Every finding on record at Compass Park

Based on observation, interview, and record review, the facility failed to ensure privacy was provided during personal care for 1 of 7 residents observed for personal care. (Resident 137)Finding includes:On 8/4/25 at 11:50 a.m., the clinical record for Resident 137 was reviewed. The diagnosis included, but was not limited to, idiopathic pulmonary fibrosis (a chronic progressive lung disease that causes irreversible scarring in the lungs).The clinical record indicated on 10/18/24 Resident 137 elected to receive hospice care.On 8/4/25 at 11:33 a.m. observed Resident 137's door half open. Resident 137 was receiving incontinent care. Resident 137 was lying in bed positioned on his right side facing the wall while CNA 2 was holding the resident in place with one hand and cleaning Resident 137's coccyx with the other hand. During an interview on 8/4/25 at 11:38 a.m., RN 3 indicated that the door should not be open when providing incontinence care.During an interview on 8/6/25 at 11:18 a.m., the Director of Nursing indicated privacy should be provided with the closing of the resident's door during personal care. On 8/6/25 at 2:50 p.m., the Director of Nursing provided a policy titled Promoting/Maintaining Resident Dignity, review date of July 2024, and indicated it was the current policy in use by facility. A review of the policy indicated, Compliance Guidelines 12.Maintain resident privacy.3.1-3(p)(4)

Based on interview and record review, the facility failed to ensure that written notification was provided to the resident, the resident's representative, and to the Office of the State Long-Term Care Ombudsman for 3 of 5 residents reviewed for written transfer and discharge notification. (Resident 140, Resident 1, Resident 123) Findings include: 1. On 9/18/24 at 2:12 p.m., Resident 140's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure, and orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down). Resident 140's face sheet had identified a family member as the emergency contact person. A progress note, dated 7/4/24 at 2:19 p.m., indicated Resident 140 was transferred to the hospital emergency department. The transfer was a facility-initiated transfer. The clinical record lacked documentation that the written notification of the Notice of Transfer or Discharge document was provided to Resident 140, the emergency contact, and the Office of the State Long-Term Care Ombudsman for the hospital transfer on 7/4/24. 2. On 9/19/24 at 10:00 a.m., Resident 1's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, acute and chronic respiratory failure, and heart failure. Resident 1's face sheet had identified a family member as the guardian and emergency contact person. A progress note, dated 4/25/24 at 10:10 a.m., indicated Resident 1's emergency contact transported Resident 1 from the facility to the hospital emergency department. The transfer was a facility-initiated transfer. A progress note, dated 3/13/24 at 2:59 p.m., indicated Resident 1 was scheduled to be transferred to the hospital on 3/14/24 and was to be admitted to the hospital. The transfer was a facility-initiated transfer. A progress note, dated 3/6/24 at 2:44 p.m., indicated Resident 1 was transferred to the hospital emergency department on 3/6/24. The transfer was a facility-initiated transfer. The clinical record lacked documentation that the written notification of the Notice of Transfer or Discharge documents were provided to Resident 1, the emergency contact, and the Office of the State Long-Term Care Ombudsman for the hospital transfers on 4/25/24, 3/14/24, and 3/6/24. 3. On 9/19/24 at 8:32 a.m., Resident 123's clinical record was reviewed. The diagnoses included, but were not limited to, cirrhosis of the liver, anxiety, schizoid personality disorder, and dementia. Resident 123's face sheet had identified an emergency contact person. A progress note, dated 8/11/24 at 9:24 p.m., indicated Resident 123 was transferred to the hospital emergency department. The transfer was a facility-initiated transfer. The clinical record lacked documentation that the written notification of the Notice of Transfer or Discharge document was provided to Resident 123, the emergency contact, and the Office of the State Long-Term Care Ombudsman for the hospital transfer on 8/11/24. During an interview on 9/19/24 at 1:54 p.m., Social Services 4 indicated the facility had not provided written notification of the Notice of Transfer or Discharge documents to the residents, their corresponding emergency contact persons, and to the Office of the State Long-Term Care Ombudsman. On 9/19/24 at 10:21 a.m., the Social Services 4 provided a copy of the Compass Park Medical or Therapeutic Leave Policy, dated 6/6/2007, and indicated it was the current policy in use by the facility. A review of the policy indicated, .it is the policy of this campus .residents [leaving for] .the facility for .medical reasons .in accordance with Federal and State guidelines . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure a written bed hold notification was provided to the resident and to the resident's representative for 3 of 5 residents reviewed for bed hold notifications. (Resident 1, Resident 123, and Resident 140) Findings include: 1. On 9/16/24 at 10:55 a.m., Resident 1's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, acute and chronic respiratory failure, and heart failure. Resident 1 had identified a family member as the resident's guardian and emergency contact person. The Quarterly Minimum Data Set (MDS) assessment, dated 7/24/24, indicated Resident 1 was moderately cognitively impaired. A review of Resident 1's progress notes indicated that Resident 1 had facility-initiated transfers out to the hospital emergency department on 4/25/24, 3/13/24, and 3/6/24. The clinical record lacked documentation that indicated the written bed hold notification was given or sent to Resident 1 and to resident's guardian and emergency contact person for these transfers. 2. On 9/19/24 at 8:32 a.m., Resident 123's clinical record was reviewed. The diagnoses included, but were not limited to, cirrhosis of the liver, anxiety, schizoid personality disorder, and dementia. Resident 123 had identified an emergency contact person. The Quarterly MDS assessment, dated 7/2/24, indicated Resident 123 was moderately cognitively impaired. A review of Resident 123's progress notes indicated Resident 123 had a facility-initiated transfer out to the hospital emergency department on 8/11/24. The clinical record lacked documentation that indicated the written bed hold notification was given or sent to Resident 123 and to resident's guardian and emergency contact person for this transfer. 3. On 9/18/24 at 2:12 p.m., Resident 140's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), chronic respiratory failure, and orthostatic hypotension (a type of low blood pressure which occurs when standing up after sitting or lying down). Resident 140 had identified a family member as the resident's emergency contact person. The Admission MDS assessment, dated 6/17/24, indicated Resident 140 was cognitively intact. A review of Resident 140's progress notes indicated Resident 140 had a facility-initiated transfer out to the hospital emergency department on 7/4/24. The clinical record lacked documentation that indicated the written bed hold notification was given or sent to Resident 140 and to resident's guardian and emergency contact person for this transfer. During an interview on 9/19/24 at 1:50 p.m., Social Service 4 indicated that the facility had not provided any written documentation of bed hold notifications for Resident 1, Resident 123, or Resident 140 to the residents or to the residents' representatives. During an interview on 9/19/24 at 2:25 p.m., the Director of Nursing Services (DNS), indicated that the facility lacked a specific bed hold policy and provided a policy titled Medical or Therapeutic Leave Policy, dated 6/15/23, and indicated it was the policy currently in use and most closely related to a bed hold notification policy. The policy indicated that for medical or therapeutic leaves for residents, the facility acted in accordance with Federal and State guidelines. 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure a baseline care plan was developed for 1 of 5 residents reviewed for new admissions. The baseline care plan lacked a information on Enhanced Barrier Precautions. (Resident 82) Finding includes: On 9/19/24 at 1:25 p.m., Resident 82's clinical record was reviewed. The Admission Assessment, dated 7/25/24, indicated Resident 82 had a feeding tube and a suprapubic catheter. The Interim Care Plan (baseline care plan), dated 7/25/24, indicated Resident 82 had a feeding tube and a suprapubic catheter. The Interim Care Plan lacked information regarding Enhanced Barrier Precautions. On 9/19/24 at 2:30 p.m., the DON indicated Resident 82's Baseline Care Plan should have indicated that Resident 82 required Enhanced Barrier Precautions. 3.1-30(a)

Based on observation, record review, and interview, the facility failed to ensure the infection control practices were implemented for 1 of 8 residents observed with Enhanced Barrier Precautions (EPB). Personal Protective Equipment (PPE) was not used to administer medications via a feeding tube for a resident on EPB. (Resident 82) Finding Includes: During an observation on 9/18/24 at 8:47 a.m., LPN 2 prepared medications to be administered via a feeding tube. LPN 2 took the medications into Resident 82's room, closed the door for privacy, washed her hands, and applied gloves. LPN 2 had begun to administer the medications. LPN 2 was queried if Resident 82 was on EBP. LPN 2 stopped and walked over to supplies of PPE and put on a gown. During an observation on 9/16/24 at 9:50 a.m., an Enhanced Barrier Precaution Sign was posted on the outside of Resident 82's room. During an interview on 9/18/24 at 1:04 p.m., the Director of Nursing (DON) indicated that all staff should wear gloves and gown with direct care for resident's on EPB. On 9/18/24 at 11:04 a.m., the DON provided a copy of policy titled, Infection Control Policy, Enhanced Barrier Precautions, revised 3/2024 and indicated it was the current policy in use by the facility. A review of the polity indicated: Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with multi drug resistant organisms as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 2 of 3 kitchen observations. Staff hair was not covered while in the kitchen. (Kitchen Staff 2, Kitchen Staff 3, Kitchen Staff 4, Cook 5, Kitchen Staff 6) Findings include: 1. During the initial kitchen observation on 11/1/23 from 11:00 a.m. to 11:30 a.m., the following was observed: - Kitchen Staff 2 was observed walking throughout the kitchen area and preparing the noon meal trays near the steam table where the noon meal was being held. Kitchen Staff 2 was observed to have multiple loose hairs, approximately 10 inches in length, in front of both ears. The loose hairs were observed to not be covered. - Kitchen Staff 3 was observed walking throughout the kitchen area and preparing the noon meal trays near the steam table where the noon meal was being held. Kitchen Staff 3 was observed to have multiple loose hairs, approximately 6 inches in length, in front of both ears. The loose hairs were observed to not be covered. - Kitchen Staff 4 was observed walking throughout the kitchen area near the steam table where the noon meal was being held. Kitchen Staff 4 was observed to have multiple loose hairs, approximately 10 inches in length, in front of both ears. The loose hairs were observed to not be covered. - Cook 5 was observed at the steam table plating the noon meal. Cook 5 was observed to have multiple loose hairs, approximately 2 inches in length, at the neckline and in front of both ears. The loose hairs were observed to not be covered. 2. During a follow up kitchen observation 11/1/23 from 12:40 p.m. to 1:00 p.m., the following was observed: - Kitchen Staff 3 was observed walking throughout the kitchen area and preparing the noon meal trays near the steam table where the noon meal was being held. Kitchen Staff 3 was observed to have multiple loose hairs, approximately 6 inches in length, in front of both ears. The loose hairs were observed to not be covered. - Cook 5 was observed at the steam table plating the noon meal. Cook 5 was observed to have multiple loose hairs, approximately 2 inches in length, at the neckline and in front of both ears. The loose hairs were observed to not be covered. - Kitchen Staff 6 was observed restocking clean plates at the steam table. Kitchen Staff 6 was observed to have multiple loose hairs, approximately 3 inches in length, across the forehead area. The loose hairs were observed to not be covered. During an interview on 11/1/23 at 11:45 a.m., the Director of Dining Services indicated staff hair was to be covered while in the kitchen. On 11/2/23 at 8:30 a.m., the Dietary Manager provided a copy of the Orientation and Education - Uniform Dress Code policy, dated June 2018, and indicated it was the current policy in use by the facility. A review of the policy indicated, .personal cleanliness and neat appearance are essential for food service worker .wear the approved hair restraint when on duty .cover all hair . On 11/8/23 at 2:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to .effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent resident's access to the materials for 1 of 5 observations. (Electrical Closet) Finding includes: On 11/2/23 at 1:00 p.m., the following was observed on the second floor of the facility: A room labeled Electrical Closet, located near the dining area and the Scottish Rite resident hallways for rooms 2104 through 2142, was ajar. The door handle was in the locked position but the door itself was not closed or latched completely and could be pushed open easily. Inside were multiple electrical panels with warning labels reading Shock and Arc Flash Hazard. No staff were visible in the immediate area. During an interview on 11/2/23 at 1:05 p.m., the Director of Nursing (DON) indicated that the Electrical Closet room door should be kept locked and latched completely. During an interview on 11/2/23 at 2:26 p.m., the DON indicated that the Scottish Rite unit had 8 of 40 residents who were cognitively impaired and independently mobile who could have had access to the opened Electrical Closet room. On 11/3/23 at 12:55 p.m., the DON provided a copy of a policy, dated 12/2/21, titled, Electrical Safety, and indicated it was the policy currently in use by the facility. A review of the policy indicated, .Breaker cabinets shall be locked at all times that are accessible to general staff or residents/patients. Secure rooms where equipment is located when unattended. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff and failed to ensure the post was easily accessible for staff and guests for 3 of 5 days during the survey period. Findings include: During an observation on 11/2/23 at 10:30 a.m., the posted daily staffing document was observed to lack the actual hours worked by staff. The document was observed to be posted behind the receptionist desk hanging on the wall approximately 6 feet from the visitor side of the receptionist desk and was difficult to read due to the small size print. On 11/3/23 at 9:30 a.m., the posted daily staffing document was observed to lack the actual hours worked by staff. The document was observed to be posted behind the receptionist desk hanging on the wall approximately 6 feet from the visitor side of the receptionist desk and was difficult to read due to the small size print. On 11/4/23 at 8:33 a.m., the posted daily staffing document was observed to lack the actual hours worked by staff. The document was observed to be posted behind the receptionist desk hanging on the wall approximately 6 feet from the visitor side of the receptionist desk and was difficult to read due to the small size print. On 11/2/23 at 11:33 a.m., the Director of Nursing, provided the posted daily staffing for October 2023. A review of the posted daily staffing documents, dated October 1 through October 31, 2023, indicated no actual staffing hours were documented on the postings. During an interview on 11/3/23 at 1:30 p.m., the DON (Director of Nursing) indicated she was unsure if the facility policy indicated if the actual hours worked should have been posted on the daily staffing postings. On 11/3/23 at 9:57 a.m., the DON provided a facility policy titled, Facility Required Postings and indicated it was the current policy being used by the facility. A review of the policy indicated The facility will post required postings in an area that is accessible to all staff and residents

Based on observation, interview, and record review, the facility failed to ensure the physician was notified when a physician's order was unable to be implemented for 1 of 2 residents reviewed for positioning devices. (Resident 246) Findings include: On 11/15/22 at 12:13 p.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/16/22 at 10:38 a.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/17/22 at 10:30 a.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/17/22 at 2:10 p.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/17/22 at 3:30 p.m., Resident 246 was observed resting in bed. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. Resident 246's clinical record was reviewed on 11/18/22 at 1:56 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order's, effective date from 11/10/22 to 11/17/22, indicated left elbow extension brace [positioning device] on in am [morning] and encourage to wear 8 hours daily, [CONDITION(S)] glove to left hand. Remove after 8 hours of wear. Check skin underneath every day and evening. A Progress Note, dated 11/10/22 at 5:38 p.m., indicated Resident 246 was cognitively intact and had a stroke that affected his left side. Resident 246's Treatment Administration Record (TAR) document indicated left elbow extension brace on in am and encourage to wear 8 hours daily, [CONDITION(S)] glove to left hand. Remove after 8 hours of wear. Check skin underneath every day and evening. Resident 246's care plan, initiated on 11/11/22 and current through 2/9/23, indicated focus: [Resident] has an alteration in neurological status related to [CONDITION(S)] [stroke] .goal: will be free from s/sx [signs and symptoms] of complications of [CONDITION(S)] .contractures . The CNA (Certified Nursing Assistant) task sheet (specific care instructions for Resident 246) indicated brace to left elbow. During an interview on 11/17/22 at 4:14 p.m., the Director of Nursing Services (DNS) indicated the facility should have verified with the physician whether Resident 246 required the left elbow brace and [CONDITION(S)] glove as indicated by the physician's admitting orders. During an interview on 11/18/22 at 2:10 p.m., Resident 246 indicated he had not worn the left elbow brace or [CONDITION(S)] glove since his admission into this facility nor were the items in the facility. During an interview on 11/18/22 at 2:20 p.m., CNA (Certified Nursing Assistant) 2 indicated she had taken care of Resident 246 most of the time since his admission and she had never seen the elbow brace or [CONDITION(S)] glove in his room nor on his person. During an interview on 11/18/22 at 2:21 p.m., RN 3 (Registered Nurse) indicated as of today [11/18/22] Resident 246's physician order was changed and now Resident 246 was to no longer wear the left elbow brace or [CONDITION(S)] glove. During an interview on 11/18/22 at 4:11 p.m., the DNS indicated Resident 246 was admitted with a physician's order to wear a left elbow brace and [CONDITION(S)] glove on a daily basis. Resident 246's left elbow brace and [CONDITION(S)] glove were not sent from the previous facility and so they were not available. The facility should have notified the physician regarding the use of the left elbow brace and [CONDITION(S)] glove and obtained the clarification for their use. During an interview on 11/21/22 at 10:20 a.m., LPN (Licensed Practical Nurse) 4 indicated at admission, Resident 246 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 246 was not able to wear either item as they were not available in the facility. On 11/21/22 at 10:30 a.m., the DNS provided a copy of the Resident Inventory Sheet, dated 11/10/22, and indicated it was the current inventory sheet for Resident 246. A review of the inventory sheet, signed by Resident 246's family member, included clothing, wheelchair, glasses, toiletries, and electronics. The inventory sheet did not include the left elbow brace or [CONDITION(S)] glove. On 11/21/22 at 10:30 a.m., the DNS provided a copy of the [NAME] at Compass Park - Nursing Policy Notification of Changes, dated October 2019, policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .The purpose of this policy, is to ensure the facility promptly informs the resident, consults the resident's physician .when there is a change requiring notification .circumstances that require a need to alter treatment .new treatment .discontinuation of current treatment . On 11/21/22 at 10:30 a.m., the DNS provided a copy of the [NAME] at Compass Park - Nursing Policy Physician Orders policy, dated October 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, when necessary, the nursing staff should seek clarification when an order is unclear or unable to be carried out as directed by the physician .the order should be clarified . 3.1-5(a)(3)

Based on interview and record review, the facility failed to complete pre and post [CONDITION(S)] assessments as ordered for 1 of 1 resident reviewed for [CONDITION(S)]. (Resident 54) Finding includes: On 11/15/22 at 1:05 P.M., Resident 54's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 9/16/22, indicated Resident 54 was cognitively intact. Resident 54's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 54 received [CONDITION(S)] treatment three days a week (Monday, Wednesday, and Friday). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Complete pre [CONDITION(S)] assessment under assessment tab one time a day every Monday, Wednesday, and Friday, initiated on 4/1/22. 2. Complete post [CONDITION(S)] assessment under assessment tab one time a day every Monday, Wednesday, and Friday, initiated on 4/1/22. On 11/18/22 at 9:05 A.M., Resident 54's pre and post [CONDITION(S)] assessments were reviewed from 9/1/22 through 11/16/22. A review of the documentation indicated the following: - On 9/2/22 (Friday) the clinical record lacked a post [CONDITION(S)] assessment. - On 9/5/22 (Monday) the clinical record lacked a pre [CONDITION(S)] assessment. - On 9/7/22 (Wednesday) the clinical record lacked a post [CONDITION(S)] assessment. - On 9/14/22 (Wednesday) the clinical record lacked both a pre [CONDITION(S)] and a post [CONDITION(S)] assessment. - On 9/16/22 (Friday) the clinical record lacked a post [CONDITION(S)] assessment. - On 9/28/22 (Wednesday) the clinical record lacked a post [CONDITION(S)] assessment. - On 9/30/22 (Friday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/3/22 (Monday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/5/22 (Wednesday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/10/22 (Monday) the clinical record lacked both a pre [CONDITION(S)] and a post [CONDITION(S)] assessment. - On 10/12/22 (Wednesday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/14/22 (Friday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/17/22 (Monday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/19/22 (Wednesday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/24/22 (Monday) the clinical record lacked a post [CONDITION(S)] assessment. - On 10/26/22 (Wednesday) the clinical record lacked both a pre [CONDITION(S)] and a post [CONDITION(S)] assessment. - On 10/28/22 (Friday) the clinical record lacked both a pre [CONDITION(S)] and a post [CONDITION(S)] assessment. - On 10/31/22 (Monday) the clinical record lacked a post [CONDITION(S)] assessment. - On 11/4/22 (Friday) the clinical record lacked a post [CONDITION(S)] assessment. - On 11/7/22 (Monday) the clinical record lacked a post [CONDITION(S)] assessment. - On 11/9/22 (Wednesday) the clinical record lacked a post [CONDITION(S)] assessment. - On 11/11/22 (Friday) the clinical record lacked a post [CONDITION(S)] assessment. - On 11/16/22 (Wednesday) the clinical record lacked both a pre [CONDITION(S)] and a post [CONDITION(S)] assessment. During an interview on 11/18/22 at 11:35 A.M., the DON (Director of Nursing) indicated that some pre and post [CONDITION(S)] assessments were missing from Resident 54's clinical record. The assessments should have been completed and recorded in the clinical record. On 11/18/22 at 11:35 A.M., the DON provided a copy of the Nursing [CONDITION(S)] policy, dated October 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated the provision of professional standards of practice for residents receiving [CONDITION(S)] treatment included, 1. Ongoing assessment of the resident's condition and monitoring for complications before and after [CONDITION(S)] treatments. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure the clinical record was accurate for 1 of 2 residents reviewed for positioning devices. An arm brace and [CONDITION(S)] glove were documented as applied and were unavailable. (Resident 246) Findings include: On 11/15/22 at 12:13 p.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/16/22 at 10:38 a.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/17/22 at 10:30 a.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/17/22 at 2:10 p.m., Resident 246 was observed resting in his recliner. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. On 11/17/22 at 3:30 p.m., Resident 246 was observed resting in bed. Resident 246's left arm was resting across his chest and no brace or [CONDITION(S)] glove were visible on the left arm. Resident 246's clinical record was reviewed on 11/17/22 at 1:56 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes, dated 11/10/22 at 5:38 p.m., indicated Resident 246 was cognitively intact and had a stroke that affected his left side. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove after 8 hours of wear. Check skin underneath every day and evening. Start date 11/11/22 and hold date from 11/17/22 to 12/1/22. The document indicated nursing staff initialed the record indicating the brace and glove were applied and removed and skin checks were performed as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 11/11/22 - day shift and evening shift 11/12/22 - day shift and evening shift 11/14/22 - day shift and evening shift 11/15/22 - day shift and evening shift 11/16/22 - day shift and evening shift 11/17/22 - day shift A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date 11/10/22 and hold date from 11/17/22 to 12/1/22. The document indicated nursing staff initialed the record indicating the brace was disengaged as ordered by the physician for the following dates and times: 11/10/22 - night shift 11/11/22 - day shift, evening shift, and night shift 11/12/22 - day shift, evening shift, and night shift 11/13/22 - day shift and night shift 11/14/22 - day shift, evening shift, and night shift 11/15/22 - day shift, evening shift, and night shift 11/16/22 - day shift, evening shift, and night shift 11/17/22 - day shift On 11/21/22 at 10:30 a.m., the DNS provided a copy of the Resident Inventory Sheet, dated 11/10/22, and indicated it was the current inventory sheet for Resident 246. A review of the inventory sheet, signed by Resident 246's family member on 11/10/22, included clothing, wheelchair, glasses, toiletries, and electronics. The inventory sheet did not include the left elbow brace or [CONDITION(S)] glove. During an interview on 11/18/22 at 2:10 p.m., Resident 246 indicated he has not worn the left elbow brace or [CONDITION(S)] glove since his admission into this facility nor were the items in the facility. During an interview on 11/18/22 at 2:20 p.m., CNA (Certified Nursing Assistant) 2 indicated she had taken care of Resident 246 most of the time since his admission and she had never seen the elbow brace or [CONDITION(S)] glove in his room nor on his person. During an interview on 11/18/22 at 4:11 p.m., DNS indicated Resident 246 was admitted with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 246's left elbow brace and [CONDITION(S)] glove were not sent from the previous facility and so they were not available. The DNS was unsure why the TAR documents indicated the brace and [CONDITION(S)] glove were signed off indicating they were applied and subsequently removed. The items were not in the building and could not have been applied to the resident. During an interview on 11/21/22 at 10:20 a.m., LPN (Licensed Practical Nurse) 4 indicated at admission, Resident 246 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 246 was not able to wear either item as they were not available in the facility. During an interview on 11/21/22 at 10:25 a.m., the DNS indicated the facility did not have a specific nursing documentation policy. The DNS indicated a guiding principle of good nursing documentation was to be accurate. On 11/21/22 at 4:15 p.m., a review of the American Nurses Association - Principles for Nursing Documentation: Guidance for Registered Nurses, dated 2010, indicated, .Nursing Documentation Principles: Principle 1. Documentation Characteristics .accurate .complete .Principle 5. Documentation Entries .accurate, valid and complete . 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a resident was free from significant medication errors for 1 of 3 residents reviewed. This resulted in a resident not progressing in therapy. (Resident B) Finding includes: During an interview on 5/12/22 at 9:20 a.m., the Director of Nursing indicated when a new admission arrived, the nurse should enter the orders into the electronic medical record and the physician was able to verify and approve those orders through the electronic medical record. The nurse should clarify any orders they question. The Director of Nursing indicated Resident B's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing was unsure if the nurse clarified the discharge orders for [MEDICATION(S)] (an antipsychotic medication) and [MEDICATION(S)] (an antidepressant medication). The clinical record for Resident B was reviewed on 5/12/22 at 9:33 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 2/7/22, indicated Resident B was cognitively intact. An After Visit Summary, dated 1/31/22, indicated the current discharge medications included, but were not limited to: [MEDICATION(S)] 200 mg (milligrams), take 200 mg by mouth, 2 times daily. [MEDICATION(S)] 300 mg, take 300 mg by mouth, daily. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 200 mg, give 2 tablets by mouth, 2 times daily for [CONDITION(S)] to start 1/31/22. [MEDICATION(S)] 300 mg, give 300 mg by mouth, 2 times a day for depression to start 1/31/22. The February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 200 mg, 2 tablets (400 mg) by mouth, 2 times daily from 2/1/22-2/18/22. [MEDICATION(S)] 300 mg, by mouth, 2 times daily on from 2/1/22-2/24/22. A Nurse's progress note, dated 2/19/22 at 12:12 p.m., indicated writer spoke with [Physician's on call service]. Expressed that Resident B's mother stated the order for [MEDICATION(S)] was not what Resident B usually takes. Let [Physician's on call service] know that the dose Resident B is on has made her drowsy and caused slurred speech. A Nurse's progress note, dated 2/20/22 at 12:45 p.m., indicated the Resident B's mother was notified the [MEDICATION(S)] was on hold. The resident's mothers indicated the resident's personal doctor told her that the medication should be on hold for 5 days as opposed the facility doctor's proposed 3 days. The resident's mother asked what should be done for the resident due to the resident not participating in therapy appropriately. The note indicated the residents mother should discuss the issue with facility management prior to discharge on the next day for nonparticipation in therapy. The note indicated some time later, the resident's mother called 911 for the resident to be evaluated at the hospital. An After Visit Summary, dated 2/20/22 at 5:18 p.m., indicated Resident B was diagnosed with an accidental overdose. The overdose although accidental is most likely the reason the resident was not improving in physical therapy as she was too sleepy to be able to participate. It is important to reevaluate whether she should be discharged home as she will most likely improve now that she is alert and awake. On 5/12/22 at 11:55 a.m., the Director of Nursing provided a copy of a facility policy, titled Physician Orders, dated 1/2017, and indicated this was the current policy used by the facility. A review of the policy indicated .documentation of medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal tag relates to Complaint IN 647. 3.1-48(c)(2)

Based on interview and record review, the facility failed to notify the Physician when a resident's urinalysis lab test was not completed as ordered for 1 of 1 resident reviewed for Physician notification. (Resident 110) Findings include: The clinical record of Resident 110 was reviewed on 10/19/21 at 1:00 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 9/21/21, indicated Resident 110 was mildly cognitively impaired, had a urinary tract infection within 30 days of admission, and had an indwelling urinary catheter. A progress note, dated 10/8/21 at 13:47, indicated .patient with complaints of pain at peri sat. [sic/genital area] writer looked at urine output and noticed a dark amber to orange-tinged urine, with a foul smell. writer dipped the urine to test for infection and urine dip was positive for nitrites [sign of urinary tract infection ([CONDITION(S)])]. on phone trying to get ahold of on call to get order for UA C&S [lab test to evaluation infection and antibiotic to treat].[sic] A progress note, dated 10/8/21 at 22:41, indicated .during incontinent care writer noticed that res [resident's] peri area red and sore. discharge noted in brief, [MEDICATION(S)] odor noted. writer contacted MVP [practitioner/physician] on-call with concerns, awaiting answer. writer did collect urine sample by pinching catheter tubing and waiting for urine. urine is amber color with odor noted. writer will take urine to [name] lab [sic] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A laboratory order, dated 10/8/21 at 10:35 P.M., indicated, urine culture collected by I/O (in and out catheterization) on 10/8/21 at 10:35 P.M. The clinical record lacked hospital documentation of having processed the urinalysis that was collected at the facility and delivered to the hospital on 10/8/21 at 10:35 P.M. Resident 110's clinical record lacked documentation their physician had been notified the urinalysis had not been processed. During an interview, on 10/20/21 at 10:50 A.M., the Director of Nursing indicated the laboratory had no record of the urinalysis. The Physician should have been notified when the facility did not get the results. On 10/21/21 at 1:00 P.M., a policy regarding Physician notification was requested from the Director of Nursing. On 10/22/21 at 12:00 P.M. The facility was unable to provide a regarding Physician notification by the end of the survey. 3.1-5(a)(3)

Based on interview and record review, the facility failed to revise a care plan for a resident's preferred code status for 1 of 29 care plans reviewed. (Resident 116) Findings include: The clinical record of Resident 116 was reviewed on 10/19/21 at 9:20 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment, dated 9/22/21, indicated Resident 116 was cognitively intact. The October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Indiana physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 10/21/21 at 2:30 P.M., Resident 116 indicated, she had chosen a code status of, do not resuscitate. Resident 116 current plan of care, dated 10/21/2021, lacked documentation Resident 116 code status was do not resuscitate. During an interview, on 10/22/21 at 8:40 A.M., the Director of Nursing indicated, Resident 116's care plan should have been updated to indicate the correct code status when Resident 116 preference had changed. On 10/21/21 at 11:30 A.M., the Director of Nursing provided a copy of a current facility policy, titled Comprehensive Care Plans, dated January 2017. A review of the policy indicated, .9. Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the intervention, initially and when changes are made. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a resident with a history of frequent falls (Resident 100) and the facility failed to implement a care plan to prevent accidents for a resident with a history of falls (Resident 93) for 2 of 4 residents reviewed for falls. Findings include: 1. On 10/19/2021 at 9:40 a.m., the clinical record of Resident 100 was reviewed. Diagnosis included, but were not limited to [CONDITION(S)] and dementia. A quarterly Minimum Data Set (MDS) assessment, dated 9/12/21, indicated Resident 100's cognitive status was moderately impaired. Resident 100 was not steady and only able to stabilize with human assistance. The resident required a walker for mobility. A Morse Fall Risk Assessment, dated 10/20/2021, indicated Resident 100 was at a high risk for falling. Resident 100 had an impaired gait (ambulation). The resident overestimated or forgot limits. A care plan, dated 2/4/21 and current through 1/9/2022, indicated Resident 100 was at Risk for Falls related to cognitive impairment, gait/balance problems, a history of falls, incontinence, and psychoactive drug use. Goal: [Resident 100] will be free form life-threatening injury and/or fracture through next review. Interventions included, but were not limited to, ensure resident's call light is within reach and encourage the resident to use it for assistance as needed. The care plan lacked an intervention that included supervision for the prevention of falls. The following progress notes indicated Resident 100 had 13 falls from February to October 2021. A Nurses Progress Note, dated 2/18/21 at 6:15 a.m., indicated Certified Nursing Assistant [CNA] went to check on Resident and found him [Resident 100] sitting on the floor in his bathroom. No injury noted. An Interdisciplinary Note (IDT), dated 2/19/21, indicated after discussion with the resident, the resident did not sustain a fall as he placed himself on the floor due to increased pain. A Nurses Progress Note, dated 4/9/21 at 5:50 a.m., indicated This writer and CNA heard a loud noise coming from [Resident 100's] room. [Resident 100] was found sitting in his bathroom on his buttocks. An IDT note, dated 4/9/21, lacked a root cause of why the fall occurred. An intervention was added to the care plan: Offer to toilet early morning. A Nurses Progress Note, dated 5/19/21 at 2:46 p.m., indicated Resident 100 was, in the main dining room and slid to the floor onto his buttocks. An IDT note, dated 5/19/21, indicated: Staff observed Resident 100 to stand without shoes on. The resident slid to the floor. New intervention is to encourage resident to wear non-skid footwear when in the common area. A Nurses Note, dated 5/20/21 at 11:22 a.m., indicated Resident 100 was observed by the writer to be sitting on his floor in his room on this buttocks. An IDT note, dated 5/20/21 at 4:06 p.m., Staff witnessed Resident 100 stand up without shoes on. New intervention is to replace slick [regular] socks with non-skid socks. A Nurses Note, dated 5/29/21 at 11:10 a.m., indicated Resent 100 was observed on the dining room floor laying on his left side. resident [Resident 100] had last been seen by staff sitting in a chair at the dining room table. Another resident stated he stood up and his one foot got hooked behind his other leg and then he fell to the floor . An IDT dated, 6/1/21, indicated Resident 100 remains impulsive and has poor safety awareness. The care plan was updated with a new intervention: offer to rest in recliner in room after breakfast. A Nurses Note, dated 6/29/21 at 8:51 p.m., indicated Resident 100 was observed ambulating in the hall way with a wheeled walker, resident's left foot became caught on right foot due to manner of ambulation causing the resident to fall on buttocks. An IDT, dated 6/30/21 at 9:30 a.m., indicated Resident 100 remains impulsive with poor safety awareness. The resident's care plan was updated with an intervention: Staff to offer toileting assistance after lunch as res [Resident 100] allows. A Nurses Note, dated 7/2/21 at 11:16 a.m., indicated this writer saw resident [Resident 100] sit up on side of bed then attempted to stand and fell to knees then on to buttocks . An IDT, dated 7/2/21, indicated follow up to fall on 7/2/21: Resident 100 had been incontinent of BM [bowel movement] and was attempting to go the the restroom. The resident's care plan was updated with a new intervention: Offer to toilet after breakfast, as resident allows. · A Nurses Note, dated 7/3/21 at 1:56 a.m., indicated Resident 100 was pacing the hall and started getting into the housekeeper's cart, the resident grabbed the mop and tried to mop the floor and the nurse witnessed the resident fall on this buttocks to the floor. An IDT Note for the fall on 7/3/21 at 1:56 a.m., was not provided by the facility. The care plan lacked a new intervention from the fall that occurred on 7/3/21 at 1:56 a.m. A Nurses Note, dated 7/30/21 at 7:00 p.m., indicated there was a loud noise in the resident's room. The resident was found sitting on the floor at the foot of his bed. A skin tear to the right outer wrist was found. An IDT note, dated 7/31/21 at 11:37 a.m., follow up to fall on 7/30/21 at 7:00 p.m., indicated resident [Resident 100] was non-compliant with using his walker. The care plan was updated with a new intervention: encourage resident [Resident 100] to leave his door open to better anticipate his needs. A Nurses Note, dated 9/6/21 at 1:21 a.m., indicted Resident 100 had an unwitnessed fall in the hallway. He was walking from chair in dining room without walker. No injury noted. An IDT Note, dated 9/7/21, lacked a root cause analysis for the fall that occurred on 9/6/21 at 1:21 a.m. The care plan was updated with a new intervention: Therapy to re-evaluate. A Nurses Note, dated 9/19/21 at 2:16 a.m., indicated this writer and another staff member heard a loud noise come from the resident's room, noted [noticed] he had got up from w/c [wheel chair] and slid down wall and landed on right buttock knocking pictures off of the table on his way down. The care plan was updated with the following intervention: offer to assist name [Resident 100] to rest in stationary chair in the afternoon. An IDT note, dated 9/20/21 at 9:27 a.m., indicated Name [Resident 100] remains impulsive and due to cognitive impairments does not also follow previously given instructions. Updated on plan of care. A Nurses Note, dated 10/10/21 at 6:51 p.m., Resident 100 was found lying face down on the floor in the dining room. Resident [Resident 100] was unable to state what happened. An IDT note, dated 10/11/21 at 9:01 a.m., indicated Resident 100 remains, impulsive with poor safety awareness. The care plan was updated. The clinical record lacked a new intervention on the resident's care plan to prevent the reoccurrence of falls. No new documented intervention was provided on the provided care plan, for the fall that occurred on 10/10/21. A Nurses Note, dated 10/14/2021 at 1:55 a.m., Resident 100 was found on the floor of his room. The resident was found with 'blood' all over him. Steri strips placed over right forehead. Neurological assessment was within normal limits. Name [Resident 100's] care plan was updated. An IDT note, dated 10/14/21 at 8:49 a.m., lacked a root cause for the fall that occurred on 10/14/21 at 1:55 a.m. A Nurses Note, dated 10/18/21 at 10:48 a.m., indicated this writer in dining room and heard a noise, looked up and noted resident to be on his hands and knees under dining room table, small abrasion to back of left hand. A Physical Therapy Note, dated 9/9/21, indicated Analysis: Root cause analysis completed: due to condition and higher level physically, Resident 100 is at increased fall risk. A Physicians report, dated 10/15/21, indicated PE: Patient has dementia or other cognitive impairment such that constant supervision is required to safely leave the home. · On 10/18/21 at 1:02 p.m., observed Resident 100 in the dining room sitting in his wheel chair. The resident had several steri strips on his forehead. Observed to have no bruising. On 10/18/21 from 2:30 p.m., until 2:45 p.m., observed Resident 100 in his room sitting in his recliner watching television. No staff were observed to be outside or inside of the resident's room. On 10/19/21 at 10:33 a.m., until 10:50 a.m., observed Resident 100 in his room sitting in his wheel chair with no staff present. On 10/19/21 at 10:33 a.m., observed staff look in resident's room and walk away. On 10/22/21 at 9:22 a.m., the Director of Nursing provided a policy titled Fall Management, dated February 2017, and indicated it was the current policy being used by the facility. A review of the policy indicated Purpose: A Fall Management program is used to provide a safe environment for residents of Indiana Masonic Home at Compass Park. The program is designed to identify residents at risk for falls 10. All falls will be reviewed and discussed by the ID team to determine the root cause of the fall and to determine the most appropriate interventions to prevent future falls. 2. On 10/18/2021 at 1:00 p.m., the clinical record of Resident 93 was reviewed. Diagnosis included, but were not limited to, Alzheimer's disease. A quarterly Minimum Data Set (MDS) assessment, dated 9/13/21, indicated Resident 93's cognitive status was severely impaired. Surface to Surface transfer: Not steady only able to stabilize with human assistance. A Morse Fall Risk Assessment, dated 10/19/2021, indicated Resident 93 was at a high risk for falling. Resident 93 has a history of falls. The resident overestimated or forgot limits. A care plan, dated 9/26/16 and current through 12/20/21, indicated Resident 93, was at risk for falls/injury related to confusion, a history of falls, antidepressant medication, dementia, gait and balance problems and incontinence. Goal: [name Resident 93] will be free from .injury and/or fracture through next review. Interventions included, but were not limited to, keep bed at wheel chair height, keep wheel chair locked next to the foot of the bed while resident is in bed, and keep her wheel chair within her reach. A Nurses Progress note, dated 9/4/2021 at 9:09 p.m., Resident 93, was found on floor. The resident was sitting on her buttocks. The Res. [Resident 93] could not give an account of what happened but stated 'I can't go.' No apparent injury noted. Vital signs were within normal limits. No c/o [complaints] voiced of pain. Res. [Resident 93] was assisted back to bed. A Nurses Progress note, dated 10/18/2021 at 2:00 p.m., Resident [Resident 93] was seen laying on the floor this a.m. Resident 93 reported that she rolled from the bed. Res. [Resident 93's] vitals are normal and no abnormal findings seen on assessments. Res. [Resident 93] is in bed sleeping at the moment. A Resident Care Sheet, undated, lacked the intervention to keep Resident 93's wheel chair next to her bed and locked, when the resident was in bed. On 10/18/21 at 11:26 a.m., Resident 93 was observed to be laying on the floor, in front of the exit to her room. Staff entered the room and assisted resident to the wheel chair. On 10/19/21 from 01:15 p.m., until 1:30 p.m., Resident 93 was observed in her room laying in bed. Resident 93 was awake and alert. The resident's wheel chair was across the room and under the window. During an interview at that time, Nurse 2 indicated the wheel chair should have been next to the bed and locked. Observed Registered Nurse 2 move the wheel chair to the bed, next to the resident and lock it. On 10/20/21 at 10:00 a.m., observed resident 93 in bed. The residents wheel chair was across the room and under the window. During an interview, on 10/20/21 at 10:05 a.m., CNA 8 indicated the CNA's use the Resident Care Sheet to know how to provide care to each resident. CNA 8 was not aware Resident 93's wheel chair needed to be next to the bed and locked while in bed. During an interview, on 10/20/21 at 9:55 a.m., the unit manager indicated the wheel chair should have been next to the bed and locked when the resident was in bed. The nursing staff use Resident Care Sheets to indicate what services to provide each resident. The intervention, to keep the wheel chair next to the bed when the resident was in bed, should have been on the Resident Care sheet so that the nursing staff knew what care and services to provide each resident. The unit manager was not sure why the intervention was not on the Resident care sheet. On 10/21/21 at 11:30 a.m., the Director of Nursing provided a policy titled Comprehensive Care Plans, dated January 2017, and indicated it was the current policy being used by the facility. A review of the policy indicated, .9. Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the facility's compactor dumpster prevented the exposure of rubbish and the facility's dumpster container was kept closed when not in use. This had the potential to affect 126 of 126 residents residing in the facility. Findings include: During the initial tour with the Manager of Environmental and Dietary Services, on 10/18/21 from 11:30 a.m. to 11:35 a.m., observed the small compactor dumpster machine, located adjacent to the kitchen back door. On the stoop next the machine were 2 large empty card board boxes. Near and around the compactor dumpster machine were multiple bees and black flies. No staff members were observed near the dumpster area. During an interview, at that time, the Manager of Environmental and Dietary Services indicated staff were to place all trash and card board boxes into the compactor dumpster machine. On 10/18/21 from 11:55 a.m. to 12:05 p.m., observed the large compactor dumpster machine, located across the parking lot from the small compactor dumpster machine and adjacent to a facility entrance/exit door used by staff. Inside the compactor dumpster machine were multiple filled trash bags and bees were flying in and around the trash bags located in the open holding area of the compactor dumpster machine. No staff members were observed near the dumpster area. During an interview, at that time, the Manager of Environmental and Dietary Services indicated staff were to place the trash into the holding area of the compactor dumpster machine and then activate the compactor mechanism to move the trash into the enclosed dumpster. However, staff did not follow the process. The Manager of Environmental and Dietary Services indicated the machine was not working properly or the machine was full which would prevent the machine from moving more trash into the enclosed dumpster section of the machine. On 10/20/21 from 9:20 a.m. to 9:25 a.m., observed the large compactor dumpster machine ([NAME]'s RJ-100 compactor), located across the parking lot from the small compactor dumpster machine and adjacent to a facility entrance/exit door used by staff. Inside the compactor dumpster machine were multiple filled trash bags and bees were flying around the trash bags located in the open holding area of the dumpster machine. The compactor dumpster machine lacked a door or lid to cover the visible trash bags in the dumpster. No staff members were observed near the dumpster area. During an interview, at that time, the Manager of Environmental and Dietary Services indicated there was no door or lid that covered exposed the trash in the dumpster container. On 10/21/21 at 3:40 p.m. to 3:50 p.m., observed the large compactor dumpster unit, located across the parking lot from the small compactor dumpster machine and adjacent to a facility entrance/exit door used by staff. Inside the compactor dumpster were multiple filled bags of trash. Several of the filled trash bags were visibly torn and had bees flying inside the bags. The compactor dumpster machine lacked a door or lid to cover the exposed trash bags in the dumpster. Also, during that time, observed a small dumpster located near the large compactor dumpster unit. On the top of the small dumpster container were two separate lids. The lid on the left side of the dumpster was observed to not be closed. Inside the small dumpster were multiple open card board boxes. No staff members were observed near the dumpsters. During an interview, at that time, the Plant and Maintenance Director indicated the large compactor dumpster unit was not equipped to be a fully enclosed unit and so all trash inside the unit would be exposed. However, for the small dumpster, the lids were to be kept closed. During an interview, on 10/18/21 at 10:30 a.m., the Administrator indicated the facility census was 126 residents. On 10/22/21 at 8:30 a.m., the Administrator provided a copy of a [NAME] Waste & Recycling Services document dated 10/21/21. A review of the document indicated, .The RJ-100 compactor placed under lease at Compass Park is not configured with a waste receiving door or gate . On 10/18/21 at 3:30 p.m., the Administrator provided a copy of the Dietary Policy: Sanitation and Infection Control - Solid Waste Disposal policy, dated October 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .keep lids to all outside trash receptacles closed . On 10/18/21 at 3:45 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(5)

Based on interview and record review, the facility failed to ensure a resident with dementia was assessed for appropriate treatment and services were delivered to attain or maintain the highest practicable psychosocial well-being for 1 of 4 residents reviewed for behaviors related to staff wearing facial masks. (Resident C) Findings include: The clinical record of Resident C was reviewed on 8/13/20 at 12:30 p.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 5/20/20, indicated Resident C was severely cognitively impaired. The clinical record lacked a behavior assessment and care plan regarding behaviors toward facial masks worn by staff while providing personal care to Resident C. Interview, on 8/13/20 at 12:44 p.m., CNA (Certified Nursing Assistant) 2 indicated Resident C .tended to pull at the staff member's mask, trying to pull it off her face, and would become upset at times when the mask was covering the CNA's mouth area. Interview, on 8/14/20 at 11:30 a.m., LPN (Licensed Practical Nurse) 1 indicated Resident C .seemed to be intimidated when staff wore facial masks covering their mouth and would attempt to pull the facial mask off the staff's face. LPN 1 was not aware of any specific assessments or care plans that addressed Resident C's behaviors in response the facial masks worn by staff. Interview, on 8/14/20 at 2:00 p.m., the Director of Nursing indicated the facility lacked a specific behavior assessment and care plan for Resident C's behaviors regarding staff wearing facial masks. On 8/14/20 at 9:00 a.m., the Director of Nursing provided a copy of the Nursing Services and Sufficient Staff policy, dated October 2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, .it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .care for resident's needs as identified through resident assessments and described in the plan of care .providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a staff member's personal protective equipment was appropriately donned when assisting a resident with personal care for 1 of 4 residents reviewed for infection control. (Resident C) Findings include: On 8/13/20, from 12:40 p.m. to 12:44 p.m., observed CNA (Certified Nursing Assistant) 2 in Resident C's room. CNA 2 was sitting directly in front of the resident, with a distance of approximately 2 feet between the two individuals. CNA 2 was assisting Resident C with her noon meal. CNA 2 was wearing a facial mask (personal protective equipment). CNA 2's nose and mouth area were observed to not be covered. During an interview at that time, CNA 2 indicated the nose and mouth area were supposed to be covered while working with the resident. Interview, on 8/13/20 at 1:00 p.m., RN (Registered Nurse) 3 indicated all staff were required to wear a facial mask and always keep the nose and mouth areas covered. The clinical record of Resident C was reviewed on 8/13/20 at 12:30 p.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 5/20/20, indicated Resident C was severely cognitively impaired. On 8/13/20 at 2:00 p.m., the Director of Nursing provided a copy of the Personal Protective Equipment Policy, dated 4/2/20, and indicated it was the current policy in use by the facility. A review of the policy indicated, .this facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff .'personal protective equipment' or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemask, goggles, and face shields) .All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities . Cloth face coverings (7/14/20) guidance was retrieved on 8/14/20 from the Centers of Disease Control (CDC) website. A review of the guidance indicated, .cloth face coverings are one of the most powerful weapons we have to slow and stop the spread of [MEDICAL CONDITION] (COVID-19), particularly when used universally within a community setting. All Americans have a responsibility to protect themselves, their families, and their communities .wear your mask correctly .put it over your nose and mouth and secure it under your chin . Guidance for Personal Services in Long-term Care (6/29/20) guidance was retrieved on 8/14/20 from the Indiana State Department of Health (ISDN) website. A review of the guidance indicated, .ensure social distancing of at least 6 feet when possible .masks are required . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure mechanical lift equipment was properly stored which resulted in a cognitively impaired and high risk fall resident having fallen and sustained a large [MEDICAL CONDITION] that required eleven sutures for closure for 1 of 1 resident reviewed for falls (Resident B) and the facility failed to provide supervision for a resident threatening and with the means to harm herself (Resident 55). Findings include: 1. On 6/17/19 at 10:15 a.m., the clinical record of Resident B was reviewed. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, dated 5/7/2019, indicated Resident B's cognitive status was moderately impaired. She required staff supervision for ambulation. She exhibited wandering behaviors. She had 2 falls with injury. A fall risk assessment, dated 1/26/19, indicated Resident B was at a high risk for falling. A care plan, dated 2/12/19 and current through 5/21/19, indicated Resident B was at high risk for falls related to, cognitive impairment, gait/balance problems, incontinence, poor safety awareness, history of falls, and use of [MEDICAL CONDITION] medication. The Care plan goal indicated Resident B would be free from life-threatening injury and/or fracture through next review. Interventions included, but were not limited to, assist resident in keeping room free from excess clutter. A nurses note, dated 2/21/19, indicated Resident B was sitting in her wheelchair at the nurses station. She tried to get up and fell over the pedals on the wheelchair. No injuries occurred. A nurses note, dated 3/4/19, indicated a Certified Nursing Assistant (CNA) was providing a shower for Resident B. The resident would not sit down and started to slip and fell . The CNA attempted to catch the resident, but was unable. The resident hit her left shoulder and forehead causing a bruise to her left shoulder. A nurses note, dated 3/10/19, indicated Resident B was found sitting on her buttocks in another resident's room. A nurses note, dated 3/11/19, indicated Resident B was found lying on the floor in front of a rocker. The rocker was located in front of the nurses station. A nurses note, dated 3/28/19, indicated the writer was called to the locked unit. Resident B had stood up from the Broda chair and fell . A nurses note, dated 5/15/19, indicated Resident B fell and was sent to the emergency room . Resident B was ambulating in the hall independently and tripped over the lift that was in the hall. Resident B had hit her head causing a laceration. Resident B's care plan was updated with a new intervention, dated 5/15/19, keep the lift out of the hall when not in use. A SEALS ambulance report, dated 5/15/19, indicated History of Present Illness: Resident B was walking and tripped over the Hoyer lift and fell face first to the floor resulting in a large triangle shaped laceration on her forehead. [NAME]son Memorial Health documentation, dated 5/15/19, indicated: Skin closure to Resident B's forehead required 11 sutures. On 6/20/19 from 8:15 a.m. to 8:31 a.m., observed the lift in the hall way (on the locked unit) next to Resident B's room. No staff were present. The resident was in her room sleeping in her bed. Interview, on 6/20/19 at 8:47 a.m., Qualified Medication Assistant (QMA) 6 indicated, the lift should be in the shower room and should not be stored in the hall way. Observed QMA 6 to move the lift from the hallway. On 6/19/19 at 9:33 a.m., requested a policy regarding care plan implementation, from the Director of Nursing. On 6/20/19 at 5:30 p.m., the policy regarding care plan implementation was not provided by the end of the survey. On 6/19/19 at 11:30 a.m., the Director of Nursing provided a policy titled Fall Management, dated (MONTH) (YEAR), and indicated it was the current policy being used by the facility. A review of the policy indicated, Purpose: .All residents are assessed for risk upon admission, re-admission, at least quarterly, and after each fall .Additional fall prevention interventions should be considered for those residents scoring in a moderate and higher risk levels .5. A Morse Fall Risk Assessment and Glasgow Coma Scale are to be competed with each fall as well. 2. The clinical record of Resident 55 was reviewed on 6/20/19 at 10:21 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 4/9/19, indicated Resident 55 was moderately impaired in her ability to make decisions and was feeling down, depressed or hopeless during 12 of the 14 day assessment period. A careplan, dated 1/1/18 and current through 6/24/19, indicated the resident, is tearful at times about placement in facility. She makes negative comments about hurting self. Interview, on 6/13/19 at 11:18 a.m., Resident 55 appeared very anxious, and indicated, I want to go home. Progress notes for 2019 indicated the following: 6/15 at 10:18 a.m. - Res (resident) up at nurses station confused wanting to go home and asking who put her in this place. Signee and another nurse attempted to redirect resident. Res stated 'I want to kill myself.' Res very tearful .son notified. Res spoke to son, after hanging up with son res started hitting herself with a clipboard. Son aware. Res continues to state 'If I stay here, I will kill myself.' Res sitting next to nurses station at present time .MD (Medical Doctor) notified. New order to send resident out to hospital. 6/15 at 10:28 a.m. - Res came back up to nurses station, res crying stated 'I'm going to kill my son when he gets here.' 6/15 at 10:30 a.m. - Res on 15 minute check. A Progress notes, dated 6/15/19 at 10:37, indicated facility found a neuropsychiatric facility who would accept Resident 55 for immediate admission. 6/15 at 10:38 a.m. - .(name of resident) again threatening to kill self and has even taken clip board from nurse's station and is now hitting self in the head with clip board and fist. 6/15 at 1:04 p.m. - Res sitting up here by nurses station crying, wanting to go home and doesn't understand what is going on or what she did. 6/15 at 2:46 p.m. - res to be picked up at 5:30 (p.m.). 6/15 at 4:36 p.m. - Res sitting at nurses station, tearful at times, states wishes to go home. Res hasn't made any negative statement this shift. Dr. (name of psychologist) visited res in room this afternoon. 15 minute safety checks continue. A Psychological Consultation, dated 6/15/19 (no time indicated) signed by the psychologist indicated, Came to see patient on an emergency basis. Received phone contact from facility (Social Service Director), 'She is threatening to kill self and actually hitting self .I understand she will be going out to Inpatient Psych later this afternoon. Would strongly support this as patient is very unstable at this time. I believe we may be seeing possible [MEDICAL CONDITION] superimposed on dementia acutely emergent. Patient is dangerous to self at this time. 6/15 at 7:46 - Res (complaints of) (left) chest pain. Progress notes, dated 6/15/19 at 7:51 p.m., indicated MD was notified, [MEDICATION NAME] was given for chest pain 3 times, then facility called 911 for resident to be transferred to an acute care hospital. Resident 55 was transferred at 8:07 p.m. In an interview, on 6/20/19 at 2:30 p.m., the Director of Nursing indicated the facility did not have a policy regarding supervision of a resident threatening and having the means to harm themselves. Staff would thoroughly evaluate a resident threatening to harm themselves, and then place the resident on routine checks, unless the resident had a means of self-harm, then the resident would be placed on 1:1 (1 staff continually staying with resident). No documentation was provided which indicated the resident received continuous supervision due to her threats of harming herself and having used of a clipboard and her fist to hit herself in the head. This Federal tag relates to Complaint IN 181. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure ongoing assessments for a change in condition for the use of side rails of a dependent resident which resulted in a side rail entrapment, a fall, and subsequent [MEDICAL CONDITION]'s right arm for 1 of 3 residents reviewed for side rails. (Resident 106) Finding Resident 106's clinical record was reviewed on 6/18/19 at 1:37 p.m. [DIAGNOSES REDACTED]. A Bed Rail Safety Assessment, dated 10/4/18, indicated Resident 106 used the side rails to grab and hold position during personal care, to reposition in bed, and to provide a feeling of comfort and security by establishing bed boundaries. Safety concerns indicated the resident was unable to transfer to and from bed safely. A call light was provided within reach as an alternative intervention. Benefits for the side rails outweighed risks and use of bed rails was determined to be appropriate for the resident. Resident 106 indicated she did desire to use the side rails after being informed of the risks and benefits of side rail usage. The clinical record lacked documentation of subsequent Bed Rail Safety Assessments. A nursing assessment, dated 10/4/18, during Resident 106's admission, indicated resident required extensive assistance with bed mobility. Resident 106 was assessed to be totally dependent on staff for transfers and mobility. The resident desired to use ¼ side rails to assist with bed mobility and to grab and hold a position during personal care. An admission Minimum Data Set (MDS) assessment, dated 10/9/18, indicated Resident 106 was cognitively intact and required extensive assist for bed mobility and transfers. The bed rails were not identified under restraints. A quarterly MDS assessment, dated 12/20/18, indicated Resident 106 was cognitively intact and required extensive assist for bed mobility and transfers. The bed rails were not identified under restraints. A quarterly MDS assessment, dated 3/13/19, indicated Resident 106 was cognitively intact and required extensive assist for bed mobility and transfers. The bed rails were not identified under restraints. A care plan, dated 10/4/18 and current through 6/17/19, indicated Resident 106 used ¼ side rails to assist with bed mobility. Interventions included completing an assessment for safety of bed rail use upon admission, quarterly, significant changes in function or condition, upon request for implementation, as needed, to observe side rails during resident care, report any issues such as missing hardware, loose rails, sharp edges, or a large gap between mattress and rail to the charge nurse and to maintenance for assessment and repair as necessary, and review the risks and benefits of rail use with the resident. A Facility Reported Incident, dated 6/18/19 at 9:40 p.m., indicated Resident 106 was found on her bottom next to her bed with her right arm in the ¼ side rail. Resident 106 indicated she thought she saw someone in her room and tried to get up. The right shoulder was assessed and noted with redness. Resident denied pain. Resident 106 was sent to the emergency room and noted to have a right humerus fracture, which was located in the same area of a prior healing fracture. A right arm immobilizer was placed on the resident. Preventive measures added, on 6/19/19, included fall preventions to keep the bed in low position, remove the ¼ side rails, obtain lab work, and follow up with an Orthopedic Doctor. On 6/14/19 at 1:05 p.m., Resident 106 was observed to have ¼ side rails on the left and right sides of her bed. Both rails were positioned up. The resident was resting quietly with eyes closed. On 6/17/19 at 2:20 p.m., Resident 106 was observed to have ¼ side rail on the left and right sides of her bed. Both rails were in the up position as resident was resting quietly with eyes closed. Interview, on 6/20/19 at 10:30 a.m., the Director of Nursing (DON) indicated Resident 106 was stable, currently wearing the right arm immobilizer, and receiving pain medication as needed. A work order had been placed yesterday (6/19/19) to remove the ¼ side rails from the resident's bed, as she was not able to assist with bed mobility as she had when admitted . The resident had no changes in condition or status. On 6/20/19 at 10:40 a.m., observed Resident 106's bed to have both side rails attached. Resident 106 was not in the room at that time. Interview, on 6/20/19 at 10:45 a.m., the Maintenance Director indicated the ¼ side rails appeared to be attached correctly, stable, and smooth to touch. Observed Maintenance Director to remove the right ¼ side rail during the interview. Interview, on 6/20/19 at 1:15 p.m., Resident 106 indicated she had been startled awake and tried to get up, as she thought someone was in her room. Interview, on 6/20/19 at 2:10 p.m., the DON indicated she was unable to provide additional Bed Rail Safety assessments and unable to provide additional maintenance information demonstrating the side rails were being monitored and maintained as required. On 6/19/19 at 1:15 p.m., the Director of Nursing (DON) provided a policy, dated (MONTH) (YEAR), and titled: Side Rail Use, and indicated it was the current policy being used by the facility. A review of the policy indicated .3. Side rails may only be used in order to assist in mobility and transfer of residents. The policy lacked documentation regarding the ongoing assessments and maintenance of the side rails. 3.1-45(a)(1)