured both residents had skin assessments completed on them. The DON reported the information to the interim Administrator, at the time, and the Corporate Nurse Consultant. The interim Administrator reported it to the Indiana Department of Health. She also spoke with the SSD who interviewed both residents on 12/19/25. The DON handled the investigation with the soft file in the absence of the Administrator. A review of the facility investigation, provided on 1/7/26 at 4:31 p.m., contained the following information: A recapitulation of the facility reported incident that occurred on 12/18/25 at 8:20 p.m. with a brief description of the resident-to-resident altercation between Resident B and Resident 76. Resident B accused roommate (Resident 76) of stealing clothing from his closet. Resident B was yelling for Resident 76 to get out of his closet. Type of Injury: None. Immediate Action Taken: The staff immediately separated the residents. The nurse completed skin assessments and neither of the residents had any issues identified. Resident 76 was moved to another room. The Administrator and DON were notified immediately of the incident. The provider and responsible parties were notified. Preventative Measures Taken: An investigation was initiated. The nurse completed skin assessment. Residents were separated. Resident 76 was moved to another room and residents were placed on 15-minute safety checks. Both residents were to be seen by psychiatry on their next visit. Psychosocial monitoring will be provided, and the care plan will be reviewed and updated as needed. Resident interviews from Resident B and Resident 76. Three resident interviews regarding safety on a different unit.Fifteen-minute safety checks for Resident B and Resident 76.An Inservice Attendance dated 12/24/25 regarding Resident-to-Resident Abuse Reporting for 112 staff members.The file lacked any staff interviews or the incident report for the altercation. On 1/8/25 at 10:50 a.m., LPN 11 indicated he was on duty on 12/18/25 in the evening at approximately 8:15 p.m. when there was an altercation between Resident B and Resident 76. Resident 76 recently became a new roommate with Resident B. LPN 11 was uncertain of the reason for Resident 76's room change. That evening CNA 25 reported to LPN 11 that Resident B and Resident 76 were in an altercation. Resident B had shoved Resident 76 into the closet door. At that time, Resident B came down the hallway and told LPN 11 he saw Resident 76 going through Resident B's closet. Resident B told LPN 11 he pushed Resident 76. He asked CNA 25 to make a call for him to the DON while he handled assessments/safety. Fifteen-minute checks were initiated on both involved residents. No injuries were found with assessments. Both residents were kept separated and Resident 76 was moved to a different room. The CNAs were instructed to complete written statements and put them under the DON's door. He observed the CNAs writing their statements before he left at the end of his shift. LPN 11 indicated he did not see where the CNAs put their written statements. Resident B calmed down prior to the end of LPN 11's shift and Resident 76 was calm and resting in bed in his new room at the end of his shift. During a telephone interview on 1/8/26 at 2:52 p.m., CNA 26 indicated she did not see the altercation between Resident B and Resident 76 on 12/18/25, but she was working on that Unit nearby when it occurred and heard the commotion. The other aides that were present on the Unit were CNA 25 and CNA 27. CNA 26 was a few doors down the hallway when she heard yellowing coming from Resident B and Resident 76's room. When she got to the room, she saw Resident B in his motorized wheelchair yelling at Resident 76 not to get in his things anymore. Resident 76 was sitting on the side of his bed and appeared shocked. Some of Resident B's personal items were on the floor in the room. CNA 26 did not see any physical contact between the two residents. She did not know what happened before she got to the room because a lot of threatening language from Resident B directed towards Resident 76 was heard. Resident B was immediately directed out of the room to separate the residents. It was reported to the Administration staff, but since they have had a lot of Administration change in the last few weeks, she was uncertain which Administration staff she spoke with. During an interview on 1/8/26 at 3:33 p.m., LPN 11 indicated Resident B's yelling and pinning Resident 76 up against the closet door on 12/18/25 was aggressive and abusive. Resident 76's clinical record was reviewed on 1/8/26 at 4:56 p.m. Diagnoses included severe vascular dementia with other behavioral disturbances, depression, and anxiety disorder. The resident census indicated Resident 76 was moved to the 300 Unit on 12/17/25, then moved again on 12/17/25 into Resident B's room. On 12/18/25, Resident 76 was moved back to the 300 Unit. All the rooms were located on the secure behavioral unit. Current physician orders for Resident 76 included the following: donepezil hydrochloride (severe vascular dementia with other behavioral disturbance) 10 mg - give one tablet by mouth at bedtime (11/13/25), and memantine hydrochloride (dementia) 5 mg - give one tablet by mouth two times a day (1/2/26). An 11/20/25, admission Minimum Data Set (MDS) assessment indicated Resident 76 was moderately cognitively impaired. No behaviors were exhibited during the assessment period. The resident did not use any mobility devices. He required supervision for all activities of daily living to include transfers and walking 10 feet. Resident 76's current care plans indicated the following: An 11/15/25, care plan for impaired cognitive function related to vascular dementia, benign intracranial hypertension, cerebrovascular disease and mild neurocognitive disorder. Interventions included: cue, reorient and supervise as needed (11/15/25), Keep the resident's routine consistent in order to decrease confusion (11/15/25). A 12/17/25, psychosocial well-being problem related to the fire alarms alarming, sudden room change related to pipe bursting (12/17/25) Interventions included: When conflict arises, remove the resident to a calm safe environment and allow the resident to vent/share feelings (12/17/25). A 12/18/25, potential to be verbally aggressive (yelling) problem, related to ineffective coping skills (12/18/25). Interventions included: Assess the resident's coping skills and support system (12/18/25), Give the resident as many choices as possible about care and activities (12/18/25), and complete a Psychiatric consultation as indicated (12/18/25). A 12/19/25, psychosocial well-being problem related to resident-to-resident altercation. The resident will be observed for any signs and symptoms of mental anguish. Interventions included: When conflict arises, remove the resident to a calm safe environment and allow to vent/share feelings and refer to psychiatric services as needed/ordered. Resident 76's progress notes indicated the following: On 12/18/25 at 11:46 a.m., indicated Resident 76 was verbally aggressive (yelling). Staff were able to intervene. The facility will proceed with the care plan. On 12/18/25 at 8:58 p.m., Resident 76 was up in his room when his roommate confronted him about going through his closet. Resident 76 denied going through his roommate's closet and stated that his roommate pushed him into the door/wall near the bathroom. Resident 76 denied placing hands on his roommate. Resident 76 denied being hit by his roommate. The DON and Administrator were notified. Instructions were received to maintain separation of the residents and move Resident 76 to another room for prevention of further incidents. On 12/18/25 at 9:41 p.m., Resident 76's skin lacked any new impairments. Review of Resident 76's fifteen-minute checks indicated the following:On 12/18/25-15-minute checks started at 2:00 p.m. On 12/18/25- 15-minute checks stopped at 6:15 p.m.On 12/18/25- 15-minute checks started at 8:15 p.m. On 12/22/25- 15-minute checks stopped at 6:15 a.m. Interviews indicated the following: On 1/8/26 at 3:46 p.m., the SSD indicated Resident B received a new roommate on 12/17/25 due to a previous roommate incompatibility for Resident 76 earlier in the day on 12/17/25. During a telephone interview on 1/8/26 at 11:17 p.m., CNA 25 indicated she was at the facility on 12/18/25 around approximately 8:15 p.m. when the resident-to-resident altercation happened between Resident B and Resident 76. She was at the nurses' station when [NAME] returned from smoking and went by the nurse station towards his room. When he got to their room, she heard a commotion. She believed it was the noise of the closet door banging and Resident B yelling at Resident 76. She could not determine what exactly was said, but it was in a yelling tone. CNA 25 was the first one to the room and she observed Resident B had Resident 76 pushed up against the closet door. They were immediately separated, then she accompanied Resident 76 down the hallway to the common area. Resident 76 explained that Resident B did not hit him but pushed him into the closet door. The other two aides CNA 26 and CNA 27 remained with Resident B. On 12/18/25 at approximately 8:30 p.m., CNA 25 called the DON to report the altercation between the residents. The DON gave instructions to keep the residents separated, move Resident 76 to another room, and for CNA 25, CNA 26, and CNA 27 to complete written statements for the DON. During a telephone interview on 1/8/25 at 11:41 p.m., LPN 28 indicated she was the nurse on shift for the 200 Unit following LPN 11 the night of 12/18/25 after the altercation occurred between Resident B and Resident 76. Both residents continued 15-minute checks during her shift with no concerns. Resident 76 had been moved to a new room on the 300 Unit. Resident 76 had been placed on the 300 Unit the night of the flood, but when she returned on her next shift he had been moved to Resident B's room and LPN 28 was uncertain why he was placed in the room with Resident B. She was familiar with both residents. Resident B was known to have a history of resident-to-resident altercations in the past as well as having anger outbursts. LPN 28 felt Resident B was not an appropriate roommate candidate for a resident who was not cognitively intact and had increased confusion in the evenings. On 1/9/25 at 2:06 p.m., the Corporate Nurse Consultant indicated pushing another resident into a door and yelling threating language was abusive during the altercation on 12/18/25. The facility needed to carefully consider their choices on room placement during room changes going forward. On 1/9/25 at 3:17 p.m., the DON was requested to provide Resident B and Resident 76's historical care plans as they were not previously included. Additional information was not provided. A current policy, revised 5/2024, titled Abuse Prevention, Identification, and Reporting Policy, provided by the Corporate Nurse Consultant on 1/7/26 at 4:31 p.m., indicated the following: Policy: To establish guidelines for preventing, identifying, and reporting abuse. All residents have the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of the facility to follow the Indiana Department of Health Policies and Procedures for Long-term Care Abuse and Incident Reporting.These procedures shall include. protection of residents and prevention. 3.1-27(a)(1)3.1-27(b)

Based on record review, interview, and observation, the facility failed to ensure residents were free of chemical restraints related to the use of antipsychotic medications without diagnoses for use, identified targeted behaviors for use, documented displayed targeted behaviors, and/or a care plan to address targeted behaviors for 3 of 5 residents reviewed for unnecessary medications. (Residents 5, 6 and 7) Findings include:1. Resident 5's clinical record was reviewed on [DATE] at 2:47 p.m. Diagnoses included Alzheimer's Disease, generalized anxiety, insomnia, and depression. The resident was admitted to the facility on [DATE]. Current physician orders included Risperdal (an antipsychotic medication) 0.5 mg- take one tablet two (2) times daily for agitation. This order originated [DATE] upon admission. A [DATE], admission, Minimum Data Set (MDS) assessment indicated the resident was rarely able to be understood or understand. The staff were interviewed regarding the resident's cognitive status. The resident was identified as having both long- and short-term memory issues. The resident displayed signs of hallucinations during the assessment period. The resident displayed physical and verbal aggression during care. They received antipsychotic medication during the assessment period. A [DATE], Psychiatry Initial Consult indicated the resident had a history ofAlzheimer's disease, anxiety, depression, cognitive communication deficit, and insomnia. Staff report the patient has been irritable and angry at times. The resident received Risperdal 0.5 MG (Risperidone)- Give 1 tablet by mouth two times a day for agitationThe start date was [DATE]. The patient was NOT currently a danger to self/others and had no delusions. The resident had impaired short- and long-term memory.A [DATE] at10:10 a.m., Late Entry Behavior Note indicated a QMA observed the resident smacking a CNA in the face when she was guiding him to recliner to take a nap. The record indicated the resident did not initiate the interaction, but resisted staff interaction to direct him.The record contained documentation of five maladaptive behaviors during the 3-month period. Three of the five behaviors were caused by staff to resident interaction and the resident resisting care. The record did not indicate the resident was agitated or aggressive prior to the staff-initiated interaction. Two of the five events were resident to resident arguments in which the resident could be and was directed from the event. No events show the resident was too agitated to be redirected or initiated an act of aggression without provocation. There were no documented behaviors which indicated the resident displaying psychotic behaviors.A [DATE] at 12:56 a.m., Behavior Note indicated the CNA on duty reported that this resident and another male resident were loudly arguing with one another in lounge earlier in shift. Both residents stated profanities at one another (shut the F up, B***h) and most of the argument was non-nonsensical and could not be understood; body language however was angry with arms waving and pacing in the room. Staff was able to redirect both residents. A [DATE] at 7:08 a.m., Late Entry Behavior Note indicated the QMA observed the resident hitting the writer on three different occasions this shift. Once when attempting to shave him, another while doing personal care, and the last time was when the resident had a book that was nasty and sticky and staff was trying to take the book to clean it. The clinical record indicated the resident responded to the staff's attempt to initiate care and when they attempted to remove an unclean item he was using. The resident did not initiate the interactions.A [DATE] at 8:04 p.m., Behavior Note indicated the resident was attempting to take a cup from another resident and when another resident tried to stop him, he swatted at her and she swatted back at him. Staff took the resident to his room.A [DATE] pharmacy Psychotropic & Sedative/Hypnotic Utilization By Resident report indicated: Resident 5 received Risperidone (Risperdal) 0.5 md two times daily to treat agitation. A medical diagnosis was not listed. A [DATE] at 5 :07 p.m., Behavior Note indicated as staff attempted to take a yellow floor sign from the resident's hands and redirect him, he became somewhat agitated and swung the sign, almost hitting another staff person who was nearby. (No contact was made.) Eventually, staff was able to redirect him to the dining room in preparation for evening meal. This behavior occurred when staff approached and interacted with the resident. He resisted the interaction as a refusal of care or redirection. He didn't initiate the interaction.The resident's clinical record lacked an identified targeted behavior for the use of the antipsychotic medication Risperdal. The record lacked a diagnosis for the use of an antipsychotic medication. The clinical record lacked a care plan related to targeted behaviors being treated by the antipsychotic medication Risperdal. During an observation on [DATE] at 11:08 a.m., Resident 5 was walking in the hallway. He had his head down. He was calm.During an observation on [DATE] at 12:05 p.m., Resident 5 was seated calmly at the dining room table awaiting meal service. During an observation on [DATE] at 9: 48 a.m., Resident 5 was ambulating by the nursing station. He walked to the doors, turned around, and walked the other direction. During an interview on [DATE] at 2:42 p.m., C.N.A. 13 indicated Resident 5 did get startled and then want people to stay away from him. He had, at times, resisted care. He never initiated aggression, he just got upset when staff startled him or attempted to provide care he didn't desire. He was usually calm. He walked around without true direction and could go into areas he did not belong in.During an interview on [DATE] at 2:46 p.m., QMA 14 indicated Resident 5 could We be resistant to care and become agitated. He did not approach staff in an agitated state care agitated him. She had never witnessed him display any hallucinations or delusions. During an interview on [DATE] at 2:51 p.m., RN 15 indicated Resident 5 wandered and was at times resistant to care or redirection. He did not display signs of delusions or hallucinations. He did not approach others with aggression or agitation. He became upset with care or redirection. 2. Resident 6's clinical record was reviewed on [DATE] at 10:35 a.m. Current diagnoses included major depressive disorder, bipolar disorder, and anxiety. Current physician's orders included Risperdal 1 mg- take 1 tablet 2 times a day for bipolar disorder. This order originated [DATE]. A [DATE], quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired, had not displayed any signs of hallucinations or delusions during the assessment period, nor did they display any maladaptive behaviors during the assessment period. They received antipsychotic and antidepressant medications during the assessment period. A [DATE], pharmacy Psychotropic & Sedative/Hypnotic Utilization By Resident report indicated Resident 6 received Risperdal 1 mg two times daily. She had received the medication since [DATE] and had never had a gradual dose reduction. A [DATE], Psychiatry Progress note indicated: The resident had trouble falling asleep and staying asleep at night. The resident frequently slept during the day. The resident denied depression, anxiety, self-harm, suicidal thoughts or suicidal ideations. The resident described her mood as stable and denied feelings of hopelessness or helplessness. She was alert, calm, and cooperative throughout the evaluation. Nursing staff report no further concerns at this time.The resident clinical record lacked an identified targeted behavior for the use of the antipsychotic medication Risperdal. The clinical record lacked documented delusions, hallucinations, or maladaptive behaviors which negatively impacted quality of life or quality of care during the past three-month period. The clinical record lacked a care plan related to targeted behaviors being treated by antipsychotic medication. During an observation on [DATE] at 11:07 a.m., Resident 6 was in her room. She was calm.During an observation on [DATE] at 12:15 p.m., the resident was calmly eating lunch.During an observation on [DATE] at 9:48 a.m., the resident was watching TV in her room. She was alert and well groomed. She was calm and conversational. During an interview on [DATE] at 2:42 p.m., CNA 13 indicated Resident 6 was forgetful and had once had a false belief that her son had died. She did not display behaviors that negatively impacted her quality of life or quality of care.During an interview on [DATE] at 2:46 p.m., QMA 14 indicated she had not observed the resident display any hallucination or delusions. The resident did at times mother other residents.During an interview on [DATE] at 2:51 p.m., RN 15 indicated the resident did not display delusions or hallucinations. She, at times, would try to give directions to other residents. 3. Resident 7's clinical record was reviewed on [DATE] at 3:20 p.m. Current diagnoses included delusional disorder, adjustment disorder, unspecified intellectual disability, anxiety, and dementia. Current physician orders included Seroquel (antipsychotic medication) 75 mg- 1 tablet daily at bedtime. This order originated [DATE]. A [DATE], modified annual, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, had not displayed any signs of hallucinations or delusions during the assessment period, nor did they display any maladaptive behaviors during the assessment period. They received antipsychotic and antianxiety medications during the assessment. The resident had one behavior note in the past three-month period (October to survey date) as follows: A [DATE] at 1 :56 p.m., Behavior Note-Late Entry indicated the nurse noticed the resident crying in the hallway. When approached, the resident stated Them guys are going in all the rooms and I'm scared. Can I move? The nurse attempted to console the resident and she appeared to calm down easily. The nurse assured the resident that she was safe and assisted her to find a seat near someone she was familiar with. She no longer appeared to be upset. A [DATE] pharmacy Psychotropic & Sedative/Hypnotic Utilization By Resident report indicated: Resident 7 received Seroquel 75 mg at bedtime. She had received the medication since [DATE] and had never had a gradual dose reduction of this medication.A [DATE] Psychiatry Progress Note indicated the resident denied depression, anxiety, hallucinations, delusions, suicidal ideation, homicidal ideation, or thoughts of self-harm. Nursing staff reported full medication compliance with no observed or reported side effects. The patient appeared alert, calm, and cooperative throughout the evaluation.The resident's clinical record lacked an identified targeted behavior for the use of the antipsychotic medication Seroquel. The clinical record lacked documented delusions, hallucinations, or maladaptive behaviors which negatively impacted quality of life or quality of care during the past three-month period. The clinical record lacked a care plan related to targeted behaviors being treated by the antipsychotic medication. During an observation on [DATE] at 11:06 a.m., Resident 7 was walking in the hallway and spoke to staff, visitors, and peers.During an observation on [DATE] at 12:05 p.m., the resident was calmly eating lunch. During an observation on [DATE] at 9:44 a.m., the resident was attending an activity. She was calm and smiling. During an interview on [DATE] at 2:42 p.m., CNA 13 indicated Resident 7 was tearful at times and stated she was lonely.During an interview on [DATE] at 2:46 p.m., QMA 14 indicated she had never witnessed the resident having delusions or hallucinations. The resident did cry at times.During an interview on [DATE] at 2:51 p.m., RN 15 indicated the resident used to cry, but didn't cry much anymore. She had never witnessed the resident having delusions or hallucinations. During an interview on [DATE] at 10:40 a.m., the Corporate RN Consultant and Social Services Director indicated they would look for resident specific targeted behaviors for the use of antipsychotic medications for Residents 5, 6, and 7. They would also look for care plans related to said behaviors and any incidents of these behaviors being documented in the clinical record.During an interview on [DATE] at 3:20 p.m., the Administrator indicated Residents 5, 6, and 7 did not have documented targeted behavioral symptoms for the use of antipsychotic medications, nor did they have documented behaviors related to the use of antipsychotic medications, nor did they have care plans that addressed targeted behavioral symptoms being treated by an antipsychotic medication. A current, 2/2025, facility policy titled, Psychotropic Medication Use, provided by the ADON on [DATE] at 9:05 a.m., indicated Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.Anti-psychotics;.Determining adequate indications for use;. the medication os determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.A resident's behavioral symptoms present a danger to the resident or others; a resident is exhibiting indications of distress that are significant to the resident. 3.1-3(w)3.1-26(k)(1)(o)

Based on record review and interview, the facility failed to complete a thorough investigation of and maintain record of the investigation of resident-to-resident abuse for 2 of 3 residents reviewed for abuse. (Resident B and Resident 76)Findings include:Review of a facility investigation for a resident-to-resident altercation, on 12/18/25, between Resident B and Resident 76, and provided by the facility on 1/7/26 at 4:31 p.m., indicated it included the following information: A recapitulation of a facility reported incident that occurred on 12/18/25 at 8:20 p.m. with a brief description of the resident-to-resident altercation. Resident B accused roommate (Resident 76) of stealing clothing from his closet. Resident B was yelling for Resident 76 to get out of his closet. Type of Injury: None. Immediate Action Taken: The staff immediately separated the residents. The nurse completed skin assessments and neither of the residents had any issues identified. Resident 76 was moved to another room. The Administrator and DON were notified immediately of the incident. The provider and responsible parties were notified. Preventative Measures Taken: An investigation was initiated. The nurse completed skin assessment. Residents were separated. Resident 76 was moved to another room and both residents were placed on 15-minute safety checks. Both residents were to be seen by psychiatry on their next visit. Psychosocial monitoring will be provided, and plan of care will be reviewed and updated as needed. Interviews from Resident B and Resident 76. Three resident interviews regarding safety on a different unit. Fifteen-minute safety checks for Resident B and Resident 76. An Inservice Attendance dated 12/24/25 regarding Resident-to-Resident Abuse Reporting for 112 staff members. The facility investigation lacked the following information: any staff statements or interviews, the facility incident report and interviews with interviewable residents who were located near the room where the altercation occurred. During an interview, on 1/8/25 at 12:56 p.m., the Corporate Nurse Consultant indicated she noticed the facility investigation lacked any staff statements in the investigation after a copy was provided of the facility investigation. A second request was made to provide the entire facility investigation for the altercation on 12/18/25 between Resident B and Resident 76. On 1/8/25 at 2:21 p.m., the Corporate Nurse Consultant indicated she was unable to find the statements in the facility investigation, even though she had seen them before. During a telephone interview on 1/8/26 at 2:52 p.m., CNA 26 indicated she did not see the altercation between Resident B and Resident 76 on 12/18/25, but she was working on that Unit nearby when it occurred and heard the commotion. The other aides who were present on the Unit were CNA 25 and CNA 27. She indicated CNA 25, CNA 26 and CNA 27 wrote out individual statements and gave them to the nurse that night, but she was uncertain of which nurse they were given to. During an interview on 1/8/26 at 3:33 p.m., LPN 11 indicated he had not previously written a statement for the facility investigation of the altercation between Resident B and Resident 76 until today, when an unidentified Administration staff member came to him and asked him to write a statement. During a telephone interview on 1/8/26 at 11:17 p.m., CNA 25 indicated she was at the facility on 12/18/25 around approximately 8:15 p.m. when the resident-to-resident altercation occurred between Resident B and Resident 76. On 12/18/25 at approximately 8:30 p.m., CNA 25 called the DON and reported the altercation between the residents. The DON gave instructions to keep the residents separated, move Resident 76 to another room, and for CNA 25, CNA 26, and CNA 27 to complete written statements for the DON. On 12/18/25, CNA 25, CNA 26, and CNA 27 wrote out their statements and together placed their individual statements in the DON's mailbox with CNA 25's statement on top. No one had asked her to provide any further information.During a telephone interview on 1/8/25 at 11:41 p.m., LPN 28 indicated she was the nurse on shift for the 200 Unit following LPN 11 the night of 12/18/25 after the altercation occurred between Resident B and Resident 76. No one had provided any written statements to her regarding the altercation that happened prior to her shift. On 1/9/25 at 2:06 p.m., the Corporate Nurse Consultant indicated the following information was required to ensure a complete and thorough investigation of resident-to -resident abuse: face sheets and orders of residents involved, pertinent progress notes, an incident report of the event, skin assessments as needed, staff and resident witness statements of anyone who witnessed it audibly or visually, statement from the nurse on duty, resident interviews with interviewable residents that were in close proximity to where the incident occurred and ensuring their safety. All of the residents interviewed, outside of the involved residents, were on another Unit on the other side of the building. The investigation did not include interviewable resident near the room the altercation took place in. The entire facility investigation should have been kept securely and ready for review upon request. A current policy, revised 5/2024, titled Abuse Prevention, Identification, and Reporting Policy, provided by the Corporate Nurse Consultant on 1/7/26 at 4:31 p.m., indicated the following: Policy: To establish guidelines for preventing, identifying, and reporting abuse. These procedures shall include.investigation.without fear of recrimination or intimidation. COMPREHENSIVE CARE FACILITIES.(d) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. Cross Reference F600. 3.1-28(d)

Based on interview and record review, the facility failed to provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 3 of 4 residents reviewed for hospitalizations. (Residents 2, 56, and 43) Findings include: 1.Resident 2's record was reviewed on 1/7/26 at 10:11 a.m. Medical diagnoses included generalized anxiety disorder, epilepsy (seizure disorder), substance abuse, and complex regional pain syndrome. A quarterly minimum data set (MDS) completed on 12/2/25 indicated the resident was cognitively intact. A 9/8/25 nurse's note indicated the resident was sent to the emergency room following mental status changes and urinary tract infection (UTI) symptoms. The clinical record lacked indication the resident and/or representative was provided a notice of transfer/discharge form and bed hold policy. A 10/22/25 nurse's note indicated the resident was transferred to the emergency room after being found unresponsive. The clinical record lacked indication the resident and/or representative was provided notice of transfer/discharge form and bed hold policy. Review of notice of transfer/discharge forms and bed hold policy, dated 9/8/25 and 10/21/25, provided by the ADON on 1/8/26 at 2:48 p.m., indicated the resident was discharged to the hospital. The documents did not indicate the resident or resident representative were provided the notices. The forms lacked documentation of who received the paperwork. 2.Resident 56's clinical record was reviewed on 1/7/26 at 10/28 a.m. Diagnoses included COPD, neurofibromatosis (a genetic disorder causing tumors), and epilepsy. A 12/30/25, significant change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 12/19/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 12/19/25, progress note indicated the resident was sent to the emergency room for a displaced nephrostomy tube (to drain urine from the kidney). A 9/9/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 9/9/25, progress note in the resident's family requested they be sent to the emergency room for altered mental status. The clinical record lacked indication the resident and/or representative was provided a copy of the transfer/discharge form and bed hold policy. Review of notice of transfer/discharge forms and bed hold policy, dated 12/19/25 and 9/9/25, provided by the ADON on 1/8/26 at 2:48 p.m., indicated the resident was discharged to the hospital. The documents did not indicate the resident or resident representative were provided the notices. The forms lacked documentation of who received the paperwork. 3. Resident 43's clinical record was reviewed on 1/6/26 at 2:44 p.m. Diagnoses included unspecified anemia, benign prostratic hyperplasia with lower urinary tract symptoms, and borderline personality disorder. A 12/4/25, quarterly MDS assessment indicated the resident was cognitively intact. A 12/12/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 12/12/25, progress note indicated the resident was difficult to awaken and had an altered mental status. The Nurse Practitioner (NP) provided an order to send the resident to the emergency room. The resident's medication list, bed hold, face sheet and code status were sent with the Emergency Medical Technicians (EMTs). The clinical record lacked indication the resident and/or representative was provided a copy of the transfer/discharge form and bed hold policy. A 11/17/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 11/17/25, eInteract observation note indicated the resident was discharged to the hospital with bloody drainage in his catheter bag. A 11/17/25, progress note indicated the resident had increased temperature and was clammy. The NP provided an order to send the resident to the emergency room. Paperwork sent and message left for the residents friend. The clinical record lacked indication the resident and/or representative was provided a copy of the transfer/discharge form and bed hold policy. Review of the notice of transfer/discharge forms and bed hold policy, dated 12/12/25 and 11/17/25, provided by the ADON on 1/8/26 at 2:48 p.m., indicated the resident was discharged to the hospital. The documents did not indicate the resident or resident representative were provided the notices. The forms lacked documentation of who received the paperwork. During a 1/8/26 interview LPN 7 indicated residents were sent out with a face sheet, medication order summary, bed hold policy, and a change of condition form. The forms were given to emergency medical services (EMS). During a 1/8/26 interview QMA 10 indicated a face sheet, medication orders, advance directive, and bed hold policy were given to EMS whenever a resident was sent out. During a 1/9/26 interview, the ADON indicated residents were sent out with a face sheet, order summary, and a physician's order for scope of treatment (POST) form indicating their code status. The documents sent were then documented in a progress note. A current undated facility policy, titled, Your Right and Protections as a Nursing Home Resident, provided by the ADON on 1/9/26 indicated the following: .The nursing home has to safely and orderly transfer or discharge you and give you proper notice of bed-hold and/or readmission requirements.

Based on record review and interview, the facility failed to ensure timely completion of a required Level 2 Preadmission Screening and Resident Review (PASARR) assessment for 1 of 2 residents reviewed for PASARR. (Resident 8 ) Findings include:Resident 8's clinical record was reviewed on 1/7/26 at 10:16 a.m. She admitted to the facility on [DATE] and remained in the facility. Diagnoses included delusional disorders, generalized anxiety disorder, unspecified psychosis not due to a substance of known physiological condition, unspecified visual disturbances, and unspecified vascular dementia. A 3/13/25, Notice of Level I PASARR Screen Outcome, indicated the referral for a Level 2 onsite for suspected mental health disability. The clinical record lacked documentation of a completed Notice of Level 2 PASSAR Screen Outcome. During an interview, on 1/8/26 at 10:30 a.m., the SSD indicated she started her position with the facility in November. She utilized the Maximus Assessment Pro online system, and the Level 2 for this resident was cancelled. She indicated the resident's Level Of Care determination letter indicated an approval for indefinite long term nursing care. The SSD indicated she thought the Level Of Care determination meant that the Level 1 and/or Level 2 was not needed. She spoke with a customer service representative specializing in these assessments and was informed that the facility should have either completed the onsite Level 2 or restarted with a new Level 1 screening process. During an interview, on 1/8/26 at 4:25 p.m., the Corporate Nurse Consultant indicated the facility did not have a policy related to PASSAR screenings. According to the Medicaid website page, Preadmission Screening and Resident Review, found at https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review, retrieved on 1/12/25 at 12:57 p.m., indicated the following: .Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities: 1. Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID) .In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care .3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to invite the resident representative to the resident's care plan meeting, offering them the opportunity to engage/contribute to the resident's admission care plan meeting for 1 of 2 residents reviewed for care planning. (Resident 11) Finding includes:During an interview on 1/6/26 at 10:55 a.m., Resident 11 indicated he had not been included in a care plan meeting. He had an appointed guardian and did not know if the guardian was invited to the care plan meeting. Resident 11's clinical record was reviewed on 1/6/26 at 2:44 p.m. Diagnoses included schizophrenia, atrial fibrillation, pulmonary embolism with acute cor pulmonale, Parkinson's Disease with dyskinesia, encephalopathy, and rhabdomyolysis. An 11/19/25, admission Minimum Data Set assessment indicated the resident was cognitively intact. Active diagnoses included schizophrenia, Parkinson's Disease, atrial fibrillation, pulmonary embolism, respiratory failure, and heart failure. Guardianship papers were in place for the resident. The clinical record lacked documentation of an invitation for the resident's representative to attend the care plan meeting. A 12/4/25, admission Care Conference was held and indicated the resident was in attendance. The resident representative was not in attendance. The care plan conference document indicated to add a reason if the resident representative was not in attendance. A reason was not provided. During a telephone interview on 1/9/26 at 11:07 a.m., the Resident 11's Representative indicated the resident had been at the facility since November following a long hospitalization. The representative had not been invited by the facility to attend any care plan meetings for the resident. On 1/9/26 at 11:21 a.m., the Social Services Director indicated they typically placed resident representative invitations to care plan meetings in a binder or in the progress notes of the resident's electronic record. She indicated she could not provide any information regarding an invitation for Resident 11's representative to attend his care plan meeting. On 1/9/26 at 2:00 p.m., the Corporate Nurse Consultant indicated residents should have their rights honored and both the resident and their representative should have been invited to participate in the resident's care plan meetings. They followed the State and Federal guidelines regarding resident rights. A current facility policy, dated March 2022, titled Care Plans, Comprehensive Person-Centered, provided by the ADON on 1/9/26 at 2:10 p.m., indicated the following: .Policy interpretation and implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. 3.1-35(c)(2)(C)

Based on observation, record review, and interview, the facility failed to provide necessary services for a resident related to humidification for high-flow rate oxygen for 1 of 2 residents reviewed for oxygen administration. (Resident 56) Findings include:During an obseration and interview, on 1/5/26 at 12:02 p.m., Resident 56 was lying in a specialty bed against the wall. The resident was wearing a nasal cannula for oxygen administration. She indicated she wore oxygen consistently and her oxygen setting was 5 liters per minute. The oxygen concentrator was positioned at bedside and was set for 5 liters per minute. The water humidification container was empty. The inside of the container was covered in a white film. The container was dated 11/25 in black marker. On 1/6/26 at 10:32 a.m., Resident 56 was lying in bed wearing a nasal cannula. The oxygen concentrator was positioned at bedside and was set for 4 liters per minute. The water humidification container was empty. The inside of the container was covered in a white film. The container was dated 11/25 in black marker. On 1/7/26 at 9:46 a.m., Resident 56 was lying in bed wearing a nasal cannula. The oxygen concentrator was positioned at bedside and was set for 5 liters per minute. The water humidification container was empty. The inside of the container was covered in a white film. The container was dated 11/25 in black marker. The resident indicated the staff didn't check the oxygen concentrator set up often. On 1/8/26 at 11:07 a.m., Resident 56 was lying in bed wearing a nasal cannula. The oxygen concentrator was positioned at bedside and was set for 5 liters per minute. The water humidification container was empty. The inside of the container was covered in a white film. The container was dated 11/25 in black marker. Resident 56's clinical record was reviewed on 1/7/26 at 10/28 a.m. Diagnoses included COPD, neurofibromatosis (a genetic disorder causing tumors), and epilepsy. Current orders included continuous oxygen 3-5 liters per minute via nasal cannula for COPD (6/10/25) and change and date oxygen and tubing, water bottle, and bag every Sunday on night shift (9/18/25). A 6/11/25, respiratory care plan indicated the resident had COPD related to smoking and had chronic respiratory failure. Interventions included to elevated the head of the bed to prevent shortness of breath while lying (6/11/25), give aerosol and bronchodilators as ordered (6/11/25), and oxygen per physician orders (6/11/25). A 12/30/25, significant change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required oxygen therapy. During an observation and interview, on 1/8/26 at 11:24 a.m., LPN 9 indicated when a resident on her assignment had oxygen orders, she would check their oxygen saturation level (SpO2) and the liters per minute level on the concentrator. The staff should check the oxygen level and water container level on each shift. LPN 9 confirmed Resident 56's water container was completely empty and dated 11/25 in black marker. Any resident utilizing oxygen without water might experience dry sinuses which could lead to nose bleeds and discomfort. During an interview, on 1/9/26 at 1:35 p.m., the Corporate Nurse Consultant indicated the expectation for nursing staff was to assess each resident utilizing oxygen on each shift. The assessment should include confirming the oxygen equipment was set appropriately and working properly. The staff should assess the water level as well. A resident receiving oxygen without proper water humidification might experience dried mucus membranes which could lead to irritation, discomfort, and even nose bleeds. She indicated there was no additional facility policy related to oxygen administration to provide. A current facility policy, revised 11/14, titled, Medication Orders, provided by the DON on 1/8/26 at 2:48 p.m., indicated the following: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . 3. Oxygen Orders- When recording orders for oxygen, specify the rate of flow, level and rationale .3.1-47(a)(6)

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies regarding Drug Labeling/Storage. Finding includes:Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey, completed on 12/17/24, indicated the facility had deficiencies related to unlabeled medications.During an interview, on 1/9/26 at 4:03 p.m. the ADON indicated the Quality Assessment and Assurance (QAA) committee met each morning and monthly to discuss current facility concerns. The current nursing topics were falls. The ADON indicated the facility had weekly audits in place for medication carts. The current QAPI binder for the facility was reviewed on 1/9/26 at 4:26 p.m. The binder lacked any audits for repeat deficiencies.Repeat concerns regarding medication storage/labeling were cited during the 1/5/26 survey as follows:Based on observation and interview, the facility failed to store medications according to professional standards relating to unlabeled medications for 2 of 4 medication carts reviewed. (100 East and 100 West)A current undated untitled facility policy, provided by the ADON on 1/9/26 at 4:47 p.m. indicated the following: .The committee will identify opportunities for improvement, address break down in systems or processes, develop and implement an improvement or corrective action plan and continuously monitor effectiveness of interventions at each monthly meeting.4. Department Directors will implement Action Plan that identifies trends and Root Cause Analysis and guide systematic changes for their areas needing improvement. These should be reviewed and presented during the QAPI meeting. 5. Each department will complete their monthly Quality Assurance Tools per calendar or as indicated per direction of the Executive Director and calculation of percentages will be completed to evaluate areas of opportunity.Cross reference F761.3.1-52(b)(2)

Based on observation, record review, and interview, the facility failed to implement the appropriate infection control precautions related to transmission based precautions per the Centers for Disease Control and Prevention (CDC) guidelines for 1 of 2 residents reviewed for infection control. (Resident 43)Findings include:During an observation, on 1/5/26 at 10:10 a.m., Resident 43's door was closed, and an orange Enhanced Barrier Precautions (EBP) sign was present. There was a yellow organizer hanging from the door with Personal Protective Equipment (PPE) available.During an interview, at the time of the observation, LPN 9 indicated the resident had an infection in his urine and he had a catheter. She wore a gown, gloves, and mask for all care. She thought the resident's infection was Candida Auris (C. Auris) and the isolation sign on the door was not the correct isolation precaution.During an observation and interview, on 1/7/25 at 9:59 a.m., Laundry Aide 20 delivered clean laundry to Resident 43's room. Laundry Aide 20 was wearing a surgical face mask. He knocked on the resident's door and entered the room without donning additional PPE. The orange EBP precaution sign and yellow organizer with PPE were hanging on the door. Laundry Aide 20 completed hand hygiene as he exited the room. He indicated he always wore a surgical face mask for personal preference. The precaution signs on some of the residents' doors were to let the nursing staff know which residents were sick and when to wear PPE.Resident 43's clinical record was reviewed on 1/6/26 at 2:44 p.m. Diagnoses included unspecified anemia, benign prostatic hyperplasia with lower urinary tract symptoms, and borderline personality disorder. A 12/4/25, quarterly, MDS assessment indicated the resident was cognitively intact and required total staff assistance for all Activities of Daily Living (ADLs), except for eating meals.Current order included strict isolation - Contact Isolation. All therapies, meals, and activities to be provided in room every shift- every shift (12/30/25).A current isolation care plan, dated 12/30/25, indicated the resident was in isolation for observation for signs and symptoms of Candidozyma Auris (fungi). Interventions included droplet yellow isolation (12/30/25), administer medications per physicians orders (12/30/25), all services in room such as meals, activities, and all ADL care (12/30/25, and notify physician as needed for complications that may be cause by C. Auris such as fever, chills, sweats, low blood pressure, high heart rate, pain, and wound infections (12/30/25).A 1/6/26, progress note indicated the resident continued on isolation per protocol for C. Auris.A 1/5/26, progress note indicated the resident continued on isolation per protocol for C. Auris.A 1/2/26, progress note indicated the resident was in good spirits, resting in bed, and continues on isolation.A 12/30/2025, progress note indicated the resident remains in Strict Isolation/Candida Auris- Contact Isolation. All therapies, meals, and activities to be provided in room every shift.During an interview, on 1/7/26, at 2:51 p.m., CNA 21 indicated when she provided care for Resident 43, she donned a gown, gloves, and a face mask. The resident was in isolation for an infection and the EBP sign and PPE hanging on his door let the staff know what to put on before entering his room. She would ask a nurse to find out the specific infection the resident had.On 1/8/26 at 11:02 a.m., Housekeeper 22 indicated when a room on her assignment has the orange EBP sign, like Resident 43's room, she wears the PPE hanging on the door to clean his room. The signs let staff know which residents have infections and what protective gear to wear. The housekeeping manager lets the housekeeping staff know which rooms require special cleaning chemicals like bleach.On 1/8/26 at 11:12 a.m., CNA 23 indicated she was unsure of the difference between EBP and Contact Isolation. The orange EBP sign on Resident 43's door means she needs to wear gowns, gloves, and a face mask because the resident has an infection. She would ask the nurses if she needed to know which infection the resident had.On 1/8/25 at 11:14 a.m., LPN 9 indicated the EBP sign means the staff needs to wear a gown, gloves, and mask for all resident care. Contact isolation means the staff have to wear all PPE to have contact with the residents. She indicated the sign on Resident 43's door was wrong and should be a Contact isolation sign since he had a C. Auris infection. Residents with C. Auris infections need to remain in their rooms at all times to prevent the spread of infection. The residents get meals, activities, and therapy in their room.On 1/8/25 at 11:45 a.m., LPN 7 indicated the EBP sign means a resident is in isolation and the staff need to wear a gown and gloves before entering the resident room to complete patient care. She thought this was the same as Contact isolation. The isolation precautions help protect the residents and staff from the spread of any infection.During a telephone interview, on 1/8/26 at 3:31 p.m., the Infection Preventionist indicated Resident 43 was in EBP's due to his catheter. She was contacted by the health department and told of the diagnoses after his arrival. He had returned to the facility with an infection, C. Auris. He was in EBP, and she thought this was appropriate. She was contacted by the Corporate Nurse Consultant today and advised the CDC recommendations require residents with C. Auris be in Contact Isolation and not just EBP.During an interview, on 1/9/26 at 11:00 a.m., the Housekeeping Manager indicated the laundry and housekeeping staff are required to follow any precautions or isolation signs on the resident's door. The EBP and Contact isolation signs require wearing a gown and gloves before providing patient care. The resident's laundry was to be placed in special yellow or red plastic bags for transportation to the laundry room.On 1/9/26 at 1:40 p.m., the Corporate Nurse Consultant indicated the facility was unaware of testing Resident 43 received prior to returning to the facility. A few days after the resident's return, the Infection Preventionist was contacted by the health department and told that the resident had tested positive for C. Auris. The swab testing sites were in the groin and axilla areas. The resident had been in EBP due to his catheter and should have been moved into Contact Isolation per the CDC guidelines. EBP requires staff to don a gown and gloves before providing patient care for someone with a catheter, wound, or PICC line. Contact Isolation required staff to don a gown, gloves, and mask prior to entering the resident's room to prevent spread of infection from the resident and the resident's environment. Resident 43 required Contact Isolation Precautions instead of the EBP.A current facility policy, revised 9/22, titled, Isolation- Categories of Transmission-Based Precautions, provided by the ADON on 1/9/25 at 9:04 a.m., indicated the following: . 1. Contact precautions are implemented for resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . 3. Contact precautions are used for residents infected or colonized with MDRO's in the following situations: a. When a resident has wounds, secretions, or excrections that are unable to be covered of contained .7. Staff and visitors wear gloves (clean, non-sterile) when entering the room .8. Staff and visitors wear a disposible gown upon entering the room .3.1-18(a)(2)

Based on record review and interview, the facility failed to offer and administer appropriate Pneumococcal vaccinations per the Center for Disease and Control (CDC) guidance for 3 of 5 residents reviewed for infection control. (Residents 56, 61, and 8)Findings include: 1. Resident 56's clinical record was reviewed on 1/7/26 at 11:41 a.m. Diagnoses included COPD (chronic obstructive pulmonary disease), neurofibromatosis (a genetic disorder causing tumors), and epilepsy. A 12/30/25, significant change, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. Review of the resident's vaccinations included the following:The resident had a historical administration of an unspecified pneumococcal vaccination on 12/21/23, prior to admission to the facility.The clinical record lacked a Pneumococcal Vaccine Consent or Declination Form.The clinical record lacked any offerings of the Pneumococcal vaccine. 2. Resident 61's clinical record was reviewed on 1/7/26 at 1:46 p.m. Diagnoses included schizophrenia, type 2 diabetes mellitus, and hypertension.A 10/28/25, quarterly, MDS assessment indicated the resident was cognitively intact. Review of the resident's vaccinations included the following:The resident had a historical administration of an unspecified pneumococcal vaccination on 5/19/16, prior to admission to the facility. The resident also had a historical administration of an unspecified pneumococcal vaccination on 12/21/23, after admission to the facility. The clinical record lacked a Pneumococcal Vaccine Consent or Declination Form.The clinical record lacked any additional offerings of the Pneumococcal vaccine since 2023.3. Resident 8's clinical record was reviewed on 1/8/26 at 9:42 a.m. Diagnoses included generalized anxiety disorder, unspecified cerebral infarction (stroke), and delusional disorders.A 12/19/25, quarterly MDS assessment indicated the resident was cognitively intact. Review of the resident's vaccinations included the following:The clinical record lacked any historical pneumococcal vaccination information.The clinical record lacked a Pneumococcal Vaccine Consent or Declination Form.The clinical record lacked any offerings of the Pneumococcal vaccine. During a telephone interview, on 1/9/26 at 11:27 a.m., the Infection Preventionist indicated she reviewed new admission paperwork to find as much vaccination information as possible. The admission paperwork did not always contain vaccination information. The resident and resident representatives weren't always familiar with their vaccination history. Any information found was documented under the immunizations tab in the electronic medical record. The facility utilized consent and declination forms for all vaccinations and these documents were uploaded to the resident's chart. She took over this task earlier this year and reviewed vaccinations at the start of the current flu season. Residents 56, 61, and 8 should have been offered the appropriate Pneumococcal vaccination per the Centers of Disease Control and Prevention (CDC) guidelines. A current facility policy, revised 8/25, titled, Pneumococcal Vaccine, provided by the ADON on 1/8/26 at 2:49 p.m., indicated the following: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series . 4. Provision of information, education, and the VIS are documented in the resident's medical record .3.1-18(b)(5)

Based on interview and record review, the facility failed to prevent resident to resident sexual abuse of two cognitively impaired residents (Residents F and B) by Resident C, who was cognitively intact with intellectual disabilities, for 2 of 5 residents reviewed for abuse. Resident F was found sitting on Resident C's bed while Resident C had his pants down while seated on the bed, exposing his erect penis and Resident F was observed with saliva on his face and mouth. Later the same day, Resident B was found in his bed with feces and blood on his shirt and incontinence brief, with his brief disheveled, and Resident C was in the same room performing self-gratification of his rectum, with feces and blood on his hands. Resident B indicated to police that Resident C had manipulated his own penis while doing the same to Resident B's penis.The immediate jeopardy began on December 6, 2025 when the facility failed to prevent resident sexual abuse of two cognitively impaired residents by another resident who was cognitively intact with intellectual disabilities. The Administrator and Director of Nursing (DON) were present when informed of the immediate jeopardy on December 11, 2025. The immediate jeopardy was removed on December 11, 2025, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:Review of a 12/7/25 anonymous complaint intake provided to the Indiana Department of Health indicated, over the previous weekend, a dependent resident on the secured behavioral unit was found with feces and blood on him following an incident involving another resident. The anonymous complainant alleged the facility refused to act to protect the residents from further abuse.A police Case Report Summary, dated 12/9/25, indicated on 12/7/25 at 6:16 p.m., a police officer interviewed Resident B with family present. The officer used techniques to allow Resident B to communicate. Resident B had responded he had been touched in a way that was wrong by his former roommate, Resident C. Resident B indicated Resident C had touched his penis. Resident C had grabbed Resident B's penis. Resident C had moved his hand on Resident B's penis in a manner to simulate sex. Resident B indicated Resident C had touched his own penis while touching Resident B's penis. He believed Resident C had ejaculated as he did so. Resident B had told Resident C to stop. He had tried to yell. He had tried to push Resident C away. A facility self-reported incident, submitted to the Indiana Department of Heath on 12/7/25 at 8:09 p.m., indicated an incident had occurred on 12/7/25 at 6:03 p.m. Resident B had been touched by his former roommate, Resident C. There were no injuries. The information provided had no indication there was an allegation of sexual abuse. During an interview on 12/10/25 at 1:51 p.m., Resident B's representative indicated they received an anonymous phone call from someone identifying themselves as a staff member. The representative indicated the facility itself had not been forthcoming with information. Based on the anonymous staff phone call, he believed there was a facility attempt to coverup a sexual assault. During an interview on 12/10/25 at 3:04 p.m., CNA 3 indicated he had been working on Saturday 12/6/25. Early that day, he was walking down the hallway and saw Resident C in his room with his pants down. His penis was exposed and erect. Resident F was in Resident C's room. Resident F was seated on the end of Resident C's bed. Resident F had clear liquid, which may have been saliva, all over his mouth. The CNA believed the two residents may have been involved in a mutual sexual activity. He did not want to embarrass them. He asked why Resident C's pants were down and the resident indicated he was going to the bathroom. He asked why Resident F was in the room. Both residents indicated Resident F had come to the room for soda pop. The CNA thought both Resident C and F were intellectually challenged. He immediately informed QMA 5 of what he had witnessed. He had believed QMA 5 was a nurse because she was passing medications that day. To his knowledge, QMA 5 informed the on-call nurse manager. The CNA believed it had been reported to management because Resident F room was moved to a different hallway later that same day. After lunch the same day, CNA 7 had come to get him. She asked him to come see Resident B and Resident C because she had a concern. When he entered the room, Resident B had handprints of fecal matter on the lower part of his shirt. His incontinence brief was messed up and looked like it had been unfastened and an attempt had been made to refasten it. Resident B was not known to pull at his brief. There was fecal matter on the outside of the brief as well. Resident C was also in the room. Resident B had fecal matter all over his hands. The CNAs separated the residents and ensured they were safe. QMA 5 was informed of what they had observed. CNA 3 thought QMA 5 was a nurse. Later that day, Resident B was moved to a new room. CNA 3 later gave a written statement about Residents B and C. During an interview on 12/10/25 at 3:16 p.m., QMA 5 indicated CNA 3 came to get her on Saturday 12/6/25, around 3:15 p.m., to look at Resident B. The QMA went to Resident B's room. The resident was covered with fecal matter and blood and fingerprints down his side. His brief was ripped at the corner and he had pants on. He had blood and fecal matter from the shoulder all the way to the bottom of his T-shirt. She thought this was on the resident's left side. His roommate, Resident C, had fecal matter and blood on his hands, which was common for him. The QMA asked Resident C if he was touching Resident B. At first, he said no. She asked Resident B if Resident C touched him, and Resident B said yes. The QMA asked Resident B if Resident C had made him uncomfortable. He said yes. The QMA asked if Resident C had touched him in an inappropriate or sexual manner, and he did not answer. The QMA told the CNAs to get Resident B cleaned up and get him out of the room. She called LPN 15, who was the on-call nurse manager, who also instructed the CNAs to help get Resident C into the shower, since he was also covered in fecal matter and blood. Resident C was already on 15-minute checks due to a tendency to insert objects into his rectum. The QMA also personally increased the time intervals for checking on him that day. The QMA also talked to either the DON or ADON about this concern. The QMA was told to move Resident B and put him on 15-minute checks. There had also been another incident that morning between Resident C, involving Resident F. CNA 3 had witnessed Resident C with his pants down and Resident F sitting on the foot of the bed. Resident F had slobber all over his face. When the QMA asked the residents what had occurred, they both became very defensive. She had never seen Resident F in Resident C's room before. Resident F was a new resident. The QMA asked Resident C why his pants were down and he said he had to go to the bathroom. When the QMA called to report this, she believed she had spoken to the on-call nurse manager, but there were a lot of people involved, so she was not sure. The QMA was instructed to move Resident F to a new room on a separate hall in order to encourage both residents to stay apart.During an interview on 12/11/25 at 12:03 p.m., RN 16 indicated she had been working in the facility on 12/6/25 but was on a different unit from where Residents B and C resided. QMA 5 came to talk to her after the event with Residents B and C. RN 16 told QMA 5 to call leadership immediately. Resident B was totally dependent, so there was no reason for him to have fecal matter on his sheet. She was concerned that Resident C could have inappropriately touched Resident B. There was a possibility that it was sexual in nature, which is why she told the QMA to notify the on-call manager. During an interview on 12/11/25 at 12:38 p.m., the Social Services Director (SSD) indicated she had not been in the facility on the weekend of 12/6/25 and 12/7/25. The event with Residents B and C happened on a Saturday. The SSD was told to complete the paperwork and notification for room changes. She received a phone call from the Administrator and was told that Resident F needed to move closer to the nurse's station due to wandering into another resident's room. The SSD notified Resident F's guardian of the room change on 12/6/25. The SSD placed the call from her home. She indicated she was not told about Resident B and Resident C having a potential sexual interaction. She was called later in the day on 12/6/25 by the Administrator and told there needed to be another room change because Resident C had put fecal matter on his roommate, Resident B. She called Resident B's family about the room change and left a message. The family called her back on Sunday 12/7/25. The family said the room move was fine and then started saying that staff had already called and told them what happened. They told her to call the director because the family had called the police. During an interview on 12/11/25 at 2:42 p.m., CNA 12 indicated, on 12/6/25, they saw CNA 3, CNA 7, and QMA 5 and followed them to see what was going on, as they were all walking pretty fast. CNA 12 was later present in the shower room with CNA 7, QMA 5, and Resident C. CNA 12 didn't know what happened. The CNA observed fecal matter fingerprints all over Resident B, when he was lying on his side and the side part of his brief was undone. The CNA observed Resident B as he was prepared for a shower by CNA 7 stayed with him and gave him the shower. Resident C regularly played with his rectum and would be doing it in his bathroom with the door open. The CNA had never seen the resident put objects in his rectum but would find items in his room covered in feces. During an interview on 12/11/25 at 3:17 p.m., LPN 15 indicated she was the on-call nurse on 12/6/25. She was first made aware of a concern on Saturday, 12/6/25 at 3:00 p.m., when QMA 5 told her that they had found Resident B with fecal matter on him that came from Resident C. She had not been called about any incident between Resident F and Resident C. She was not aware that Resident F had been moved to a different room. QMA 5 did not say anything about Resident B's brief, and did not tell her where the fecal matter had been found on Resident B. She did not say anything about it being sexual in nature. QMA 5 only asked about moving Resident B. LPN 15 called the ADON and told her QMA 5 had called and wanted to move Resident B. She said she already told them they could make the move. LPN 15 called back and told QMA 5 it was okay to move Resident B and they needed to implement 15-minute checks and to complete full body assessments for the residents. LPN 15 did not ever talk to the nurse on duty at the facility. On weekends, the nurse on duty was in charge of facility oversite, and LPN 15 assumed QMA 5 was the nurse. During an interview on 12/11/25 at 3:27 p.m., LPN 13 indicated she first became aware of a concern when called at home by the ADON on Sunday (12/7/25) at 7:59 p.m. The ADON told her of the allegation of the event on 12/6/25 and that the police were in the facility. The ADON wanted LPN 13 to come into the facility for support, as there was an allegation of inappropriate touching. Resident C touched Resident B. The family had been told something else and called the police. The ADON asked LPN 13 to do skin assessments of all residents who were unable to speak. Resident B was one of the residents selected. LPN 13 spoke to the family prior to and during the assessment and encouraged them to send Resident B to the hospital. LPN 13 did not see anything of concern but just wanted to be safe. After the assessment, Resident B's family indicated there was no need for him to go to the hospital. There were no signs or symptoms of injury to the anus or genital areas. The family told them Resident B had been masturbated by Resident C. LPN 13 did interview Resident C. When he was asked if he had touched anyone in the building inappropriately, he said no. Resident C saw the police and thought he was going to jail. During an interview on 12/11/25 at 3:00 p.m., Unit Manager (LPN) 17 indicated she was not working on Saturday 12/6/25 and did not get any calls until Sunday when the ADON called her between 6:00 and 6:30 p.m. regarding an allegation of inappropriate touching regarding Resident C and Resident B. Allegedly, Resident C had physically touched Resident B. Resident B's family was going to the facility and calling the police because they were told Resident B was sexually assaulted. When she arrived, the family was outside talking to a police officer. The Unit Manager called the Administrator and told her Resident B's family and the police were there. The Administrator said she was aware that there was an allegation of sexual abuse. After the police interview, the Unit Manager provided incontinence care and completed a physical assessment. She looked at Resident B's genitals and rectum and did not see anything abnormal. After the assessment, Resident B's family said they had received a call saying the resident had been sexually assaulted and they wanted Resident C sent out for safety reasons. The family felt all evidence had been washed away because staff had given the residents a shower. The family said they believed Resident C had masturbated Resident B. The police officer later told the Unit Manager there was an allegation of sexual abuse and other interviews may be conducted later. The police officer asked what the facility was going to do to ensure Resident B's and other residents' safety from Resident C. The Unit Manager assured him Resident C would have one on one supervision.During an interview on 12/11/25 at 11:22 a.m., with both the Administrator and the DON, the Administrator indicated she was first contacted regarding Resident B and C on 12/6/25 at 3:36 p.m. She verified the time by looking at her phone. She had spoken to ADON, who was concerned Resident B had fecal matter on his shirt and brief. The DON indicated she had been notified on 12/6/25 at 3:11 p.m., by QMA 5 and was told either Resident B or Resident C needed to be moved. Resident B was covered in poop from Resident C touching him and his pants were messed with. The DON was concerned because QMA 5 had already contacted her that day without following chain of command. She indicated there was fecal matter and blood spots on Resident B. The DON asked if she had contacted the on-call nurse first. The DON asked the QMA to get the residents cleaned up and have a skin assessment completed. The Administrator indicated she had not been notified about any concern about possible sexual misconduct until Sunday (12/7/25) at 5:58 p.m. On Sunday, 12/7/25 at 6:03 p.m., the Administrator called to talk to Resident B's family after she was informed by the Social Services Director that they were upset. The family told her he had received two anonymous phone calls, who said that Resident B had been sexually assaulted. The Administrator notified corporate of the allegation. She was aware the family had called the police and that police were coming to investigate. The DON indicated she was notified by QMA 5 before the Administrator had been notified. The DON asked QMA 5 if Resident B's brief was intact. She thought the staffs' concern was related to infection prevention. She assumed the fecal matter was from Resident C because he had a habit of anal manipulation. Both the Administrator and DON indicated they had not been informed of any concern of a sexual nature regarding Resident C and Resident F. The DON indicated she had been involved with the decision to move Resident F to another room. She believed the concern was related to Resident F wandering. She thought Resident C was in his bathroom when Resident F wandered into his room. The DON did not ask why the nurses present in the facility on 12/6/25 were not involved, assessing or sharing information, when multiple calls were made that day. She did not ask to speak with a nurse, she simply redirected QMA 5 to follow chain of command. The Administrator indicated they asked staff to report allegations of abuse to their supervisors, who would then report said concerns to management.Review of staff statements, provided by the facility on 12/10/25 following Entrance Conference, indicated the following:Review of the DON's undated, written timeline statement indicated the following: On 12/6/25 at 6:43 a.m., QMA 5 called to discuss a sick employee. She was given education about staff illness. At 3:11 p.m., QMA 5 called about Resident C touching Resident B and Resident B having poop on him. Resident B's pants were messed with. There was a need for a possible room move. The DON told QMA 5 she needed to reach out to the on-call nurse. The DON then called back immediately and asked for more details. She was told Resident B had poop and bloody handprints on his shirt and outside of his brief. Resident B was not wearing pants, just briefs. He had a spot on the outside of his brief and his brief was intact. The DON said to shower both residents and ensure a skin assessment was completed. On 12/7/25 at 7:11p.m., the ADON and asked if she knew about an incident on 12/6/25 involving Residents C and B. The DON screen shot a message and said they would meet on Monday. On 12/8/25, the facility began an investigation and received staff statements.A 12/6/25, written statement by QMA 5, indicated on that afternoon, at around 3 p.m., the CNA had come to her because Resident B had poop and blood all over him and his brief was messed with. His roommate, Resident C, had blood and poop on his hands. Both residents were separated and showered. She called and talked to management about moving one of them. When Resident B was questioned, he was reluctant to answer but was glad to move to a new room. Resident C indicated he did not realize he wasn't allowed to touch Resident B.A 12/6/25 written statement by SSA 8 indicated she had spoken to Resident B after the alleged event. She interviewed Resident B, who indicated Resident C had made him uncomfortable. He shook his head to indicate no when asked if he was a victim of sexual assault. SSA 8 asked staff if they saw Resident C touch Resident B and they said they had not.A 12/7/25, written statement by LPN 17 indicated, after obtaining permission, she and LPN 13 completed a skin assessment for Resident B on 12/7/25. No rectal or genital trauma was observed. The family was concerned because the resident was showered and evidence was washed away. The resident had not been penetrated, and his penis had been pulled out and masturbated. The family had called the police and filed a report in response to an anonymous call from a staff member. The police officer came to the building and interviewed Resident B. The officer asked what the facility was going to do to keep Resident B safe from Resident C. She informed the police officer that the facility had Resident C under one-to-one observation to ensure everyone's safety. A 12/7/25 written statement from LPN 13 indicated the family and Resident B were asked permission to complete a skin assessment for Resident B. Both indicated a skin assessment could be completed. The skin assessment was completed and no injuries were noted. During the skin assessment the family stated they felt the Administrator was attempting a cover-up conspiracy. The family member stated they had been informed the resident had not been penetrated. He had been masturbated by Resident C. LPN 13 later asked Resident C if he had touched Resident B in an unwanted way. He indicated he had not. He stated he had touched him with dirty hands. A 12/7/25 written statement by CNA 6 indicated she worked night shift on 12/6/25. Through the night shift, Resident B didn't talk much and seemed to be in a daze. In the morning (12/7/25 at 5:00 a.m.) Resident B had a bowel movement, which was loose and out of the ordinary for him. He was also crying while having the bowel movement. CNA 6 could not be reached for an interview during the survey dates. A 12/8/25 written statement by QMA 11 indicated she had interviewed Resident B after the event on 12/6/25. Resident B said Resident C had made him feel uncomfortable and he was happy with his room move. Resident B indicated no when asked if he had been touched inappropriately. A 12/8/25 written statement by the ADON indicated on Saturday, 12/6/25 at 3:16 p.m., she received a group text from QMA 5 requesting a member of management to call. She called QMA 5 and learned Resident B had been found with fecal matter on the outside of his brief and on his T-shirt. The ADON asked if the brief was intact and was told it was. She told QMA 5 to ensure both residents were showered, to continue 15-minute checks, and one resident would be relocated soon. She would return the call with information about the room move. At 3:40, she received a call from LPN 15, who had also spoken to QMA 5. It was decided Resident B would be relocated and the SSD would notify family regarding the room move. A 12/8/25 written statement signed by the SSD indicated Resident B's family spoke to her on the phone. The family stated the facility was trying to hide something and staff had told them what happened. They wanted to know everything that happened to Resident B. The family indicated they knew what had happened and called the police. The representative stated they had the police coming there so the SSD needed to call the facility director to meet the family there with the police. They then hung up the phone. An undated written statement by CNA 3 indicated CNA 7 had gotten him and asked him to come to Resident B and C's room, because she had a concern. Resident B had feces stains on his T-shirt that looked like fingerprints. His brief looked like it had been messed with. Resident C had feces on his hands. They removed Resident B from the room. An undated, typed, written statement by CNA 7 indicated the CNA went to the hallway to check on Resident C, who was on 15-minute checks. When she got to the room, she found Resident C on all fours on the floor in his restroom inserting his hand into his rectum. His rectum was bleeding. She had Resident C get up and go to the shower room to shower. After taking him to the shower room, she went to the room to check on his roommate. The roommate, Resident B, had a ripped brief. He had both blood and feces on his shirt. She got CNA 3 to come see what was happening. CNA 7 made sure QMA 5 knew the concern. Resident B was moved to another room during the shift. CNA 7 could not be reached for an interview during the survey dates. An undated written statement by CNA12 indicated she and three other staff (QMA 5, CNA 7, and CNA 3) went to the shower with Resident C after an alleged incident. They interviewed the resident and asked him questions. The resident was defensive and denied anything happened. An undated written statement by LPN 15 indicated on 12/6/25 at 3:30 p.m., QMA 5 notified her that Resident C had touched Resident B with fecal matter on his hands. QMA 5 said Resident B was moved to another room. Both residents were showered due to having fecal matter all over them. At 3:40 p.m., she spoke to the ADON about a good room move. The ADON was already aware of the issue. At 3:45 p.m., she spoke with QMA 5 and asked her to have all staff write statements and put them under the Administrator's door. The SSD would notify families about the room moves. On 12/7/25 at 6:30 p.m., she received a message from the ADON and was requested to come into the facility and do skin assessments. An allegation was made regarding yesterday's event, and police were in the building. At 7:00 p.m., she was interviewed by police officers and informed them she had never been informed the event from the previous day was sexual in nature.An undated statement signed by the Administrator indicated, on 12/7/25 at 5:58 p.m., the Social Service Director notified the Administrator that Resident B's representative was very upset and heading to the facility with police due to being notified anonymously that Resident B had been sexually assaulted by his roommate (Resident C).Resident C's clinical record was reviewed on 12/10/25 at 12:10 p.m. Diagnoses included attention deficient hyperactive disorder (ADHD), bipolar disorder, major depression, oppositional defiant disorder, unspecified mood disorder, obsessive compulsive disorder (OCD), mild intellectual disabilities, a history of TIA/CVA (stroke) , and severe bulimia nervosa.Resident C's 12/2/25, admission, Minimum Data Set (MDS) assessment indicated he was cognitively intact, had clear speech, was understood by others, and understood others. He had no limitation in range of motion.Resident C had a May 27, 2025 Order to Continue Guardianship, granted to the family and indicated [Resident C's name] is a disabled adult with limited mental capacity and is unable to provide own care.Resident C had a 12/6/25 at 3:13 p.m., Skin Check completed by RN 14 which indicated the resident's skin was warm and dry, skin color within normal limits, and turgor normal. There was no other description of the resident's skin. All other check boxes were blank. The form did not address the resident's genitals or rectum's appearance or condition.The clinical record lacked documentation of the 12/6/25 events. Resident B's clinical record was reviewed on 12/10/25 at 11:53 a.m. Diagnoses included traumatic brain injury (TBI), post concessional syndrome, aphasia, anxiety, bipolar disorder, dysarthria, restlessness and agitation, severely impaired decision making and severely impaired short- and long-term memory.Resident B's 10/28/25, quarterly, MDS assessment indicated he did not speak, was rarely or never understood, sometimes understood others, had both long- and short-term memory impairment, could not complete the Brief Interview for Mental Status (BIMS) interview due to rarely speaking, had impaired range of motion in both his upper and lower extremities, and he used a wheelchair propelled by others.The clinical record indicated Resident B was non-verbal but able to answer affirmative and negative questioning via head nod.Resident B had a 5/21/24 Power of Attorney Paperwork for both health decisions and financial decisions granted to a family member.Resident B had a 12/6/25 at 3:03 p.m., Skin Check completed by RN 14 which indicated the resident's skin was warm and dry, skin color within normal limits, with turgor normal. There was no other description of the resident's skin. All other check boxes were blank. The form did not address the resident's genitals or rectum's appearance or condition.Resident B had a second skin assessment, titled Skin Monitoring: Comprehensive C.N.A. Shower Review, signed by LPN 13 and completed on 12/7/25 (one day after the incident). The form indicated there was no bleeding and no trauma to the rectal area.The clinical record indicated Resident B was not sent to the hospital and was not examined forensically. The clinical record lacked documentation of the 12/6/25 events. Resident F's clinical record was reviewed on 12/11/25 at 2:28 p.m. Diagnoses included type 2 diabetes, moderate vascular dementia with behaviors, schizoaffective disorder, impulse disorder, mild cognitive impairment, anxiety disorder, and lack of coordination. The resident was admitted to the facility on [DATE]. A Brief Interview for Mental Status Evaluation, dated 12/5/25, indicated the resident was moderately cognitively impaired. A Functional Assessment, dated 12/5/25 indicated the resident had no impairments to upper or lower extremities and required supervision/touch assistance for activities of daily living to include ambulation.Guardianship paperwork, dated 9/30/25, indicated Resident F was provided a court appointed guardian due to him being unable to maintain financial and personal affairs due to his incapacity.The clinical record indicated no care plan problem of sexually inappropriate behaviors towards other residents. A current, undated, facility policy titled, Abuse Prevention and Prohibition Policy, provided by the Administrator on 12/10/25 following the entrance conference, indicated the following: This policy is to identify guidelines for preventing and reporting abuse or alleged abuse whether being Resident to Resident, Resident to Employee, or Employee to Resident.Sexual Abuse: Inappropriate touching of any resident.Procedures.3. The Administrator and/or DON, Social Services Director, shall be notified of the incident immediately. 4. Appropriate documentation shall be completed relative to the individual incident (report of concern, incident/accident report, etc.) . 5. If the involved residents are roommates, immediate alternative placement within the facility will be secured to ensure each resident's safety. 6. The incident shall be reported to the state/certification agency, the Ombudsman, and Adult Protective services as applicable. The immediate jeopardy that began on December 6, 2025 was removed on December 11, 2025 when the facility completed education with nursing staff regarding abuse and completed screenings of other residents for potential abuse, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility had not completed a comprehensive review of their abuse policy and procedures and a comprehensive review of Resident C's behavior interventions to mitigate risk for recurrence.This citation relates to Intakes 2686505 and 2687065. 3.1-27(a)(1)

Based on interview and record review, the facility failed to report an allegation of resident-to-resident sexual abuse immediately to the Administrator to facilitate protection from further abuse when a cognitively impaired resident (Resident F) was found on the bed of another resident (Resident C) who was exposing his erect penis and Resident F was observed with saliva over his face and mouth for 2 of 5 residents reviewed for abuse (Residents F and B). The facility failed to report the allegation to the State Agency once the Administrator was made aware of the allegations. The facility also failed to accurately report an additional allegation of resident-to-resident sexual abuse later the same day when Resident B was found with feces and blood on his shirt and brief while Resident C was in the same room performing self-gratification of his rectum. Resident B was found in his bed with feces and blood on his shirt and incontinence brief, with his brief disheveled, and Resident C was in the same room performing self-gratification of his rectum, with feces and blood on his hands. Resident B indicated to police that Resident C had manipulated his own penis while doing the same to Resident B's penis.The immediate jeopardy began on December 6, 2025 when the facility failed to report internally to the Administrator and to the State Agency allegations of resident sexual abuse of two cognitively impaired residents by another resident who was cognitively intact with intellectual disabilities. The Administrator and Director of Nursing (DON) were present when informed of the immediate jeopardy on December 11, 2025. The immediate jeopardy was removed on December 11, 2025, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:Review of a 12/7/25 anonymous complaint intake provided to the Indiana Department of Health indicated, over the previous weekend, a dependent resident on the secured behavioral unit was found with feces and blood on him following an incident involving another resident. The anonymous complainant alleged the facility refused to act to protect the residents from further abuse.A police Case Report Summary, dated 12/9/25, indicated on 12/7/25 at 6:16 p.m., a police officer interviewed Resident B with family present. The officer used techniques to allow Resident B to communicate. Resident B had responded he had been touched in a way that was wrong by his former roommate, Resident C. Resident B indicated Resident C had touched his penis. Resident C had grabbed Resident B's penis. Resident C had moved his hand on Resident B's penis in a manner to simulate sex. Resident B indicated Resident C had touched his own penis while touching Resident B's penis. He believed Resident C had ejaculated as he did so. Resident B had told Resident C to stop. He had tried to yell. He had tried to push Resident C away. A facility self-reported incident, submitted to the Indiana Department of Heath on 12/7/25 at 8:09 p.m., indicated an incident had occurred on 12/7/25 at 6:03 p.m. Resident B had been touched by his former roommate, Resident C. There were no injuries. The information provided had no indication there was an allegation of sexual abuse. During an interview on 12/10/25 at 1:51 p.m., Resident B's representative indicated they received an anonymous phone call from someone identifying themselves as a staff member. The representative indicated the facility itself had not been forthcoming with information. Based on the anonymous staff phone call, he believed there was a facility attempt to coverup a sexual assault. During an interview on 12/10/25 at 3:04 p.m., CNA 3 indicated he had been working on Saturday 12/6/25. Early that day, he was walking down the hallway and saw Resident C in his room with his pants down. His penis was exposed and erect. Resident F was in Resident C's room. Resident F was seated on the end of Resident C's bed. Resident F had clear liquid, which may have been saliva, all over his mouth. The CNA believed the two residents may have been involved in a mutual sexual activity. He did not want to embarrass them. He asked why Resident C's pants were down and the resident indicated he was going to the bathroom. He asked why Resident F was in the room. Both residents indicated Resident F had come to the room for soda pop. The CNA thought both Resident C and F were intellectually challenged. He immediately informed QMA 5 of what he had witnessed. He had believed QMA 5 was a nurse because she was passing medications that day. To his knowledge, QMA 5 informed the on-call nurse manager. The CNA believed it had been reported to management because Resident F room was moved to a different hallway later that same day. After lunch the same day, CNA 7 had come to get him. She asked him to come see Resident B and Resident C because she had a concern. When he entered the room, Resident B had handprints of fecal matter on the lower part of his shirt. His incontinence brief was messed up and looked like it had been unfastened and an attempt had been made to refasten it. Resident B was not known to pull at his brief. There was fecal matter on the outside of the brief as well. Resident C was also in the room. Resident B had fecal matter all over his hands. The CNAs separated the residents and ensured they were safe. QMA 5 was informed of what they had observed. Later that day, Resident B was moved to a new room. CNA 3 later gave a written statement about Residents B and C. During an interview on 12/10/25 at 3:16 p.m., QMA 5 indicated CNA 3 came to get her on Saturday 12/6/25, around 3:15 p.m., to look at Resident B. The QMA went to Resident B's room. The resident was covered with fecal matter and blood and fingerprints down his side. His brief was ripped at the corner and he had pants on. He had blood and fecal matter from the shoulder all the way to the bottom of his T-shirt. She thought this was on the resident's left side. His roommate, Resident C, had fecal matter and blood on his hands, which was common for him. The QMA asked Resident C if he was touching Resident B. At first, he said no. She asked Resident B if Resident C touched him, and Resident B said yes. The QMA asked Resident B if Resident C had made him uncomfortable. He said yes. The QMA asked if Resident C had touched him in an inappropriate or sexual manner, and he did not answer. The QMA told the CNAs to get Resident B cleaned up and get him out of the room. She called LPN 15, who was the on-call nurse manager, who also instructed the CNAs to help get Resident C into the shower, since he was also covered in fecal matter and blood. Resident C was already on 15-minute checks due to a tendency to insert objects into his rectum. The QMA also personally increased the time intervals for checking on him that day. The QMA talked to either the DON or ADON about this concern, as well as the on-call nurse manager. The QMA was told to move Resident B and put him on 15-minute checks. There had also been another incident that morning between Resident C, involving Resident F. CNA 3 had witnessed Resident C with his pants down and Resident F sitting on the foot of the bed. Resident F had slobber all over his face. When the QMA asked the residents what had occurred, they both became very defensive. She had never seen Resident F in Resident C's room before. Resident F was a new resident. The QMA asked Resident C why his pants were down and he said he had to go to the bathroom. The QMA called to report this, she believed she had spoken to the on-call nurse manager, but there were a lot of people involved, so she was not sure. The QMA was instructed to move Resident F to a new room on a separate hall in order to encourage both residents to stay apart.During an interview on 12/11/25 at 12:03 p.m., RN 16 indicated she had been working in the facility on 12/6/25 but was on a different unit from where Residents B and C resided. QMA 5 came to talk to her after the event with Residents B and C. RN 16 told QMA 5 to call leadership immediately. Resident B was totally dependent, so there was no reason for him to have fecal matter on his sheet. She was concerned that Resident C could have inappropriately touched Resident B. There was a possibility that it was sexual in nature, which is why she told the QMA to notify the on-call manager. During an interview on 12/11/25 at 12:38 p.m., the Social Services Director (SSD) indicated she had not been in the facility on the weekend of 12/6/25 and 12/7/25. The event with Residents B and C happened on a Saturday. The SSD was told to complete the paperwork and notification for room changes. She received a phone call from the Administrator and was told that Resident F needed to move closer to the nurse's station due to wandering into another resident's room. The SSD notified Resident F's guardian of the room change on 12/6/25. The SSD placed the call from her home. She indicated she was not told about Resident B and Resident C having a potential sexual interaction. She was called later in the day on 12/6/25 by the Administrator and told there needed to be another room change because Resident C had put fecal matter on his roommate, Resident B. She called Resident B's family about the room change and left a message. The family called her back on Sunday 12/7/25. The family said the room move was fine and then started saying that staff had already called and told them what happened. They told her to call the director because the family had called the police. The SSD indicated she did not know anything about the concern. The family did not say anything about sexual behavior. During an interview on 12/11/25 at 2:42 p.m., CNA 12 indicated, on 12/6/25, they saw CNA 3, CNA 7, and QMA 5 and followed them to see what was going on, as they were all walking pretty fast. The other staff asked Resident C questions, then CNA 12 asked him questions about what happened. Resident C said he didn't touch him (Resident B) and stuff. They reported the incident to the Administrator and DON right after they got Resident B out of the room. CNA 12 didn't know what happened. The CNA observed fecal matter fingerprints all over Resident B, when he was lying on his side and the side part of his brief was undone. The CNA observed Resident B as he was prepared for a shower by CNA 7 stayed with him and gave him the shower. During an interview on 12/11/25 at 3:27 p.m., LPN 13 indicated she first became aware of a concern when called by the ADON on Sunday (12/7/25) at 7:59 p.m. The ADON told her of the allegation of the event on 12/6/25 and that the police were in the facility. The ADON wanted LPN 13 to come into the facility for support as there was an allegation of inappropriate touching. Resident C touched Resident B. The family had been told something else and called the police. During an interview on 12/11/25 at 3:00 p.m. Unit Manager (LPN) 17 indicated she was not working on Saturday 12/6/25 and did not get any calls until Sunday when the ADON called her between 6:00 and 6:30 p.m. regarding an allegation of inappropriate touching regarding Resident C and Resident B. Allegedly, Resident C had physically touched Resident B. Resident B's family was going to the facility and calling the police because they were told Resident B was sexually assaulted. When she arrived, the family was outside talking to a police officer. The Unit Manager called the Administrator and told her Resident B's family and the police were there. The Administrator said she was aware that there was an allegation of sexual abuse. The police officer later told the Unit Manager there was an allegation of sexual abuse and other interviews may be conducted later. During an interview on 12/11/25 at 11:22 a.m., with both the Administrator and the DON, the Administrator indicated she was first contacted regarding Resident B and C on 12/6/25 at 3:36 p.m. She verified the time by looking at her phone. She had spoken to ADON, who was concerned Resident B had fecal matter on his shirt and brief. The DON indicated she had been notified on 12/6/25 at 3:11 p.m., by QMA 5 and was told either Resident B or Resident C needed to be moved. Resident B was covered in poop from Resident C touching him and his pants were messed with. The DON was concerned because QMA 5 had already contacted her that day without following chain of command. She indicated there was fecal matter and blood spots on Resident B. The DON asked if she had contacted the on-call nurse first. The DON asked the QMA to get the residents cleaned up and have a skin assessment completed. The Administrator indicated she had not been notified about any concern about possible sexual misconduct until Sunday (12/7/25) at 5:58 p.m. On Sunday, 12/7/25 at 6:03 p.m., the Administrator called to talk to Resident B's family after she was informed by the Social Services Director that they were upset. The family told her he had received two anonymous phone calls, who said that Resident B had been sexually assaulted. The Administrator notified corporate of the allegation. The Administrator indicated it was her responsibility that the self-reported incident had not identified the allegation of sexual abuse. Her previous guidance and training had not led her to include it. She was aware the family had called the police and that police were coming to investigate. She did not include this information in the self-reportable to IDOH. Both the Administrator and DON indicated they had not been informed of any concern of a sexual nature regarding Resident C and Resident F. The Administrator indicated they asked staff to report allegations of abuse to their supervisors, who would then report said concerns to management.Review of staff statements, provided by the facility on 12/10/25 following Entrance Conference, indicated the following:Review of the DON's undated, written timeline statement indicated the following: On 12/6/25 at 6:43 a.m., QMA 5 called to discuss a sick employee. She was given education about staff illness. At 3:11 p.m., QMA 5 called about Resident C touching Resident B and Resident B having poop on him. Resident B's pants were messed with. There was a need for a possible room move. The DON told QMA 5 she needed to reach out to the on-call nurse. The DON then called back immediately and asked for more details. She was told Resident B had poop and bloody handprints on his shirt and outside of his brief. Resident B was not wearing pants, just briefs. He had a spot on the outside of his brief and his brief was intact. The DON said to shower both residents and ensure a skin assessment was completed. On 12/7/25 at 7:11p.m., the ADON and asked if she knew about an incident on 12/6/25 involving Residents C and B. The DON screen shot a message and said they would meet on Monday. On 12/8/25, the facility began an investigation and received staff statements.A 12/6/25, written statement by QMA 5, indicated on that afternoon, at around 3 p.m., the CNA had come to her because Resident B had poop and blood all over him and his brief was messed with. His roommate, Resident C, had blood and poop on his hands. Both residents were separated and showered. She called and talked to management about moving one of them. When Resident B was questioned, he was reluctant to answer but was glad to move to a new room. Resident C indicated he did not realize he wasn't allowed to touch Resident B.A 12/8/25 written statement signed by the SSD indicated Resident B's family spoke to her on the phone. The family stated the facility was trying to hide something and staff had told them what happened. They wanted to know everything that happened to Resident B. The family indicated they knew what had happened and called the police. The representative stated they had the police coming there so the SSD needed to call the facility director to meet the family there with the police. They then hung up the phone. An undated written statement by CNA 3 indicated CNA 7 had gotten him and asked him to come to Resident B and C's room, because she had a concern. Resident B had feces stains on his T-shirt that looked like fingerprints. His brief looked like it had been messed with. Resident C had feces on his hands. They removed Resident B from the room. An undated, typed, written statement by CNA 7 indicated the CNA went to the hall to check on Resident C, who was on 15-minute checks. When she got to the room, she found Resident C on all fours on the floor in his restroom inserting his hand into his rectum. His rectum was bleeding. She had Resident C get up and go to the shower room to shower. After taking him to the shower room, she went to the room to check on his roommate. The roommate, Resident B, had a ripped brief. He had both blood and feces on his shirt. She got CNA 3 to come see what was happening. CNA 7 made sure QMA 5 knew the concern. Resident B was moved to another room during the shift. CNA 7 could not be reached for an interview during the survey dates. An undated written statement by LPN 15 indicated on 12/6/25 at 3:30 p.m., QMA 5 notified her that Resident C had touched Resident B with fecal matter on his hands. On 12/7/25 at 6:30 p.m., she received a message from the ADON and was requested to come into the facility and do skin assessments. An allegation was made regarding yesterday's event, and police were in the building. At 7:00 p.m., she was interviewed by police officers and informed them she had never been informed the event from the previous day was sexual in nature.An undated statement signed by the Administrator indicated, on 12/7/25 at 5:58 p.m., the Social Service Director notified the Administrator that Resident B's representative was very upset and heading to the facility with police due to being notified anonymously that Resident B had been sexually assaulted by his roommate (Resident C).An incident report was not filed with the State Agency (IDOH) regarding the allegation of sexual abuse of Resident F by Resident C as of the date of exit from the facility on12/12/25. Resident C's clinical record was reviewed on 12/10/25 at 12:10 p.m. Diagnoses included attention deficient hyperactive disorder (ADHD), bipolar disorder, major depression, oppositional defiant disorder, unspecified mood disorder, obsessive compulsive disorder (OCD), mild intellectual disabilities, a history of TIA/CVA (stroke) , and severe bulimia nervosa.Resident C's 12/2/25, admission, Minimum Data Set (MDS) assessment indicated he was cognitively intact, had clear speech, was understood by others, and understood others. He had no limitation in range of motion.Resident C had a May 27, 2025 Order to Continue Guardianship, granted to the family and indicated [Resident C's name] is a disabled adult with limited mental capacity and is unable to provide own care.Resident C had a 12/6/25 at 3:13 p.m., Skin Check completed by RN 14 which indicated the resident's skin was warm and dry, skin color within normal limits, and turgor normal. There was no other description of the resident's skin. All other check boxes were blank. The form did not address the resident's genitals or rectum's appearance or condition.The clinical record lacked documentation of the 12/6/25 events. Resident B's clinical record was reviewed on 12/10/25 at 11:53 a.m. Diagnoses included traumatic brain injury (TBI), post concessional syndrome, aphasia, anxiety, bipolar disorder, dysarthria, restlessness and agitation, severely impaired decision making and severely impaired short- and long-term memory.Resident B's 10/28/25, quarterly, MDS assessment indicated he did not speak, was rarely or never understood, sometimes understood others, had both long- and short-term memory impairment, could not complete the Brief Interview for Mental Status (BIMS) interview due to rarely speaking, had impaired range of motion in both his upper and lower extremities, and he used a wheelchair propelled by others.The clinical record indicated Resident B was non-verbal but able to answer affirmative and negative questioning via head nod.Resident B had a 5/21/24 Power of Attorney Paperwork for both health decisions and financial decisions granted to a family member.Resident B had a 12/6/25 at 3:03 p.m., Skin Check completed by RN 14 which indicated the resident's skin was warm and dry, skin color within normal limits, with turgor normal. There was no other description of the resident's skin. All other check boxes were blank. The form did not address the resident's genitals or rectum's appearance or condition.Resident B had a second skin assessment, titled Skin Monitoring: Comprehensive C.N.A. Shower Review, signed by LPN 13 and completed on 12/7/25 (one day after the incident). The form indicated there was no bleeding and no trauma to the rectal area.The clinical record indicated Resident B was not sent to the hospital and was not examined forensically. The clinical record lacked documentation of the 12/6/25 events. Resident F's clinical record was reviewed on 12/11/25 at 2:28 p.m. Diagnoses included type 2 diabetes, moderate vascular dementia with behaviors, schizoaffective disorder, impulse disorder, mild cognitive impairment, anxiety disorder, and lack of coordination. The resident was admitted to the facility on [DATE]. A Brief Interview for Mental Status Evaluation, dated 12/5/25, indicated the resident was moderately cognitively impaired. A Functional Assessment, dated 12/5/25 indicated the resident had no impairments to upper or lower extremities and required supervision/touch assistance for activities of daily living to include ambulation.Guardianship paperwork, dated 9/30/25, indicated Resident F was provided a court appointed guardian due to him being unable to maintain financial and personal affairs due to his incapacity.The clinical record indicated no care plan problem of sexually inappropriate behaviors towards other residents. A current, undated, facility policy titled, Abuse Prevention and Prohibition Policy, provided by the Administrator on 12/10/25 following the entrance conference, indicated the following: This policy is to identify guidelines for preventing and reporting abuse or alleged abuse whether being Resident to Resident, Resident to Employee, or Employee to Resident.Sexual Abuse: Inappropriate touching of any resident.Procedures.3. The Administrator and/or DON, Social Services Director, shall be notified of the incident immediately. 4. Appropriate documentation shall be completed relative to the individual incident (report of concern, incident/accident report, etc.) . 5. If the involved residents are roommates, immediate alternative placement within the facility will be secured to ensure each resident's safety. 6. The incident shall be reported to the state/certification agency, the Ombudsman, and Adult Protective services as applicable. The immediate jeopardy that began on December 6, 2025 was removed on December 11, 2025 when the facility completed staff education regarding abuse reporting, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility had not completed a comprehensive review of their abuse policy and procedures, including reporting to the Administrator and State Agency, to mitigate risk for recurrence.Cross reference F600. This citation relates to Intakes 2686505 and 2687065. 3.2-28(c)

Based on interview and record review, the facility failed to initiate investigative protocols and protective interventions for allegations of resident-to-resident sexual abuse for 2 of 5 residents reviewed for abuse (Residents F and B) by Resident C when Resident F was found on the bed of Resident C, who was exposing his erect penis while Resident F was observed with saliva over his face and mouth and when Resident B was found with feces and blood on his shirt and brief while Resident C was in the same room performing self-gratification of his rectum later the same day. Resident B indicated to police that Resident C had manipulated his own penis while doing the same to Resident B's penis.The immediate jeopardy began on December 6, 2025 when the facility failed to immediately implement facility policy and protocols to investigate allegations of sexual abuse of two cognitively impaired residents by another resident who was cognitively intact with intellectual disabilities. The Administrator and Director of Nursing (DON) were present when informed of the immediate jeopardy on December 11, 2025. The immediate jeopardy was removed on December 11, 2025, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:Review of a 12/7/25 anonymous complaint intake provided to the Indiana Department of Health indicated, over the previous weekend, a dependent resident on the secured behavioral unit was found with feces and blood on him following an incident involving another resident. The anonymous complainant alleged the facility refused to act to protect the residents from further abuse.A police Case Report Summary, dated 12/9/25, indicated on 12/7/25 at 6:16 p.m., a police officer interviewed Resident B with family present. The officer used techniques to allow Resident B to communicate. Resident B had responded he had been touched in a way that was wrong by his former roommate, Resident C. Resident B indicated Resident C had touched his penis. Resident C had grabbed Resident B's penis. Resident C had moved his hand on Resident B's penis in a manner to simulate sex. Resident B indicated Resident C had touched his own penis while touching Resident B's penis. He believed Resident C had ejaculated as he did so. Resident B had told Resident C to stop. He had tried to yell. He had tried to push Resident C away. A facility self-reported incident, submitted to the Indiana Department of Heath on 12/7/25 at 8:09 p.m., indicated an incident had occurred on 12/7/25 at 6:03 p.m. Resident B had been touched by his former roommate, Resident C. There were no injuries. The information provided had no indication there was an allegation of sexual abuse. During an interview on 12/10/25 at 1:51 p.m., Resident B's representative indicated they received an anonymous phone call from someone identifying themselves as a staff member. The representative indicated the facility itself had not been forthcoming with information. Based on the anonymous staff phone call, he believed there was a facility attempt to coverup a sexual assault. During an interview on 12/10/25 at 3:04 p.m., CNA 3 indicated he had been working on Saturday 12/6/25. Early that day, he was walking down the hallway and saw Resident C in his room with his pants down. His penis was exposed and erect. Resident F was in Resident C's room. Resident F was seated on the end of Resident C's bed. Resident F had clear liquid, which may have been saliva, all over his mouth. The CNA believed the two residents may have been involved in a mutual sexual activity. He did not want to embarrass them. He asked why Resident C's pants were down and the resident indicated he was going to the bathroom. He asked why Resident F was in the room. Both residents indicated Resident F had come to the room for soda pop. The CNA thought both Resident C and F were intellectually challenged. He immediately informed QMA 5 of what he had witnessed. He had believed QMA 5 was a nurse because she was passing medications that day. To his knowledge, QMA 5 informed the on-call nurse manager. The CNA believed it had been reported to management because Resident F room was moved to a different hallway later that same day. After lunch the same day, CNA 7 had come to get him. She asked him to come see Resident B and Resident C because she had a concern. When he entered the room, Resident B had handprints of fecal matter on the lower part of his shirt. His incontinence brief was messed up and looked like it had been unfastened and an attempt had been made to refasten it. Resident B was not known to pull at his brief. There was fecal matter on the outside of the brief as well. Resident C was also in the room. Resident B had fecal matter all over his hands. The CNAs separated the residents and ensured they were safe. QMA 5 was informed of what they had observed. Later that day, Resident B was moved to a new room. CNA 3 later gave a written statement about Residents B and C. During an interview on 12/10/25 at 3:16 p.m., QMA 5 indicated CNA 3 came to get her on Saturday 12/6/25, around 3:15 p.m., to look at Resident B. The QMA went to Resident B's room. The resident was covered with fecal matter and blood and fingerprints down his side. His brief was ripped at the corner and he had pants on. He had blood and fecal matter from the shoulder all the way to the bottom of his T-shirt. She thought this was on the resident's left side. His roommate, Resident C, had fecal matter and blood on his hands, which was common for him. The QMA asked Resident C if he was touching Resident B. At first, he said no. She asked Resident B if Resident C touched him, and Resident B said yes. The QMA asked Resident B if Resident C had made him uncomfortable. He said yes. The QMA asked if Resident C had touched him in an inappropriate or sexual manner, and he did not answer. The QMA had not been trained regarding how to interview a person if abuse was suspected. She was not instructed to interview the resident. She thought that when a person refused to answer a question about abuse, it could mean they were reluctant to answer because it was either true or false. The QMA told the CNAs to get Resident B cleaned up and get him out of the room. She called LPN 15, who was the on-call nurse manager, who also instructed the CNAs to help get Resident C into the shower, since he was also covered in fecal matter and blood. Resident C was already on 15-minute checks due to a tendency to insert objects into his rectum. The QMA also personally increased the time intervals for checking on him that day. The QMA talked to either the DON or ADON about this concern, as well as the on-call nurse manager. The QMA was told to move Resident B and put him on 15-minute checks. There had also been another incident that morning between Resident C, involving Resident F. CNA 3 had witnessed Resident C with his pants down and Resident F sitting on the foot of the bed. Resident F had slobber all over his face. When the QMA asked the residents what had occurred, they both became very defensive. She had never seen Resident F in Resident C's room before. Resident F was a new resident. The QMA asked Resident C why his pants were down and he said he had to go to the bathroom. The QMA called to report this, she believed she had spoken to the on-call nurse manager, but there were a lot of people involved, so she was not sure. The QMA was instructed to move Resident F to a new room on a separate hall in order to encourage both residents to stay apart.During an interview on 12/11/25 at 12:03 p.m., RN 16 indicated she had been working in the facility on 12/6/25 but was on a different unit from where Residents B and C resided. QMA 5 came to talk to her after the event with Residents B and C. RN 16 told QMA 5 to call leadership immediately. Resident B was totally dependent, so there was no reason for him to have fecal matter on his sheet. She was concerned that Resident C could have inappropriately touched Resident B. There was a possibility that it was sexual in nature, which is why she told the QMA to notify the on-call manager. During an interview on 12/11/25 at 12:38 p.m., the Social Services Director (SSD) indicated she had not been in the facility on the weekend of 12/6/25 and 12/7/25. The event with Residents B and C happened on a Saturday. The SSD was told to complete the paperwork and notification for room changes. She received a phone call from the Administrator and was told that Resident F needed to move closer to the nurse's station due to wandering into another resident's room. The SSD notified Resident F's guardian of the room change on 12/6/25. The SSD placed the call from her home. She indicated she was not told about Resident B and Resident C having a potential sexual interaction. She was called later in the day on 12/6/25 by the Administrator and told there needed to be another room change because Resident C had put fecal matter on his roommate, Resident B. She called Resident B's family about the room change and left a message. The family called her back on Sunday 12/7/25. The family said the room move was fine and then started saying that staff had already called and told them what happened. They told her to call the director because the family had called the police. The SSD indicated she did not know anything about the concern. The family did not say anything about sexual behavior. During an interview on 12/11/25 at 2:42 p.m., CNA 12 indicated she forgot to date her first written statement and completed another one after the police were there. She gave it to the Administrator. CNA 12 indicated, on 12/6/25, they saw CNA 3, CNA 7, and QMA 5 and followed them to see what was going on, as they were all walking pretty fast. CNA 12 was later present in the shower room with CNA 7, QMA 5, and Resident C. The other staff asked Resident C questions, then CNA 12 asked him questions about what happened. Resident C said he didn't touch him (Resident B) and stuff. They reported the incident to the Administrator and DON right after they got Resident B out of the room. CNA 12 didn't know what happened. Resident C regularly played with his rectum and would be doing it in his bathroom with the door open. The CNA had never seen the resident put objects in his rectum but would find items in his room covered in feces. CNA 12 indicated they had not been trained to interview residents but was never told to not ask a resident question after the event. Staff were asking questions due to a concern about inappropriate sexual touching. The CNA observed fecal matter fingerprints all over Resident B, when he was lying on his side and the side part of his brief was undone. The CNA observed Resident B as he was prepared for a shower by CNA 7 stayed with him and gave him the shower. During an interview on 12/11/25 at 3:17 p.m., LPN 15 indicated she was the on-call nurse on 12/6/25. She was first made aware of a concern on Saturday, 12/6/25 at 3:00 p.m., when QMA 5 told her that they had found Resident B with fecal matter on him that came from Resident C. She had not been called about any incident between Resident F and Resident C. She was not aware that Resident F had been moved to a different room. QMA 5 did not say anything about Resident B's brief, and did not tell her where the fecal matter had been found on Resident B. She did not say anything about it being sexual in nature. QMA 5 only asked about moving Resident B. LPN 15 called the ADON and told her QMA 5 had called and wanted to move Resident B. She said she already told them they could make the move. LPN 15 called back and told QMA 5 it was okay to move Resident B and they needed to implement 15-minute checks and to complete full body assessments for the residents. LPN 15 did not ever talk to the nurse on duty at the facility. On weekends, the nurse on duty was in charge of facility oversite, and LPN 15 assumed QMA 5 was the nurse. During an interview on 12/11/25 at 3:27 p.m., LPN 13 indicated she first became aware of a concern when called by the ADON on Sunday (12/7/25) at 7:59 p.m. The ADON told her of the allegation of the event on 12/6/25 and that the police were in the facility. The ADON wanted LPN 13 to come into the facility for support as there was an allegation of inappropriate touching. Resident C touched Resident B. The family had been told something else and called the police. The ADON asked LPN 13 to do skin assessments of all residents who were unable to speak. Resident B was one of the residents selected. LPN 13 spoke to the family prior to and during the assessment and encouraged them to send Resident B to the hospital. LPN 13 did not see anything of concern but just wanted to be safe. After the assessment, Resident B's family indicated there was no need for him to go to the hospital. There were no signs or symptoms of injury to the anus or genital areas. The family told them Resident B had been masturbated by Resident C. LPN 13 did interview Resident C. When he was asked if he had touched anyone in the building inappropriately, he said no. Resident C saw the police and thought he was going to jail. LPN 13 was not asked to interview Resident C as part of the facility's investigation; she chose to do so on her own. QMA 5 never contacted her with information or concerns.During an interview on 12/11/25 at 3:00 p.m. Unit Manager (LPN) 17 indicated she was not working on Saturday 12/6/25 and did not get any calls until Sunday when the ADON called her between 6:00 and 6:30 p.m. regarding an allegation of inappropriate touching regarding Resident C and Resident B. Allegedly, Resident C had physically touched Resident B. Resident B's family was going to the facility and calling the police because they were told Resident B was sexually assaulted. When she arrived, the family was outside talking to a police officer. The Unit Manager called the Administrator and told her Resident B's family and the police were there. The Administrator said she was aware that there was an allegation of sexual abuse. After the police interview, the Unit Manager provided incontinence care and completed a physical assessment. She looked at Resident B's genitals and rectum and did not see anything abnormal. After the assessment, Resident B's family said they had received a call saying the resident had been sexually assaulted. They wanted Resident C sent out for safety reasons. The family felt all evidence had been washed away because staff had given the residents a shower. The family said they believed Resident C had masturbated Resident B. The police officer later told the Unit Manager there was an allegation of sexual abuse and other interviews may be conducted later. The police officer asked what the facility was going to do to ensure Resident B's and other residents' safety from Resident C. The Unit Manager assured him Resident C would have one on one supervision.During an interview on 12/11/25 at 11:22 a.m., with both the Administrator and the DON, the Administrator indicated she was first contacted regarding Resident B and C on 12/6/25 at 3:36 p.m. She verified the time by looking at her phone. She had spoken to ADON, who was concerned Resident B had fecal matter on his shirt and brief. The DON indicated she had been notified on 12/6/25 at 3:11 p.m., by QMA 5 and was told either Resident B or Resident C needed to be moved. Resident B was covered in poop from Resident C touching him and his pants were messed with. The DON was concerned because QMA 5 had already contacted her that day without following chain of command. She indicated there was fecal matter and blood spots on Resident B. The DON asked if she had contacted the on-call nurse first. The DON asked the QMA to get the residents cleaned up and have a skin assessment completed. The Administrator indicated she had not been notified about any concern about possible sexual misconduct until Sunday (12/7/25) at 5:58 p.m. On Sunday, 12/7/25 at 6:03 p.m., the Administrator called to talk to Resident B's family after she was informed by the Social Services Director that they were upset. The family told her he had received two anonymous phone calls, who said that Resident B had been sexually assaulted. The Administrator notified corporate of the allegation. The Administrator indicated it was her responsibility that the self-reported incident had not identified the allegation of sexual abuse. Her previous guidance and training had not led her to include it. She was aware the family had called the police and that police were coming to investigate. She did not include this information in the self-reportable to IDOH. The DON indicated she was notified by QMA 5 before the Administrator had been notified. She asked QMA 5 if Resident B's brief was intact. She thought the staffs' concern was related to infection prevention. She assumed the fecal matter was from Resident C because he had a habit of anal manipulation. Both the Administrator and DON indicated they had not been informed of any concern of a sexual nature regarding Resident C and Resident F. The DON indicated she had been involved with the decision to move Resident F to another room. She believed the concern was related to Resident F wandering. She thought Resident C was in his bathroom when Resident F wandered into his room. The DON did not ask why the nurses in the facility on 12/6/25 were not involved, assessing or sharing information, when multiple calls were made that day. She did not ask to speak with a nurse, she simply redirected QMA 5 to follow chain of command. The Administrator indicated they asked staff to report allegations of abuse to their supervisors, who would then report said concerns to management.During an interview on 12/12/25 at 12:33 p.m., Social Services Assistant (SSA) 8 indicated she was working as a CNA on the weekend in question. She was going to the 300 hall with the ice chest and was met by CNA 7 who said Resident B was found with fecal matter on his shirt. SSA 8 asked CNA 7 if she had seen Resident C touching Resident B, and she said no. They both went to see Resident B. SSA 8 indicated she spoke with Resident B and asked him if anyone had ever touched in inappropriately. He said no. She asked him if anyone removed his brief. He said no. She asked if someone had made him feel uncomfortable, and he said yes. SSA 8 indicated she asked the resident questions because of her SSA background. She was not sure if allegation of abuse interviews should be done. She asked him the questions because of what she had heard and did not think it was outside her job duties. She had not been trained to interview abuse victims. She had been trained to be a social services assistant by the past SSD. She did not have social services certification. A few days after the event, the Administrator told her that she should not have taken it upon herself to ask questions concerning the allegation.During an interview on 12/12/25 at 12:54 p.m., QMA 11 indicated she worked on Sunday 12/7/25, but did not work on Saturday 12/6/25. She went with SSA 8 to see Resident B just to make sure he was okay. She had heard several different stories floating around and wanted to hear it directly from Resident B. She was not trained in interviewing regarding abuse and was not asked to interview the resident. She was not aware the police were involved. Review of staff statements, provided by the facility on 12/10/25 following Entrance Conference, indicated the following:Review of the DON's undated, written timeline statement indicated the following: On 12/6/25 at 6:43 a.m., QMA 5 called to discuss a sick employee. She was given education about staff illness. At 3:11 p.m., QMA 5 called about Resident C touching Resident B and Resident B having poop on him. Resident B's pants were messed with. There was a need for a possible room move. The DON told QMA 5 she needed to reach out to the on-call nurse. The DON then called back immediately and asked for more details. She was told Resident B had poop and bloody handprints on his shirt and outside of his brief. Resident B was not wearing pants, just briefs. He had a spot on the outside of his brief and his brief was intact. The DON said to shower both residents and ensure a skin assessment was completed. On 12/7/25 at 7:11p.m., the ADON and asked if she knew about an incident on 12/6/25 involving Residents C and B. The DON screen shot a message and said they would meet on Monday. On 12/8/25, the facility began an investigation and received staff statements.A 12/6/25, written statement by QMA 5, indicated on that afternoon, at around 3 p.m., the CNA had come to her because Resident B had poop and blood all over him and his brief was messed with. His roommate, Resident C, had blood and poop on his hands. Both residents were separated and showered. She called and talked to management about moving one of them. When Resident B was questioned, he was reluctant to answer but was glad to move to a new room. Resident C indicated he did not realize he wasn't allowed to touch Resident B.A 12/6/25 written statement by SSA 8 indicated she had spoken to Resident B after the alleged event. She interviewed Resident B, who indicated Resident C had made him uncomfortable. He shook his head to indicate no when asked if he was a victim of sexual assault. SSA 8 asked staff if they saw Resident C touch Resident B and they said they had not.A 12/7/25, written statement by LPN 17 indicated, after obtaining permission, she and LPN 13 completed a skin assessment for Resident B on 12/7/25. No rectal or genital trauma was observed. The family was concerned because the resident was showered and evidence was washed away. The resident had not been penetrated, and his penis had been pulled out and masturbated. The family had called the police and filed a report in response to an anonymous call from a staff member. The police officer came to the building and interviewed Resident B. The officer asked what the facility was going to do to keep Resident B safe from Resident C. She informed the police officer that the facility had Resident C under one-to-one observation to ensure everyone's safety. A 12/7/25 written statement from LPN 13 indicated the family and Resident B were asked permission to complete a skin assessment for Resident B. Both indicated a skin assessment could be completed. The skin assessment was completed and no injuries were noted. During the skin assessment the family stated they felt the Administrator was attempting a cover-up conspiracy. The family member stated they had been informed the resident had not been penetrated. He had been masturbated by Resident C. LPN 13 later asked Resident C if he had touched Resident B in an unwanted way. He indicated he had not. He stated he had touched him with dirty hands. A 12/8/25 written statement by QMA 11 indicated she had interviewed Resident B after the event on 12/6/25. Resident B said Resident C had made him feel uncomfortable and he was happy with his room move. Resident B indicated no when asked if he had been touched inappropriately. A 12/8/25 written statement by the ADON indicated on Saturday, 12/6/25 at 3:16 p.m., she received a group text from QMA 5 requesting a member of management to call. She called QMA 5 and learned Resident B had been found with fecal matter on the outside of his brief and on his T-shirt. The ADON asked if the brief was intact and was told it was. She told QMA 5 to ensure both residents were showered, to continue 15-minute checks, and one resident would be relocated soon. She would return the call with information about the room move. At 3:40, she received a call from LPN 15, who had also spoken to QMA 5. It was decided Resident B would be relocated and the SSD would notify family regarding the room move. A 12/8/25 written statement signed by the SSD indicated Resident B's family spoke to her on the phone. The family stated the facility was trying to hide something and staff had told them what happened. They wanted to know everything that happened to Resident B. The family indicated they knew what had happened and called the police. The representative stated they had the police coming there so the SSD needed to call the facility director to meet the family there with the police. They then hung up the phone. An undated written statement by CNA 3 indicated CNA 7 had gotten him and asked him to come to Resident B and C's room, because she had a concern. Resident B had feces stains on his T-shirt that looked like fingerprints. His brief looked like it had been messed with. Resident C had feces on his hands. They removed Resident B from the room. An undated, typed, written statement by CNA 7 indicated the CNA went to the (number) hall to check on Resident C, who was on 15-minute checks. When she got to the room, she found Resident C on all fours on the floor in his restroom inserting his hand into his rectum. His rectum was bleeding. She had Resident C get up and go to the shower room to shower. After taking him to the shower room, she went to the room to check on his roommate. The roommate, Resident B, had a ripped brief. He had both blood and feces on his shirt. She got CNA 3 to come see what was happening. CNA 7 made sure QMA 5 knew the concern. Resident B was moved to another room during the shift. CNA 7 could not be reached for an interview during the survey dates. An undated written statement by CNA12 indicated she and three other staff (QMA 5, CNA 7, and CNA 3) went to the shower with Resident C after an alleged incident. They interviewed the resident and asked him questions. The resident was defensive and denied anything happened. An undated written statement by LPN 15 indicated on 12/6/25 at 3:30 p.m., QMA 5 notified her that Resident C had touched Resident B with fecal matter on his hands. QMA 5 said Resident B was moved to another room. Both residents were showered due to having fecal matter all over them. At 3:40 p.m., she spoke to the ADON about a good room move. The ADON was already aware of the issue. At 3:45 p.m., she spoke with QMA 5 and asked her to have all staff write statements and put them under the Administrator's door. The SSD would notify families about the room moves. On 12/7/25 at 6:30 p.m., she received a message from the ADON and was requested to come into the facility and do skin assessments. An allegation was made regarding yesterday's event, and police were in the building. At 7:00 p.m., she was interviewed by police officers and informed them she had never been informed the event from the previous day was sexual in nature.An undated statement signed by the Administrator indicated, on 12/7/25 at 5:58 p.m., the Social Service Director notified the Administrator that Resident B's representative was very upset and heading to the facility with police due to being notified anonymously that Resident B had been sexually assaulted by his roommate (Resident C).Resident C's clinical record was reviewed on 12/10/25 at 12:10 p.m. Diagnoses included attention deficient hyperactive disorder (ADHD), bipolar disorder, major depression, oppositional defiant disorder, unspecified mood disorder, obsessive compulsive disorder (OCD), mild intellectual disabilities, a history of TIA/CVA (stroke) , and severe bulimia nervosa.Resident C's 12/2/25, admission, Minimum Data Set (MDS) assessment indicated he was cognitively intact, had clear speech, was understood by others, and understood others. He had no limitation in range of motion.Resident C had a May 27, 2025 Order to Continue Guardianship, granted to the family and indicated [Resident C's name] is a disabled adult with limited mental capacity and is unable to provide own care.Resident C had a 12/6/25 at 3:13 p.m., Skin Check completed by RN 14 which indicated the resident's skin was warm and dry, skin color within normal limits, and turgor normal. There was no other description of the resident's skin. All other check boxes were blank. The form did not address the resident's genitals or rectum's appearance or condition.The clinical record lacked documentation of the 12/6/25 events. Resident B's clinical record was reviewed on 12/10/25 at 11:53 a.m. Diagnoses included traumatic brain injury (TBI), post concessional syndrome, aphasia, anxiety, bipolar disorder, dysarthria, restlessness and agitation, severely impaired decision making and severely impaired short- and long-term memory.Resident B's 10/28/25, quarterly, MDS assessment indicated he did not speak, was rarely or never understood, sometimes understood others, had both long- and short-term memory impairment, could not complete the Brief Interview for Mental Status (BIMS) interview due to rarely speaking, had impaired range of motion in both his upper and lower extremities, and he used a wheelchair propelled by others.The clinical record indicated Resident B was non-verbal but able to answer affirmative and negative questioning via head nod.Resident B had a 5/21/24 Power of Attorney Paperwork for both health decisions and financial decisions granted to a family member.Resident B had a 12/6/25 at 3:03 p.m., Skin Check completed by RN 14 which indicated the resident's skin was warm and dry, skin color within normal limits, with turgor normal. There was no other description of the resident's skin. All other check boxes were blank. The form did not address the resident's genitals or rectum's appearance or condition.Resident B had a second skin assessment, titled Skin Monitoring: Comprehensive C.N.A. Shower Review, signed by LPN 13 and completed on 12/7/25 (one day after the incident). The form indicated there was no bleeding and no trauma to the rectal area.The clinical record indicated Resident B was not sent to the hospital and was not examined forensically. The clinical record lacked documentation of the 12/6/25 events. Resident F's clinical record was reviewed on 12/11/25 at 2:28 p.m. Diagnoses included type 2 diabetes, moderate vascular dementia with behaviors, schizoaffective disorder, impulse disorder, mild cognitive impairment, anxiety disorder, and lack of coordination. The resident was admitted to the facility on [DATE]. A Brief Interview for Mental Status Evaluation, dated 12/5/25, indicated the resident was moderately cognitively impaired. A Functional Assessment, dated 12/5/25 indicated the resident had no impairments to upper or lower extremities and required supervision/touch assistance for activities of daily living to include ambulation.Guardianship paperwork, dated 9/30/25, indicated Resident F was provided a court appointed guardian due to him being unable to maintain financial and personal affairs due to his incapacity.The clinical record indicated no care plan problem of sexually inappropriate behaviors towards other residents. A current, undated, facility policy titled, Abuse Prevention and Prohibition Policy, provided by the Administrator on 12/10/25 following the entrance conference, indicated the following: This policy is to identify guidelines for preventing and reporting abuse or alleged abuse whether being Resident to Resident, Resident to Employee, or Employee to Resident.Sexual Abuse: Inappropriate touching of any resident.Procedures.3. The Administrator and/or DON, Social Services Director, shall be notified of the incident immediately. 4. Appropriate documentation shall be completed relative to the individual incident (report of concern, incident/accident report, etc.) . 5. If the involved residents are roommates, immediate alternative placement within the facility will be secured to ensure each resident's safety. 6. The incident shall be reported to the state/certification agency, the Ombudsman, and Adult Protective services as applicable. The immediate jeopardy that began on December 6, 2025 was removed on December 11, 2025 when the facility completed education with nursing staff regarding abuse and investigation of allegations but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility had not completed a comprehensive review of their abuse policy and procedures, including investigative protocols, to mitigate risk for recurrence.Cross reference F600.This citation relates to

A. Based on observation, interview and record review, the facility failed to ensure a resident with known suicidal ideations with plastic bags had interventions in place, including no access to plastic bags for 1 of 3 resident reviewed for accidents (Resident C). The Immediate Jeopardy began on 4/11/23 when a resident with previous suicidal ideations with plastic bags was found by staff applying a plastic bag to her head. During an observation of the resident's room, on 4/13/23, there were plastic bags observed in two trash cans. The DON, ADON, SSD and Medical Records Nurse were notified of the Immediate Jeopardy on 4/13/23 at 3:23 p.m. The Immediate Jeopardy was removed on 4/14/23, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. B. Based on observation, interview and record review, the facility failed to follow the facility's fall protocol for a resident who had a fall with fracture (Resident E) for 1 of 3 residents reviewed for accidents. Findings include: A. Resident C's clinical record was reviewed on 4/12/23 at 10:50 a.m. Diagnoses included unspecified mood [affective] disorder, major depressive disorder, recurrent, moderate, depressive disorder, recurrent, borderline personality disorder, mild cognitive impairment of uncertain or unknown etiology, major depressive disorder, recurrent, severe with psychotic symptoms, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and suicidal ideations. Her current medications included, quetiapine fumarate (antipsychotic) 100 mg (milligram) in the morning, quetiapine fumarate 300 mg at bedtime, trazodone (treat insomnia) 50 mg daily, clonazepam (treat anxiety) 0.5 mg twice daily, and lithium carbonate (treat borderline personality disorder) 150 mg twice daily. A quarterly MDS (Minimum Data Set) assessment, dated 2/1/23, indicated she was cognitively intact. Her PHQ-9 (questionnaire for depression) was normal, she did not have thoughts she would be better off dead or hurting herself in some way. She had verbal behavior symptoms directed towards other (e.g., threatening others, screaming at others, cursing at others) that occurred one to three days during the assessment period. She required supervision of one staff member for bed mobility, locomotion on and off the unit, dressing, eating and personal hygiene. She required extensive assistance of two staff members for toileting. She had a current, 10/7/22, care plan for diagnosis of depression and had a history of symptoms such as negative statements, sad mood, tearfulness, and suicidal ideation. She voiced feelings of being down, depressed, hopeless and a poor appetite during the assessment. Her goal was her overall mood would improve AEB (as evidenced by), her PHQ-9 score of less than three (normal) during the next review. Her interventions were to encourage her out of her room for activities (10/7/22), medication per physician orders and monitor for side effects (10/07/22), and no trash bags in her room (3/7/23). She had a current, 10/7/22, care plan for voiced suicidal ideations AEB recent psychiatric stay due to suicidal ideation. Her goal was she would not harm herself through next review. Her interventions were to allow her to voice all concerns (10/7/23), notify the physician and her representative of new or continued verbalization of ideations (10/7/22), and provide one on one visits as needed (10/7/22). Review of nurses notes indicated the following: On 2/28/23 at 10:55 a.m., a behavior note indicated the nurse knocked and entered her room to give her insulin. She was in bed with a plastic bag loosely over her head, it was not secured around her neck. She was alert and oriented to person, place and time. The nurse immediately removed the bag and asked her what she was doing, she stated no one cared about her, she just wanted to die. The SSD (Social Service Director), Administrator and DON was notified. She was brought out to the nurse's station with the SSD. A 2/28/23 behavior note indicated she had been found in bed at 10:55 a.m. with a bag over her head. The SSD and DON met with her, she had a flat affect and voiced she was extremely depressed, and if her son didn't care about her, then why should she care about herself. She was unable to get ahold of her son and upset he would not buy her clothing. It was explained to her her son had lost his phone and he was doing the best to care for her needs. The psychiatric NP and physician were notified. The SSD did one on one visits with her until the EMTs arrived. She was sent to the ER for an evaluation. Review of a hospital HPI (history of present illness) document, dated 2/28/23 at 12:31 p.m., indicated the history was provided by the patient and the nursing home staff. She presented to the ER with complaints of suicidal ideation. She reported she had not been able to get in touch with her son, and this had increased her depression. She stated she had put a trash bag over her head in an attempt to kill herself. She denied previous attempts to kill herself. Staff at the nursing home reported she saw the nurse walking into a room and she pulled a bag over her head, and the bag was on her head for less than 30 seconds. On 3/7/23 at 3:10 p.m., she returned to the facility from the hospital. She continued to state she didn't want to come back to the facility. Her son didn't buy her anything, etc. Trash bags were removed from her room. On 3/7/23 at 10:03 p.m., she continued past behaviors. She was unwilling to talk. She stated she had no pain medication and refused hydrocodone. She desired to return to the hospital. On 4/10/23 at 10:03 p.m., she had tried to call her son multiple times with no answer. She exhibited attention seeking behaviors. She refused her evening medications. She came to the nurses' station and stated she wanted to go to the hospital because she was depressed and refused her night medications. The Psychiatric NP (Nurse Practitioner) was called with orders received for her to be monitored and put on 15 minute checks. The SSD was made aware. On 4/11/23 at 4:56 p.m., the QMA called the nurse to her room. The resident requested to be sent to the hospital because she was in pain. She reported she was unable to get pain medication like the other residents in the facility. Her hands were slightly shaking. She was hurting all over, especially her head. Her vital signs were within limits. The NP was made aware, with no new orders. They would continue to monitor her. On 4/11/23 at 8:05 p.m., she continued to complain about her pain, and she was offered acetaminophen (pain reliever). She refused and stated it would not help her, she wanted the pain medication she was promised. She was very upset, she said she needed to use the phone, and proceeded to call 911 to have them take her to the ER. She continued with attention seeking behaviors. The NP was called and an order was received to send her to the ER for evaluation and treatment. All parties were notified. The history of present illness from the local hospital dated 4/11/23 at 9:48 p.m., indicated she had suicidal ideations, with multiple attempts over the last six months and had attempted again today, when she placed a plastic bag over her head. She stated the reason for being suicidal was she did not like the facility she resided in currently. She felt the nurses were mean and did not give her adequate pain medication. She stated she would continue to attempt suicide if she was returned to the facility. During an interview with Resident C, on 4/12/23 at 1:42 p.m., she indicated she had gone to the hospital the previous night because she had put a bag over her head and she was brought back to the facility. The nurses and doctors were not good at the facility. They refused to give her any of her medications. She had a headache and they wanted to give her acetaminophen and it did not work for her. She was going to live the rest of her life in her room with no showers or nothing and she would die in this facility. During the interview with Resident C, there was a plastic bag observed in her trash can near her nightstand and a plastic bag in her bathroom trash can. During an interview, on 4/12/23 at 1:52 p.m., LPN 31 indicated it was different every other day for Resident C, as she would have a good day, then a bad day. It mattered how much attention she received, or if she didn't get the answers she wanted. She got obsessive with topics, such as not having shoes, clothing or bras. Her family lived out of state. She complained about clothes, when she received new clothes, she felt they were not the right size. She received the right sized clothes but she then threw them away or gave them away. Last night (4/11/23) she put a bag over her head. They were doing 15 minute checks on her. She was sent to the hospital and they put her on an antibiotic for a urinary tract infection. They had found towels and washcloths in her room and rolls of plastic bags. During an interview with the Housekeeping Supervisor, on 4/12/23 at 2:06 p.m., she indicated Resident C had been suicidal and put bags over her head. The Housekeeping Supervisor was informed, on 4/11/23, by the DON not to put plastic bags in her room. She had not told the other housekeepers not to put the bags in the resident's trash can. During an interview with Housekeeper 3 and Unit Manager 16, on 4/12/23 at 2:08 p.m., the Housekeeper indicated she was not aware Resident C was suicidal and not to put plastic bags in her trash cans until five minutes prior to the interview. Unit Manager 16 indicated on 4/11/23, they found three rolls of plastic bags under Resident C's mattress. During an interview with LPN 24, on 4/12/23 at 2:50 p.m., she indicated Resident C was basically having attention - seeking behaviors. She was upset about wanting a pain pill and had called 911. She continuously said she wanted to go to the hospital and she was going to do something to herself until she succeeded. She was on 15 minute checks. LPN 24 was told in report she had placed a bag over her head. The resident would get mad if her family didn't answer the phone and she would refuse to eat and take medications. During an interview with CNA 11, on 4/12/23 at 3:11 p.m., she indicated all she knew about Resident C was she liked to hoard things. She did not know of anyone, and had not been told of anyone, in the facility with suicidal ideation. She knew she was to check on Resident C every 15 minutes since she had been back from the hospital. During an interview with CNA 17, on 4/12/23 at 3:18 p.m., she indicated that Resident C had been suicidal on 4/11/23. She turned on her call light before supper when they were trying to get everyone to the dining room. She went to her room to answer her call light and she was in the act of putting a plastic trash bag on her head. The ADON removed the trash bags from three of the trash cans that were in her room. They brought her to the TV lounge. She didn't want to go to the dining room to eat so, she ate in her room. She told the nurse she was in pain and they gave her some medicine. She was on 15 minute checks and they encouraged her to go to activities. On 4/11/23 CNA 17 was told not to put trash bags in her room. During an interview with the ADON, on 4/13/23 at 11:20 a.m., she indicated she talked with Resident C, who said she was in pain and talked about the other residents getting medication. She had no outward signs of pain and she ignored difficult questions. The NP was notified of her complaints of pain and there were no new orders given. Because of her history she knew her, but if was the first time you met her, you may not see it like that. Later in the shift she did place a bag on her head. She was in the facility until 7:00 p.m. but worked as the nurse until 6:00 p.m. She was upset and continued to complain of pain and did not help, so she used the phone and called 911. The NP was made aware and there was an order to send to her to the ER at 10:05 p.m. She had not witnessed her putting a bag on her head and they did remove the bags from her room. She did not document in the nurse's notes when it was reported to her the resident had put a bag over her head. During an interview with QMA 9, on 4/13/23 at 2:27 p.m., she indicated on 4/11/23, Resident C mostly complained of having pain. She told her she could have acetaminophen, but she did not have other orders for pain. She refused to take acetaminophen. She would get upset and frustrated, she said she wanted to go to the hospital and she was going to put bags on her head, so they made sure she didn't have bags in her room. She was on 15 minute checks. She had not witnessed her putting a bag on her head but had seen her grab one. She got upset if she was unable to get ahold of her family, then she wanted to go to the hospital. She wanted pain medication and refused her medications. She had tried to put a bag on her head many times and would frequently say she would put a bag over her head. QMA 9 had done sweeps of her room before and removed bags from her room. She would hide them in her drawers or under her mattress. QMA 9 found eight rolls of bags in her room before. A 12/2007, revised policy titled, Suicide Threats, provided by the DON, on 4/13/23 at 3:12 p.m., indicated the following: .Policy Statement: Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation .5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately .7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record B. Resident E's clinical record was reviewed on 4/12/23 at 2:00 p.m. Diagnoses included catatonic schizophrenia, generalized anxiety disorder, type II diabetes mellitus without complications, schizoaffective disorder, bipolar type, essential (primary) hypertension, chronic obstructive pulmonary disease, diabetes mellitus due to underlying condition with diabetic neuropathy, and pain in left arm. His current physician orders included lisinopril (treat blood pressure) 40 mg daily, paliperidone palmitate (antipsychotic) 234 mg/1.5 ml (milliliters) every 28 days, trazodone (antidepressant) 100 mg daily, buspirone (antianxiety)10 mg twice daily, carvedilol (treat blood pressure) 6.25 mg twice daily, gabapentin (treat neuropathy) 300 mg twice daily, haloperidol (antipsychotic) 5 mg twice daily, tramadol (pain reliever) 50 mg every six hours as needed (4/9/23), and anti-roll back bars on wheelchair (11/9/22). His fall risk assessments, dated 2/22/23 and 4/12/23, indicated he was at a high risk for falls. A quarterly, 3/27/23, MDS (Minimum Data Set) assessment indicated he was cognitively intact. He required limited assistance of one staff member for bed mobility. He required extensive assistance of one staff member for transfers. He required supervision with set up help only for walking in his room, the corridor, and locomotion on the unit. He required supervision of one staff member for locomotion off the unit, dressing and personal hygiene. He required extensive assistance of two staff members for toilet use. He used a wheelchair. He had a current, 6/28/22, care plan for being at risk for falls. His goal was he would not sustain serious injury. His interventions included anticipate and meet his needs (6/28/22), assist with toileting (6/28/22), assist with transfers (6/28/22), he was to utilize foot wear with non-skid soles (6/28/22), he was to utilize a wheel chair with anti-roll back bars on it when outside smoking (8/31/22), and educate him on taking smaller, slower inhalations of his cigarette (9/20/22). Review of nurses notes indicated the following: A late entry nurses note, dated 4/7/23 at 10:13 a.m. and created on 4/12/23 at 10:17 a.m., indicated during routine care he was found to have a yellow/purple bruise covering his left arm/shoulder/armpit/hand, with swelling noted, and he had very limited ROM (Range of Motion). He complained of pain to the area and was unable to move his arm/hand. He reported he had fallen a couple of days ago. The ADON and the NP were made aware. On 4/7/23 at 7:21 p.m., he complained of pain, and his left arm had dark purple bruising from his armpit to his elbow. He had no ROM in his shoulder or his elbow. He was slightly able to move his fingers. He stated he fell in the dining room a few days ago. He had a history of being a poor historian. The ADON and NP was notified, and a new order was received to send him to the emergency room for an evaluation and treatment. A review of the final report of the emergency physician progress report, dated 4/7/23 at 9:33 p.m., indicated Resident E was brought to the emergency department with complaints of left upper extremity swelling. He stated that he fell a couple days ago and was noted to have a swollen left upper extremity with ecchymoses (discoloration from bruising) from the shoulder to the hand. An impression of an x-ray of his left humerus (upper arm bone) indicated comminuted (broken in at least two places) humerus fractures with mildly displaced fracture fragments and intra-articular (inside the joint) extension. On 4/8/23 at 8:00 a.m., he returned to the facility via ambulance. He had a fracture to his left humerus. He was to follow up with orthopedics in two to three days. A late entry social service note, dated 4/11/23 at 11:21 a.m. and created on 4/12/23 at 11:24 a.m., indicated he reported to a QMA that he fell in his room. He reported to the Social Service Director that he fell in the dining room after smoking and reported to the CNA that he fell in the bathroom. He was asked about this and he reported that he just fell . A late entry nurses note, dated 4/11/23 at 11:35 a.m. and created on 4/12/23 at 11:40 a.m., indicated he returned to the facility from an orthopedic appointment with new orders for a referral for a surgery consultation, scheduled for 4/14/23. He was encouraged to wear the sling but most of the times, he refused. During an interview with Resident E, on 4/12/23 at 2:25 p.m., he indicated he fell out of his wheelchair in the dining room. Two men helped him up off the floor. He could not remember when it happened, but thought it was in the afternoon. He sometimes walked, except when he went out to smoke, then staff put him in his wheelchair. During an interview with CNA 7, on 4/12/23 at 3:18 p.m., she indicated a little over a week ago, she thought, on Monday 4/3/23, at the last smoke break after supper, Resident E was outside. He had a lit cigarette in one hand and an unlit cigarette in his other hand. He walked in the door to the dining room and fell . She yelled for CNA 14 to get LPN 16. Resident E was trying to get up and she thought he was holding his left arm. LPN 16 and CNA 14 picked Resident E up off of the floor. During an interview with LPN 16, on 4/13/23 at 8:11 p.m., he indicated he did not have a recollection of Resident E falling on Monday 4/3/23, but he was not saying it didn't happen, he just couldn't recall. He was the only nurse most of the evenings he worked. It got extremely busy with the acuity level, behaviors, and being the only licensed nurse in the building. The typical procedure was, after a resident fell , he would put a note in the computer, enter the fall into risk management, and then let the ADON know about the fall. During an interview with CNA 14, on 4/13/23 at 8:27 p.m., he indicated on Monday 4/3/23, Resident E got up out of his wheelchair and started running into the building. He bounced off the doorway, stumbled, and fell on his face in the dining room. He went to get LPN 16. LPN 16 did an assessment on him, and together they got Resident E off of the floor. He did not complain of pain that night, but the next day he complained of pain in his left arm. An undated current facility policy titled, Fall Protocol, and provided by the DON, on 4/13/23 at 3:12 p.m., indicated the following: .1. Ensure resident safety. 2. Assess resident, check for any injuries, obtain vital signs. 3. Call physician's office .to determine if the resident should be sent to ER and make a progress note with this information. 4. Notify family .5. Complete required documentation: Risk management (includes progress note with description of what happened leading up to the fall) neuro checks if applicable. 6. Text Administrator, DON and ADON The immediate jeopardy that began on 4/11/23 was removed on 4/14/23, when the facility educated staff on suicidal threats protocol for the identification and reporting of threats, and the safety of residents with threats of suicide, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because all staff had not yet been educated. This Federal tag relates to complaint IN00405975. 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure a resident with dysphagia and at risk for choking received supervision while eating for 1 of 3 residents at risk for choking. This deficient practice resulted in the resident choking, coded, emergency services being called and the resident died on [DATE]. (Resident B) The immediate jeopardy began on [DATE] when a Certified Nursing Assistant served Resident B a peanut butter and jelly sandwich and left the resident with no assistance or supervision. The Administrator was notified of the immediate jeopardy on [DATE] at 4:07 p.m. Findings include: Review of an Indiana Department of Health (IDOH) reportable, provided by the Administrator on [DATE] at 10:40 a.m., indicated on [DATE] at approximately 8:01 p.m., staff entered the resident's room and found him unresponsive. The resident appeared to have soft food in his mouth, which the nurse removed. The resident did not have a pulse and Cardiopulmonary Resuscitation (CPR) was initiated due to possible choking. 911 was called CPR continued until Emergency Management Team (EMT) arrived and took over compressions. Review of a statement provided by Nurse Aide 1, indicated she was told by QMA 2 Resident B had a peanut butter and jelly sandwich for a snack. She was charting for her 2nd shift and decided to check on the resident. He was unresponsive so she called for the nurse on the hall to help. She was not in the room prior to finding the resident unresponsive. A statement by CNA 3 indicated she took the resident a peanut butter and jelly sandwich and that was the last time she saw him. She thought QMA 2 delivered his meal tray. A statement by QMA 3 indicated someone had given him the sandwich between 4:30 p.m. and 5:00 p.m. She was in his room when he was coming out of the bathroom. She was unsure who took his tray into his room. A statement by LPN 5 indicated she arrived at 6:00 p.m. At approximately 7:30 p.m. to 7:35 p.m., Nurse Aide 1 stepped out of the room and said something was wrong with Resident B. She opened the door and he was on the bed with his feet hanging off, leaning back. She checked for a pulse and ran to page for additional staff. QMA 2 was directed to call 911. She then grabbed the crash cart and removed soft food with a finger sweep from his mouth. She then began CPR until the EMTs arrived. The clinical record for Resident B was reviewed on [DATE] at 11:39 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], dysphagia and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. He required supervision with one staff member while eating. He required a therapeutic diet and had no swallowing disorders or difficulty chewing. A care plan, initiated [DATE], indicated the resident had self-care performance related to activity intolerance and musculoskeletal impairment. His goal was that he would maintain his current level of function. Interventions included, but not limited to, required supervision to total assistance for eating. A speech therapy evaluation was completed on [DATE] related to increased swallowing difficulty reported by nursing staff. The resident was to remain on a mechanical soft diet with thin liquids and required supervision with meals. No speech treatment was indicated at that time. Precautions included, but were not limited to, difficulty with self-feeding and occasional agitation when staff assisted with meals. A new order was received on [DATE] at 11:04 a.m., to give half of sandwich three times daily for potential weight gain. Staff were to provide a sandwich between meals and at night. A nurse's note, dated [DATE] at 2:42 a.m., indicated the resident had increased difficulty while swallowing thin liquids and increased drooling. Fluids were changed to nectar thick as a nursing measure. The physician and dietary were made aware. A nurse's note, dated [DATE] at 11:26 a.m., indicated the resident had increased difficulty swallowing. The physician was notified and a new order was received for speech to evaluate and treat. A dietary note, dated [DATE] at 8:49 p.m., indicated a current diet order for mechanical soft, ground meat and nectar thick liquids. Resident B also received a full sandwich three times daily between meals. The resident was able to feed himself with set-up and supervision. He has had increased issues swallowing and his diet was modified [DATE]. A new order, dated [DATE] at 11:09 a.m, indicated to provide a full sandwich three times daily between meals and at night for potential for weight loss. A progress note, dated [DATE] at 7:40 p.m., indicated a CNA went into the room and immediately asked for help. The nurse entered the room and found the resident laying on his back with soft food in his mouth. He did not respond to his name. The nurse completed a finger sweep to remove the food and checked for a pulse with no response. CPR was initiated and another staff person called 911. EMTs arrived and took over compressions. They were notified of the code status and requested paperwork. EMT indicated they had confirmed with the emergency room physician and declared his time of death 8:00 p.m. A late entry progress note, dated [DATE] at 2:20 p.m., indicated the resident refused his supper tray, but had a full sandwich and that was been noted in his mouth. During an interview on [DATE] at 1:02 p.m., the Director of Nursing (DON) indicated staff could find the level of assistance a resident required on the Kardex (desktop file system). During an interview on [DATE] at 2:34 p.m., LPN 5 indicated Nurse Aide 1 had come out of the room and seemed rattled and said something was wrong with Resident B. The resident usually ate in his room and was able to feed himself. When she entered, she noted food in his mouth and when she removed it, the food came out in pieces. She was unsure of what the food actually was. He often requested a peanut butter and jelly sandwich. During an interview on [DATE] at 2:53 p.m., Nurse Aide 1 indicated she had completed her CNA classes and was waiting to take the test. She was doing her charting and decided to ask him about his meals and snacks. She found him laying on his back, unresponsive. He had a blue tint and she said his names a couple times and he did not respond. She did not exit the room but remained in the doorway and called for the nurse. Staff initiated CPR while the aide provided care to other residents. He often ate a peanut butter and jelly sandwich. During an interview on [DATE] at 3:02 p.m., the MDS coordinator was asked if the resident had a diet waiver. She did not think he did, but she would check his hard chart. One was not scanned into the computer. On [DATE] at 3:20 p.m.,the MDS coordinator provided a hard copy diet waiver dated [DATE]. During a telephone interview on [DATE] at 8:57 a.m., Speech Therapist 6 indicated she has not been in the facility since the end of December. She recalled doing the evaluation, but had no other information related to Resident B. On [DATE] at 9:25 a.m., CNA 3 and the DON were interviewed. CNA 3 indicated the resident had requested several sandwiches throughout the day. She took him one around 4:30 p.m. and he put his call light on again and asked for another one. She indicated supper would be coming and to wait instead. The DON indicated the resident refused his supper tray and a peanut butter and jelly sandwich was substituted. She was unsure who took the resident the sandwich, possibly someone from dietary. CNA 3 indicated he ate most meals in his rooms and if you attempted to help him, he would yell and cuss at you. During an interview on [DATE] at 11:07 a.m., the DON indicated following the incident with Resident B, they realized they had a problem with Point Click Care (healthcare software) not being utilized as it should. They have since went in and modified residents who have specific identified risks that would then prompt staff as to their needs. During an interview on [DATE] at 11:15 a.m, the Assistant Director of Nursing (ADON) indicated both nurses and CNAs have to give a report to the oncoming staff person related to their needs and care. A current facility policy, dated [DATE], Meal Service and Supplements, provided by the DO Non [DATE] at 9:13 a.m. indicated the following: .Procedure: Meals Meal trays are prepared according to physician order and resident's likes and dislikes Alternate Foods or Substitutions Alternate food choices will be available to replace foods that are disliked, not tolerated, or to which the resident has an allergy The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility [NAME] staff regarding supervision during meals, encourage residents to eat in the dining room, frequent rounding during meal and snack time. Speech Therapy (ST) to screened all residents who were identified with swallowing difficulties and adding diet orders to the CNA task list. The noncompliance remained at no actual harm, but potential for minimal harm because monitoring was on going. This Federal tag relates to complaint IN 979. 3.,d+[DATE](a)(2)

Based on interview and record review the facility failed to prevent physical abuse by a staff member toward a resident for 1 of 4 residents reviewed for abuse (Resident B). This deficient practice resulted in LPN 1 slapping Resident B across the face. Findings include: The clinical record for Resident B was reviewed on 3/23/2022 at 10:45 a.m diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No cognitive assessment was available for review. During an observation on 3/23/2022 at 11:25 a.m., Resident B rested in bed with her eyes closed. During an observation on 3/23/2022 at 12:10 p.m., the resident ambullated in the hallway of the secured unit. The resident did not acknowledge nor speak when approached for interview. The resident was heard making nonsensical speech. No aggressive behavior was observed when staff re-directed the resident. During an interview on 3/23/2022 at 11:43 a.m., QMA (Qualified Medication Aide) 3 indicated Resident B had been awake and more than likely had been playing possum and that dependent on her mood, may or may not speak to the surveyor. The facility investigation (which was still in progress) on 3/23/2022 at 11:58 a.m., indicated on 3/21/2022 at 7:01 p.m., LPN 1 (agency staff) struck Resident B across the face in reaction to having been struck across the face by the resident. Review of a written statement by LPN 2, dated 3/21/2022 at 6:45 p.m., indicated the resident had been very anxious and wound up. LPN 2 had the resident at the nurses' station when LPN 1 arrived and grabbed the door and pulled it to her, shutting the door in front of the resident. The resident became upset and grabbed the door handle and shook it. The resident then smacked LPN 1 and LPN 1 reacted by smacking the resident in the face on the left cheek. LPN 1 stated she had just popped her. The resident was immediately removed from the nurses' station. Review of a progress note, dated 3/21/2022 at 7:00 p.m., indicated the resident was agitated, yelling and trying to open doors. The resident slapped another person and in return that person slapped the resident on the left side of her face. The two were separated immediately. During an interview on 3/23/2022 at 1:03 p.m., LPN 2 indicated on 3//21/2022 she had Resident B with her at the nurse's station to keep the resident from wandering into other residents' rooms. While she and Resident B were in the nurses's station, LPN 1 arrived on the unit and came to the nurses' station. LPN 1 pulled the door towards herself and stood in the doorway so the resident could not get out. Resident B grabbed the door handle and attempted to pull it open and leave the nurses' station. The resident hit LPN 1 on the arm and LPN 1 immediately smacked the resident across the face. During an interview on 3/23/2022 at 1:47 p.m., LPN 1 indicated on 3/21/2022 she went to the secured unit to inform the nurse they were getting an admission. She indicated Resident B was yelling and screaming. She attempted to talk around the resident and before she knew it the resident had cold cocked her in the face. She indicated she raised her hand and tapped her on the cheek. I told her people do not liked to be hit. Review of a current undated policy titled Abuse and Prevention Policy, provided by the Administrator on 3/23/2022 at 11:58, indicated the following: . Physical Abuse: 1. Actually laying hands on a resident in an abrupt manner. 2. Transporting a resident in an abrupt manner. 3. Striking a resident with an object. This Federal tag relates to Complaint IN 965. 3.1-27(a)(1)

Based on record review and interview the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for significant medication error. This deficient practice resulted in a resident having an altered mental status, being intubated and presenting in the emergency room with two opioid medication patches (Resident B). Findings include: The clinical record of Resident B was reviewed on 11/20/2018 at 11:00 AM. [DIAGNOSES REDACTED]. Review of the current Significant Change Minimum Data Set (MDS) assessment, dated 10/1/2018, indicated the resident was cognitively intact. Review of a care plan titled Substance Abuse- Addiction, dated 7/4/2018 last updated 10/18/2018, indicated the resident was addicted to pain medication and tobacco use. Interventions included, but were not limited to, medications as ordered. Current physician orders [REDACTED]. a. [MEDICATION NAME] ([MEDICATION NAME] medication) 100 mcg/hour to be change every 3 days. This order was dated 10/31/2018. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) indicted the [MEDICATION NAME] was removed on 11/8/2018 and a new patched placed. The MAR indicted the placement of the patch was checked every shift from 11/8/2018 through 11/11/2018 b. Remove the old [MEDICATION NAME] prior to placing the new patch and to check the placement of the patch every shift. This order was dated 10/31/2018. Review of the (MONTH) (YEAR) MAR indicated no discrepancies. Review of a nursing note, dated 11/11/2018, indicated the resident was found with a decreased level of consciousness and abnormal speech. Vital signs were documented as the following: blood pressure 70/49, heart rate of 159, respirations of 30 and oxygen saturation of 76% on room air. Review of a nursing progress note, dated 11/11/2018 at 4:15 PM, indicated the resident was sent to the emergency room via ambulance for suspicion of aspiration of emesis. Lung sound assessment indicated the resident had crackles noted throughout. Review of the emergency department (ED) physician progress notes [REDACTED]. The resident was intubated upon arrival to the emergency room . The emergency response team indicated the resident was unresponsive when they arrived to the facility but would respond to painful stimuli. The ED Physician note indicated the resident presented with two [MEDICATION NAME]es to the left chest, which were removed upon arrival, and had been medicated with [MEDICATION NAME] earlier that day. No photographs or description of the patches available. Review of the Inpatient Critical Care Progress Note, dated 11/12/2018, indicated Resident B was admitted to the ICU for altered mental status- possibly related to opiates and acute [MEDICAL CONDITION]-possibly related to opiates/aspiration pneumonia. During an interview on 11/20/2018 at 9:07 AM, the ED Physician indicated the resident was already intubated upon arrival to the facility and presented with two [MEDICATION NAME]es. During an interview on 11/20/2018 at 1:03 PM, LPN 2 indicated she had been working the 6:00 AM to 2:30 PM shift on 11/11/2018 and provided care to Resident B. LPN 2 indicated the resident behaved normally during the shift and did not display any abnormal behaviors. The resident was a known drug seeker. The patch placement was checked and no concerns were noted. She indicated RN 5 worked the evening shift. During an interview on 11/20/2018 at 1:12 PM., the DON (Director of Nursing) indicated she had not been in the facility at the time Resident B was sent to the hospital. She indicated when she returned to the facility the following Monday, she called the hospital for information related to the resident. She was told about the concern related to the patches. The DON provided staff education related to medication administration after she talked to the hospital. She indicated no other investigation was performed. Multiple unsuccessful attempts were made to contact RN 5 throughout the survey. Review of a current undated policy, titled [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] Patch Monitoring And Destruction and provided by the Corporate Clinical Consultant on 11/20/2018 at 1:44 PM indicated the following: Purpose: [MEDICATION NAME]es shall be monitored and discarded in a manner to assure the prevention of illegal use/diversion. Policy: It is the policy of this facility to appropriately monitor use and to discarded/destroy used or discontinued [MEDICATION NAME]es in a manner to prevent potential diversion. Procedure: 1. A [MEDICATION NAME] should be administered as per physician's orders [REDACTED]. Said dating will prevent false documentation of a replacement patch, when the original patch might be re-used and the new patch diverted. 2. In most cases, the patch will be replaced at a frequency of every (3) days. Thus, subsequent to initial application, each shift thereafter must visually inspect the resident for the presence of the patch and initial the medication administration record which will denote the observed presence of the patch, in place, intact, and without indication of tampering. This federal tag relates to Complaint IN 341. 3.1-48(c)(2)

Based on clinical record review and interview, the facility failed to ensure continued contact was made with the physician related to a resident's problem with penile discharge (Resident #L), and failed to notify the physician promptly when a resident developed an open area (Resident #44), for 2 of 9 residents reviewed for physician notification in a Stage 2 Sample of 36. Findings include: 1.) The clinical record for Resident #L was reviewed on 2/4/12 at 2 p.m. [DIAGNOSES REDACTED]. A health care plan problem, dated 5/25/11 and reviewed on 11/23/11, indicated Resident #L The clinical record indicated the resident had an anchored foley catheter and problems with chronic urinary tract infections related to a history of [MEDICAL CONDITION] secondary to a urethral stricture. Interventions for this problem included, but were not limited to, administer "medications as ordered" and "observe urine color, amount, odor, consistency, and frequency and notify the charge nurse of noted problems for further evaluation and possible physician and responsible party notification." A nursing note, dated 11/21/11 at 10:00 p.m., indicated "Res (resident) noted to have moderate amt (amount) of penile discharge this shift-brownish, creamy. No c/o (complaints of) pain in penile/scrotal area..... Will cont (continue) to monitor for discharge." The clinical record lacked any information related to the physician having been made aware of the resident's penile discharge. Nursing notes, dated 11/22/11 at 2:20 a.m. and 2 p.m. indicated no penile drainage was noted at those times. A nursing note, dated 11/22/11 at 10:00 p.m., indicated "Res having large amt of creamy brownish discharge from penis. No c/o pain. +malodorous. Increase amt when res turned. Res to see MD (medical doctor) at next available time for eval (evaluation)...." A nursing note, dated 11/23/11 at 2 p.m., indicated the physician had looked at the resident related to his penile discharge and no orders were received at that time. The note did not indicate whether the resident had a penile discharge at the time of the physicians visit. The clinical record lacked any physician progress notes [REDACTED]. A nursing note, dated 11/23/11 at 10 p.m., indicated a slight amount of brownish creamy colored penile discharge had been noted on that shift. A nursing note, dated 11/24/11 at 10 p.m., indicated a small amount of brownish creamy penile discharge had been noted. A nursing note, dated 11/25/11 at 2 p.m., indicated "Mod amount discharge from penis and light brown in color...." A nursing note, dated 11/25/11 at 8:05 p.m., indicated "When resident turned and repositioned, moderate amount of light brown thin foul smelling drainage comes from penis...." A nursing note, dated 11/26/11 at 1:55 p.m., indicated "res has had a small amt of drainage from penis...." A nursing note, dated 11/26/11 at 10 p.m., indicated "...small amt of creamy brownish discharge noted from penis...." A nursing note, dated 11/27/11 at 5 a.m., indicated "Res noted to have small amt of brownish/yellow penile discharge this shift..." A nursing note, dated 11/27/11 at 1:30 p.m., indicated "Res continues to have small amt of drainage from penis." A nursing note, dated 11/27/11 at 10 p.m., indicated "Res has sm (small) amt of creamy discharge from penis.... Res c/o pain all over-requested pain pill...." A nursing note, dated 11/28/11 at 2:25 p.m., indicated "Res had small amt of discharge...." The clinical record lacked any physician notification of the resident's continued problems with penile discharge and/or the development of a foul smell associated with the drainage from the time of the physician's visit on 11/23/11 and the visit by the Nurse Practitioner noted below late in the evening on 11/28/11. A nursing note, dated 11/28/11 at 11:20 p.m., indicated "Nurse Practitioner here and receive new order." A progress note written at the time of this visit indicated the resident had a brown mucus penile discharge and the assessment was "Candidiasis." A physician's orders [REDACTED]. During an interview with the Director of Nursing (DoN) on 2/7/12 at 10:40 a.m., additional information was requested related to the delay in making the physician aware of the continued drainage and foul odor of the drainage noted above During an interview on 2/7/12 at 2:25 p.m., the DoN indicated she had no information to provide related to physician notification of the continued penile drainage and development of a foul odor associated with the drainage as noted above. 2.) The clinical record for Resident #44 was reviewed on 2/2/12 at 10:50 a.m. Resident # 44's current [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, dated 10/27/11, indicated the resident was totally dependent upon the staff for all activities of daily living. A Braden Scale (a tool used to predict the risk of developing pressure sores), dated 10/26/11, indicated Resident #44 was at a high risk for developing a pressure sore. The resident had a healthcare plan initiated 5/6/11 and updated 1/31/12 which indicated the resident had a problem listed as, is at risk for development of pressure ulcers due to decreased mobility, Alzheimer's dementia, [MEDICAL CONDITION], bowel and bladder incontinence, delicate skin and history of pressure areas. Interventions for this problem included, but were not limited to, staff to observe skin when providing care, notify the charge nurses of any skin problems for further assessment and possible physician and responsible party notification, apply preventive topical medication as ordered and notify Hospice of any skin issues. The resident had a physician's orders [REDACTED]. The original order date was 1/14/11. The treatment sheets for October, November, December 2011 indicated the 1:1:1 ointment was applied every shift until 12/12/11. A nursing note,dated 12/9/11 (Friday), indicated the following, resident has a 3 centimeter by 3 centimeter bright red open area on top of right buttock - was informed by the hospice aide, skin sheet initiated. The skin sheet for Resident #44, dated 12/9/11, indicated the resident had a Stage 2 open area to the right buttock. The nurses notes lacked any indication the physician was notified of the open area until 12/12/11. (Monday) A physician's orders [REDACTED]. The December 2011 treatment sheet for Resident #44 indicated the "Dr. D's" treatment to the open area was started on 12/12/11. The weekly skin sheet indicated the open area was assessed on 12/16/11 and the area had remained unchanged in size. During an interview with the Director of Nursing on 2/3/12 at 4:00 p.m. additional information was requested related to the delay in treatment of [REDACTED]. During an interview with the Director of Nursing on 2/7/12 at 1:30 p.m. she indicated she had no additional information to provide related to the resident having a pressure area observed on 12/9/11 and no change in treatment was given until 12/12/11. She indicated the physician should be notified when an open area was first observed and treatment started as soon as possible. This resulted in a 3 day period of the resident having an open area and receiving no medical treatment to the area. 3.) Review of the current facility policy, dated 1/06, titled "ACUTE CHANGE IN CONDITION/EMERGENCY PHYSICIAN SERVICES PROCEDURE," provided by the Director of Nursing on 2/7/12 at 8:25 a.m., included, but was not limited to, the following: "Purpose: To ensure an acute change in a resident's condition will be addressed in a timely manner as it pertains to needed transfer to an acute care setting. Procedure: 1. Contact the attending physician/on-call physician when the resident's condition requires immediate attention or acute care follow-up. 2. If the attending or on-call physician is not available or does not return the phone call, contact the facility's medical director...." This federal tag relates to Complaint IN 436. 3.1-5(a)(2) 3.1-5(a)(3)

Based on clinical record review and interview, the facility failed to ensure medication was given as ordered by the physician (Resident #L), failed to ensure sliding scale insulin was given in accordance with physician's orders [REDACTED].#44), for 3 of 36 residents reviewed for following the plan of care in a Stage 2 Sample of 36. Findings include: 1.) The clinical record for Resident #L was reviewed on 2/4/12 at 2 p.m. [DIAGNOSES REDACTED]. A nursing note, dated 11/27/11 at 5 a.m., indicated "Res noted to have small amt of brownish/yellow penile discharge this shift..." A nursing note, dated 11/27/11 at 1:30 p.m., indicated "Res continues to have small amt of drainage from penis." A nursing note, dated 11/27/11 at 10 p.m., indicated "Res has sm (small) amt of creamy discharge from penis.... Res c/o pain all over-requested pain pill...." A nursing note, dated 11/28/11 at 2:25 p.m., indicated "Res had small amt of discharge...." A nursing note, dated 11/28/11 at 11:20 p.m., indicated "Nurse Practitioner here and receive new order." A progress note written at the time of this visit indicated the resident had a brown mucus penile discharge and the assessment was "Candidiasis." A physician's orders [REDACTED]. This order was transcribed to the November 2011 medication administration record (MAR). The MAR lacked any documentation that the medication was given. The dates the medication was to be given were blank without any initials. The nursing notes for November 29, 30, and December 1, 2011 lacked any documentation related to the medication having been given. During an interview with the Director of Nursing (DoN) on 2/7/12 at 10:40 a.m., additional information was requested related to the lack of documentation of the [MEDICATION NAME] medication having been given as ordered by the physician. During an interview on 2/7/12 at 2:25 p.m., the DoN indicated she did not know why the nursing staff had not given the [MEDICATION NAME] medication as ordered by the physician on 11/28/11. 2.) Clinical record review for Resident #58 was reviewed on 2/2/12 at 2:00 p.m. [DIAGNOSES REDACTED]. Resident #58 had a health care plan problem, dated 10/20/11 and last reviewed on 1/19/12, which indicated she was at risk for experiencing [DIAGNOSES REDACTED] and/or [MEDICAL CONDITION] related to her [DIAGNOSES REDACTED]." The November 2011, December 2011, January 2012, and current physician's orders [REDACTED]. Accuchecks tid (three times daily) and at bedtime. Call MD if blood sugar below 50 or above 500. Humalog sliding scale coverage at bedtime: 200-250=2 units, 251-300=4 units, 301-350=6 units, 351-400=8 units, 401-450=10 units, 451-500=12 units These accucheck and sliding scale insulin coverage orders were present on the medication administration records (MAR) worded as above. Documentation of the sliding scale readings and insulin given was not recorded on the MARs. A notation on the MAR indicated "See flow sheets." The "Blood glucose monitoring records" for those months indicated accuchecks were being done three times daily before meals. No accuchecks were being completed at bedtime. The monitoring records indicated sliding scale insulin was being given based on the before meal accucheck readings which was not in accordance with the sliding scale insulin order noted above on the physician's recapitulation of orders. Sliding scale insulin coverage ranging between 2 and 6 units was given before meals on over 75 occasions during those months based on the accucheck readings. The physician's orders [REDACTED]. During an interview with the RN consultant on 2/6/12 at 1:30 p.m., additional information was requested related to the physician's orders [REDACTED]. [REDACTED]. During an interview with the DON on 2/6/12 at 1:40 p.m., she provided a telephone order, dated 10/11/11, which indicated coverage at bedtime was to be discontinued, but sliding scale insulin was to be given as noted above tid before meals based on the accucheck results. She provided a telephone order, dated 10/17/11, which indicated the bedtime accucheck was to be discontinued (since no coverage was to be given). She indicated she did not know why these orders were not correct on the physician's recapitulation of orders and did not know why nursing and/or pharmacy staff had not noted the errors. She indicated the physician had been contacted related to the discrepancies noted above. She provided a physician's orders [REDACTED]. 3. The clinical record for Resident #44 was reviewed on 2/2/12 at 10:50 a.m. Resident # 44's current [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, dated 10/27/11, indicated the resident was totally dependent upon the staff for all activities of daily living. A Braden Scale (a tool used to predict the risk of developing pressure sores), dated 10/26/11, indicated Resident #44 was at a high risk for developing a pressure sore. The resident had a healthcare plan initiated 5/6/11 and updated 1/31/12 which indicated the resident had a problem listed as, is at risk for development of pressure ulcers due to decreased mobility, Alzheimer's dementia, [MEDICAL CONDITION], bowel and bladder incontinence, delicate skin and history of pressure areas. Interventions for this problem included, but were not limited to, staff to observe skin when providing care, notify the charge nurses of any skin problems for further assessment and possible physician and responsible party notification, apply preventive topical medication as ordered and notify Hospice of any skin issues. The resident had a physician's orders [REDACTED]. The original order date was 1/14/11. The treatment sheets for October, November, December 2011 indicated the 1:1:1 ointment was applied every shift until 12/12/11. A nursing note,dated 12/9/11 (Friday), indicated the following, resident has a 3 centimeter by 3 centimeter bright red open area on top of right buttock - was informed by the hospice aide, skin sheet initiated. The skin sheet for Resident #44, dated 12/9/11, indicated the resident had a Stage 2 open area to the right buttock. The nurses notes lacked any indication the physician was notified of the open area until 12/12/11. (Monday) A physician's orders [REDACTED]. The December 2011 treatment sheet for Resident #44 indicated the "Dr. D's" treatment to the open area was started on 12/12/11. The weekly skin sheet indicated the open area was assessed on 12/16/11 and the area had remained unchanged in size. During an interview with the Director of Nursing on 2/3/12 at 4:00 p.m. additional information was requested related to the delay in treatment of [REDACTED]. During an interview with the Director of Nursing on 2/7/12 at 1:30 p.m. she indicated she had no additional information to provide related to the resident having a pressure area observed on 12/9/11 and no change in treatment was given until 12/12/11. She indicated the physician should be notified when an open area was first observed and treatment started as soon as possible. This resulted in a 3 day period of the resident having an open area and receiving no medical treatment to the area. This federal tag relates to Complaint IN 436. 3.1-35(g)(2)

Based on clinical record review and interview, the facility failed to ensure continued contact was made with the physician related to a resident's problem with penile discharge (Resident #L), and failed to notify the physician promptly when a resident developed an open area (Resident #44), for 2 of 9 residents reviewed for physician notification in a Stage 2 Sample of 36. Findings include: 1.) The clinical record for Resident #L was reviewed on 2/4/12 at 2 p.m. [DIAGNOSES REDACTED]. A health care plan problem, dated 5/25/11 and reviewed on 11/23/11, indicated Resident #L had an anchored foley catheter and problems with chronic urinary tract infections related to a history of [MEDICAL CONDITION] secondary to a urethral stricture. Interventions for this problem included, but were not limited to, administer "medications as ordered" and "observe urine color, amount, odor, consistency, and frequency and notify the charge nurse of noted problems for further evaluation and possible physician and responsible party notification." A nursing note, dated 11/21/11 at 10:00 p.m., indicated "Res (resident) noted to have moderate amt (amount) of penile discharge this shift-brownish, creamy. No c/o (complaints of) pain in penile/scrotal area..... Will cont (continue) to monitor for discharge." The clinical record lacked any information related to the physician having been made aware of the resident's penile discharge. Nursing notes, dated 11/22/11 at 2:20 a.m. and 2 p.m. indicated no penile drainage was noted at those times. A nursing note, dated 11/22/11 at 10:00 p.m., indicated "Res having large amt of creamy brownish discharge from penis. No c/o pain. +malodorous. Increase amt when res turned. Res to see MD (medical doctor) at next available time for eval (evaluation)...." A nursing note, dated 11/23/11 at 2 p.m., indicated the physician had looked at the resident related to his penile discharge and no orders were received at that time. The note did not indicate whether the resident had a penile discharge at the time of the physicians visit. The clinical record lacked any physician progress notes [REDACTED]. A nursing note, dated 11/23/11 at 10 p.m., indicated a slight amount of brownish creamy colored penile discharge had been noted on that shift. A nursing note, dated 11/24/11 at 10 p.m., indicated a small amount of brownish creamy penile discharge had been noted. A nursing note, dated 11/25/11 at 2 p.m., indicated "Mod amount discharge from penis and light brown in color...." A nursing note, dated 11/25/11 at 8:05 p.m., indicated "When resident turned and repositioned, moderate amount of light brown thin foul smelling drainage comes from penis...." A nursing note, dated 11/26/11 at 1:55 p.m., indicated "res has had a small amt of drainage from penis...." A nursing note, dated 11/26/11 at 10 p.m., indicated "...small amt of creamy brownish discharge noted from penis...." A nursing note, dated 11/27/11 at 5 a.m., indicated "Res noted to have small amt of brownish/yellow penile discharge this shift..." A nursing note, dated 11/27/11 at 1:30 p.m., indicated "Res continues to have small amt of drainage from penis." A nursing note, dated 11/27/11 at 10 p.m., indicated "Res has sm (small) amt of creamy discharge from penis.... Res c/o pain all over-requested pain pill...." A nursing note, dated 11/28/11 at 2:25 p.m., indicated "Res had small amt of discharge...." The clinical record lacked any physician notification of the resident's continued problems with penile discharge and/or the development of a foul smell associated with the drainage from the time of the physician's visit on 11/23/11 and the visit by the Nurse Practitioner noted below late in the evening on 11/28/11. A nursing note, dated 11/28/11 at 11:20 p.m., indicated "Nurse Practitioner here and receive new order." A progress note written at the time of this visit indicated the resident had a brown mucus penile discharge and the assessment was "Candidiasis." A physician's orders [REDACTED]. During an interview with the Director of Nursing (DoN) on 2/7/12 at 10:40 a.m., additional information was requested related to the delay in making the physician aware of the continued drainage and foul odor of the drainage noted above During an interview on 2/7/12 at 2:25 p.m., the DoN indicated she had no information to provide related to the lack of physician notification of the continued penile drainage and development of a foul odor associated with the drainage as noted above. 2.) The clinical record for Resident #44 was reviewed on 2/2/12 at 10:50 a.m. Resident # 44's current [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, dated 10/27/11, indicated the resident was totally dependent upon the staff for all activities of daily living. A Braden Scale (a tool used to predict the risk of developing pressure sores), dated 10/26/11, indicated Resident #44 was at a high risk for developing a pressure sore. The resident had a healthcare plan initiated 5/6/11 and updated 1/31/12 which indicated the resident had a problem listed as, is at risk for development of pressure ulcers due to decreased mobility, Alzheimer's dementia, [MEDICAL CONDITION], bowel and bladder incontinence, delicate skin and history of pressure areas. Interventions for this problem included, but were not limited to, staff to observe skin when providing care, notify the charge nurses of any skin problems for further assessment and possible physician and responsible party notification, apply preventive topical medication as ordered and notify Hospice of any skin issues. The resident had a physician's orders [REDACTED]. The original order date was 1/14/11. The treatment sheets for October, November, December 2011 indicated the 1:1:1 ointment was applied every shift until 12/12/11. A nursing note,dated 12/9/11 (Friday), indicated the following, resident has a 3 centimeter by 3 centimeter bright red open area on top of right buttock - was informed by the hospice aide, skin sheet initiated. The skin sheet for Resident #44, dated 12/9/11, indicated the resident had a Stage 2 open area to the right buttock. The nurses notes lacked any indication the physician was notified of the open area until 12/12/11. (Monday) A physician's orders [REDACTED]. The December 2011 treatment sheet for Resident #44 indicated the "Dr. D's" treatment to the open area was started on 12/12/11. The weekly skin sheet indicated the open area was assessed on 12/16/11 and the area had remained unchanged in size. During an interview with the Director of Nursing on 2/3/12 at 4:00 p.m. additional information was requested related to the delay in treatment of [REDACTED]. During an interview with the Director of Nursing on 2/7/12 at 1:30 p.m. she indicated she had no additional information to provide related to the resident having a pressure area observed on 12/9/11 and no change in treatment was given until 12/12/11. She indicated the physician should be notified when an open area was first observed and treatment started as soon as possible. This resulted in a 3 day period of the resident having an open area and receiving no medical treatment to the area. 3.) Review of the current facility policy, dated 1/06, titled "ACUTE CHANGE IN CONDITION/EMERGENCY PHYSICIAN SERVICES PROCEDURE," provided by the Director of Nursing on 2/7/12 at 8:25 a.m., included, but was not limited to, the following: "Purpose: To ensure an acute change in a resident's condition will be addressed in a timely manner as it pertains to needed transfer to an acute care setting. Procedure: 1. Contact the attending physician/on-call physician when the resident's condition requires immediate attention or acute care follow-up. 2. If the attending or on-call physician is not available or does not return the phone call, contact the facility's medical director...." 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure medication was given as ordered by the physician (Resident #L), failed to ensure sliding scale insulin was given in accordance with physician's orders [REDACTED].#44), for 3 of 36 residents reviewed for following the plan of care in a Stage 2 Sample of 36. Findings include: 1.) The clinical record for Resident #L was reviewed on 2/4/12 at 2 p.m. [DIAGNOSES REDACTED]. A nursing note, dated 11/27/11 at 5 a.m., indicated "Res noted to have small amt of brownish/yellow penile discharge this shift..." A nursing note, dated 11/27/11 at 1:30 p.m., indicated "Res continues to have small amt of drainage from penis." A nursing note, dated 11/27/11 at 10 p.m., indicated "Res has sm (small) amt of creamy discharge from penis.... Res c/o pain all over-requested pain pill...." A nursing note, dated 11/28/11 at 2:25 p.m., indicated "Res had small amt of discharge...." A nursing note, dated 11/28/11 at 11:20 p.m., indicated "Nurse Practitioner here and receive new order." A progress note written at the time of this visit indicated the resident had a brown mucus penile discharge and the assessment was "Candidiasis." A physician's orders [REDACTED]. This order was transcribed to the November 2011 medication administration record (MAR). The MAR lacked any documentation that the medication was given. The dates the medication was to be given were blank without any initials. The nursing notes for November 29, 30, and December 1, 2011 lacked any documentation related to the medication having been given. During an interview with the Director of Nursing (DoN) on 2/7/12 at 10:40 a.m., additional information was requested related to the lack of documentation of the [MEDICATION NAME] medication having been given as ordered by the physician. During an interview on 2/7/12 at 2:25 p.m., the DoN indicated she did not know why the nursing staff had not given the [MEDICATION NAME] medication as ordered by the physician on 11/28/11. 2.) Clinical record review for Resident #58 was reviewed on 2/2/12 at 2:00 p.m. [DIAGNOSES REDACTED]. Resident #58 had a health care plan problem, dated 10/20/11 and last reviewed on 1/19/12, which indicated she was at risk for experiencing [DIAGNOSES REDACTED] and/or [MEDICAL CONDITION] related to her [DIAGNOSES REDACTED]." The November 2011, December 2011, January 2012, and current physician's orders [REDACTED]. Accuchecks tid (three times daily) and at bedtime. Call MD if blood sugar below 50 or above 500. Humalog sliding scale coverage at bedtime: 200-250=2 units, 251-300=4 units, 301-350=6 units, 351-400=8 units, 401-450=10 units, 451-500=12 units These accucheck and sliding scale insulin coverage orders were present on the medication administration records (MAR) worded as above. Documentation of the sliding scale readings and insulin given was not recorded on the MARs. A notation on the MAR indicated "See flow sheets." The "Blood glucose monitoring records" for those months indicated accuchecks were being done three times daily before meals. No accuchecks were being completed at bedtime. The monitoring records indicated sliding scale insulin was being given based on the before meal accucheck readings which was not in accordance with the sliding scale insulin order noted above on the physician's recapitulation of orders. Sliding scale insulin coverage ranging between 2 and 6 units was given before meals on over 75 occasions during those months based on the accucheck readings. The physician's orders [REDACTED]. During an interview with the RN consultant on 2/6/12 at 1:30 p.m., additional information was requested related to the physician's orders [REDACTED]. [REDACTED]. During an interview with the DON on 2/6/12 at 1:40 p.m., she provided a telephone order, dated 10/11/11, which indicated coverage at bedtime was to be discontinued, but sliding scale insulin was to be given as noted above tid before meals based on the accucheck results. She provided a telephone order, dated 10/17/11, which indicated the bedtime accucheck was to be discontinued (since no coverage was to be given). She indicated she did not know why these orders were not correct on the physician's recapitulation of orders and did not know why nursing and/or pharmacy staff had not noted the errors. She indicated the physician had been contacted related to the discrepancies noted above. She provided a physician's orders [REDACTED]. 3. The clinical record for Resident #44 was reviewed on 2/2/12 at 10:50 a.m. Resident # 44's current [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, dated 10/27/11, indicated the resident was totally dependent upon the staff for all activities of daily living. A Braden Scale (a tool used to predict the risk of developing pressure sores), dated 10/26/11, indicated Resident #44 was at a high risk for developing a pressure sore. The resident had a healthcare plan initiated 5/6/11 and updated 1/31/12 which indicated the resident had a problem listed as, is at risk for development of pressure ulcers due to decreased mobility, Alzheimer's dementia, [MEDICAL CONDITION], bowel and bladder incontinence, delicate skin and history of pressure areas. Interventions for this problem included, but were not limited to, staff to observe skin when providing care, notify the charge nurses of any skin problems for further assessment and possible physician and responsible party notification, apply preventive topical medication as ordered and notify Hospice of any skin issues. The resident had a physician's orders [REDACTED]. The original order date was 1/14/11. The treatment sheets for October, November, December 2011 indicated the 1:1:1 ointment was applied every shift until 12/12/11. A nursing note,dated 12/9/11 (Friday), indicated the following, resident has a 3 centimeter by 3 centimeter bright red open area on top of right buttock - was informed by the hospice aide, skin sheet initiated. The skin sheet for Resident #44, dated 12/9/11, indicated the resident had a Stage 2 open area to the right buttock. The nurses notes lacked any indication the physician was notified of the open area until 12/12/11. (Monday) A physician's orders [REDACTED]. The December 2011 treatment sheet for Resident #44 indicated the "Dr. D's" treatment to the open area was started on 12/12/11. The weekly skin sheet indicated the open area was assessed on 12/16/11 and the area had remained unchanged in size. During an interview with the Director of Nursing on 2/3/12 at 4:00 p.m. additional information was requested related to the delay in treatment of [REDACTED]. During an interview with the Director of Nursing on 2/7/12 at 1:30 p.m. she indicated she had no additional information to provide related to the resident having a pressure area observed on 12/9/11 and no change in treatment was given until 12/12/11. She indicated the physician should be notified when an open area was first observed and treatment started as soon as possible. This resulted in a 3 day period of the resident having an open area and receiving no medical treatment to the area. 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure continued contact was made with the physician and medication was given as ordered by the physician to prevent a decline in the residents condition resulting in the need for antibiotic therapy and hospitalization for 1 of 6 residents (Resident #L) reviewed for monitoring of a change in condition and failed to ensure sliding scale insulin was correctly given as ordered by the physician for 1 of 5 residents (Resident #B) reviewed for insulin administration in a Stage 2 Sample of 36. Findings include: 1.) The clinical record for Resident #L was reviewed on 2/4/12 at 2 p.m. [DIAGNOSES REDACTED]. A health care plan problem, dated 5/25/11 and reviewed on 11/23/11, indicated Resident #L The clinical record indicated the resident had an anchored foley catheter and problems with chronic urinary tract infections related to a history of [MEDICAL CONDITION] secondary to a urethral stricture. Interventions for this problem included, but were not limited to, administer "medications as ordered" and "observe urine color, amount, odor, consistency, and frequency and notify the charge nurse of noted problems for further evaluation and possible physician and responsible party notification." A nursing note, dated 11/21/11 at 10:00 p.m., indicated "Res (resident) noted to have moderate amt (amount) of penile discharge this shift-brownish, creamy. No c/o (complaints of) pain in penile/scrotal area..... Will cont (continue) to monitor for discharge." The clinical record lacked any information related to the physician having been made aware of the resident's penile discharge. Nursing notes, dated 11/22/11 at 2:20 a.m. and 2 p.m. indicated no penile drainage was noted at those times. A nursing note, dated 11/22/11 at 10:00 p.m., indicated "Res having large amt of creamy brownish discharge from penis. No c/o pain. +malodorous. Increase amt when res turned. Res to see MD (medical doctor) at next available time for eval (evaluation)...." A nursing note, dated 11/23/11 at 2 p.m., indicated the physician had looked at the resident related to his penile discharge and no orders were received at that time. The note did not indicate whether the resident had a penile discharge at the time of the physicians visit. The clinical record lacked any physician progress notes [REDACTED]. A nursing note, dated 11/23/11 at 10 p.m., indicated a slight amount of brownish creamy colored penile discharge had been noted on that shift. A nursing note, dated 11/24/11 at 10 p.m., indicated a small amount of brownish creamy penile discharge had been noted. A nursing note, dated 11/25/11 at 2 p.m., indicated "Mod amount discharge from penis and light brown in color...." A nursing note, dated 11/25/11 at 8:05 p.m., indicated "When resident turned and repositioned, moderate amount of light brown thin foul smelling drainage comes from penis...." A nursing note, dated 11/26/11 at 1:55 p.m., indicated "res has had a small amt of drainage from penis...." A nursing note, dated 11/26/11 at 10 p.m., indicated "...small amt of creamy brownish discharge noted from penis...." A nursing note, dated 11/27/11 at 5 a.m., indicated "Res noted to have small amt of brownish/yellow penile discharge this shift..." A nursing note, dated 11/27/11 at 1:30 p.m., indicated "Res continues to have small amt of drainage from penis." A nursing note, dated 11/27/11 at 10 p.m., indicated "Res has sm (small) amt of creamy discharge from penis.... Res c/o pain all over-requested pain pill...." A nursing note, dated 11/28/11 at 2:25 p.m., indicated "Res had small amt of discharge...." The clinical record lacked any physician notification of the resident's continued problems with penile discharge and/or the development of a foul smell associated with the drainage from the time of the physician's visit on 11/23/11 and the visit by the Nurse Practitioner noted below late in the evening on 11/28/11. A nursing note, dated 11/28/11 at 11:20 p.m., indicated "Nurse Practitioner here and receive new order." A progress note written at the time of this visit indicated the resident had a brown mucus penile discharge and the assessment was "Candidiasis." A physician's orders [REDACTED]. This order was transcribed to the November 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The dates the medication was to be given were blank without any initials. The nursing notes for November 29, 30, and December 1, 2011 lacked any documentation related to the medication having been given. A nursing note, dated 11/29/11 at 1:15 p.m., indicated "Noted res has mod amt drainage from penis. Scrotum swollen.... Call placed to (name of nurse practitioner). Message left..." A nursing note, dated 11/29/11 at 5 p.m., indicated "...scrotum swollen. MD made aware...." A physician's orders [REDACTED]. The nursing notes indicated that Resident #L was seen by the physician on 11/30/11 at 12:45 p.m. Oral antibiotic therapy and intramuscular antibiotic therapy was ordered. The resident was to be sent to a urologist in 2-3 days if the swelling did not subside. The resident continued to have problems with scrotal swelling and swelling of the right testicle was noted on 12/1/11. A scrotal ultrasound was ordered and completed on 12/2/11 with abnormal results. After consult with the family, the resident was sent to the emergency room for evaluation on 12/2/11 and then admitted to the hospital for treatment of [REDACTED]. During an interview with the Director of Nursing (DoN) on 2/7/12 at 10:40 a.m., additional information was requested related to the delay in making the physician aware of the continued drainage and foul odor of the drainage noted above and the lack of documentation of the [MEDICATION NAME] medication having been given as ordered by the physician. During an interview on 2/7/12 at 2:25 p.m., the DoN indicated she had no information to provide related to physician notification of the continued penile drainage and development of a foul odor to the drainage noted above. She indicated she did not know why the nursing staff had not given the [MEDICATION NAME] medication as ordered by the physician on 11/28/11. 2.) The clinical record for Resident #B was reviewed on 2/3/11 at 1:16 p.m. Resident #B's current [DIAGNOSES REDACTED]. Resident #B had physician's orders [REDACTED]. A. [MEDICATION NAME] (insulin) inject 5 units subcutaneous every morning. The original date of this order was 1/19/12. B. Humalog (insulin) inject 14 units subcutaneous daily at noon with meal and 10 units with evening meal. The original date of this order was 12/15/11. C. Monitor blood glucose levels before meals and at bedtime: 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m. The original date of this order was 7/20/10. D. Administer Humalog sliding scale insulin coverage based on blood glucose results according to the scale below, 200 - 250 = 2 units 251 - 300 = 4 units 301 - 350 = 6 units 351 - 400 = 8 units 401 - 450 = 10 units 451 - 500 = 12 units less than 50 call physician or greater than 500 call physician A health care plan, dated 4/1/11 indicated Resident #B had a problem listed as, the resident has a [DIAGNOSES REDACTED]. Interventions for this problem included, monitor blood sugars as ordered and administer medication as ordered. Review of the November and December 2011, and January 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] November 13, 6:30 a.m. blood sugar result was 279, no insulin was documented as having been given, the resident should have received 4 units. November 17, 9:00 p.m. blood sugar result was 238, 4 units of insulin was documented as having been given, the resident should have received 2 units. December 6, 4:30 p.m. blood sugar result was 218, no insulin was documented as having been given, the resident should have received 2 units. January 22, 4:30 p.m. blood sugar result was 480, 10 units of insulin was documented as having been given, the resident should have received 12 units. January 30, 4:30 p.m. blood sugar result was 353, 6 units of insulin was documented as having been given, the resident should have received 8 units. During an interview with the Director of Nursing (DoN) on 2/7/12 at 10:22 a.m. additional information was requested related to the incorrect amounts of sliding scale insulin coverage having been documented as give on the dates and times noted above. The facility failed to provide any additional information as of exit on 2/7/12. 3.) Review of the current facility policy, titled "INJECTIONS, INSULIN," provided by the Director of Nursing on 2/7/12 at 8:25 a.m., included, but was not limited to, the following: "PURPOSE: Insulin is injected to aid oxidation and utilization of the blood sugar by the tissues, and to control blood sugar levels in residents with Diabetes Mellitus. POLICY: Insulin is administered by licensed personnel as ordered by the physician.... ...1. Check the physician's orders [REDACTED]. ...7. Hold insulin syringe with correct calibration in view and withdraw ordered dosage of insulin...." 3.1-37(a)