Every finding on record at Core of Dale

Based on observation, interview, and record review, the facility failed to ensure safe storage and preparation of food to prevent the outbreak of foodborne illness during 2 of 2 observations of the kitchen. During the kitchen observations the eggs were noted to not be pasteurized and the two scoops lying on the flour and sugar bulk containers were not covered. (Kitchen)Findings include:On 3/31/26 at 8:45 A.M., during a brief tour of the kitchen, the eggs in the refrigerator were noted not to be marked with a P and the box did not indicate that the eggs were pasteurized. At that time, Dietary Aide 5 pulled the egg box from the refrigerator and indicated she did not see a P on the eggs, nor was the box marked as pasteurized. She indicated she was not sure if the eggs were pasteurized or not.On 3/31/26 at 8:45 A.M., in the dry storage area a scoop was observed to be lying on top of the bulk container of flour and another scoop on the bulk container of sugar. The scoops were not covered.On 4/1/26 at 10:57 A.M., two scoops were observed lying on the bulk containers of flour and sugar uncovered. At that time, the Dietary Manager indicated she did not know if the scoops needed to be covered.During an interview on 4/2/26 at 11:29 A.M., [NAME] 7 indicated the eggs in the refrigerator were not pasteurized. He indicated they had a hard time getting them. At that time, the Dietary Manager indicated she would contact their supplier to find out if the eggs were pasteurized or not.During an interview on 4/6/26 at 11:15 A.M., the Dietary Manager indicated the supplier notified her that the eggs were not pasteurized, and she had been ordering those eggs for the last month. She indicated those eggs were used for three residents to make over easy eggs. Resident 18, Resident 14, and Resident 47 were served over easy eggs every morning for breakfast. She indicated they used liquid eggs for all the other residents.During an interview on 4/6/26 at 11:44 A.M., the Director of Nursing (DON) indicated she was not aware of Resident 18 or Resident 14 having any gastrointestinal issues in the last month. She indicated Resident 47 was admitted on [DATE] and had not had any gastrointestinal issues.During an interview on 4/6/26 at 11:45 A.M., Resident 47 indicated since he was admitted on [DATE] he had gotten an egg over easy per his preference every morning, and he had not had any stomach upset, vomiting, diarrhea or any problems.During an interview on 4/6/26 at 12:05 P.M., Dietary Aide 5 indicated she cooked the over easy eggs until the whites were cooked and flipped the eggs twice while cooking them. During an interview on 4/6/26 at 1:05 P.M., Certified Nurse Aide (CNA) 9 indicated she had worked at the facility for a year. She indicated Resident 14's stools were always loose. She indicated she fed him breakfast that morning and he ate 100%. His eggs were runny that morning and they always were for breakfast.On 4/6/26 at 1:29 P.M., an undated Food Procurement policy was provided by the Dietary Manager which indicated, Policy: The purpose is to purchase high quality, tested and inspected products from reliable and dependable purveyors with written statements that food is processed and delivered under regulated quality and sanitary controls. A. Buy according to specifications as follows: 1. Graded infertile eggs, fresh and frozen.On 4/7/26 at 10:13 A.M., the DON indicated they did not have a policy for the scoops for bulk items, but they should be covered just like the ice scoop.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure medications were given as ordered for 1 of 2 closed records reviewed, 1 of 5 residents reviewed for unnecessary medications, and 1 random observation during a medication pass. Insulin was not held as indicated in the order, blood pressure medication was not held as indicated, and medications were found under a resident's bed. (Resident 16, Resident B, Resident N)Findings include:1. On 4/1/26 at 7:10 A.M., Resident N's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent Minimum Data Set (MDS) assessment, dated 2/7/26, indicated a severe cognitive impairment. Resident N was dependent on staff with toileting, transferring, bed mobility, showering, and eating. Current physician orders included, but were not limited to: Tresiba subcutaneous solution 100 UNIT/ML (milliliters) (Insulin Degludec) inject 26 unit subcutaneously in the afternoon. Hold for blood sugar less than 150, dated 2/5/26 through 3/18/26. Resident N's Medication Administration Record (MAR) indicated, but was not limited to, the following: 2/8/26 at 2:00 P.M. Triseba insulin was administered. Blood sugar at that time was 102. 2/25/26 at 2:00 P.M. Triseba insulin was administered. Blood sugar at that time was 121. 2. On 4/1/26 at 10:18 A.M., Resident 16's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension (high blood pressure). The most recent annual Minimum Data Set (MDS) assessment, dated 1/10/26, indicated Resident 16 had moderate cognitive impairment. Current physician orders included, but was not limited to the following: Amlodipine Besylate Oral Tablet 10 milligrams (MG) (hypertension medication) Give 1 tablet by mouth one time a day related to primary hypertension. Hold the medication if the systolic blood pressure is less than 110, dated 10/01/2025 Lisinopril Oral Tablet 20 MG (hypertension medication) Give 1 tablet by mouth one time a day related to primary hypertension. Hold the medication if the systolic blood pressure is less than 110, dated 10/01/2025 On the following dates, hypertension medications were given when Resident 16's systolic blood pressure was less than 110: October 15, 2025: amlodipine and lisinopril were given for a blood pressure of 107/72. October 18, 2025: amlodipine and lisinopril were given for a blood pressure of 100/62. January 5, 2026: amlodipine and lisinopril were given for a blood pressure of 101/74. During an interview on 4/6/26 at 10:39 A.M., the Director of Nursing (DON) indicated the blood pressure medication should not have been given when the systolic blood pressure was less than 110. 3. During an observation on 4/1/26 at 6:38 A.M., Housekeeper 3 exited Resident B's room with a dustpan and asked Licensed Practical Nurse (LPN) 2 if she knew what the 2 white oblong pills and 1 circular orange pill was that she found under Resident B's bed. At that time, LPN 2 indicated she did not know what they were. During an interview on 4/6/26 at 10:29 A.M., LPN 2 indicated nursing staff had a note to watch Resident B and make sure pills were not pocketed in his mouth, and nursing staff should watch all residents swallow their medications. On 4/7/26 at 10:58 A.M., the DON provided a current Administering Medications policy, reviewed 12/23/25 that indicated, Medications are administered in a safe and timely manner.Medications are administered in accordance with prescriber orders. This citation relates to Intake 2793190. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure notification to a provider as ordered. The physician was not notified of a resident's blood sugar outside of parameters for 1 of 2 closed records reviewed. (Resident N) Finding includes:On 4/1/26 at 7:10 A.M., Resident N's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus.The most recent Minimum Data Set (MDS) assessment, dated 2/7/26, indicated a severe cognitive impairment. Resident N was dependent on staff with toileting, transferring, bed mobility, showering, and eating.Current physician orders included, but were not limited to:Blood glucose monitoring before meals and at bedtime, call physician if blood sugar less than 60 or greater than 400, dated 8/19/24 through 12/23/25.Blood glucose monitoring two times a day, call physician if blood sugar less than 60 or greater than 400, dated 12/23/25 through 3/18/26.Resident N's Medication Administration Record (MAR) indicated, but was not limited to, the following blood sugar readings:10/4/25 at 7:30 A.M. blood sugar 4210/14/25 at 11:30 A.M. blood sugar 5410/16/25 at 7:30 A.M. blood sugar 4410/19/25 at 7:30 A.M. blood sugar 3510/29/25 at 7:30 A.M. blood sugar 4710/30/25 at 7:30 A.M. blood sugar 4111/10/25 at 7:30 A.M. blood sugar 5711/14/25 at 7:30 A.M. blood sugar 3511/18/25 at 7:30 A.M. blood sugar 3911/21/25 at 7:30 A.M. blood sugar 4912/18/25 at 4:30 P.M. blood sugar 40212/22/25 at 4:30 P.M. blood sugar 4122/22/26 at 8:00 A.M. blood sugar 502/28/26 at 8:00 A.M. blood sugar 59Resident N's clinical record lacked physician notification for the blood sugars that were outside of normal parameters.On 4/6/26 at 1:06 P.M., the Director of Nursing (DON) indicated she was unable to locate documentation of notification, and that nursing staff should call the physician as indicated in the order when a blood sugar was out of range.On 4/7/26 at 10:00 A.M., the DON provided a current Notification of Changes policy, dated 12/13/25, that indicated The facility staff must inform the resident, consult with the resident's physician, notify the resident's family member or legal representative, and administration (when needed) when there is a change requiring such notification410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)

Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing forms were posted daily with the total working hours of unlicensed staff (CNA/QMA) for 5 of 5 days reviewed during the survey period. The posted nurse staffing form lacked the facility name and the total working hours of unlicensed staff was not included on the form. Finding includes:On 3/31/26 at 9:07 A.M., the posted nurse staffing forms were observed hanging in the hallway across from the entrance. It lacked the facility name on it and the unlicensed staff (CNA/QMAs) did not have the total hours worked listed. There have not been total hours listed for the CNAs. They don't have the facility name on it. The same was observed on 4/1/26, 4/2/26, 4/6/26, and 4/7/26.On 4/6/26 at 2:00 P.M., the Business Office Manager indicated she posted the unlicensed staff and the Director of Nursing (DON) did the licensed (nurse) staff. She was not aware that the facility name needed to be on the form. She indicated the total hours worked for the unlicensed staff was not posted, just the total hours for each CNA on each shift. On 4/7/26 at 9:22 A.M., a current Posted Nurse Staffing policy, dated 7/26/23 was provided by the DON and indicated . The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: . The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .

Based on observation, interview, and record review, the facility failed to ensure the past survey results were easily accessible to visitors, residents, family members, and legal representatives of residents for 5 of 5 days during the survey period. The survey binder was in a closed room behind the East Hall nurse's station. Findings include:On 4/1/26 at 7:15 A.M., a sign was observed in the entrance area of the facility that indicated the survey binder was available at the East side nurse's station.On 4/6/26 at 10:15 A.M., Certified Nurse Aide (CNA) 22 retrieved the survey binder from a closed room behind the East Hall nurse's station and indicated there was a spot on the shelf in that room for the binder and that was usually where it was kept. On 4/7/26 at 9:17 A.M., a current non dated Resident Rights Policy was provided by the Director of Nursing (DON) and indicated, The resident has the right to the following: examination of the results of the most recent annual survey of the facility conducted by federal or state surveyors, any plan of correction in effect with respect to the facility, and any subsequent surveys. The results must be available for examination in the facility in a place readily accessible to residents . 410 Indiana Administration Code (IAC) 16.2-3.1-3(b)(1)

Based on observation, interview, and record review, the facility failed to appropriately test the dishwasher to verify it was functioning correctly. Staff lacked knowledge of the test strips used to test the sanitation chemicals in 1 of 2 observations of dishwasher use. Finding includes: On 9/16/25 at 8:05 A.M., the Dietary Manager indicated she was unsure of what kind of dishwasher the facility had, and that staff checked to make sure the temperature reached 120 degrees Fahrenheit. At that time, she indicated that the staff failed to test the dishwasher with chlorine strips and was unable to find strips.During an observation on 9/16/25 at 8:18 A.M., Maintenance 11 indicated the dishwasher is a low-temperature dishwasher, and he verified the temperature reached 120 degrees Fahrenheit daily. At that time, he indicated he was not a dietary employee, so he did not check the chemicals on the dishwasher.During an interview on 9/16/25 at 9:45 A.M., the Maintenance Supervisor indicated the dishwasher should be tested with a chlorine strip every shift. At that time, she located a container of strips and tested the dishwasher. The strip showed 10 parts per million (ppm). The Maintenance Supervisor indicated it should be at 100 ppm.During an interview on 9/16/25 at 10:30 A.M., the Director of Nursing (DON) indicated kitchen staff should notify maintenance of any problems. At that time, she indicated they were not aware of the problem, and a call had been placed to the manufacturer of the dishwasher.On 9/16/25 at 9:45 A.M., the Maintenance Supervisor provided a current manual as a policy, dated 10/29/07, that indicated chlorine levels should be between 50-100 ppm.This Federal tag relates to Intake 2607081.3.1-21(i)(3)

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of food and nutrition services. The Dietary Manager lacked appropriate certification. Finding includes: On 9/16/25 at 8:05 A.M., the current Dietary Manager indicated she started in that role on 9/5/25 and lacked a current certification and was working to become re-certified. On 9/25/25 at 9:48 A.M., the Director of Nursing (DON) provided a current, undated, Dietary Manager job description as their policy that indicated, Required Qualifications Minimum requirements include one of the following: Certification as a dietary manager. Certification as a food service manager .Must also meet State requirements for food service managers or dietary managers . This Federal tag relates to Intake 2607081.3.1-20(h)

Based on observation, interview, and record review, the facility failed to ensure specific, comprehensive care plans were revised for 4 of 4 reviewed for behaviors related to sexual offenders. Care plans were not revised to include specific behaviors, restrictions, and interventions. (Resident B, Resident C, Resident D, Resident F)Findings include:On 9/24/25 at 9:55 A.M., a binder was provided by the Director of Nursing (DON) with a list of registered sexual offenders that were currently residents or had previously been a resident at the facility.The Sex Offender Registry list on the [NAME] County Sheriff's Department website was retrieved on 9/24/25 at 2:20 P.M. The list included registered sex offenders who have been convicted of a sexual offense and were mandated to register as a sexual offender annually and were within a one mile radius of the facility address (510 [NAME] St Dale, Indiana 47523). The registry included 16 residents currently residing at the facility. It included the type of offense, but lacked specific details about the resident's conviction and restrictions. Resident B was listed as a sex offender (a general category for individuals convicted of sex offenses). Resident C and Resident D were listed as a sexually violent predators (a specific designation for offenders deemed a high risk to re-offend and a threat to the public).1. On 9/25/25 at 11:51 A.M., Resident B was observed sitting in a wheelchair in the dining room.On 9/25/25 at 9:33 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, multiple sclerosis.The most recent quarterly MDS assessment, dated 7/29/25, indicated a moderate cognitive impairment.A current Behavior Care Plan, (last reviewed date unknown), indicated Resident D had the potential for sexually inappropriate behavior related to sexual offender history. Interventions included the following:Monitor for inappropriate sexual behaviorsInvolve resident in activitiesEncourage appropriate communication and socializationNotify SSD if behaviors occurExplain to the resident why behaviors were inappropriate1:1 (staff to resident watch) as needed15 minute checks (staff to observe resident every 15 minutes) as neededPsychology services as neededChildren present under age [AGE] to remain supervised by an adult.The care plan lacked resident specific sexual offender history and behaviors, restrictions, and interventions.2. On 9/16/25 at 12:58 P.M., Resident C was observed sitting in his bed.On 9/19/25 at 12:30 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure, diabetes mellitus type II, anxiety disorder, and depression.The most recent quarterly MDS assessment, dated 9/6/25, indicated Resident C was cognitively intact. A current Behavior Care Plan, initiated 6/11/25 and last reviewed on 9/7/25, indicated Resident D had the potential for behaviors that included sexually inappropriate behavior related to sex offender history, verbal aggression (yelling, cursing), and refusing medications. Interventions, initiated on 6/11/25, included the following:Monitor for inappropriate sexual behaviorsInvolve resident in activitiesEncourage appropriate communication and socializationNotify SSD if behaviors occurExplain to the resident why behaviors were inappropriate1:1 (staff to resident watch) as needed15 minute checks (staff to observe resident every 15 minutes) as neededPsychology services as neededChildren present under age [AGE] to remain supervised by an adultThe care plan lacked resident specific sexual offender history and behaviors, restrictions, and interventions.3. On 9/24/25 at 9:08 A.M., Resident D was observed in his motorized wheelchair telling a nurse that he was leaving the facility to go to church.On 9/18/25 at 12:51 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, psychoactive substance abuse, unspecified sexually transmitted disease, and noncompliance with other medical treatment and regimen.The most recent annual MDS assessment, dated 8/2/25, indicated a moderate cognitive impairment.A current Behavior Care Plan, initiated on 5/19/25 and revised on 5/27/25, indicated Resident D had the potential to be physically aggressive. Interventions, initiated on 5/19/25, included the following:The resident's triggers for physical aggression were not getting what he wants when he wants it. The resident's behaviors were de-escalated by promptly assisting resident as soon as possibleAdminister medications as ordered and monitor/document for side effects and effectivenessAnalyze and document time of day, places, circumstances, triggers, contributing sensory deficits and what de-escalated behaviorAssess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.Provide physical and verbal cues to alleviate anxietyGive positive feedbackAssist with verbalization of source of agitationAssist to set goals for more pleasant behaviorEncourage seeking out of staff member when agitatedGive the resident as many choices as possible about care and activitiesModify environment: Adjust room temperature to comfortable level, Reduce noise, dim lights, place familiar objects in room, keep door closed, etcMonitor and document observed behavior and attempted interventions in behavior log as neededMonitor/document/report any signs and symptoms of resident posing a danger to self and others as neededPsychiatric/Psychogeriatric consult as indicatedThe resident needed ample amount of personal spaceWhen the resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress, engage calmly in conversation. If response was aggressive, staff to walk calmly away, and approach later.The care plan lacked resident specific sexual offender history and any restrictions.4. On 9/24/25 at 2:15 P.M., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to diabetes mellitus type II, chronic kidney disease, and history of stroke.A current Behavior Care Plan, initiated 6/10/25, indicated Resident F had the potential for behaviors that included sexually inappropriate behavior related to a history of inappropriate behavior and making inappropriate comments to staff. Interventions, initiated on 6/10/25, included the following:Encourage appropriate communication and socializationInvolve resident in activitiesMonitor for inappropriate sexual behaviorPsychology services as neededNotify social services if behavior occurredSocial service visits as neededThe care plan lacked resident specific sexual offender history and behaviors, restrictions, and interventions.On 9/25/25 at 8:57 A.M., an email, dated 8/22/25 at 12:16 P.M., addressed to the Social Services Director (SSD) from Resident F's parole officer was provided by the DON and indicated, . The Indiana Parole Board issued a warrant for [resident name] due to him having the cell phone. We started looking into it more and there were several pornographic photos and videos on it as well as a head shot image of a minor girl. [resident last name] denied it was his, however, there is no way to prove it since it was in his possession. These are major rule violations and [resident last name] was very well aware he was not to have a phone as well as images like that . Most likely the Sheriff's Dept [department] will serve the warrant and possibly today. A Discharge Summary Note on 8/22/25 at 5: 49 P.M., indicated resident was discharged due to violation of his parole by the sheriff's office.During an interview on 9/24/25 at 8:43 A.M., the Social Services Director (SSD) indicated there were currently sexual offenders residing in the facility and the office registered them on the sexual offender registry. There were restrictions to follow with the residents currently on probation and those residents were visited by the probation officers monthly, and once a resident was no longer on probation, they have no restrictions to enforce. They just have to abide by the laws in Indiana. She indicated they kept files on all the sexual offenders in the building at the office that included the resident specific restrictions to follow and these restrictions were on the resident care plans. If a resident was on probation, they were not allowed to go into the community without someone with them. She indicated staff were informed of behaviors, whether the resident was on probation, and the restrictions they had to enforce. During an interview on 9/25/25 at 9:10 A.M., Registered Nurse (RN) 8 indicated the staff communicate through verbal nurse to nurse report if there were any behavioral flare-ups to closely monitor. They were trained to de-escalate and separate residents if they were combative with each other but not on what to expect dealing with sexual offenders or personal safety. She indicated the facility was particular on which male residents they put on the East Hall (women's hall). Kids that come to the facility have to be supervised at all times. She indicated Resident B was not allowed to go to the East Hall for any reason. They were not notified which residents were sex offenders. Most of the time, they found out on their own from other staff and it was verbally understood who can and can't do things. They monitor all residents for behaviors.On 9/25/25 at 9:53 the DON indicated all the residents were treated the same regardless of why they were in the facility. She indicated they were a behavioral health facility, not a typical nursing home, and all their residents have behaviors of some sort. She wasn't sure how staff was supposed to know the specific restrictions for the residents that were sexual offenders. For Resident F, they did not know at that time that he was not allowed to have electronics until they were notified by cops. They have not incorporated the restrictions (if known) into resident specific interventions for the residents. During an interview on 9/25/25 at 1:40 P.M., the Administrator indicated after the nearby school closed a few years ago, they started admitting sexual offenders. They work closely with the parole officers who let the facility know what the residents can and can not do. On 9/25/25 at 8:30 A.M., a current Care Plan Revision Policy, last revised 8/27/24, was provided by the DON and indicated, The purpose of this procedure is to provide a consistent process for reviewing and revising the resident specific care plan . The comprehensive care plan will be reviewed, and revised as necessary . The MDS Coordinator or appropriate staff member, will review and update the resident's care plan and intervention(s) as needed . On 9/25/25 at 1:55 P.M., a current Facility Safety Plan for Offenders Policy/Procedure, dated 9/25/25, was provided by the DON and indicated, It is the policy of this facility to maintain the safety of the residents, staff, visitors, and the community in the presence of residents with a history of a violent/sexual offense.This citation relates to Intake 2609464.3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure accurate resident assessments for 10 of 13 resident records reviewed. Minimum Data Set (MDS) assessments did not reflect accurate resident information. (Resident 6, Resident B, Resident D, Resident 3, Resident 1, Resident 8, Resident 2, Resident 19, Resident 23, Resident C)Findings include: 1. On 9/18/25 at 10:48 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, alcohol-induced dementia, anxiety, depression, and bipolar disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/26/25, indicated a moderate cognitive impairment. The MDS assessment indicated the use of antipsychotic, antidepressant, hypnotic, opioid, anticoagulant, antiplatelet, and hypoglycemic medications. The MDS assessment indicated a gradual dose reduction (GDR) had been completed on 4/16/25, as well as a contraindication to a GDR on 4/16/25. Current physician orders included, but were not limited to: duloxetine (Cymbalta) (antidepressant) 60mg (milligrams) once a day, dated 4/16/25. Gabapentin Oral Capsule (anticonvulsant) 300mg at bedtime, dated 2/27/25. Buspirone (antianxiety) 5mg three times a day, dated 3/6/25. Lamictal (anticonvulsant) 100mg once a day, dated 7/13/25. Resident 3 lacked a current physician order for an antipsychotic medication. Resident 3 lacked a current physician order for a hypnotic medication. Resident 3 lacked a current physician order for an anticoagulant medication. Resident 3's July 2025 medication administration record (MAR) lacked documentation that an antipsychotic, hypnotic, or anticoagulant had been administered during the look-back period for the 7/26/25 MDS assessment. A social services note, dated 4/16/25, indicated a GDR meeting had taken place with a contraindication to decrease Cymbalta due to the resident was taking it for neuropathy. No medications were approved for a GDR at that time. On 9/25/25 at 11:56 A.M., the MDS Coordinator indicated she thought Lamictal was an antipsychotic, but was actually an anticonvulsant and should have been marked on the 7/26/25 MDS assessment. She indicated hypnotic and anticoagulant should not have been marked as given on the MDS assessment, and buspirone could have been marked as the antipsychotic. She further indicated the MDS assessment should have only indicated contraindication on 4/16/25, as a GDR did not take place. 2. On 9/25/25 at 9:23 A.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent quarterly MDS assessment, dated 8/23/25, indicated no cognitive impairment, and independent with bed mobility. The MDS assessment indicated bed rails were used daily for physical restraints. Resident 6's clinical record lacked a physician's order for physical restraints. Resident 6's clinical record lacked a care plan for the use of physical restraints. On 9/25/25 at 8:58 A.M., Resident 6 was observed lying in bed. The left side of the bed was against the wall, and a side rail was observed on the right side of the bed. At that time, Registered Nurse (RN) 8 indicated no one on that hall utilized restraints, and bed rails were used as enablers only. 3. On 9/25/25 at 9:33 A.M., Resident B's clinical record was reviewed. The most recent quarterly MDS assessment, dated 7/29/25, indicated a moderate cognitive impairment, substantial to maximum assistance (helper does more than half the effort) with bed mobility, and use of side rails for physical restraints. Resident B's clinical record lacked a physician's order for physical restraints. Resident B's clinical record lacked a care plan for the use of physical restraints. On 9/24/25 at 8:47 A.M., RN 18 indicated Resident B used bed rails to help move in bed as an enabler, but they were not used as restraints. 4. On 9/18/25 at 12:51 P.M., Resident D's clinical record was reviewed. The most recent annual MDS assessment, dated 8/2/25, indicated a moderate cognitive impairment, independent with bed mobility, and use of side rails for physical restraints. Resident D's clinical record lacked a physician's order for physical restraints. Resident D's clinical record lacked a care plan for the use of physical restraints. On 9/25/25 at 8:49 A.M., Resident D was observed lying in bed with the side rail on the right side. At that time, RN 18 indicated Resident D wanted the side rail to assist with transfers. She indicated the side rails were not used as restraints. 5. On 9/19/25 at 8:55 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, and bipolar disorder. The most recent quarterly MDS assessment, dated 7/12/25, indicated Resident 1 was cognitively intact and was taking a hypnotic and anticoagulant medication and not taking an anticonvulsant or antiplatelet medication. The July 2025 Medication Administration Record (MAR) was reviewed from 7/1/25 to 7/12/25 and included, but was not limited to, the following medications administered to Resident 1: Plavix (antiplatelet) 75 mg daily, ordered 6/28/25 lamotrigine (anticonvulsant) 100 mg daily, ordered 2/28/25 melatonin (over-the-counter sleep aid)10 mg at bedtime, ordered 2/27/25 On 9/25/25 at 11:44 A.M., during an interview with the MDS Coordinator, she indicated that Plavix and melatonin were coded incorrectly as an antiplatelet and hypnotic. The lamotrigine was missed and should have been included in medications as an anticonvulsant. 6. On 9/18/25 at 9:54 A.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, vascular dementia without behaviors, schizophrenia, and bipolar disorder. The most recent significant change MDS assessment, dated 8/4/25, indicated Resident 8's cognition was severely impaired, totally dependent on staff for toileting, showering, bed mobility, and transfers, and was not receiving hospice services at that time. Physician Orders included, but were not limited to, (hospice company name) to provide services, ordered 1/22/25. During an interview on 9/24/25 at 9:12 A.M., RN 8 indicated Resident 8 was currently receiving hospice services. On 9/25/25 at 11:53 A.M., during an interview with the MDS Coordinator, she indicated that hospice services was marked no in error. 7. On 9/19/25 at 12:40 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder and dementia with behaviors. The most recent quarterly MDS assessment, dated 8/23/25, indicated Resident 2's cognition was moderately impaired, taking an anticoagulant and diuretic medication, and not taking an anticonvulsant or an antiplatelet medication. The August 2025 MAR was reviewed from 8/1/25 to 8/23/25 and included, but was not limited to, the following medications administered to Resident 2: Plavix (antiplatelet) 75 mg daily, ordered 2/27/25 Depakote sprinkles (anticonvulsant) 125 mg by mouth three times a day for dementia, ordered 4/18/25 The physician's orders and August 2025 MAR lacked a diuretic medication being administered to Resident 2. On 9/25/25 at 11:51 A.M., the MDS Coordinator indicated the resident had received Plavix and Depakote, but not a diuretic medication, during the lookback period. The MDS assessment medications were coded incorrectly. 8. On 9/19/25 at 12:30 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, depression, and anxiety disorder. The most recent quarterly MDS assessment, dated 9/6/25 indicated no cognitive impairment, and independent with bed mobility. The MDS indicated that bed rails were used daily for physical restraints. Resident C's clinical record lacked a physician's order for physical restraints. Resident C's clinical record lacked a care plan for the use of physical restraints. On 9/17/2025 9:06 A.M., Resident C was observed asleep in his bed. The head of his bed was against the wall, and there was a side rail that was observed on both sides of the bed. 9. On 9/23/25 at 12:24 P.M., Resident 19's clinical record was reviewed. Diagnosis included, but was not limited to, muscular dystrophy. The most recent quarterly MDS assessment, dated 7/19/25, indicated no cognitive impairment, and independent with bed mobility. The MDS indicated that bed rails were used daily for physical restraints. Resident 19's clinical record lacked a physician's order for physical restraints. Resident 19's clinical record lacked a care plan for the use of physical restraints. On 9/25/25 at 8:56 A.M., Resident 19 was observed sitting in a wheelchair in his room. At that time, the head of his bed was against the wall with a side rail on the right side of the bed. Resident 19 indicated it was to help him roll. 10. On 9/23/25 at 12:43 P.M., Resident 23's clinical record was reviewed. Diagnosis included, but was not limited to, stroke affecting the left dominant side. The most recent quarterly MDS assessment, dated 7/19/25, indicated no cognitive impairment, and independent with bed mobility. The MDS indicated that bed rails were used daily for physical restraints. Resident 23's clinical record lacked a physician's order for physical restraints. Resident 23's clinical record lacked a care plan for the use of physical restraints. On 9/25/25 at 9:00 A.M., Resident 23 was observed sitting in his wheelchair in his room. At that time, the head of his bed and the right side of the bed were against the wall. A side rail was observed on the left side. Resident 23 indicated he used the bed rail to get up and down in bed. During an interview on 9/25/25 at 9:01 A.M., Registered Nurse (RN) 8 indicated they do not have any restraints in the facility. All side rails are utilized as enablers. During an interview on 9/25/25 at 11:39 A.M., the MDS Coordinator indicated all side rails in the building were utilized for mobility. She indicated the facility does not use restraints and was unsure if restraints should have been coded on the MDS for the side rails. During an interview on 9/25/25 at 11:45 A.M., the MDS Coordinator indicated she used the Resident Assessment Instrument (RAI) manual as the policy.

Based on interview and record review, the facility failed to deliver mail to the residents on Saturdays. Ten of ten anonymous residents interviewed indicated they failed to get mail every Saturday. Findings include: During a resident council meeting on 9/23/25 at 9:41 A.M., an anonymous resident indicated they failed to receive mail on Saturdays and they would like to receive it, but their Business Office Manager was not at the facility on Saturday's to deliver it. During an interview on 9/23/25 at 9:44 A.M., the Business Office Manager indicated she delivered mail to the residents and since she does not work on Saturdays, the residents do not receive mail on Saturdays. On 9/25/25 at 11:04 A.M., the Director of Nursing (DON) provided a current, undated, Residents Mail and Finances policy that indicated, .All personal mail is given to the Activities Director to take to the residents . 3.1-3(s)(1)

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for 6 of 15 resident rooms reviewed for the environment. Rooms and a hall had a strong urine odor, peri-cleanser and cream (used for incontinence care) were found in a resident refrigerator, call light strings in the bathrooms were soiled, and grab bars and the toilet seat were loose. (East Hall, [NAME] Hall, Resident rooms and or shared bathrooms, Rooms 101, 102, 103/105, 108/110, 207/209, 204/206)Findings include:1. On 9/16/25 12:33 P.M., room [ROOM NUMBER] and the private bathroom was observed with a strong urine odor.On 9/24/25 at 9:10 A.M., the same was observed. 2. On 9/16/25 at 12:35 P.M., room [ROOM NUMBER], there was cream in an open clear cup and a bottle of peri-cleanser observed in Resident 8's refrigerator with three cans of soda.On 9/24/25 at 9:11 A.M., the same was observed.On 9/24/25 at 9:23 A.M., Certified Nurse Aide (CNA) 22 indicated those shouldn't be stored there, took them out, and discarded them in the trash can. 3. On 9/16/25 12:38 P.M., room [ROOM NUMBER]'s bathroom (shared with room [ROOM NUMBER]) was observed with a strong urine odor.On 9/24/25 at 9:08 A.M., the same was observed. 4. On 9/16/25 at 12:46 P.M., room [ROOM NUMBER] and bathroom (shared with 110) was observed with a strong urine odor, the handle bars and the toilet seat they were connected to were loose, and the call light cord was brown.On 9/24/25 at 9:06 A.M., the same was observed. 5. On 9/16/25 at 12:48 P.M., room [ROOM NUMBER]'s bathroom (shared with room [ROOM NUMBER]) was observed with a brown call light cord that was wrapped around a grab bar.On 9/24/25 at 9:04 A.M., the same was observed. 6. On 9/16/25 at 12:57 A.M., room [ROOM NUMBER]'s bathroom (shared with room [ROOM NUMBER]) was observed with a brown call light cord and a strong urine odor.On 9/24/25 at 9:02 A.M., the same was observed. During an interview on 9/24/25 at 9:25 A.M., Housekeeper 5 indicated they do have rooms that smell because the residents forget to flush or did't hold the handle down long enough. At that time, she indicated staff located the source and used bio enzymatic odor eliminator spray. They cleaned the rooms and bathrooms daily and as needed. If the call light cord was brown, it would need to be changed by maintenance. The housekeeper was responsible for taking the resident refrigerator temperatures daily and when they looked inside at thermometer, if there was something in it that shouldn't be, they would discard it. On 9/25/25 at 9:29 A.M., the Director of Nursing (DON) indicated the facility didn't really have a policy for the environment but they would follow the regulations. This citation relates to Intake 2607081. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure services provided by the facility met professional standards for 1 of 2 residents reviewed for nutrition. A resident's weights were not transferred into the clinical record, the medical provider and family were not notified of weight loss, the dietitian's recommended orders were not put into place, and the resident continued to have weight loss. (Resident G)Finding includes:On 9/19/25 at 12:06 P.M., Resident G was observed sitting in a Broda chair in the dining room while staff fed him.On 9/18/25 at 12:48 P.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, dementia.The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/12/25, indicated Resident G's cognitive status could not be assessed and was dependent on staff for eating, showering, toileting, bed mobility, and transfers. He was on a mechanical diet (consisting of foods that are modified to be easy to chew and swallow) and experienced a weight loss. His current weight was 156.0 pounds (lbs) and height was 66 inches.Current orders included, but were not limited to,weight monthly, ordered 3/1/25magic cup (supplement) at 5:00 P.M. with supper daily, ordered 2/1/25regular diet with mechanical soft texture, ordered 2/27/25A current Nutrition Care Plan, last revised 7/12/25, included, but was not limited to, the following interventions initiated on 6/27/24:Monitor monthly weightsMonitor/record/report to Medical Doctor (MD) as needed, a significant weight loss (greater than 5% in one month, greater than 7.5% in three months, or 10% in six monthsProvide and serve supplements to me as orderedRegistered Dietitian (RD) to evaluate and make recommendations as neededThe most recent Nutritional Risk Assessment, dated 7/12/25, completed by the RD recommended to increase the magic cup from daily to twice daily.The clinical record lacked documentation of the resident being seen by the RD since 7/12/25.The Medication Administration Record (MAR) for September 2025 was reviewed from 9/1/25 through 9/17/25 and indicated Resident 41 was only getting the magic cup with his supper.The clinical record lacked documentation of notification to the MD or Nurse Practitioner (NP) of the weight loss.On 6/1/25, the resident weighed 166.4 lbs. On 7/1/25, the resident weighed 155.6 lbs, which was a weight loss of 6.49%.The clinical record lacked documentation of notification to the MD or Nurse Practitioner (NP) of the weight loss.The clinical record lacked documentation of any weights completed since then.On 9/24/25 at 9:23 A.M., Certified Nurse Aide (CNA) 22 CNAs weighed the residents when the nurse notified them to do it. She indicated that, to her knowledge, he only got a magic cup with his supper.On 9/24/25 at 9:35 A.M., Registered Nurse 8 indicated he was a monthly weight. He should get the magic cup as ordered. At that time, she indicated the dietary manager usually went through the clinical records and looked for weight loss. They would notify the dietician, MD, and DON, and they would decide what to do. To her knowledge, the RD came to the facility monthly. During an interview on 9/24/25 at 10:06 A.M., the Dietary Manager indicated she just took over (9/5/25) and didn't have a list of residents with weight loss currently in the facility.On 9/25/25 at 9:40 A.M., the RD indicated she came to the facility 8 hours per month. The process was to see all residents on admission, quarterly, and as needed. Nursing or the Dietary Manager would refer her for evaluation. She had not seen the resident in August or 9/19/25 when she was at the facility. She was not sure why there was not a recent weight in Resident G's clinical record or why his magic cup was not increased. On 9/25/25 at 9:53 A.M., the Director of Nursing indicated the Assistant Director of Nursing (ADON) had papers on her desk with August and September 2025 weights for Resident G. His August weight was 154.4 lbs, and his September weight was 145.6 lbs, but these were not put into the clinical record. She said the resident had aspiration pneumonia recently, which could have been the cause of the weight loss, but generally, he ate well. She would usually be the one to notify the MD of the RD recommendations and was not sure why the magic cup was not increased after the 7/12/25 visit. She also had no visit notes from the dietician in August or September. She indicated that the weights not being in the clinical record would have caused the dietitian to miss seeing him, and the MD not being notified.On 9/25/25 at 12:06 P.M., a current Nutritional Risk Program Policy, last revised 9/10/13, was provided by the DON and indicated, It is the policy of this facility to monitor the weight status of each resident and that appropriate interventions be initiated should weight decline or incline unplanned . This citation relates to Intake 26070813.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a notice of transfer or discharge notice and a bed hold policy was given to residents or resident representatives for 2 of 2 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a notice of transfer or discharge and a bed hold at the time of hospitalization. (Resident 1, Resident 7)Findings include: 1. On 9/18/25 at 9:38 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and anxiety disorder. Resident 7 was admitted from the facility to the hospital on 7/21/25 and returned to the facility from the hospital on 7/28/25. Resident 7 was admitted from the facility to the hospital on 8/19/25 and returned to the facility from the hospital on 8/20/25. Resident 7 was admitted from the facility to the hospital on 8/31/25 and returned to the facility from the hospital on 9/3/25. Resident 7's clinical record lacked a notice of transfer/discharge and bed hold policy given to the resident or a representative at the time of the transfers. 2. On 9/19/25 at 8:55 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type II diabetes, and bipolar disorder. Resident 1 was admitted from the facility to the hospital on 7/27/25 and returned to the facility on 8/4/25. Resident 1's clinical record lacked a notice of transfer/discharge and bed hold policy given to the resident or a representative at the time of the transfer. On 9/24/25 at 9:43 A.M., the Social Services Director (SSD) indicated that when a resident is transferred from the facility, the nurses fill out the transfer and discharge notice along with the bed hold policy. A copy of them was kept in her office in a binder, but not put into the clinical record. On 9/25/25 at 1:55 P.M., a current non-dated Notice of Transfer/Discharge Policy was provided by the Director of Nursing (DON) and indicated, . A copy of the completed and signed transfer/discharge notice will be placed in the clinical record . On 9/25/25 at 2:29 P.M., a current Bed Hold Policy, dated 8/22/24, was provided by the DON and indicated, . The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file . 3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to ensure residents were free from misappropriation for 1 of 3 residents reviewed for misappropriation. A resident's debit card was taken without consent and used by staff to withdraw $305.00 from the resident's bank account. (Resident D) Finding includes: During a review of facility reported incidents on 5/19/25 at 10:15 A.M., an incident dated 5/6/25, indicated Resident D had been alerted of suspected fraudulent activity from his bank. A withdraw was made from a local automatic teller machine (ATM) on 5/5/25 at 2:05 A.M. for $305.00. CNA 13 indicated that Resident D asked her to withdraw $300.00 from the bank at 2:00 A.M. during her lunch break. During a review of the facility's investigation into the incident on 5/19/25 at 10:20 A.M., a typed note, dated 5/6/25 and signed by the Facility Administrator indicated Resident D came to the office after he received an alert of suspected fraud at the bank. Resident D indicated he had asked CNA 13 to call the bank for him and check on his account balance and gave her his Personal Identification Number (PIN). A withdrawal was made at 2:05 A.M. on 5/5/25 for $305.00. A Disciplinary Notice Record, dated 5/7/25, indicated CNA 13 had been terminated from employment for using a resident's debit card to withdraw money against facility policy. During record review on 5/19/25 at 10:30 A.M., Resident D's diagnoses included, but were not limited to, heart failure, chronic obstructive pulmonary disease (COPD), and chronic pain. Resident D's most recent quarterly minimal data set (MDS) assessment, dated 3/22/25, indicated the resident had no cognitive impairment. During an interview on 5/19/25 at 10:40 A.M., Resident D indicated that CNA 13 had used his personal debit card to withdraw money from a local ATM. Resident D indicated he did not give CNA 13 his debit card or ask her to withdraw money for him, and that he would not have asked anyone for money at 2:00 A.M. Resident D indicated he never received the money that had been withdrawn from his account and that he was waiting on his account to be reimbursed. Resident D felt taken advantage of and was inquisitive about the results of a local police department's investigation of the incident. During an interview on 5/19/25 at 11:20 A.M., the Facility Administrator indicated the local police had shared with him that CNA 13 could be seen on video making a withdraw from the local ATM at 2:05 A.M. on 5/5/25. During an interview on 5/19/25 at 1:30 P.M., CNA 7 indicated that staff should notify the Director of Nursing (DON), Business Office Manager (BOM), or Facility Administrator when a resident requests staff make a purchase for them. A form should be filled out with the amount of money and what the money is for, then a receipt of purchase is filed for the transaction, and nursing staff must witness and sign when the resident receives their goods or any money that may be returned. During an interview on 5/19/25 at 2:05 P.M., the DON indicated that CNA 13 admitted to using Resident D's debit card but insisted that Resident D had asked her to do so. The whereabouts of the withdrawn cash had not been determined, and the money remained unaccounted for. On 5/19/25 at 10:55 A.M., the Facility Administrator supplied a facility policy titled, Policy and Procedure for Money Transactions and Shopping for Residents, dated 1/24/24. The policy included, .A resident may request for a staff member to take their debit card or money to the bank or store for cash or personal items, which must be approved. Procedure . 2. When the Activity Director is not available or it is after business hours or on a weekend and the resident is requesting for a staff member to go shopping for them it has to be approved by the Administrator or Director of Nursing if the staff is taking the residents debit card. 3. The charge nurse must complete the Money Transaction Shopping Form . This citation relates to complaint IN00459045. 3.1-28(a)

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed for abuse. A resident was allegedly threatened with physical abuse and then was smacked by a staff member in retaliation for the resident striking the staff member during care. (Resident L) Finding includes: During a review of state reportable incidents on 1/7/25 at 11:15 A.M., an incident report dated 1/5/25 at 6:50 P.M. indicated Certified Nurse Aide (CNA) 13 reported herself to the nurse after an incident with Resident L. Resident L allegedly hit CNA 13 in the face and CNA 13 then hit [Resident 13] back in the ribs. During record review on 1/7/25 at 12:00 P.M., Resident L's diagnoses included but were not limited to, hemiplegia affecting left side, anxiety, depression, bipolar disorder, schizoaffective disorder, dementia, traumatic brain injury, and conduct disorder. Resident L's most recent quarterly Minimum Data Set (MDS) assessment, dated 10/12/24, indicated the resident's cognition was moderately impaired. Resident L's care plan included, but was not limited to; Resident has a behavior problem due to traumatic brain injury and being physically/verbally aggressive. Resident hits/punches others (initiated 11/8/23). Interventions included, but were not limited to, caregivers to provide opportunity for positive interaction, approach/speak in a clam manner. Resident L's progress notes included, but were not limited to, an incident note, dated 1/7/25 at 8:32 A.M., that indicated Resident L was re-assessed due to recent incident. Resident asked to point to the area on his right side. Resident touched the upper right rib area. No bruising, swelling or other marks were noted. During review of the facility's investigation into the incident between Resident L and CNA 13, a witness statement from Qualified Medication Aide (QMA) 4 indicated that on 1/5/25 at 6:50 P.M., Resident L's call light went off. QMA 4 answered the light and began changing the resident due to an incontinent episode. CNA 13 walked in to Resident L's room to assist with incontinence care. Resident L became very annoyed with the staff during care and began mocking and cursing at the two staff members. Resident L then hit CNA 13 in the face and CNA 13 then smacked him back. An interview signed by the Director of Nurses (DON) with Resident L, dated 1/6/25, indicated that Resident L felt CNA 13 was being too rough during incontinent care. Resident L told CNA 13 that he would hit her and CNA 13 told the resident, if you hit me, I will hit you back. Resident L indicated that he playfully placed his closed fist on CNA 13's cheek, and she punched him in the side. During an interview on 1/7/25 at 1:50 P.M., CNA 9 indicated that if a resident is being physically or verbally aggressive towards staff, the staff member should remove themselves from the situation and allow the resident to calm down. Staff should re-approach the resident at a later time. The facility's investigation of the incident included an inservice training of the facility's Procedure for Abuse Prohibition, Reporting, and Investigation policy. The policy indicated, It is the policy of [Facility] to ensure that each resident is free of physical, mental, verbal and sexual abuse, corporal punishment, mental and physical neglect and involuntary seclusion . C. Verbal abuse . can include resident to resident or staff to resident verbal threats of harm . This citation relates to complaint IN00449658 3.1-27(b)

A. Based on interview and record review, the facility failed to ensure supervision of two cognitively impaired residents; and failed to follow the facility elopement policy resulting in elopements for 2 of 2 residents reviewed for accidents. Resident B exited the facility by a side door and walked 0.5 miles to a gas station. An hour later, the resident's brother notified the facility that Resident B had left the facility. Resident C exited the facility by the front door after being returned to the facility by the son after an overnight stay. Twenty minutes later the resident was found outside the facility walking in the grass away from the facility next to the road, Highway 62. (Resident B, Resident C) This deficient practice resulted in an Immediate Jeopardy. This Immediate Jeopardy began on August 4, 2024, when the facility failed to ensure a cognitively impaired resident was adequately supervised and was allowed to leave the facility by the front door. On August 5, 2024, another cognitively impaired resident left the facility by the side door. The second resident had a history of wandering and was not adequately monitored for these behaviors. The Administrator was notified of the Immediate Jeopardy on August 13, 2024 at 2:29 P.M. The Immediate Jeopardy was removed on 8/15/24 at approximately 3:30 P.M., but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. B. Based on observation, record review, and interview, the facility failed to develop and implement interventions to reduce the risk of falls, fall risk assessments were failed to be completed after falls, and neurological checks were not completed after unwitnessed falls for 2 of 7 residents reviewed for accidents, (Resident 18, Resident 33). Findings include: A 1. On 8/13/24 at 9:15 A.M., the Indiana Department of Health (IDOH) incident reports were reviewed and indicated on 8/5/24 at 4:51 P.M., Charge nurse called stated that resident called his brother and said I'm at a gas station come pick me up. Brother called facility and staff immediately went and picked him up. On 8/13/24 at 9:30 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain injury, epilepsy with status epilepticus, unsteadiness on feet, rheumatoid arthritis, dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, unspecified mood (affective) disorder, conversion disorder with seizures, anxiety, and unspecified psychosis. The most recent Annual MDS (Minimum Data Set) Assessment, dated 8/3/24, indicated Resident B's cognition was severely impaired, supervision of 1 staff with set up for bed mobility, transfers, eating, and toileting, did not have behaviors of wandering or exit seeking, and wore a WanderGuard (device worn to prevent elopement) daily. The physician orders, dated, 10/11/23, (prior to 8/5/24 when Resident B eloped), indicated facility staff should monitor Resident B for behaviors including, but not limited to, elopement, wandering, and to check placement and function of the WanderGuard every shift. A plan of care for history of elopement, dated 7/28/24, included, but were not limited to, interventions for staff to use distraction techniques, structured and individual activities, music, Activities of Daily Living (ADL) care, and a WanderGuard to prevent further elopement attempts. The care plan did not include documentation to show the plan was revised with interventions to prevent another elopement. A plan of care for Psycho-Social Distress Risk, dated 11/3/23, included but were not limited to, intervention to monitor behavior episodes, attempt to determine underlying cause, and to document behavior and potential causes. An elopement risk evaluation, dated 7/30/24, indicated the resident did not have a history of elopement, did not wander, and was not at risk for elopement. The progress notes were reviewed from 8/1/24 through 8/13/24 and lacked documentation of exit seeking behavior. A nursing progress note, dated 8/5/24 6:00 P.M., indicated one-to one (continuous) supervision was provided for two hours followed by 15-minute checks per facility protocol that ended on 8/6/24 at 10:15 A.M. The August 2024 MAR (Medication Administration Record), dated 8/1/24 through 8/12/24, indicated Resident B demonstrated behavior of exit seeking on the evening shift of 8/5/24. The facility's investigation of Resident B's elopement on 8/5/24 included the following: Resident B approached LPN (Licensed Practical Nurse) 5 at approximately 4:48 P.M. and asked where he could get a meal. The report indicated LPN 5 told Resident B supper would be served in 10 minutes, but did not include documentation to determine interventions to prevent elopement were implemented in accordance with the plan of care. At approximately 5:45 P.M., LPN 5 answered the phone and the resident's brother said he got a phone call from Resident B telling him he was outside the facility at a gas station and he wanted to be picked up. A (Name of Door Repair Company) technician reported on 8/5/24 (time unknown) the hinges on the side door (employee entrance) were adjusted to so the door would close properly. Maintenance Employee 7 indicated on 8/5/24 (exact time unknown but after door repair company was there that day) inspected the side door and noticed the door was still not closing properly against the alarm sensor. A (Name of Door Repair Company) technician report about the side door dated 8/6/24 at 1:30 P.M., indicated upon arrival, maintenance stated that from time to time the Maglock would not engage when the door closed and the alarm would not sound when door was left ajar as expected. The technician identified a wiring problem that prevented the alarm equipment from functioning properly. During an interview on 8/13/24 at 9:49 A.M., LPN 5 indicated Resident B needed some supervision, had behavior of wandering up and down the halls, wore a WanderGuard, and had a very poor short term memory. At that time, she indicated he had eloped before but not for at least a year and was not exit seeking or voicing that he wanted to leave the facility. She indicated they do not document random wandering in his clinical record. It's only documented if he's intrusive to other residents. At that time, LPN 5 indicated the Elopement Risk Evaluation, dated 7/30/24, was filled out incorrectly. During an interview on 8/13/24 at 9:57 A.M., CNA (Certified Nurse Aide) 6 indicated Resident B was mainly independent, did wander in the halls, and staff only had to check on him every now and then. She indicated he had not eloped before that she knew of and she was not working the day he eloped but was told that Resident B wanted turkey for an evening meal and went to get one for himself. During an interview on 8/13/24 at 10:08 A.M., the SSD (Social Services Director) indicated Resident B had a history of elopement and vocalization that he did not want or need to be in the facility and he wanted to leave, but nothing recently. He had not been exhibiting exit seeking behavior prior to the elopement. He had a thought in his head at that minute, found a way out, and then left the facility to get what he wanted. At that time, she indicated he did wander, but they were not tracking wandering behaviors because it was considered his normal activity. During an interview on 8/13/24 at 10:16 A.M., the Administrator indicated Resident B has had exit seeking/wandering and aggressive behavior in the past but not recently. To keep the resident safe, they use a WanderGuard but it does not sound an alarm at any of the 3 exterior doors as you would expect. It only sounds when those residents enter and exit through the double doors from the dining room. During mealtimes and activities, the facility disables that alarm because so many residents pass through the doors at those times. At that time, he indicated on 8/5/24 he got a call from a nurse that Resident B went to the nurse's station and asked for a sandwich. Resident B was told to follow the CNA's to the dining room. Resident B went to the dining room, knocked on the kitchen door, asked for a turkey sandwich, and was told it would be on his meal tray. At that time, the resident sat down at a table, got up and walked down the hall, and went out of the side door near the dining room. The nurse was contacted at 5:45 P.M. by the resident's brother and notified that the resident had left the facility and was at a gas station. The staff only documented Resident B's behaviors if they were accelerated and since wandering was his normal, they don't document that. The Administrator indicated he would expect staff to provide interventions to prevent elopement in accordance with the care plan for a cognitively impaired resident at risk for elopement. During an interview on 8/13/24 at 10:35 A.M., the Maintenance Director indicated maintenance staff was not expected to randomly check the doors of the facility to make sure they were functioning properly. They were only checked when maintenance staff were alerted to a problem with them and staff did not keep any documentation about it. During an interview on 8/13/24 at 2:01 P.M., CNA 4 indicated he was working at the time Resident B eloped and was working on the [NAME] Hall where Resident B's room was. CNA 4 indicated Resident B had a history of eloping from the facility. CNA 4 indicated when he went to pick up the resident from the gas station after they were notified Resident B was missing, the resident was confused and didn't know where he was but said he went to (name of restaurant) across the street from the gas station and got himself a drink and a sandwich. According to the Iphone map application, the restaurant where the resident went was 0.5 miles away from the facility and would take 11 minutes to walk there. The resident had to cross Indiana Highway 62 and [NAME] Street twice to get to the restaurant and then to the gas station where he was picked up by staff. 46882 A 2. On 8/13/24 at 9:15 A.M., an Indiana Department of Health Incident Report, dated 8/4/24, indicated Resident C was found walking up the road by a staff member. Facility was investigating how she got out. It was reported that a nurse left for lunch and resident may have followed the nurse out the front entrance door. Resident C was immediately returned to facility and placed on 1:1 for 2 hours and 15 minute checks for 72 hours. Facility immediately notified maintenance to check the doors and called (Name of Door Repair Company #1) to come and inspect the doors. On 8/13/24 at 9:30 A.M., Resident C's medical records were reviewed. admitted was 2/8/24. Diagnosis included, but were not limited to rheumatoid arthritis, coronary artery disease, hypertension, non-Alzheimer's dementia, seizure disorder, anxiety disorder, asthma, and hallucinations. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident C was moderately cognitively impaired, needed supervision of one for bed mobility, supervision with set up for transfers and eating and limited assistance of one for toilet use. Resident had no behavior of wandering, no hallucinations, no delusions, no physical or verbal behavioral symptoms, and used a wander/elopement alarm daily. Current physician orders, dated 7/25/24, indicated facility staff should monitor Resident C for behaviors including, but not limited to elopement and check placement and function of the WanderGuard every shift. A plan of care for risk of elopement/wandering, dated 7/8/24, included, but were not limited to, interventions for staff to use distraction techniques, structured and individual activities, music, quiet time, identify patterns of wandering, and a WanderGuard to prevent further elopement attempts. Care plan interventions were not updated after Resident C eloped on 8/4/24. Progress Notes included, but were not limited to the following: 7/18/24 5:46 A.M. Health Status Note Note Text: Resident pacing from room to lobby multiple times. c/o [complained of] being cold. Resident given a jacket and went back to room. 7/18/24 8:38 A.M. Health Status Note Note Text: Resident pacing from room to lobby. Snack given, went back to room. 7/20/24 12:20 P.M. Behavior Progress Note Note Text: Resident restless, walking up and down hallway, standing next to nursing cart, and following nurse from room to room. Resident laid down at noon for a nap. 7/25/2024 12:50 P.M. Behavior Progress Note Note Text: Resident has been pacing today and standing at the nurses [sic] station multiple times today. Resident is not causing any issues. Resident has brought some of her greeting cards from her room to the nurses [sic] station and has read them repeatedly to whomever is there at the nurses [sic] station to listen, otherwise resident stands there quietly. Resident has been asked if there are any unmet needs. Resident denies and unmet needs. 7/26/24 5:13 A.M. Health Status Note Note Text: Resident restless and pacing early in shift between 6 P.M. to 8 P.M. Once resident was assisted with getting ready for bed, rested well with C-Pap on. 8/4/2024 1:48 A.M. Health Status Note Note Text: OOF [out of facility]- Family went out with resident and to be returned to facility 5pm [sic] per report given. RSD [resident] has not been returned to facility at this time. Calls made to family via phone. Pending response back. 8/4/2024 1:33 P.M. Health Status Note Note Text: Resident has returned to facility at this time with son. 8/4/2024 2:29 P.M. Incident Note Note Text: This nurse received a phone call from employee who was leaving on lunch break that this resident was walking outside facility and he was assisting her back to front door. This nurse and CNAs [Certified Nurses Aides] ran to front door and assisted resident back into the facility where she was assessed. Temp [Temperature] 96.5, Resp [Respirations] 16, HR [Heart Rate] 99, BP [Blood Pressure] 120/95, 93% RA [Room Air]. Resident had just returned from overnight stay with son and stated that she was trying to get home to her son. Resident is currently on 1 on 1 supervision for 2 hours. Administrator, DON [Director of Nursing], PCP [Primary Care Provider], andfamily [sic] notified. 8/4/2024 4:41 P.M. Elopement Evaluation done by LPN 5 had an Elopement Score of 3 which indicated Resident C was an elopement risk and wandered. A progress note dated 8/5/24 8:38 A.M. indicated Resident C was on 15 minute checks for 72 hours. A Fifteen Minute Checks Form was completed every 15 minutes starting on 8/4/24 at 4:30 P.M. through 8/7/24 at 11:45 P.M. A progress note by Social Services, dated 8/5/24 3:55 P.M., indicated Social Services met with Resident C in her room and talked about the weekend. Resident C talked about other things not related to the elopement. No exit seeking had been reported. A progress note, dated 8/5/24 8:13 P.M., indicated Resident C had no exit seeking. She stayed in her room or stood at the nurse's desk. She went to the dining room for supper. She refused to wear bipap and had to be put to bed 4 (four) times. She will be monitored. A progress note, dated 8/7/24 5:19 P.M., indicated Resident C was very confused, wandering on the unit, almost blocked another resident's doorway. The other resident raised their voice to get her to move. Both residents were redirected successfully. A progress note, dated 8/11/24 11:48 A.M., indicated Resident C was seen wandering by the front door several times, pushing on the double doors by the front door. Alarm was applied to front door and Resident C was monitored for safety. The most recent Core Behavior Risk Assessment completed on 4/25/24 indicated Resident C was on psychotropic medications, was cognitively impaired, had no history of mental illness and no aggressive behaviors in the last 3 months. The August 2024 Medication Administration Record (MAR), dated from 8/1/24 through 8/13/24, indicated Resident C had no behaviors on any shift and the WanderGuard was checked for placement and function every shift, except for the evening of 8/3/24, which was blank. A handwritten note signed by LPN 5 indicated on 8/4/24 when she went to the front door to get Resident C from Dietary Aide 3, she noticed the front entrance door was not latched and the alarm was not sounding. A typed note by LPN 12, dated 8/4/24, indicated she went out the front entrance door to put belongings in her car. She heard the front entrance door slam. She helped Resident c through the second set of double doors by the entrance after explaining to the resident that her son had left. After Resident C was in the hallway, LPN 12 went to the [NAME] Hall. Since the door had slammed LPN 12 assumed it closed. When she left the facility, LPN 12 noticed the front entrance door was not closing all the way and was staying open. The door had to be pushed on to close it when leaving. A typed note, dated 8/4/24, by Maintenance Tech 26, indicated he was called by the Maintenance Supervisor that the front door was malfunctioning. He was unable to repair the door due to multiple damages. He let his supervisor know and the (Name of Door Repair Company #1) was contacted. Fire Watches were conducted every 15 minutes (from 6:40 P.M. through 7:10 P.M.) until (Name of Door Repair Company #1) arrived. (Name of Door Repair Company #1) was unable to repair the front entrance door due to multiple damages and recommended the code to enter and exit the front entrance door be changed for safety measures. The code was changed. A typed note by the Maintenance Supervisor, dated 8/4/24, indicated nothing was reported to her that the front entrance door had any problems. She was called about the door malfunctioning. When (Name of Door Repair Company #1) indicated they were unable to fix the door, she called the Administrator and he called (Name of Door Repair Company #2) to come and repair the front entrance door. Review of the (Name of Door Repair Company #1) invoice dated 8/4/24 indicated Technician called facility to inform of arrival time. Apon [sic] arrival technician met with facility and began troubleshooting front door. With nothing on door, door swings open 8 inches due to the bottom hinge rotting out. Technician tried to adjust two door closers to hold door shut for maglock to engage. Door closers do not have enough force to keep door from moving back out of range for maglock to engage. Technician spaced out bottom hinge to realign door. Spacing was unsuccessful and if we step up the spacing anymore it will blow the door out of what is remaining for the bottom hinge. The side and top of the door frame moves and shifts with the door. The bottom threshold has soft wood under it. Door is locked down until further work is done. Review of the (Name of Door Repair Company #2) work order, dated 8/5/24, indicated the front entrance door was not shutting all the way. Bottom pivot was busted and moving around. Replaced the bad pivots with a continuous hinge. We fabricated a brace for hinge side jams/top of frame. We also made a door stop for the bottom of the door. Door is short on width. Note: It was reported a resident busted out of the door and did some damage. During an interview 8/13/24 at 9:58 A.M., the DON (Director of Nursing) indicated Resident C was checked every two hours for check and change since she was incontinent. She was not followed by staff when ambulating in the hall since it was a locked building. The DON indicated Resident C wandered but did not have a history of exit seeking. From the time Resident C was admitted , she wandered the halls looking out the front double doors for her son's car in the parking lot but didn't try to go out the doors. She had a WanderGuard on, and staff redirected her away from the doors. She liked to hang out with the nurses. She was a jailer on night shift all her life and liked making rounds with the nurses. The DON indicated the son picked Resident C up on Saturday for an overnight stay and brought her back on Sunday. The son did take her to her room. The son indicated that he turned around to make sure the door was shut. The DON indicated that there were no problems with the alarm system on 8/4/24 and maintenance checked the doors and alarms routinely. Wander Guard would not trigger if a resident went out the front door. During an interview on 8/13/24 at 11:02 A.M., CNA (Certified Nurse Aide) 6 indicated Resident C did not have a history of elopement. Her son had dropped her off and she told CNA 6 after the elopement that she was going to whoop his butt because she was not done staying at home. Thirty minutes after Resident C was returned the elopement happened. CNA 6 heard the alarm but did not respond because she was on the end of the hall with a resident. Resident C was in the parking lot and had already been out there at that point. During an interview on 8/13/24 at 11:32 A.M., LPN (Licensed Practical Nurse) 5 indicated she usually worked on the [NAME] Hall but had worked with Resident C on 8/4/24. Resident C needed limited to extensive assistance with care, depending on what it is. She required her meat to be cut but could ambulate on her own. Elopement assessments were done quarterly and could be seen under assessments in the medical records. Resident C did not have a history of exit seeking but she wandered and wore a WanderGuard. At the time of the elopement on 8/4/24, LPN 5 indicated she was doing charting at the desk at the opposite end of the East Hall, not in view of the front entrance door. The son brought Resident C back at 1:30 P.M. About 1:50 P.M., kitchen employee called and said resident was walking outside. LPN 5 indicated she did not see Resident C go out the front door. When she got outside Resident C was in parking lot. She brought her inside and kept her at the nurse's desk for 1:1 for 2 hours. Resident C did go to the dining room for supper and had no further behaviors. LPN 5 indicated Resident C has had no other attempts of exiting the building. LPN 5 indicated the alarm at the front door went off anytime someone went in or out of the building. Each nurse's desk had box on the wall that indicated where the alarm was going off. Any employee could check an alarm to see if a resident was setting it off. During an interview on 8/13/24 at 2:01 P.M., CNA 4 indicated he was working the day Resident C eloped. He indicated the alarm would sound, but he always had to press the front entrance door back because you didn't know if it would stay closed. He indicated Resident C was warm when she came back into the facility. They had to put cool cloths on her and make sure her air conditioner unit was turned up in her room. During an interview on 8/13/24 at 2:12 P.M., Dietary Aide 3 indicated he went out the back door going on lunch break around 2:00 P.M. He indicated he was leaving the parking lot when he saw Resident C standing in the grass next to the facility sign facing Indiana Highway 62. He called the nurse to notify her the resident was outside and turned around as soon as possible. He parked his Jeep in the parking lot, called Resident C's name and she walked to him. He assisted her to the front door where staff was waiting. During an interview on 8/14/24 at 8:59 A.M., Resident C indicated her son brought her back to the facility on [DATE] because he had to [NAME] the yard. She indicated her son's truck was broke down and didn't want her to have to deal with that as well. Resident C could not recall any specifics about the elopement incident. During an interview on 8/14/24 at 9:44 A.M., the DON indicated that care plans might be updated by MDS (Minimum Data Set) Coordinator, Social Services or Activities depending on what the care plan entails. As far as when care plans were to be updated, the DON indicated that usually that was done with quarterly MDS assessments, or if there was something that arose such as infection, injury, or something of an acute nature. On 8/14/24 at 11:55 A.M., the weather report for 8/4/24 at 1:53 P.M. to 2:53 P.M. found on TimeandDate.com/weather indicated the temperature was 91 degrees and the humidity was 52%. On 8/14/24 at 8:33 A.M., the DON provided an undated Elopement Policy and Procedure that indicated, .The facility team will assess the environment to identify potential risks associated with elopement and/or hazards associated with elopement. Elopement is defined as follows: When a cognitively impaired resident leaves the physical structure of the facility unattended and without staff knowledge and displays exit seeking behavior. [name of company] will implement individualized interventions to strive to prevent elopement .Complete Elopement Plan of Care as applicable .Review and evaluate assessments and risk factor data and make a determination of risk for elopement .Review and revise plan of care as needed .Review and correct deficiencies in practice as they relate to the following, including, .response to alarms, testing alarms .Validate that the resident is wearing an electronic/alarm device as indicated and check that electronic/alarms systems are functioning according to manufacturer recommendations. Record residents at risk for elopement on patient care guide/assignment sheets .If in the event a resident is found to be missing or suspected to be missing a FULL FACILITY head count will be completed and the Missing Resident Action Plan will be initiated .The interdisciplinary team will re-evaluate cognitively impaired residents who have attempted (unsuccessfully or successful) to elope from the facility. Individualized interventions will be developed and initiated to manage the elopement behavior .Review and update plan of care and evaluate risk factors identified . On 8/14/24 at 11:37 A.M., the DON indicated that the missing resident action plan was not completed after the incident, as per policy, as staff was not aware of where the forms were located, but she would expect the form to be completed in the event a resident was missing. On 8/14/24 at 8:33 A.M., the DON provided a Behavior Management Policy, dated 3/11/24, that indicated, A Behavior Risk Assessment will be completed on all residents upon admission, quarterly, and when new or worsening behavior occurs. All residents who score 3 or above on the behavior risk assessment may be deemed high risk for behaviors and may require a review of the current care plan by the IDT (Inter-disciplinary Team) and/or the medical provider. All residents will be monitored for behaviors every shift. If an identified behavior occurs, it will be documented in the medical record . On 8/14/24 at 11:37 A.M., the DON indicated that the missing resident action plan was not completed for Resident B and Resident C as staff was not aware of where the forms were located to complete it. The Immediate Jeopardy, that began on 8/4/24, was removed on 8/15/24 when the facility in-serviced facility staff on exterior door policy, revised elopement policy and identification, missing person action plan, use of Wanderguard system, additional updates to exterior doors, and wandering behaviors but the noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. 45933 B 1. On 8/14/24 at 9:55 A.M., Resident 18 was observed sleeping in bed with a fall mat placed on the ground. On 8/15/24 at 12:09 P.M., Resident 18's clinical record was reviewed. The diagnoses included, but were not limited to: non-traumatic brain dysfunction, seizure disorder, and depression. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 6/21/24, indicated Resident 18 was an extensive assistance of two or more persons for: bed mobility, transfers, and toileting. The MDS indicated he had two or more falls since admission or the prior assessment. Care plans included, but were not limited to, I am at risk for falls r/t [related to] Psychoactive drug use, dementia, tremors, repeated falls, lack of coordination, unsteadiness on feet, restless leg syndrome, degenerative disease of nervous system, anemia, uses a wheelchair and uses walker at times for ambulation . revised 7/1/24. Resident 18's fall history included, but was not limited to: Fall 1: On 7/19/24 Resident 18 fell in the bathroom after breakfast. Resident 18's clinical record lacked an update to his care plan after that fall. Fall 2: On 7/24/24 resident was sitting in chair enjoying his activity and when he was done he just jumped up and started to try to walk across the floor. legs were weak and he fell to floor on buttock . did not hit his head. and received no injuries . Resident 18's clinical record lacked an update to his care plan and notification to his family and doctor. Fall 3: On 7/26/24 Resident 18 was leaning to his left side and fell when he tried to stand up. His clinical record lacked an update to his care plan after that fall. Fall 4: On 7/28/24 Resident 18 was found kneeling on his fall mat. His clinical record lacked a notification to his family. During an interview on 8/16/24 at 1:29 P.M., the MDS Coordinator indicated the care plan was not updated after every fall and the interdisciplinary team should update the care plans after a fall and family and the physician should be notified after a fall by the nurse on duty. B 2. On 8/19/24 at 10:57 A.M., Resident 33 was observed awake and in bed with both feet hanging off the right side of the bed and the wheelchair was placed by the bathroom door. The resident indicated he wanted to get up. The resident was asked to use his call light, but it was wrapped around the bed rail, hanging down, and stuck between the bedrail and mattress. The resident attempted twice but was not able to pull it out to use it. At that time, there was not a sign to call and don't fall observed in Resident 33's room. On 8/20/24 at 8:32 A.M., Resident 33 was asleep in his bed and the wheelchair was by the closet door. On 8/15/24 at 11:50 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, dementia with behaviors, and schizophrenia. The most recent Admission MDS Assessment, dated 6/12/24, indicated Resident 33 was cognitively intact, an extensive assist of 1 staff for bed mobility, transfers, and toileting. A current Risk for Falls Care Plan, dated 6/19/24, included, but was not limited to, the following interventions: Be sure the resident's call light is within reach, initiated 6/19/24 Follow facility fall protocol, initiated 6/19/24 Staff to ensure wheelchair is at bedside for self-transfers, initiated 7/15/24 Vision sign call don't fall for reminder, initiated 7/30/24 The following were the only Fall Risk Assessments documented in Resident 33's clinical record: 6/9/24 indicated resident was not a high risk to fall. 8/12/24 indicated resident was not a high risk to fall. On 8/19/24 at 9:36 A.M., the DON (Director of Nursing) provided the following Fall reports on Resident 33 that included, but were not limited to, the following falls: 7/11/24 at 6:40 P.M., Resident 33 was observed on the floor next to his bed on both knees and indicated he was trying to get to bed. A post Fall Risk Assessment was not documented in the clinical record. 7/21/24 at 7:30 P.M., CNA (Certified Nurse Aide) reported to nurse that Resident 33 fell in his room and was observed laying on his right side close to his bed. Resident 33 indicated that he hit his head on the wall and felt dizzy. The fall report indicated he slid on food crumbs he dropped accidentally on the floor while having supper. Resident 33 was transferred to the emergency room for further assessment. Upon his return to the facility on [DATE], the clinical record lacked documentation that neurologic [TRUNCATED]

Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalization s. There was no documentation of a resident or representative receiving a bed hold policy at the time of hospitalization . (Resident 12, Resident 33, Resident 6, Resident 18, Resident 7) Findings include: 1. On 8/15/24 at 1:07 P.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and dementia without behaviors. Resident 12 was admitted from the facility to the hospital on 4/28/24 and returned back to the facility from the hospital on 5/6/24. Resident 12's records lacked documentation a bed hold policy was given to the resident or a representative at the time of the transfer. During an interview on 8/20/24 at 10:52 A.M., the DON (Director of Nursing) indicated the facility did not have documentation of Resident 12 or Resident 12's representative receiving a bed hold policy on 4/28/24 but they should have. 2. On 8/15/24 at 11:50 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and dementia with behaviors. Resident 33 was admitted from the facility to the hospital on 7/21/24 and returned back to the facility from the hospital on 7/22/24. Resident 33's records lacked documentation a bed hold policy was given to the resident or a representative at the time of the transfer. During an interview on 8/20/24 at 10:52 A.M., the DON indicated the facility did not have documentation of Resident 33 or Resident 33's representative receiving a bed hold policy on 7/21/24 but they should have. 45933 3. On 8/15/24 at 8:21 A.M., Resident 18's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 11/30/23, 5/2/24, and 5/25/24. Resident 18's records lacked a bed hold policy given to the resident or a representative at the time of each transfer. During an interview on 8/19/24 12:07 P.M., the DON (Director of Nursing) indicated the facility did not have a record of Resident 18 or Resident 18's representative receiving a bed hold policy on 11/30/23, 5/2/24, and 5/25/24. 4. On 8/15/24 at 9:28 A.M., Resident 6's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 12/2/24. Resident 6's records lacked a bed hold policy given to the resident or a representative at the time of the transfer. During an interview on 8/19/24 12:07 P.M., the DON indicated the facility did not have a record of Resident 6 or Resident 6's representative receiving a bed hold policy on 12/2/24. 50827 5. On 8/20/24 at 1:10 p.m. Resident 7's clinical record was reviewed regarding hospitalization on [DATE]. Resident 7's record lacked documentation of Resident or Resident representative being given a bed hold policy for hospitalization on [DATE]. On 8/21/24 at 8:45 A.M., the DON provided a current bed hold/bed reservation policy, dated August 28, 2012, that indicated prior to discharge, or as soon as possible if discharge is on emergency basis a written reservation agreement will be completed. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalization s. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization . (Resident 12, Resident 33, Resident 6, Resident 18, Resident 7) Findings include: 1. On 8/15/24 at 1:07 P.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and dementia without behaviors. Resident 12 was admitted from the facility to the hospital on 4/28/24 and returned back to the facility from the hospital on 5/6/24. Resident 12's records lacked a notice of transfer/discharge given to the resident or a representative at the time of the transfer. During an interview on 8/20/24 at 10:52 A.M., the DON (Director of Nursing) indicated the facility did not have documentation of Resident 12 or Resident 12's representative receiving a notice of transfer or discharge on 4/28/24 but they should have. 2. On 8/15/24 at 11:50 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and dementia with behaviors. Resident 33 was admitted from the facility to the hospital on 7/21/24 and returned back to the facility from the hospital on 7/22/24. Resident 33's records lacked a notice of transfer/discharge given to the resident or a representative at the time of the transfer. During an interview on 8/20/24 at 10:52 A.M., the DON indicated the facility did not have documentation of Resident 33 or Resident 33's representative receiving a notice of transfer or discharge on 7/21/24 but they should have. 45933 3. On 8/15/24 at 8:21 A.M., Resident 18's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 11/30/23, 5/2/24, and 5/25/24. Resident 18's records lacked a notice of transfer/discharge given to the resident or a representative at the time of each transfer. During an interview on 8/19/24 12:07 P.M., the DON (Director of Nursing) indicated the facility did not have a Record of Resident 18 or Resident 18's representative receiving a notice of transfer or discharge on the hospitalization s on 11/30/23, 5/2/24, and 5/25/24. 4. On 8/15/24 at 9:28 A.M., Resident 6's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 12/2/24. Resident 6's records lacked a notice of transfer/discharge given to the resident or a representative at the time of the transfer. During an interview on 8/19/24 12:07 P.M., the DON indicated the facility did not have a record of Resident 6 or Resident 6's representative receiving a notice of transfer or discharge on 12/2/24. 50827 5. On 8/20/24 at 1:10 p.m. Resident 7's clinical record was reviewed regarding hospitalization on [DATE]. Resident 7's clinical record lacked documentation of Resident or Resident representative being given transfer discharge paperwork for hospitalization on [DATE]. The Director of Nursing indicated, on 8/21/24 at 11:16 a.m., that their policy was to follow the transfer discharge form. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on observation and interview, the facility failed to ensure infection control practices were in place for 4 of 4 residents during incontinence care and 1 of 1 resident during wound care. Staff failed to sanitize hands and change gloves between dirty to clean tasks. Staff failed to lather for at least 20 seconds when washing hands. (Resident 2, Resident 12, Resident 15, Resident 31, Resident 35) Findings include: 1. On 8/21/24 at 9:38 A.M., Registered Nurse (RN) 25 was observed to change a dressing for Resident 35. RN 25 entered the room with supplies, and did not wash or sanitize hands prior to putting on gloves. With gloved hands, RN 25 removed the dressing from the resident's left shin, retrieved the garbage can from beside the bed touching the side of the bed and nightstand and placed it by the resident who was sitting in a wheelchair, and threw away the old dressing. Without changing gloves, RN 25 placed a piece of gauze in her palm, and sprayed it with wound cleanser. That gauze was then used to rub the wound area. The area was then dried, ointment placed, and a new clean border bandage was placed while RN 25 touched the inside of the bandage prior to placing with her gloved hand. Gloves were not changed during the dressing change, and hands were not sanitized. RN 25 removed the gloves, and washed hands with a 12 second lather. 2. On 8/21/24 at 10:05 A.M., the Infection Preventionist (IP) indicated staff did not use an infection assessment tool or management algorithm for infections. She indicated she had not used anything like that since she had taken the position in February 2024. She indicated instead of using an assessment tool, it was nursing judgement or the nurses brought their concerns to her to address. 46416 3. During an observation on 8/20/24 at 10:39 A.M., incontinence care on Resident 2 was performed by CNA (Certified Nurse Aide) 6 and CNA 24. Both CNAs put on gloves without sanitizing their hands after getting the resident into the shower room. Both CNAs locked his wheelchair, told resident to grab the handrail, assisted resident to stand and pivot to sit on the toilet. CNA 6 took off the soiled incontinence pad and with the same gloves, grabbed a wash cloth, turned on the water faucet, wet the cloth, turned off the faucet, grabbed the bottle of peri wash sitting on the sink and sprayed it onto the wet wash cloth. CNA 6 wiped the resident's backside, folded the wash cloth, wiped again, then using the same wash cloth, wiped the front of the resident. CNA 24 asked the resident to grab the handrail again, and CNA 6 assisted resident to stand by grabbing his shirt, then grabbed the back of the new incontinence pad to pull it up and helped CNA 24 fasten it still wearing the same gloves. CNA 6 pulled on the wheelchair armrest with her gloved hand to get it closer to Resident 2 and assisted the resident to stand, discarded the soiled wash cloth, and pushed the wheelchair towards CNA 24. Both CNA 6 and CNA 24 took off their gloves and washed their hands, CNA 6 with a 5 second lather and CNA 24 with a 10 second lather. Then CNA 24 left the room with Resident 2 without asking resident if he wanted to wash his hands. 45933 4. During an observation on 8/20/24 at 8:39 A.M., CNA (Certified Nurse Aide) 6 and CNA 24 provided incontinence care on Resident 12. CNA 6 removed a bedpan that had stool in it, wiped Resident 12's buttocks with 3 washrag's, and then placed a clean brief under Resident 12. CNA 6 failed to perform hand hygiene and change gloves between dirty and clean tasks. 50827 5. On 8/20/24 at 2:19 p.m. CNA's (Certified Nursing Aides) 22 and 24 observed while Resident 15 was assisted to the bathroom. Both CNA's 22 and 24 did not wash hands or use hand sanitizer before care was started. After the soiled brief was removed, both CNA'S 22 and 24, kept soiled gloves on throughout the rest of incontinence care, including when a clean brief was put on Resident. 46882 6. During an observation on 8/19/24 at 12:11 P.M., CNA 28 and CNA 22 performed incontinence care on Resident 31. CNA 28 and CNA 22 put on PPE (Personal Protective Equipment) for Enhanced Barrier Precautions. CNA 28 went into the bathroom to wet a wash cloth while CNA 22 unfastened and pushed the brief down. CNA 22 used the wet wash cloth to clean the front perineal area, placed the dirty wash cloth in a plastic bag. CNA 28 assisted Resident 31 to turn to the left side. CNA 22 used the brief to remove stool from the buttocks, rolled up brief and put in trash bag. CNA 28 went into the bathroom to get two wet wash cloths. CNA 22 washed the resident's buttocks with a wet wash cloth, put it in a plastic bag, used another wet wash cloth to wash the buttocks again and put the wash cloth in a plastic bag, CNA 22 did not change gloves and worked to remove the resident's shirt while he had a tight grip on it. After removing the shirt, CNA 22 assisted the resident to turn to the right side. CNA 28 put a clean brief under the resident, turned him to his back and fastened the brief. CNA 28 put sweat pants on resident and assisted resident to turn to left side. CNA 22 placed the lift pad under the resident and turned resident to the right side. CNA 28 pulled the lift pad through. CNA 22 placed the lift over the bed and both CNAs fastened the lift pad to the lift. CNA 22 lifted the resident off the bed while CNA 28 positioned the high-back wheelchair closer to the lift and guided the resident over the chair. CNA 22 lowered the resident into the chair. CNA 28 put a shirt over the residents head and CNA 22 raised the chair to sitting. CNA 22 leaned the resident forward while CNA 28 pulled the resident's shirt down in the back. CNA 28 put the dirty linens in the plastic bag and removed trash bag with dirty brief, tying both. Neither CNAs changed gloves or cleaned hands during the process. Both CNAs removed PPE and put in tall, black trash can in room. CNA 22 cleaned her hands with sanitizer and pushed the resident to the dining room. CNA 28 carried the bags to the dirty linen room. On 8/21/24 at 10:38 A.M., the Infection Preventionist (IP) provided an undated Hand Hygiene policy which indicated 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .5. Hand hygiene technique when using soap and water: a. Wet hands with water .b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet .6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . On 8/21/24 at 10:38 A.M., the Infection Preventionist (IP) provided an undated Perineal Care policy which indicated .6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate .9. a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes .16. Remove gloves and discard. Perform hand hygiene . On 8/21/24 at 10:38 A.M., the Infection Preventionist (IP) provided an undated Infection Control Tips policy which indicated 1. Do not touch anything with gloves other than pericare items with gloves on before performing pericare .4. Once you have touched wet or soiled objects, such as clothing, briefs, linens, etc .you cannot touch any other surfaces in the room without performing hand hygiene. You must remove your gloves, clean hands and reglove, before touching anything .5. Always clean the residents hands. Either give them a soapy washcloth and then a clean one to rinse or assist them to the sink. This needs to be done with incontinence care . On 8/21/24 at 10:38 A.M., the Infection Preventionist (IP) provided an undated How to Safely Remove Personal Protective Equipment (PPE) which indicated .5. Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE . 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to clarify a Resident's code status for 1 of 2 residents reviewed for advanced directives. A Resident's current Physician Orders did not match the signed DNR (Do Not Resuscitate) form. (Resident 41) Finding includes: On [DATE] at 9:34 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, hypertension and hyperlipidemia. The most recent Admission MDS (Minimum Data Set) Assessment, dated [DATE], indicated Resident 41 was cognitively intact. Current Physician's Orders included, but was not limited to, full code status, dated [DATE]. Current care plans included, but was not limited to, Advanced Directives .Code Status: CPR [Cardiopulmonary resuscitation] . dated [DATE] A current State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form was signed by Resident 41 and Nurse Practitioner 43 on [DATE]. During an interview on [DATE] at 9:53 A.M., Resident 41 indicated he wanted to be a DNR. During an interview on [DATE] at 10:40 A.M., RN (Registered Nurse) 25 indicated Resident 41 is a full code and CPR would be performed if he was not responsive. During an interview on [DATE] at 10:46 A.M., the DON (Director of Nursing) indicated Resident 41 should be a DNR and all nursing staff is responsible for updating resident's code status and it should immediately be updated when the code status is changed. On [DATE] at 8:45 A.M., the DON provided an undated Advance Directive Policy that indicated .To provide services to our residents that will recognize and respect their dignity as individuals for freedom of choice related to healthcare .The copy of the Advance Directive will become a permanent part of the medical record . 3XXX,d+[DATE](5)

A. Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 1 resident reviewed for discharge. A resident (Resident B) with a court order to remain at the facility was allowed to leave and did not return. The resident was being monitored for suicide precautions at the time the resident was allowed to leave with an unknown female and has never returned. The resident's whereabouts was currently unknown. Legal authorities and the physician were not notified of the resident's departure from the facility or failure to return. As an endangered adult, the resident has the potential of harming himself if not under supervision. The resident had a history of being aggressive which has the potential of others being harmed as well. (Resident B) B. Based on observation, interview, and record review. The facility failed to protect each resident from physical and verbal abuse for 2 of 3 residents reviewed for abuse. A staff member struck a resident on his chest when perineal care was being provided. (Resident C, Resident E) This Immediate Jeopardy began on July 4, 2023 when the facility failed to implement a court order to ensure Resident B was under 24-hour supervision and allowed the resident to leave the facility. When the resident called the following day to inform staff he was not returning, staff failed to notify the physician or the Adult Protective Services (APS) representative handling his case. The Administrator was notified of the Immediate Jeopardy on July 28, 2023 at 8:35 A.M. The Immediate Jeopardy was removed on July 31, 2023, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: A. 1. On 7/26/23 at 8:42 A.M., Resident B's clinical record was reviewed. admitted was 6/29/23. Diagnosis included, but were not limited to, borderline personality disorder, schizophrenia, diabetes mellitus, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). On admission, Resident B was cognitively intact, alert and oriented to name, place, month, and time. A referral assessment tool form (not dated) indicated Resident B to be admitted from another long-term care facility. Resident B required assistance of one staff member for mobility and needed therapy. Handwritten notes included Schizophrenia COPD Cirrhosis CHF . refuses meds [at] times . plays music very loud . protective order from court to be in facility - cannot leave . court order to be in NH [nursing home]. Goes back to court 7/20/23 - APS involved . Wants to get out asap. Admission records from the previous facility included the following information: Resident B was his own responsible party with emergency contact information for the APS representative handling his case, a friend, and a sister (with name listed). A new admit form, dated 6/29/23, indicated Will make up things about sister, family, APS etc. He will say it's OK to do this or that. He has a cell phone - be watchful that he does NOT take pictures of others. We can take away per court order if does. A resident information sheet indicated Resident B was admitted [DATE] at 11:30 A.M., the APS representative was listed as emergency contact #1, and Resident B was his own person, no guardian or power of attorney (POA). A 48-hour care plan, dated 6/29/23, lacked information related to a court case, or APS. The care plan did not indicate that Resident B was to stay in the facility. A care plan, dated 6/30/23, indicated Resident B had potential to fabricate stories related to a sister and others. Physician orders included, but were not limited to, the following: LOA (leave of absence) with responsible party as needed, dated 6/30/23. Send to ER (emergency room ) for psych evaluation and treatment, dated 7/2/23. A current court order, filed 5/8/23, indicated the following: IN THE MATTER OF PROTECTIVE SERVICES FOR [RESIDENT B] . That [Resident B] is an endangered adult as defined by I.C. 12-10-3-2 .That [Resident B] is in need of the proposed emergency protective services . IT IS NOW ORDERED, ADJUDGED, AND DECREED by the Court all as follows . That the objectives of the Emergency Protective Order are to secure the safety and well Being and person of [Resident B] . That the medical provider delivers the lease restrictive protective services necessary to attain the objective of the Adult Protective Services Protective Order. The medical provider shall place the endangered adult [Resident B] in a medical facility/nursing facility that specializes in geriatric psych if needed or recommended by physician with 24-hour care. Facility may restrict the use of cellular device at their discretion for the duration of sixty (60) business days or until the order is terminated by the petitioner . The healthcare provider shall maintain custody of the endangered adult for a period of not less than sixty (60) business days unless the order is terminated by the petitioner . A report triage note, dated 7/2/23 and signed by the Nurse Practitioner (NP), indicated a request to have an order to send Resident B to the ER for evaluation and treatment. She indicated he was off the chain and refuses all his meds. She indicated she was not aware of Resident B's admission and knew nothing about him. Staff did not notify her of his admission to the facility. Police had been called to get a handle on him because he was scaring the other residents. She indicated the Administrator was going to work on having him sent somewhere else that week. A history and physical form, dated 7/4/23, indicated Patient seen today for admission to [name of facility] for continued care and rehab. He has been in and out of behavioral inpatient facilities, held on ED [emergency detention] holds several times, due to his schizophrenia that is often unmanaged. In addition to this dx [diagnosis], he also has medical conditions such as CHF, DM [diabetes mellitus], HTN [hypertension] that are often unmanaged as well due to not taking medications. He believes he is healthy as an ox and his medical records are incorrect. He went as far as to steal his medical record (MAR) this weekend and attempt to hide it from staff. He also became aggressive with staff, yelling and cursing at staff and other. He was refusing medications and was sent to the ER. Police had to be called to get him to go with EMS [emergency medical services]. ER evaluated him and then sent him back with no new orders. He is under APS yet is still adamant that he is his own person. Very high thoughts of himself, that he has tons of money and lots of resources. Told me several inaccurate accounts of what has transpired over the years to him. He is on a diabetic diet and 2000 ml [milliliter] fluid restriction. He currently has a tooth abscess and is on ATBs [antibiotics] for this. Recently went to dentist for this. He uses a walker and wc [wheelchair] for ambulation but states he can walk independently just fine. SS [social services] is attempting to locate a behavioral health center to transfer him to as this is not the appropriate environment for him at this time. He needs more psych management than this facility will be able to provide . He tells me that he is going to a family function this afternoon with his sibling. Unsure if this is a delusion or a correct statement. Staff is unsure as well. I have been able to locate his prior records in EPIC [electronic medical record system], although it is not comprehensive view given, he has been in numerous facilities over the years that are not part of that EHR [electronic health record] system or integrated onto it. The form indicated Resident B had a confused cognitive status and was signed by the NP. Progress notes included, but were not limited to, the following: 7/3/23 (no time listed) . Judge does not want him released to community. Resident risk to self and others. APS reported they are able to give consent for treatment and sign paperwork. Homeland security called D/T [due to] resident called SS [social security] office threatening to commit suicide if they didn't help him. They wanted to make sure he was not living [sic] or had access to leaving . Resident was informed that APS is in charge and able to handle his affairs and can sign . Primary notified d/t [due to] reports that he made threats to commit suicide . Resident B was currently on 15-minute checks. 7/3/23 (no time listed) Received order for inpatient psych eval 7/4/23 5:00 P.M. Resident's sister and brother-in-law picked resident up at 4:30 P.M. that day, signed by LPN 7. 7/5/23 (no time listed) Resident went LOA with a female who he reported was family on 7/4/23. Resident did not return. Administrator communicating with APS. Resident did call SSD to report he was okay and proceeded to report reasons why he left. All a fabrication, signed by the SSD. On 7/28/23 at 9:25 A.M., a 15-minute check form was provided for Resident B. Checks began 7/3/23 at 11:30 A.M. and the last one was completed 7/4/23 at 4:30 P.M. A blank form was already filled out with the resident's name for 7/5/23. A sign out sheet indicating Resident B was signed out by a person accepting responsibility was dated 7/4/23. On 7/26/23 at 10:02 A.M., the Social Services Director (SSD) indicated she was aware of a court order that Resident B was supposed to be in a nursing home until his court date but did not know that date. She indicated he had a history of using his cell phone inappropriately and it could be taken if needed. The court order was included in all the other information given to staff when Resident first came to the facility, but there was nothing in the court order that said he could not leave the building and go LOA. APS told her that he was not supposed to be discharged to the community and needed to be in a long-term care facility. He did not have a wander guard. She indicated while here, Resident B displayed a lot of socially inappropriate behavior, blaring of music on his phone, verbal cursing of the staff, and refusing care. She indicated Resident B said that was how he was going to act, and he would not change his behavior. She indicated he was educated about his behavior and would apologize and then do it again. Other residents complained of his behavior. She indicated Resident B had gone to theER on [DATE], and on his way back on 7/3/23, he called the social security office in (city name) and threatened to commit suicide in their office if they did not make him the payee of his social security. Because of the threat, Resident B was placed on a suicide watch when he returned to the facility, but the next day was a holiday and administrative staff were all off. She indicated nursing staff should have documented the suicide watches, and should not have let him leave while on the watches, as they were to remain in effect until an evaluation was completed by psych. She indicated she questioned that decision, but the nurse on duty thought the person that came was family, so she allowed him to leave. Upon her return to the facility on [DATE], she had an inpatient facility for him to be transferred to, but he was gone. On 7/26/23 at 10:15 A.M., the Administrator indicated the information provided from Resident B's previous facility included, but were not limited to vaccine information, diagnosis information, medication information, and allergies. She was also notified that Resident B had behaviors of playing music very loud and had a court order to take his phone as needed. Resident B had an order to be in a facility and had no guardian or POA. On 7/28/23 at 7:53 A.M., Licensed Practical Nurse (LPN) 3 indicated if a resident expressed suicidal ideation she would document in the resident's chart as a behavior and report to the SSD. Staff should also notify the resident's family and physician. Staff should initiate 15-minute checks as an immediate intervention and document those checks on a form for at least 48-72 hours, possibly longer depending on if the resident continued with the suicidal comments or behaviors and may be placed on 1:1 supervision. She indicated staff should then implement whatever the physician or psych services ordered. The resident may be sent out for a psych evaluation. If a resident were on 15-minute checks due to suicidal ideation, staff should absolutely not allow them to go LOA without approval from the physician, administrator, etc. The following information was provided by confidential correspondence: The facility accepted Resident B from another long-term care facility. APS had a current order related to Resident B that he was not to leave the facility. APS was trying to find him a guardian due to a doctor deeming him incompetent. APS notified the facility of Resident B's court order and behaviors on 7/28/23 prior to admission, as well as Resident B would try anything to leave the facility. APS was assured by the facility there were other residents with mental health concerns and their staff could handle Resident B. It was made very clear that Resident B was not to leave the facility for any reason and the court order indicated he was to remain in a 24-hour facility. The facility indicated Resident B had already called them about a sister he wanted to visit with. The facility was then informed Resident B did have a sister, but they did not have contact with each other, and he could not leave the facility for any reason. It was requested that if Resident B wanted to visit with anyone, that they needed to come to the facility to see him. On 7/5/23, the APS office indicated Resident B had called them from a different state and had paid someone from a social media account to claim they were his sister and brother in law to come pick him up from the facility the day before. APS was not notified that Resident B was missing and failed to follow a court order signed by a judge. Resident B was in extreme danger to himself and others. The facility spoke with the APS office on 7/3/23 about looking into moving Resident B into another facility. The facility did not want him as a resident after only a few days related to his behaviors and manipulations which they had indicated prior they were equipped to handle. The court order for Resident B indicated he was to remain in a 24-hour facility, as when it was originally executed, Resident B was found on his floor unable to get up and was hours from passing away. A welfare check was done to the individuals that came to pick up Resident B from the facility, but Resident B could not be located. Both individuals had a criminal record. A current non-dated missing resident action plan was provided 7/28/23 at 9:17 A.M. and indicated when a resident was missing, staff should notify police, the Director of Nursing (DON), family or responsible party, the physician, the facility Administrator, and the state agency. A current abuse policy, dated 9/15/17, was provided 7/28/23 at 7:45 A.M. and indicated It is the policy of [facility name] to ensure that each resident is free of physical, mental, verbal and sexual abuse, corporal punishment, mental and physical neglect and involuntary seclusion. [name of facility] prohibits the mistreatment, neglect, abuse of residents and misappropriation of residents' property by anyone including staff, other residents, or persons from outside the facility . Neglect can also be ab [sic] action or lack of action that places one or more residents in a life-threatening situation. A current non-dated suicidal precautions policy was provided 7/26/23 at 10:04 A.M. and indicated It is the policy of the facility to protect the rights of the residents but keep the resident safe. When a resident makes statements to cause harm to self or attempts to cause harm to self the resident must be immediately placed on precautions. At first the resident must be placed on 1:1 until the incident has been assessed and determined if the resident needs sent out. A current non-dated notification of change policy was provided 7/28/23 at 9:28 A.M. and indicated The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Circumstances requiring notification include . A transfer or discharge of the resident from the facility The Immediate Jeopardy, that began on 7/28/23, was removed on 7/31/23 when the facility in-serviced facility staff on abuse, neglect, and elopement identification, reporting, and behaviors, but the 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 a systemic plan of correction had not been developed and implemented to prevent recurrence. 45933 B.1. An incident report form, dated 7/22/23 at 5:01 A.M., indicated Resident G had reported to a CNA (Certified Nurse Aide) 8 that CNA 13 hit Resident E in the chest twice when care was provided. CNA 13 had been removed from the schedule until further notice. Social services staff interviewed other residents for abuse. A written letter was provided by CNA 13 that indicated Resident E did not wake up when CNA 13 called his name and told him what tasks were going to be performed. CNA 13 provided care and Resident E woke up agitated during care. During an interview on 7/24/23 at 9:15 A.M., Resident C indicated a staff member with the same name is mean and talked to him negatively. On 07/25/23 2:08 P.M., Resident C's clinical record was reviewed. The most recent quarterly MDS, dated [DATE], indicated Resident C was cognitively intact. On 7/25/23 at 1:32 P.M., Resident E's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and anxiety. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 6/24/23 indicated Resident E's brief interview for mental status could not be assessed due to Resident E not being understood. Resident E was an extensive assist of 1 staff member for bed mobility, transfers, eating, and toileting. A current behavioral symptoms care plan dated 7/23/23 indicated to stop care if Resident E tried to hit staff and have the nurse assist with care. During the month of July, Resident E did not have any of the following behaviors documented: inappropriate behavior, mood changes, anxiety, anger, hitting, cursing, or screaming. On 7/25/23 at 2:17 P.M., Resident G's clinical record was reviewed. The most recent quarterly MDS, dated [DATE], indicated Resident G was cognitively intact. Resident G lacked a care plan related to fabricating stories. During the month of July, Resident G did not have any of the following behaviors documented: anxiety, cursing, fabricating, or refusing care. An untimed progress note dated 7/22/23 indicated .this morn [morning] around 5:00 A.M. [staff name] came in here et [and] she must have thought I was asleep because [Resident E] was giving her a hard time et [and] I know he can be difficult @ [at] times but still what she did is not right. He was not wanting her to change him et [and] he kept resisting et [and] she punched him twice in the chest et [and] I seen et [and] heard it et [and] she hit him hard .I asked [Resident E] if he had been hit et [and] he looked @ [at] me et [and] said yeah in my chest. This nurse then asked if I could see his chest et [and] he pulled his shirt up et [and] I assessed et [and] noted there to be an area pinkish in color to left side of his chest. Area is blanchable skin is intact. No other areas noted during head-to-toe assessment. I did tell housekeeper earlier this morn [morning] after breakfast that [Resident E] wasn't acting like his normal self et [and] she said he does not seem to be staying completely bent over for some reason . During an interview on 8/1/23 at 8:55 A.M., LPN (Licensed Practical Nurse) 29 indicated CNA 8 notified her that Resident G informed her that CNA 13 punched Resident E in the chest twice and she didn't realize that Resident G was awake. LPN 29 asked Resident E if he had been hit and Resident E stated, yea, in my chest. LPN 29 assessed Resident E and noted he had a pink area on his chest. During an interview on 8/1/23 at 9:02 A.M., Resident G indicated CNA 13 came in the room to provide incontinence care to Resident E and did not pull the privacy curtain. Resident G witnessed CNA 13 hit Resident E in the chest twice. Since Resident G notified staff, Resident G indicated he was told CNA 13 was not allowed back in his room and his call light gets ignored. CNA 13 walked by the door and does not notify other staff since she had returned to work and he felt like they had retaliated on him. During an interview on 8/1/23 at 9:12 A.M., the Administrator indicated CNA 13 did not have any restrictions on which rooms she can provide care in. During an interview on 8/1/23 at 10:04 A.M., Staff 16 indicated CNA 13 was not allowed to provide care in Resident G's room per the DON (Director of Nursing). During an interview on 8/1/23 at 12:41 P.M., LPN 29 indicated neither Resident E nor Resident G had behaviors. On 8/2/23 at 7:31 A.M., Resident E was observed in the common area slouched over in a wheelchair. A current abuse policy, dated 9/15/17, was provided 7/28/23 at 7:45 A.M. and indicated It is the policy of [facility name] to ensure that each resident is free of physical, mental, verbal and sexual abuse, corporal punishment, mental and physical neglect and involuntary seclusion. [name of facility] prohibits the mistreatment, neglect, abuse of residents and misappropriation of residents' property by anyone including staff, other residents, or persons from outside the facility . This Federal tag relates to complaint IN00412693. 3.1-27(a)(1) 3.1-27(a)(3)

Based on interview and record review, the facility failed to provide care to maintain the residents highest practicable well-being for 2 of 4 residents reviewed. The Nurse Practitioner was not notified of abnormal laboratory results, diabetic protocol was not implemented for a newly diagnosed diabetic resident, blood glucose levels were not checked and elevated blood glucose results were not reported to physician or nurse practitioner. This resulted in a hospitalization for a blood glucose level of 889 mg/dL (milligrams per deciliter) and the incorrect dose of insulin being given. (Resident B and Resident D) Findings include: 1. On 1/11/23 at 10:00 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with/ mood disturbance, history of TBI (Traumatic Brain Injury), hypothyroidism, and diabetes mellitus. The most recent annual MDS (Minimum Data Set) Assessment, dated 11/21/22, indicated the resident was moderately cognitively impaired and independent for bed mobility and transfers. Resident B's clinical record lacked a care plan for diabetes care and hypothyroidism. On 12/13/22 at 5:10 A.M., lab work was drawn on Resident B that included, but was not limited to the following lab results: Glucose 309 mg/dL Reference range (74-106 mg/dL) Hemoglobin AC 8.7% Reference range (4-6%) TSH (thyroid stimulating hormone) 0.419 uIU/ml (micro-international units per milliliter) Reference range (0.465--4.680 uIU/mL) The clinical record lacked documentation that the ordering Medical Doctor (MD) or Nurse Practitioner (NP) was notified of abnormal results. Telephone orders, dated 10/26/22, included the following: D/C (discontinue) tramadol. Start Tylenol 500 mg 1 tablet by mouth four times daily. D/C atorvastatin. Start rosuvastatin 20 mg 1 tablet by mouth at bedtime. Telephone orders, dated 12/21/22, included the following: metformin 500 mg tablet 1 (one) tablet by mouth twice daily for diabetes mellitus type II. Decrease levothyroxine to 100 mcg daily for hypothyroidism. Repeat TSH in 2 weeks. Review of the December 2022 MAR indicated that levothyroxine 100 mcg by mouth daily at 8:00 A.M. and metformin 500 mg by mouth twice daily at 8:00 A.M. and 4:00 P.M., were administered starting on 12/23/22. Review of the December 2022 TAR (treatment administration record) indicated that a TSH level was to be drawn on 1/4/23. January 2023 physician's order rewrites included, but were not limited to, the following: levothyroxine 200 mcg (microgram) 1 (one) tablet by mouth daily for hypothyroidism, ordered on 4/11/14. January 2023 physician's order rewrites did not include metformin 500 mg (milligram) 1 (one) tablet by mouth twice daily for diabetes ordered on 12/21/22. Review of the January 2023 MAR indicated the order placed on 12/21/22 was not continued on the current MAR as the dose of levothyroxine was 200 mcg by mouth daily, and that the 8:00 A.M. dose of metformin 500 mg was not documented as given. Review of the January 2023 TAR lacked an order for a TSH level to be drawn on 1/4/23. Lab results from 1/5/23 were reviewed and a repeat TSH level was not included with the other labs drawn. The progress note from the Nurse Practitioner, dated 12/21/22, was reviewed and included, but was not limited to, the following: Patient did have low TSH as well as an elevated A1c. We will be decreasing his levothyroxine to 100 mcg and putting patient on metformin 500 mg b.i.d. [twice a day]. Spoke with staff about labs and medication changes. Spoke to staff about getting repeat labs . The progress note from the Nurse Practitioner, dated 12/21/22, included, but was not limited to the following medications: levothyroxine 100 mcg 1 capsule by mouth once a day atorvastatin 40 mg 1 tablet by mouth once a day Keppra 500 mg 1 tablet by mouth at bedtime acetaminophen 325 mg 2 capsules every four hours tramadol 50 mg 2 tablets twice a day metformin 500 mg 1 tablet twice a day The progress note from the Nurse Practitioner, dated 12/21/22, included, but was not limited to the following lab results, dated 12/13/22: A1c 8.70 TSH 0.419 Glucose 309 The progress note from the Nurse Practitioner, dated 12/21/22, included, but was not limited to the following assessments and plans: hypothyroidism: chronic-progressive; will continue to monitor levothyroxine will be decreasing to 100 mcg daily and will get repeat TSH in 3 weeks. diabetes mellitus type II: New diagnosis; will be starting patient on metformin 500 mg po BID and will get repeat labs in 3 months. Current MAR and order rewrites, signed by the nurse practitioner on 1/12/23, did not match the Nurse Practitioner's progress note, dated 12/21/22, list of medications and assessment and plan included the following: The Nurse Practitioner's note indicated resident was on levetiracetam (Keppra) 500 mg 1 tablet in the A.M. and Keppra 500 mg 1 tablet in the P.M. The current MAR/rewrite orders indicate Keppra 500 mg in the A.M. and Keppra 500 mg 2 tablets in the P.M. The Nurse Practitioner's note indicated resident was on levothyroxine 100 mcg daily. The current MAR and rewrite orders indicate levothyroxine 200 mcg daily. The Nurse Practitioner's note indicated acetaminophen 325 mg 2 capsules every 4 hours. The current MAR and rewrite orders indicate acetaminophen 500 mg 1 tablet four times a day. The Nurse Practitioner's note indicated atorvastatin 40 mg 1 tablet daily. The current MAR and rewrite orders indicated Rosuvastatin 20 mg at bedtime. The Nurse Practitioner's note indicated tramadol 50 mg 2 tablets twice a day. The current MAR and rewrite orders did not have tramadol listed. The Nurse Practitioner's note and the current MAR indicated metformin 500 mg twice daily but it was not included on the rewrite orders. The Nurse Practitioner's note indicated that the repeat TSH lab was due in 3 weeks. The Nursing notes dated 12/21/22 indicated the repeat TSH was due in 2 weeks. The current TAR and rewrite did not include orders to repeat TSH or repeat labs for diabetes in 3 months. Nursing Notes reviewed and included, but not limited to, the following: 12/21/22 1:53 P.M. Nurse practitioner here this day. Received new order to decrease levothyroxine to 100 mcg daily. Repeat TSH in 2 weeks (1/4/23). New order for Metformin 500 mg 1 (one) tablet by mouth twice daily. Resident aware. 1/5/23 10:30 A.M. Resident showing weakness and requiring assist to transfer. 1/5/23 1:45 P.M. Resident sitting in the lobby and started projectile vomiting. 1/6/23 12:00 P.M. Resident coming out of bathroom and had loose stool on the floor. Resident slipped and fell to the floor. Slight bump noted on top right side of head. 1/7/23 8:00 A.M. Resident choking on medications. Received order to send to hospital for evaluation. 1/7/23 EMS (emergency medical services) arrived. 1/10/23 9:30 A.M. Received a call from social worker at hospital. She indicated resident was on a ventilator and not doing well. The Neurological assessment after the fall on 1/6/23 was reviewed and indicated documentation was completed from 1/6/23 at 12:00 P.M. to 1/7/23 at 6:45 A.M. Of those entries reviewed, 14 of 15 were normal until 6:45 A.M. Neurostatus Starting 12:00 P.M. cst (central stardard time) 1/6/23 14 of 15 neuro checks normal until 6:45 A.M. (cst) 1/7/23 recorded by LPN 12 (agency)-Nurse Practitioner was not notified until 8:04 A.M. of mental status and neuro changes Hospital records were reviewed and indicated the following: 1/7/23 EMS dispatched at 8:25 [cst] en route at 8:27 [cst] arrived at 8:30 [cst] and w/pt at 8:35 [cst] pt [patient] and bed are saturated with urine to the point it is dripping through the mattress and onto the floor .hematoma on right side of his head . staff decided to call ambulance after him having trouble swallowing breakfast . pupils are unequal and sluggish, left larger then right .lungs clear .staff indicated the last time anyone checked on him was probably when he fell yesterday . staff initially stated that they wanted to clean him up now that we were here to help . Resident arrived in ER [emergency room ] and into room at 10:25 a.m est (eastern standard time used while at hospital), orders for labs placed by physician at 10:26 a.m, lab received order at 10:38 a.m, collected at 11:10 a.m .physical exam . pupils round, equal bilat .tachycardic .no respiratory distress, normal breath sounds., no stridor .1/7/23 1115 (11:15 A.M.) point of care glucose monitor unable to register noting high . 1158 (11:58 A.M.): . given glucose of 889 . 1241 (12:41 P.M.) clinical impression: hypernatremia, hyperglycemia, disorientation, fall from ground level .chart review shows the patient had increasing serum levels approx. 3 wk ago with sodium at upper limit of normal .believe hypernatremia is subacute .patient admitted in stable condition to ICU . On 1/7/23 at 12:07 A.M., nurse called NH [nursing home] to request more info [information] from nurse in charge of pt [patient] per provider request . nh [nursing home] nurse states he is not diabetic . baseline is 'normally up going to the bathroom on his own and normally takes care of himself' nurse states the way pt [patient] was behaving before he left via ems was 'not his norm' . On 1/7/23 at 3:32 P.M., Resident admitted to ICU . positive for lethargy and altered mental status . diminished breath sounds at bases bilat [bilaterally] . On 1/9/23 at 3:06 A.M., Resident admitted to the hospital for hyperosmolar hyperglycemic state . rapid intubation at bedside . patient had become unresponsive During an interview with the Nurse Practitioner on 1/12/23 at 12:05 P.M., they indicated that Resident B's baseline was alert and oriented and he used his wheelchair to get around. They would have expected a call the same day when that abnormal lab results from 12/13/22 came back with glucose of 309 and A1c of 8.7 but she was not notified until she was at the facility on 12/21/23. She did believe that was too long to not be notified of abnormal lab results. When they gave verbal order to the nurse, they were under the impression the facility had a diabetic protocol to initiate when a resident was newly diagnosed with diabetes mellitus. They would expect new medications to be ordered the same day from the pharmacy. The NP further indicated that she did not receive a call from staff about the resident's neurological and mental status change after his fall until 8:04 A.M. on 1/7/23. the NP indicated that she was told by staff at that time the resident had a decline in mental status, weakness in his extremities, and difficulty swallowing and that it started the night before. Staff told her they weren't sure why she wasn't notified at the time it was noticed The NP indicated she would have expected a call immediately. During an interview on 1/12/23 at 3:00 P.M., RN 2 and LPN 9 observed in current MAR that levothyroxine was listed as 200 mcg. They indicated that the dose should be 100 mcg. They observed that the levothyroxine package in the med cart was labeled 100 mcg daily with Resident B's name. They further indicated they were not sure why was it documented from 1/1/23 to 1/7/23 as giving 200 mcg when resident was actually getting 100 mcg. During an interview on 1/13/23 at 12:00 P.M., LPN 6 indicated she would need to follow an order for any medication given or treatment done for residents. She was unsure if the agency nurses knew Resident B should only get 100 mcg and not 200 mcg and why the dosage on the MAR was not clarified. She further indicated with using agency staff, she felt things may have gotten missed because they don't know the processes and procedures of how to do things, document things, what treatments need done, etc. She also indicated if they don't have agency come help, then it's short staffed and there's one nurse sometimes for the whole building and things get missed in documentation that way too. She indicated the previous DON (Director of Nursing) and ADON Assistant Director of Nursing) lived 2 hours away so if they needed them it usually took them approximately 3 hours to get to the facility. During an interview on 1/12/23 at 3:00 P.M., LPN 9 indicated she wasn't sure if she knew Resident B was a diabetic when he had called for assistance because of weakness and vomited on 1/5/23. An accu-check was not performed at that time. She is not sure why the nurse who noticed the decline after his fall did not call the provider sooner. During an interview on 1/12/23 at 3:00 P.M., LPN 9 and RN 2 indicated that if they received a lab back that was that abnormal, they would have called the provider to ask for new orders at that time. They were unaware of a newly diagnosed diabetic protocol. They indicated that when the Nurse Practitioner gives an order, the nurse should write it down on a telephone order form, fax that to the pharmacy, notify family of changes, and document the order and actions taken in the nurse's notes of the medical record. Then they should place the order form in the basket at the nurse's station for the DON to review. The DON would update the current MAR/TAR, care plans, diagnoses if needed, have the Nurse Practitioner sign the order form and then it would get placed in the resident's medical record. During an interview on 1/18/23 at 1:10 P.M., the Administrator indicated they use an app from (company name) to communicate to healthcare providers about the residents and the conversation is supposed to be documented in the nurse's notes as well. She indicated that (pharmacy name) is responsible for the monthly rewrites and that the DON was supposed to be reviewing the notes from the NP after visits with residents when they sent them because they went to the DON's email. She further indicated that the NP note, MAR, TAR, and order rewrites should have been verified that they all matched and clarified with the NP if needed. Those documents should have been updated along with any changes needed to be made in the chart. 46882 2. On 1/11/23 at 10:15 A.M., Resident D's clinical records were reviewed. Diagnosis included, but was not limited to diabetes mellitus, type 2. Resident D was admitted on [DATE]. The most recent quarterly MDS Assessment, dated 11/28/22, indicated independence for bed mobility, transfer and toileting. Resident D was cognitively intact. Current physician's orders included, but were not limited to accucheck before meals and at bedtime with sliding scale Novolog ordered on 2/22/16: 151-200=1 unit 201-250=2 units 251-300=3 units 301-350=4 units 351-400=5 units >400=Call MD (medical doctor) A current care plan for Diabetes, dated 9/1/22, included, but was not limited to the following interventions: monitor for signs and symptoms of hypoglycemia and hyperglycemia and administer medications as ordered. On 1/17/23 at 11:45 A.M., review of Resident D's December 2022 and January 2023 Diabetic Flow Sheet and MAR indicated on the following dates the blood sugars were over 400 and the medical record lacked documentation that the Medical Doctor/Nurse Practitioner was notified and orders received for the amount of insulin given : 12/2/22 at 4:30 P.M. blood sugar 424 Novolog 5 units documented as given 12/3/22 at 4:30 P.M. blood sugar 549 Novolog 7 units documented as given; 10:00 P.M. blood sugar 596 Novolog 3 units documented as given 12/15/22 at 11:30 A.M. blood sugar 412 Novolog 5 units documented as given 12/30/22 8:00 P.M. blood sugar 404 amount of insulin given was not documented On 1/17/23 at 11:45 A.M., review of Resident D's December 2022 and January 2023 Diabetic Flow Sheet and MAR indicated on 12/14/22 at 4:30 P.M. blood sugar was 194 and 5 units of Novolog was given. December 2022 and January 2023 Diabetic Flow Sheet and MAR lacked documentation of the amount of insulin given on the following dates: 12/16/22 at 8:00 P.M. blood sugar 173 12/17/22 at 6:00 A.M. blood sugar 298 12/30/22 8:00 P.M. blood sugar 404 1/1/23 4:30 P.M. blood sugar 192 1/10/23 6:00 A.M. blood sugar 313; 11:30 A.M. 173 During an interview on 1/12/23 at 3:00 P.M., RN 2 and LPN 9 indicated they should notify MD if blood sugars are less than 60 or greater than 400 for further orders. During an interview on 1/18/23 at 1:14 P.M., the Administrator indicated the nurses use (name of internet app) [method of communicating through technology with the nurse practitioner/medical doctor with staff concerning residents] to notify the physician. During an interview on 1/19/23 at 8:58 A.M., the Administrator indicated they were unable to find any documentation of notification in the (name of internet app) for Resident D for the last 6 months. A current Provision of Physician Ordered Services policy, dated October 2022, provided by the Administrator on 1/13/23 at 11:35 A.M., indicated 3. Qualified nursing personnel will receive and review the diagnostic test reports . communicate the results to the ordering physician within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies . ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention . 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record A current non dated Notification of Changes policy provided by the Administrator on 1/13/23 at 11:35 A.M., 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 requiring notification include . 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . A current Verbal Orders policy, dated November 2017, provided by the Administrator on 1/17/23 at 2:04 P.M., indicated 1. Repeat any prescribed orders back to the physician or healthcare provider. 2. Use clarification questions to avoid misunderstandings. 3. Enter the order into the medical record manually or electronically. 4. Write T.O. (telephone order) or V.O. (verbal order), including date, time, name of the resident, the complete order; and sign the name of the physician or healthcare provider and nurse . A current Medication Orders policy, dated November 2017, provided by the Administrator on 1/17/23 at 2:04 P.M., indicated this facility shall use uniform guidelines for the ordering of medication . the order should be recorded on the physician order sheet, and the MAR . A current non dated Blood Glucose Monitoring policy provided by the Administrator on 1/13/23 at 11:35 A.M., indicated Report critical test results to physician timely. A current Comprehensive Care Plan policy, dated November 2017, provided by the Administrator on 1/13/23 at 11:35 A.M., indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . The comprehensive care plan will describe, at minimum, . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being This Federal tag relates to Complaint IN00398997. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 2 of 3 residents reviewed for accidents, resulting in 1 resident to be stabbed in the neck and suffer psychological harm of feeling bad and being afraid. (Resident B, Resident L, Resident M, Resident N, Resident P, Resident Q, Resident R) Findings include: 1. On 6/21/22 at 2:50 P.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to paranoid [CONDITION(S)] and [CONDITION(S)]. The most recent admission MDS (minimum data set) Assessment, dated 4/18/22, indicated Resident N's cognitive status was unable to be assessed, was short tempered, easily annoyed, had trouble concentrating, and rejected care. Resident N was admitted [DATE]. A therapy note, dated 4/19/22, indicated Resident N had a history of physical aggression. A nurse's note, dated 6/4/22 at 3:00 A.M., indicated Heard someone yelling 'Help me' ran down hall to find [Resident N] standing over [Resident B] [with] a ball point pen in hand. Blood noted to [Resident B] face [and] neck . [Resident B] has 4 superficial puncture wounds to his neck. A current mood and behavior care plan, initiated 4/15/22, indicated persistent anger with self or others. Undated interventions included, but were not limited to, monitor mood. A current mood and behavior care plan, initiated 4/15/22, indicated delusions related to a diagnosis of [CONDITION(S)]. Undated interventions included, but were not limited to, 1:1 (staff supervision) On 6/21/22 at 2:55 P.M., Resident B was observed from the West Hall nurses station sitting in the common area with 3 (three) red marks in the middle of the neck. On 6/24/22 at 3:00 P.M., Resident N was observed walking from the smoking area door to the nurses station on the West Hall. Resident N was repeating are you nuts over an over, progressively getting louder. At the nurses station, while RN (Registered Nurse) 3 obtained a cup of water for him, Resident N was speaking non-sensical, continuing to get louder. After drinking the water, Resident N was assisted to his room by RN 3. During an interview on 6/22/22 at 11:15 A.M., Resident B indicated the incident on 6/4/22 made him feel bad and that he continued to be afraid of Resident N. At that time, Resident B was observed with 3 (three) red marks on his neck, approximate size was .6 cm. During an interview on 6/22/22 at 8:23 A.M., the DON (Director of Nursing) indicated staff was supposed to provide 1:1 supervision with Resident N. 2. On 6/23/22 at 8:57 A.M., Resident L's clinical record was reviewed. Diagnoses included but were not limited to paranoid [CONDITION(S)], mood disorder, anxiety, and major depressive disorder. The most recent admission MDS (minimum data set) Assessment, dated 3/21/22, indicated Resident L was severely cognitively impaired. Resident L was admitted on [DATE]. A nurse's note, dated 3/14/22 at 12:50 P.M., indicated that Resident L was easily agitated with other residents. Nurse's notes indicated that Resident L wandered into other residents rooms on 3/20/22 at 9:30 P.M., 4/14/22 at 11:00 A.M., 4/24/22 at 8:00 A.M., and 6/2/22 at 1:00 P.M. An incident report, dated 5/20/22, indicated that Resident L wondered into Resident R's room while Resident R was in the restroom. Resident L entered the restroom and hit Resident R in the face. The incident report further indicated there was a small amount of blood Resident R's nose. An incident report, dated 5/26/22, indicated that Resident M sat beside Resident L while he was eating in the sitting room. Resident M reached over to take the lunch ticket off of Resident L's tray and Resident L reached out and struck Resident M on the head. An incident report, dated 5/30/22, indicated that Resident L hit Resident Q because Resident Q took Resident L's oatmeal off his tray. A nurse's note, dated 6/2/22 at 6:30 A.M., indicated Resident L entered female peers room. When Resident P asked him to go out, he struck her in the face, scratched her arm, and threw water at her. A current mood and behavior care plan for Resident L, initiated 3/15/22, indicated history of aggression. Undated interventions included listen/redirect, encourage activities, and educate/validate frustration. A current mood and behavior care plan for Resident L, initiated 3/15/22, indicated wandering rooms behaviors. Undated interventions included, but were not limited to, redirect and orient. On 6/25/22 at 9:34 A.M. Resident N was observed near the Administrator's office while the dining room, East Hall, office doors, and West Hall doors were all closed. Resident L was observed entering into same hallway at 9:38 A.M. through the West Hall doors. Resident N and Resident L were observed in the same area and no staff was present. During an interview on 6/23/22 at 11:28 A.M., Resident M indicated the incident on 5/26/22 made him feel bad and that he tried to stay away from Resident L. During an interview on 6/23/22 at 2:09 P.M., the Social Service Director indicated that Resident L followed staff into rooms and wandered into rooms. She indicated staff was supposed to redirect Resident L. During an interview on 6/24/22 at 10:57 A.M., CNA (Certified Nursing Aide) 19 indicated that Resident L wandered over to the East Hall and staff was to redirect him back to West Hall. CNA 19 indicated she was unaware of a history of physical altercation with other residents. CNA 19 indicated that he wandered into other resident's rooms. CNA 19 indicated this had not gotten better or worse since admission. During an interview on 6/24/22 at 11:04 A.M., RN (Registered Nurse) 3 indicated that Resident L had the same wandering behavior since admission. On 6/24/22 at 8:30 A.M., a current non-dated policy titled Behavioral Health Services, indicated The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes . Ongoing monitoring of mood and behavior . Care plan development and implementation This Federal tag relates to Complaint IN 975, IN 895 and Complaint IN 379. 3.1-45(a)(2) :

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place to prevent elopement for 3 of 4 residents reviewed for elopement. A resident (Resident 24) with Impulse Disorder, [MEDICAL CONDITIONS] disorder, and multiple elopement attempts, was not prevented from exiting a secured patio area by utilizing an outdoor chair to climb over the fence. On 11/28/19 the resident climbed over the secured outdoor area fence and walked around to the front of the building and rang the doorbell. On 1/10/20, the resident was observed in the secured outdoor patio area at 4:30 P.M. At 5:00 P.M., the facility staff was unable to locate the resident. The resident was located at 5:10 P.M., 0.4 miles away at a gas station. A resident (Resident 15) exited the building 3 times, once the resident was found in the staff parking lot, and two times the resident was found outside by the front door. A resident (Resident 28) exited the building 2 times, once Resident 28 pushed another resident out of a secured door. (Resident 24, Resident 28, Resident 15) This Immediate Jeopardy began on November 28, 2019, when the facility failed to ensure Resident 24 did not exit the secured patio area by climbing over the fence. The facility failed to ensure Resident 24 did not climb over the patio area fence again on January 10, 2020, and walked 0.4 miles to the gas station. There are no sidewalks along the road between the facility and the gas station. The facility is located 0.3 miles from a major U.S. highway. The Administrator, DON (Director of Nursing), and Social Worker were notified of the Immediate Jeopardy on January 24, 2020 at 1:25 P.M. The Immediate Jeopardy was removed on January 27, 2020 at 12:40 P.M., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. On 1/22/20 at 9:50 A.M., the secured patio area was observed. A chair was observed to be overturned by the fence. On 1/24/20 at 8:32 A.M., Resident 24's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 12/3/19, indicated Resident 24 had mild cognitive impairment, other behavioral symptoms not directed towards others, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The Care Plans included, but were not limited to: At risk for falls, initiated 7/10/19 Impaired Central Nervous System related to [MEDICAL CONDITION], as evidenced by, frequent falls, shuffling gait, initiated 7/10/19. At risk for depression as evidenced by repetitive verbalization, persistent anger with self or others, expressions of what appear to be unrealistic fears, initiated 7/12/19. Psychosocial well-being or safety risk related to hallucinations, initiated 7/12/19. Presence of behavioral symptoms that may be harmful to self or others, or interfering with function or care, initiated 7/12/19. Alteration in thought related to mental illness Diagnoses: [REDACTED]. There were no care plans related to elopement. An Inpatient Psychiatric Evaluation, dated 5/15/19, included, but was not limited to: .presented to the ED (Emergency Department) for evaluation and was initially seen by Care Team who noted: (Name of Resident 24) is a (age), single, Caucasian male, who presented to (Name of Hospital) ER (emergency room ) by EMS (Emergency Medical Services) from his Assisted Living Facility (Name of Assisted Living Facility) in (Name of City). He is here on a CIT (Crisis Intervention Team) by the (Name of Police Department). He is here alone. He is here upon recommendation of self and (Name of Police Department) due to depression with suicidal ideation with a plan to jump from his 2nd (second) story balcony to kill himself. Information for this assessment was obtained by speaking with the patient, ER staff, review of the CIT report by the (Name of Police Department), the assisted living facilities patient information packet, and the patients (name of program) medical record. Per the CIT report by (name of officer and police department): 'Officers were dispatched to (Name of Assisted Living Facility and city), in reference to the consumer calling dispatch informing them he was suicidal. (Name of Officer) arrived and spoke with the consumer, who informed him he was upset due to being discharged from the living facility. The consumer informed the officers he wanted to jump from one of the facilities balconies to kill himself. I (name of officer) was informed the consumer suffers from [MEDICAL CONDITION] Disorder, Hallucinations (sic), and [MEDICAL CONDITION] . A [DIAGNOSES REDACTED]. The most recent signed Physician's Recapitulation orders, signed 12/9/19, included, but were not limited to: Leave of absence with staff only, initiated 9/26/19. The Nurse's Notes included, but were not limited to: 9/3/19 at 6:30 P.M., Resident was in his room while the nurse and CNA were assisting another resident to bed. CNA was talking to the resident about clothes and hangers on his bed and room while he was eating ice cream. CNA stated that we will have to help him clean up items before bed. Resident instantly started to get agitated again. Resident started yelling and calling CNA an expletive and to get out. Resident jumped out of his bed and swung door open and exited the bedroom. The nurse followed the resident out of his bedroom trying to talk to resident. Resident began to yell at the nurse and jumped on the couch and threw his spoon and ice cream at the nurse. Resident then walked really fast down the hallway to the front door and attempted to exit the front door. The nurse attempted to redirect the resident. The resident screamed at the nurse to let him out the front door. The nurse stated unsure of the code. Resident became very agitated and picked up a two foot statue and swung it at the nurse. The nurse got out of the way of the resident. The resident then picked up his walker and attempted to throw it at the front door several times. CNA from East Hall came to attempt to redirect the resident. CNA from East Hall was able to redirect resident from foyer and calm down for a minute. 9/3/19 at 6:48 P.M., The nurse called and notified AD (Activity Director) (on call) AD talked to resident on the phone. Resident seemed to be calm for a few minutes but then became agitated with AD and slammed the phone down. The nurse got back on the phone with AD. AD instructed the nurse to call emergency services. At that time the resident pulled the fire alarm in the foyer. The nurse contacted emergency personnel. 9/3/19 at 7:00 P.M., Police arrived and took resident outside to talk to him EMT's arrived shortly after. 9/3/19 at 7:06 P.M., Called physician and received the order to send resident to hospital for evaluation for aggressiveness and agitation. 9/3/19 at 7:15 P.M., called physician and received order 9/3/19 at 7:20 P.M., Called residents POA. 9/3/19 at 7:35 P.M., Called hospital and gave report. 9/7/19 at 1:00 P.M., Resident very upset, stated he wanted to go shopping and no one would take him. Yelled at staff, made phone calls, and was offered to sign AMA (Against Medical Advice). Resident placed on 15 minute checks. 9/26/19 at 1:30 A.M., Resident displayed inappropriate behaviors, stripped his bed, threw hangers, slammed doors, punched walls, threw his phone down hallway. Resident thought fleas were everywhere. Resident stated maintenance man had his boots on his bed and that's how it started (fleas everywhere). Staff cleansed bed, no fleas noted. Resident then went to the bathroom and threw some of his belongings in the sink, turned the water on and flooded the bathroom. Resident was manic, gait ataxic, would not sit still. Resident was redirected. 10/21/19 at 7:40 P.M., Resident displaying inappropriate behavior. Resident would not leave television on bedside dresser. Resident took three totes and stacked them up and placed television on top of them. Resident reminded safety concerns for him and others, remains non-complaint. 11/18/19 at 10:00 P.M., Alarm sounding by back door by time clock. Kitchen personnel was coming out of doorway by dining room. Staff saw resident by door and with much encouragement resident redirected down hallway, then to his room. Administration on call notified. Resident placed on 15 minute checks. 11/18/19 at 11:00 P.M., 15 minute checks continue. 11/20/19 at 5:10 A.M., No exit seeking behavior, has remained in room or by West Nursing Station all night. 15 minute checks continue. 11/21/19 at 5:30 A.M., Remains on 15 minute checks. 11/21/19 10:10 P.M., No exit seeking this evening. 11/26/19 at 2:00 P.M., Resident attempting to leave building due to wanting to go to consignment shop. Arrangements for resident to go to consignment shop tomorrow 11/27/19. Resident placed on 15 minute checks for precaution. 11/28/19 at 7:35 P.M., Resident climbed over fence and walked around to front of building and rang door bell. Resident stated he got out patio door after another resident came in back door. Notified POA (Power of Attorney) and Administration on call of incident. Resident stated I just wanted to play a prank on staff. Resident was placed on 15 minute checks and chair that was used was removed and thrown in dumpster due to chair being broken. 11/29/19 at 1:30 P.M., No exit seeking behavior noted. 11/29/19 at 6:45 P.M., Resident remains on 15 minute checks. Resident has been pleasant thus far. No playing pranks on staff thus far. 12/6/19 at 2:30 A.M., Resident upset due to Fleas in my bed. Itching all over. Repeatedly asking for hand sanitizer for reasons he would not say. Wheelchair taken to shower room and cleaned and placed back in resident's room. Continues to slam doors and go into the middle of the hall and slammed those doors shut waking multiple residents up. Redirection not effective. 12/6/19 at 7:15 P.M., Resident has had increased agitation. Cursing at staff while on the phone, yelling at other residents, throwing wheelchair, walker, and lids from storage containers into hallway without regard to resident or staffs safety, slamming doors to his room. 12/27/19 at 6:00 P.M., Resident took a chili off of another resident's tray. The resident was not easily redirected. He is ambulating quickly up and down the hall, he isn't slowing down, and he went outside but came back in from the back smoking area. (Resident 24 does not smoke) He took all of his furniture and moved it around. 12/27/19 at 7:00 P.M., Resident having behaviors at this time. Resident is running and slamming into the wall, slinging around boxers, kicking doors, not easily redirected. 1/3/20 at 7:15 P.M., Resident came running out of his room towards medication cart and grabbed the water pitcher off of the medication cart. The resident pulled his arm back and was screaming at staff while attempted to hit staff with the water pitcher. 1/10/20 at 4:30 P.M., Resident was in the smoking area (secured patio area), he would ring the doorbell then run away from the door, will continue to monitor. 1/10/20 at 5:00 P.M., Began to search for the resident, could not find him inside the facility or in the smoking area, full search began. 1/10/20 at 5:10 P.M., Resident found at the (name of gas station) per staff. Resident returned to the facility without difficulty. Resident stated he wanted to get pizza. 1/10/20 at 5:20 P.M., skin assessment done, no open or red areas noted. 1/10/20 at 6:30 P.M., physician notified of leave of absence. 1/11/20 at 9:00 P.M., 15 minute checks continue, one episode of exit seeking behavior noted. 1/14/20 at 1:45 P.M., spoke with physician related to leave of absence alone or with staff as ordered, physician stated with staff. An Elopement Risk Assessment, dated 9/13/19, indicated Resident 24 was a medium risk for elopement and had tried to climb over the back fence. An Elopement Risk Assessment, dated 12/9/19, indicated Resident 24 was a high risk for elopement and had a history of [REDACTED]. A Fall Risk Assessment, dated 1/6/20, indicated Resident 24 had intermittent confusion. On 1/24/20 at 9:44 A.M., the Administrator indicted Resident 24 does not smoke but is able to go to the secured patio area (smoking area). The Administrator indicated Resident 24 knew the code to get through the locked door onto the secured patio. The Administrator indicated Resident 24 took a chair and climbed over the fence and left the property on 1/10/20. The Administrator indicated the code to the secured patio area had not been changed and Resident 24 still knew the code to exit the building onto the secured patio area. The Administrator indicated they have scheduled a monthly outing for Resident 24 since he they believed he wanted to go shopping. On 1/24/20 at 1:45 P.M., Door B (locked door to the secured patio area) was observed to remain unlocked for one minute and thirty seconds. The code to the locked door was posted next to the keypad, in a framed picture. On 1/26/20 at 3:00 P.M., CNA 22 indicated when Resident 24 eloped, she was working the East Hall. Resident 24 resided on the West Hall. CNA 22 indicated a staff member came down the hall indicating to hold the hall trays because Resident 24 was missing. Resident 24 had been found in the conference room the previous day, so CNA 22 checked there first. CNA 22 indicated Resident 24 was not there. CNA 22 indicated Resident 24 had told an unknown staff member earlier in the day that he wanted to go shopping at the Dollar Store. Resident 24 had told another CNA that he was going to the store and would be back when he was finished. CNA 22 indicated several staff members went outside the building looking for him. When Resident 24 was not found, one CNA got into their care and drove towards the highway and two other CNA's (CNA 23 and CNA 24) got into a car and drove in the opposite direction. CNA 23 and CNA 24 spotted Resident 24 at the gas station. CNA 23 and CNA 24 reported that when Resident 24 saw the CNA's he ran away laughing. CNA 22 was unsure how they got Resident 24 back to the building. On 1/27/20 at 9:20 A.M., the Therapy Director indicated he was the manager on duty on 1/10/20. The Therapy Director indicated that staff called him at home that evening to notify him Resident 24 had climbed over the fence and went to the gas station. The Therapy Director indicated by the time he was notified, the resident had been located. On 1/27/20 at 12:30 P.M., CNA 24 indicated someone on that shift indicated Resident 24 was missing. CNA 24 indicated they began looking for Resident 24 and decided to get in the car and drive. CNA 24 indicated when they arrived at the stop light, CNA 23 saw Resident 24 inside the gas station. CNA 24 indicated Resident 24 began to run away from them laughing. CNA 24 indicated they were able to get Resident 24 into the car without incident and returned to the facility. CNA 24 indicated Resident 24 told them he ran to the gas station. 2. The clinical record for Resident 28 was reviewed on 1/25/20 at 8:45 A.M., and indicated Resident 28 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly MDS Assessment, dated 12/6/19, indicated Resident 28 experienced moderate cognitive impairment and needed no assistance with transferring or walking. A care plan initiated 8/27/19 titled, Mood and Behavior Symptoms Assessment, indicated Resident 28 was at risk for wandering and elopement. The following interventions included, but were not limited to, 15 minute checks, one on one activities, an assessment of activities interest, increasing activities, a wandergaurd, and an alarm mat located at the East exit door. A physician's orders [REDACTED].wanderguard check function Q shift to right ankle A physician's orders [REDACTED].LOA (leave of absence) with responsible party as needed . The following Elopement Assessments, dated 4/17/19, 6/18/19, and 12/14/19, indicated Resident 28 was at high risk for elopements. During an observation on 1/26/20 at 4:09 P.M., the alarm on the East Hall exit door was sounding. CNA 22 ran to the common area and told Resident 26 he should go to the West Hall exit if he wanted to smoke. An incident report dated 9/14/20 at 11:01 A.M. read as follows: .Resident went out the door, alarm sounded, staff went out door sounding and found resident sitting in a chair. Resident brought back in .Resident put on 15 minute checks . An incident report dated 10/8/19 at 3:30 P.M. read as follows: .Resident 28 (name of resident) was found outside the facility, Resident 28 pushed another resident .in his wheelchair outside with him .Staff responded to the alarms .Residents were brought back inside the facility .preventive measures added .15 minutes checks . A Nurse's Note dated 10/8/19 at 3:20 P.M. read as follows: .Resident noted outside with another resident and immediately brought back inside and both were put on 15 minute checks . During an interview on 1/24/20 at 2:20 P.M. LPN 16 indicated the alarm was placed at the back door of the East Hall because of Resident 26. She indicated he became confused and thought that was the door he was supposed exit whenever he smoked. During an interview on 1/24/20 at 2:56 P.M., the Social Services Director indicated that, in May of 2019, a Wandergaurd was placed on Resident 26's ankle because he had exhibited exit seeking. During an interview on 1/25/20 at 8:05 A.M., LPN 16 indicated the Wanderguard only worked on the South Hall door. LPN 16 indicated the reason they located the alarms on the doors in the South hallway (before the dining room entry) was because there were several exits, such as the exit in the activities room, the dining room, the kitchen, and the exit door staff used whenever they smoked. (No other doors were equipped with a wanderguard sensor) 3. On 1/28/20 at 11:53 A.M., the clinical record for Resident 15 was reviewed. The quarterly MDS Assessment, dated 11/13/19, indicated Resident 15 had severe cognitive impairment with continuous inattention and disorganized thinking. Resident 15's [DIAGNOSES REDACTED]. A care plan, revised on 11/18/19, indicated Resident 15 with exit seeking behavior, looked for wife, followed others, and needed to get home. Interventions included, but were not limited to, wanderguard for 6 months. A physician's orders [REDACTED]. A psychological progress note, dated 8/15/19, indicated Resident 15 had been issued a wanderguard due to elopement and it would remain in place for 6 months. Nursing notes indicated on 5/16/19 at 11:30 P.M., the alarm at the time clock door was going off. Resident 15 was found outside of the building by a staff member's car. Resident 15 indicated he was going home to fix a vacuum. Resident 15 was brought back inside the facility and a wanderguard was placed on ankle. On 6/3/19 the wanderguard was discontinued. On 6/28/19 Resident 15 followed a staff member out the front door of the facility. The incident report, dated 6/29/19, stated the staff member went to her car and when backing out noticed (Resident 15) standing outside of building. Resident 15 was brought back inside the facility and a wanderguard was placed on the left ankle. Nursing notes indicated a physician's orders [REDACTED]. On 8/8/19 an order was received to continue the wanderguard and re-evaluate in 6 months. On 9/13/19 Resident 15 exited the building through an undisclosed door. The incident report dated 9/13/19 stated that Resident 15 exited the building and staff responded to alarm and went out the door and escorted resident back into the building. On 1/24/20 at 1:46 P.M., Resident 15 was observed with a wanderguard bracelet. At that time, LPN 2 indicated the only wanderguard door alarm in the facility is down the middle (south) hall between the kitchen and social services office. The alarm box was observed with LPN 2 at that location. On 01/29/20 at 9:08 A.M. the facility Administrator indicated the wanderguard bracelet is only activated on the middle (south hall) dining doors and does not lock the east, west, or front doors of the facility. The Administrator indicated Resident 15 exited a door on 9/13/19 that is not protected by wanderguard. On 1/26/20 at 4:40 P.M., the ADON provided the current Elopement Prevention policy, revised 1/24/20. At that time, the policy was reviewed and included, but was not limited to: Elopement is a serious event that can result in injury and even DEATH! Be aware of your surroundings at all times! If you know that someone is a (sic) elopement risk and they are headed to an unsupervised area (other than their room), redirect them. The persons at highest risk for elopement are the one who are independently mobile and confused . 3.1-45(a) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility utilized alarms in place of supervision; failed to ensure alarms used for fall prevention were working properly and were positioned correctly; and failed to ensure a resident's bed was in the low position, resulting in 1 resident falling and obtaining a fractured hip, for 4 of 4 residents reviewed for falls, in a sample of 12. Residents L, C, H, and F Findings include: 1. On 8/1/17 at 9:15 A.M., during the initial tour, LPN 2 indicated Resident L had fallen recently and obtained a fractured hip. Resident L was observed up in a wheelchair at that time. The clinical record of Resident L was reviewed on 8/2/17 at 10:00 A.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An additional physician's orders [REDACTED]. A Fall Risk Assessment, dated 4/2/17, indicated the resident had intermittent confusion, a history of 1-2 falls in the previous 3 months, was chair bound, had balance problems, and scored a 20. The assessment indicated, Total score above 10 represents HIGH RISK. An annual Minimum Data Set (MDS) assessment, dated 6/14/17, indicated Resident L scored a 3 out of 15 for cognition, with 15 indicative of no memory impairment. Resident L required extensive assistance of one staff for transfer, and did not ambulate. A test for balance from seated to standing position, from moving on/off the toilet, and for surface to surface transfer, indicated Not steady, only able to stabilize self with staff assistance. The resident had fallen once since the previous assessment, with a minor injury occurring. A Care Plan, dated 6/16/17, indicated, Problems, At risk for fall/injury AEB (as evidenced by) History of Falls, Potential for fall, R/T (related to) TBI (traumatic brain injury), Weakness in legs, Us of assistive devices: W/C (wheelchair) .hx (history) of removing alarms, placing pressure on alarm to keep from sounding. The Interventions included: Remind resident and reinforce safety awareness, Toileting schedule, Pressure pad alarm to bed (and) w/c, 7/1/7 (Change) alarm box, mat 2 floor, staff educated on (checking) alarm boxes. Nurse's Notes included the following notations: 6/30/17 at 4:50 P.M.: Noted alarm sounding. Entered room (and) found res (resident) lying on the floor beside bed on R (right) side. Floor was wet (with) water from water cup up ended. Bed alarm did not sound (and) was not functioning. New alarm put in place. Assisted to w/c .Mattress placed on bedside. An Incident report, dated 6/30/17, indicated, Noted chair alarm sounding. Entered room (and) found res on floor on (right) side. Bed alarm not functioning. Alarm replaced A New Fall Risk Assessment, dated 6/30/17, indicated the resident had a score of 18, and remained at a high risk for falls. Nurse's Notes continued: 7/7/17 at 7:20 P.M.: Resident found on floor next to bed lying face down. Resident stated he slipped out of bed. Immediate intervention - reposition pad (alarm) under resident .Also c/o (complains of) (left) hip pain An Incident report, dated 7/7/17, indicated, Resident fell off bed, laying on stomach on mat on floor next to bed .Does resident use an alarm? Yes .Not positioned under resident enough to sound alarm The resident was transferred to the hospital on [DATE] with a [DIAGNOSES REDACTED]. On 8/2/17 at 3:45 P.M., during an interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the DON indicated on 6/30/17, the resident was apparently in bed, and tried to get into the wheelchair. She indicated the bed alarm did not sound, but the chair alarm apparently sounded as he fell . 2. On 8/1/17 at 9:15 A.M., during the initial tour, LPN 3 indicated Resident C had fallen recently. On 8/1/17 at 10:05 A.M., Resident C was observed lying in bed. The bed was in the high position. No alarm was observed on the bed. He had a leg over the siderail, and was stating, I need help. CNA 5 was alerted at that time. The clinical record of Resident C was reviewed on 8/1/17 at 2:00 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An annual MDS assessment, dated 4/21/17, indicated the resident had a short term and long term memory problem, and was moderately impaired in cognitive skills for daily decision making. The resident was totally dependent on two+ staff for transfer and bed mobility and did not ambulate. A test for balance during surface-to-surface transfer indicated, Not steady, only able to stabilize with staff assistance. A Fall Risk Assessment, dated 4/27/17, indicated the resident had intermittent confusion, had no falls in the past 3 months, was chair bound, gait balance was NA (not applicable), and the resident had no predisposing diseases for fall risk. The resident's score was listed as 10, or at high risk for falls. Nurses Notes included the following notations: 7/13/17 at 9:45 A.M.: Resident seen lying on floor by CNA. Looks as if resident put leg over (and) slipped to floor. Was seen earlier sideways in bed 7/19/19 at 12:15 A.M.: Resident observed on his back on floor next to his bed. Res assisted back to bed. Upon skin assessment -ST (skin tear) noted to lt (left) (lower) hand .and abrasion to lt great toe A Care Plan, initially dated 9/5/16 and updated 7/19/17, indicated: Problems, At risk for fall/injury AEB Potential for fall R/T dementia, general weakness, poor coordination . The Interventions included: Low platform bed, Mat to floor, Remind resident and reinforce safety awareness, Bed alarm - check function q shift, 7/19/17 bed in low position against wall. On 8/2/17 at 3:45 P.M., during an interview with the Director of Nursing and Assistant Director of Nursing, they indicated the resident did not have any alarms. When shown the physician's orders [REDACTED]. 3. On 8/1/17 at 9:15 A.M., during the initial tour, LPN 3 indicated Resident H had fallen recently. The clinical record of Resident H was reviewed on 8/1/17 at 1:10 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Check placement and function q shift. An annual MDS assessment, dated 7/6/17, indicated Resident H had a short term and long term memory problem and was moderately impaired in skills for daily decision making. The resident required extensive assistance of two+ staff for transfer, and extensive assistance of one staff for toileting. The resident did not ambulate. A test for balance while seated to standing, while moving on/off toilet, and surface-to-surface transfer, indicated, Not steady, only able to stabilize with staff assistance. A Fall Risk Assessment, dated 7/6/17, indicated the resident was alert and oriented and was chair bound. The gait/balance portion was left blank. The total score was listed as 8. Nurses Notes included the following notations: 7/15/17 at 10:45 A.M.: Summoned to resident's room per CNA (name). Resident was in his bathroom laying on Rt. (right) side in bathroom. Had attempted to transfer self from toilet to w/c. Alarm was sounding. CNA unable to get to res. on time. This nurse was on West Unit. 3 assist to w/c An Incident report, dated 7/15/17, indicated, Resident had transferred self to BR (bathroom) toilet from w/c. Apparently tried to transfer self from toilet to w/c et (and) fell . Laying on Rt side in BR .CNA heard alarm. She was in another resident's room. Nurse was on West. CNA did not get back to res. on time. A Care Plan, dated 7/6/17, indicated, Problems, At risk for fall/injury AEB History of Falls, Potential for fall R/T dementia, [DIAGNOSES REDACTED] - need for ADL (activities of daily living) assist .noncompliance (with) asking for assist prior to transfer/toileting. The Interventions included: Remind resident and reinforce safety awareness, Educate/remind resident to request assistance prior to transfers, Chair alarm, 7/17/17 Do not resident (sic) unattended in BR, answer all alarms immediately, educating staff, toileting 4. The clinical record of Resident F was reviewed on 8/2/17 at 9:10 A.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An annual MDS assessment, dated 5/25/17, indicated Resident F had a short term and long term memory problem, and was moderately impaired in cognitive skills for daily decision making. Resident F required extensive assistance of two+ staff for transfer, and extensive assistance of one staff for ambulation. A test for balance indicated the resident was Not steady, only able to stabilize with staff assistance for a seated to standing position, walking and turning around, and surface-to-surface transfer. A Fall Risk Assessment, dated 6/2/17, indicated the resident had a score of 15, and was at a high risk of falls. A Nurse's Note, dated 6/13/17 at 10:45 A.M., indicated, Resident found laying on floor in room between beds. No injuries noted .Will cont to monitor. An Incident report, dated 6/13/17, indicated, .found laying on blue pad on floor between beds .Immediate Intervention(s) to prevent reoccurrence: plugged bed alarm in - was not plugged in A Care Plan, dated 2/9/17 and updated 6/14/17, indicated: Problems, At risk for fall/injury AEB History of Falls, Potential for fall R/T Disease process, Functional problem . The Interventions included: 6/14/17 Check for function of alarms, (Change) box to alarm pad; functioning properly. On 8/1/17 at 10:45 A.M., the Assistant Director of Nursing provided CNA assignment sheets. The assignment sheets indicated there were 25 residents on the West Unit. 6 residents had some type of an alarm. There were 22 residents on the East Unit. 5 residents had some type of an alarm. On 8/2/17 at 4:25 P.M., the Director of Nursing provided the current facility policy on Accidents and Incidents, dated 6/2010. The policy included: It is the policy of this facility to ensure .that each resident received adequate supervision and assistant devices to prevent accidents .Do not leave a resident who utilizes an alarm, who is leaning, or who is not properly seated in a chair unattended on a commode or in the shower chair. Always lower the bed to the lowest position before leaving the room .Anticipate the resident's needs This Federal tag relates to Complaint IN 056. 3.1-45(a)(2)