Every finding on record at Greenfield Healthcare Center

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 4 residents observed during the medication pass observation for 2 medication errors in a total of 29 total opportunities for error in medication administration. This resulted in a medication error rate of 6.89%. (Residents C and D, and LPN 3 and RN 6) Findings include:1. During 1 of 4 medication pass observations with 4 residents and 5 facility staff members, LPN 3 was observed to prepare the morning medications for Resident C on 8-25-26 at 9:37 a.m. During the process of LPN 3 preparing the medications, he was queried regarding adding 2 different preparations of a medication by the same name, specifically nifedipine extended release (used for control of high blood pressure and chest pain) 30 milligrams (mg) 2 pills and nifedipine extended release osmotic 60 mg 1 pill, as to the accuracy of the medication order. LPN 3 indicated this was how Resident C's medications were ordered and continued to prepare the medications for the resident. Upon review of Resident C's medication orders, the physician orders indicated the following: Nifedipine ER [extended release] Oral Tablet Extended Release 24 Hour 60 MG Give 1 tablet by mouth one time a day for angina [chest pain], ordered on 8-19-26. In an interview with the Corporate Nurse on 8-26-26 at 10:50 a.m., she indicated she had spoken with LPN 3 and he recalled he had only administered the single pill of the 60 mg dose of Nifedipine.In an interview with Resident C on 8-26-26 at 10:35 a.m., he indicated he was admitted to the facility about 1 week prior. He added he was not entirely sure, but he may have not received his medications for one morning, but was unsure of the exact date, as he had been asleep.In an interview with the Corporate Nurse on 8-26-26 at 2:45 p.m., she indicated it has been confusing as to exactly why the resident received the card of the 60 mg doses and the card for the 30 mg doses, in addition to a roll-pack of 60 mg doses. After looking at this, it appears the card of the [30 mg] 8 pills [4 doses[ [received]on 8-19-26, and the card of 3 pills or 3 doses of the 60 mg strength [received] on 8-20-26, in addition to the 7-day roll-pack [received on 8-22-26, which included his other medications for the morning medicine], there may have been some confusion as to which medications to give for the order of Nifedipine ER 60 mg once daily. After reviewing this, there was a chance that he may not have received his morning meds on 8-19-26, even though they are documented as given. The Corporate Nurse identified the current supply of Nifedipine ER included a card of 30 mg ER pills of 8 tablets, or 4 doses, received on 8-19-26, with 2 pills or 1 dose missing and 6 pills or 3 doses remaining and a card of 60 mg ER pills of 3 tablets or 3 doses, received on 8-20-26 with 2 pills or 2 doses missing and 1 pill or 1 dose remaining. The roll-pack, which included all of the medications Resident C was to receive for a 7-day period, was received on 8-22-26, but was not specified as to how much remained.2. During 1 of 4 medication pass observations with 4 residents and 5 facility staff members, RN 6 was observed to prepare a dose of a Novolog Flexpen [type of injectible delivery device for insulin] for administration to Resident D on 8-25-26 at 11:45 a.m. RN 6 was observed to ready the medication for administration, locate the resident in the dining room and inform the resident she was going to administer the insulin. RN 6 was observed to administer the insulin into the left lower quadrant of Resident D's abdomen, with other residents present in the dining room. After the insulin was injected, RN 6 was observed to immediately remove the needle from Resident D's abdomen, without any wait period. In an interview with RN 6 at 11:50 a.m., she indicated she was uncertain as to what the facility's policy regarding administering injections in the dining room were. RN 6 explained she normally waits for a count of 5 or 5 seconds before she withdraws the needle of a flexpen to allow all the medication to exit the pen and for some reason did not do that with this injection.On 8-25-26 at 4:29 p.m., the ED provided a copy of an undated policy entitled, Medication Administration. This policy indicated, It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer. Administer medications only as prescribed by the provider .Observe the five rights in giving each medication: the right resident; the right time; the right medication; the right dose; the right route Provide for privacy/dignity .Always follow manufacturer guidelines for specific medication use .Documentation of medication will be current for medication administration. Documentation of medications will follow accepted standards of nursing practice.On 8-25-26 at 4:29 p.m., the ED provided a copy of an undated policy entitled, Injection Subcutaneous. This policy indicated, It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. The purpose of this policy is to provide guidance for nursing staff when providing residents with subcutaneous [portion of the skin which is a fatty layer, lying under the skin/dermal layer, but above the muscle layer] injections .For insulin pens .follow the manufacturer's recommendations for proper injection methods .insert needle quickly up to or close to the hub and inject quickly .Allow the needle to remain in the skin up to 3-5 seconds to allow the solution to flow into the skin without leakage and withdraw needle.The recommendations for the use of a Novolog Injection FlexPen, (revised 2/2023) was retrieved on 8-27-26, from the Novo Norodisk, Inc., website. The recommendations included, but were not limited to, Insert the needle into your skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Be careful only to push the button when injecting. Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the neeedle has been pulled out from the skin .This Federal tag relates to Intake 3153877.3.1-25(b)(9)3.1-48(c)(1)

Based on observation, interview and record review, the facility failed to ensure a resident's privacy and dignity were maintained while receiving an injectable medication in one of the dining rooms of the facility, and had the potential to upset this resident. (Resident D and RN 6) Findings include:During 1 of 4 medication pass observations with 4 residents and 5 facility staff members, RN 6 was observed to prepare a dose of a Novolog Flexpen [type of injectible delivery device for insulin] for administration to Resident D on 8-25-26 at 11:45 a.m. RN 6 was observed to ready the medication for administration, locate the resident in the dining room and inform the resident she was going to administer the insulin. RN 6 was observed to administer the insulin into the left lower quadrant of Resident D's abdomen, with other residents present in the dining room. In an interview with RN 6 at 11:50 a.m., she indicated she was uncertain as to what the facility's policy regarding administering injections in the dining room.On 8-25-26 at 4:29 p.m., the ED provided a copy of an undated policy entitled, Medication Administration. This policy indicated, It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer .Provide for privacy/dignity .This Federal tag relates to Intake 3153877.3.1-3(a)(1)

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the attending physician or nurse practitioner, to ensure controlled substances were documented on the narcotic log, to ensure a certified medication aide (a qualified medication assistant or QMA) notified a licensed nurse of potential for administration of a controlled substance prior to its administration and to ensure nursing staff followed the facility's procedure and the manufacturer's recommendations for the use of a medical device used for delivery of a diabetic medication. (Residents B, C and D, LPN 3, QMA 4, LPN 5 and RN 6) Findings include:1. During 1 of 4 medication pass observations with 4 residents and 5 facility staff members, LPN 3 was observed to prepare the morning medications for Resident C on 8-25-26 at 9:37 a.m. During the process of LPN 3 preparing the medications, he was queried regarding adding 2 different preparations of a medication by the same name, specifically nifedipine extended release (used for control of high blood pressure and chest pain) 30 milligrams (mg) 2 pills and nifedipine extended release osmotic 60 mg 1 pill, as to the accuracy of the medication order. LPN 3 specified this was how Resident C's medications were ordered and continued to prepare the medications for the resident. Upon review of Resident C's medication orders, the physician orders indicated the following: Nifedipine ER [extended release] Oral Tablet Extended Release 24 Hour 60 MG Give 1 tablet by mouth one time a day for angina [chest pain], ordered on 8-19-26. In an interview with the Corporate Nurse on 8-26-26 at 10:50 a.m., she indicated she had spoken with LPN 3 and he recalled he had only administered the single pill of the 60 mg dose of Nifedipine.In an interview with Resident C on 8-26-26 at 10:35 a.m., he indicated he was admitted to the facility about 1 week prior. He added he was not entirely sure, but he may have not received his medications for one morning, but was unsure of the exact date, as he had been asleep.In an interview with the Corporate Nurse on 8-26-26 at 2:45 p.m., she indicated it had been confusing as to exactly why the resident received the card of the 60 mg doses and the card for the 30 mg doses, in addition to a roll-pack of 60 mg doses. After looking at this, it appears the card of the [30 mg] 8 pills [4 doses[ [received]on 8-19-26, and the card of 3 pills or 3 doses of the 60 mg strength [received] on 8-20-26, in addition to the 7-day roll-pack [received on 8-22-26, which included his other medications for the morning medicine], there may have been some confusion as to which medications to give for the order of Nifedipine ER 60 mg once daily. After reviewing this, there was a chance that he may not have received his morning meds on 8-19-26, even though they are documented as given. The Corporate Nurse identified the current supply of Nifedipine ER included a card of 30 mg ER pills of 8 tablets, or 4 doses, received on 8-19-26, with 2 pills or 1 dose missing and 6 pills or 3 doses remaining and a card of 60 mg ER pills of 3 tablets or 3 doses, received on 8-20-26 with 2 pills or 2 doses missing and 1 pill or 1 dose remaining. The roll-pack, which included all of the medications Resident C was to receive for a 7-day period, was received on 8-22-26, but was not specified as to how much remained.2. In an interview with the Executive Director (ED) on 8-25-26 at 12:25 p.m., he indicated Resident B had recently been identified as having a significant medical decline related to metastatic cancer (cancer that had spread), was receiving end of life care and had returned to the facility on 8-4-26 after a recent hospitalization. He indicated she had been physician-ordered to receive pain medication of Morphine 20 mg/5ml (milliliters) strength and to administer 2.5 ml, or 10 mg, every 4 hours as needed for pain. He indicated during the early morning hours of 8-5-26, QMA 4 administered Resident B a dose of Morphine around 4:00 a.m. or 5:00 a.m. The ED clarified QMA 4 had informed him she had pulled up the full dose of 2.5 ml into the syringe, but had only given about 1 ml of it because Resident B started coughing and this was identified as a change in condition by QMA 4 and she stopped administering the medication. The ED indicated QMA 4 was not sure exactly how much of the morphine the resident retained. He voiced QMA 4 indicated she notified the licensed nurse on duty as the resident seemed more lethargic. The nurse [LPN 5] notified our telemedicine doctor and was told to give her Narcan [an opioid antagonist, used to rapidly reverse the effects of an opioid medication] due to her becoming more lethargic and to send her out to the hospital for further evaluation. She ended up getting 2 doses of the Narcan by the time the EMS [emergency medical staff] got to the facility. The nurse questioned the dosage of the morphine because our nurses were not used to giving such large doses of morphine. She did find out the order was for the 2.5 ml, so that was not a medication error at all because she was not able to administer the full dose. The ED shared Resident B remained at the hospital and passed away on 8-5-26. In an interview with LPN 5 on 8-25-26 at 8:08 p.m., she indicated she was contacted by QMA 4 on 8-5-26, around 4:00 a.m. or 5:00 a.m., and said she had given the resident a dose of morphine because she seemed very uncomfortable and was moaning out loudly, but had only given a partial dose of it because when she had starting giving it to her, the resident started coughing real bad. LPN 5 indicated when she checked the order, it kind of worried me because it was for 2.5 ml's. I had never seen a dose that large for that strength of morphine before. I immediately called the on-call doctor, the telehealth doctor, and he ordered for me to give her Narcan and I ended up giving her 2 doses and it didn't seem to make a difference .I had given the 2 doses of Narcan by the time EMS arrived and took over. Our [name of the electronic health records system] would not allow the QMA's to enter narrative notes in the chart and when a prn [as needed and not routinely administered medication] was given, [the name of the electronic health records system] automatically prompts you to enter a note about it. So, this meant the licensed nurse had to document the prn medication as given, even though the QMA actually administered it. However, the QMA documents what he or she gave on the narcotic log. LPN 5 did not know the QMA did not fill out the narcotic log. The QMA did not let LPN 5 know about her giving the prn morphine until after she had already given it. My understanding was the QMA's were supposed to notify the licensed nurse before they actually gave it.An interview with QMA 4 was unable to be accomplished, despite multiple attempts to speak with her. A written statement from QMA 4, dated 8-6-26, indicated she notified LPN 5, that I needed to administer a PRN dose of Morphine to [name of Resident B]. I verified the dose and began to administer then stopped after 1ml due to patient coughing .I ensured she was breathing and comfortable and quickly went to get [name of LPN 5] .[name of LPN 5] arrived and took over and contacted [name of telehealth company].In an interview with the ED on 8-26-26 at 3:01 p.m., he indicated after more details and concerns were brought to the attention to him and the Corporate nurse this morning regarding the situation with Resident B's morphine dosing on the morning of 8-4-26, he spoke with QMA 4 this morning. He shared QMA 4's initial statement said she had notified the nurse on duty prior to giving the morphine. However, when he addressed if she had spoken to the nurse on duty about receiving permission to administer a prn, she didn't really give us a response. He indicated the facility provided education immediately with her regarding QMA's were to receive permission from a licensed nurse to give a prn medication before it was given and the reason it was being given.3. During 1 of 4 medication pass observations with 4 residents and 5 facility staff members, RN 6 was observed to prepare a dose of a Novolog Flexpen [type of injectible delivery device for insulin] for administration to Resident D on 8-25-26 at 11:45 a.m. RN 6 was observed to ready the medication for administration, locate the resident in the dining room and inform the resident she was going to administer the insulin. RN 6 was observed to administer the insulin into the left lower quadrant of Resident D's abdomen, with other residents present in the dining room. After the insulin was injected, RN 6 was observed to immediately remove the needle from Resident D's abdomen, without any wait period. In an interview with RN 6 at 11:50 a.m., she indicated she was uncertain as to what the facility's policy was regarding administering injections in the dining room are. RN 6 explained she normally waits for a count of 5 or 5 seconds before she withdraws the needle of a flexpen to allow all the medication to exit the pen and for some reason did not do that with this injection.On 8-25-26 at 4:29 p.m., the ED provided a copy of an undated policy entitled, Medication Administration. This policy indicated, It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer. Administer medications only as prescribed by the provider .Observe the five rights in giving each medication: the right resident; the right time; the right medication; the right dose; the right route .Medications will be charted when given. Narcotics will be signed out when given .PRN medications will have a reason documented for giving and the effectiveness of the drug .Provide for privacy/dignity .Always follow manufacturer guidelines for specific medication use .Documentation of medication will be current for medication administration. Documentation of medications will follow accepted standards of nursing practice.On 8-25-26 at 4:29 p.m., the ED provided a copy of an undated policy entitled, Injection Subcutaneous. This policy indicated, It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. The purpose of this policy is to provide guidance for nursing staff when providing residents with subcutaneous [portion of the skin which is a fatty layer, lying under the skin/dermal layer, but above the muscle layer] injections .For insulin pens .follow the manufacturer's recommendations for proper injection methods .insert needle quickly up to or close to the hub and inject quickly .Allow the needle to remain in the skin up to 3-5 seconds to allow the solution to flow into the skin without leakage and withdraw needle.The recommendations for the use of a Novolog Injection FlexPen, (revised 2/2023) was retrieved on 8-27-26, from the Novo Norodisk, Inc., website. The recommendations included, but were not limited to, Insert the needle into your skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Be careful only to push the button when injecting. Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the neeedle has been pulled out from the skin .On 8-26-26 at 3:45 p.m., the ED provided a copy of the Indiana State regulation the facility uses to educate staff on the QMA Scope of Practice, 412 IAC (Indiana Administrative Code) 2-1-9. This regulation indicated, Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following .Document in the resident record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including time of contact .Ensure the resident's record is cosigned by the licensed nurse who gave permission by the end of the nurse's shift or, if the nurse was on call, by the end of the nurse's next tour of duty.This Federal tag relates to Intake 3153877.3.1-25(b)(1)3.1-25(b)(3)3.1-25(b)(8)3.1-25(b)(9)

Based on interview and record review, the facility failed to timely ensure vision services were provided for 2 of 2 residents reviewed for vision and hearing services. (Residents B and H)Findings include: 1.The clinical record for Resident H was reviewed on 1/6/26 at 10:37 a.m. Her diagnoses included, but were not limited to, photophobia, anxiety, and dementia. She was admitted to the facility on [DATE]. The Request For Service form, dated 7/7/25, signed by Family Member 4, indicated they would make alternate arrangements for eye care services. The impaired visual function care plan, initiated 7/3/25, indicated an intervention was to arrange consultation with eye care practitioner as needed, initiated 7/3/25. An interview was conducted with Family Member 4 on 1/6/26 at 12:49 p.m. She indicated Resident H had macular degeneration and needed to be seen by the eye doctor. She informed the MCUM (Memory Care Unit Manager) of this the other day. She also informed the unit's previous unit manager over two months ago and no one followed through with scheduling an appointment. There were no progress notes or eye consultation notes in the clinical record to indicate Resident H was seen by the eye doctor or that an appointment was scheduled. An interview was conducted with the SSD (Social Services Director) on 1/8/26 at 2:14 p.m. She indicated she was responsible for contacting the facility's eye care provider, if a resident needed to be seen. When a resident was admitted to the facility, she collected ancillary consent forms at their initial care plan meeting to be signed by the resident or their representative. Whether or not the resident wished to be seen by the eye doctor was revisited at each subsequent care plan meeting. She was not the SSD when Resident H was admitted to the facility in July, 2025. She reviewed Resident H's electronic clinical record and indicated there were no eye care consultation notes for her. The facility's eye care provider was in the facility on the following dates: 11/17/25, 9/16/25, and 7/22/25. Resident H was not seen on any of those dates. 2. The clinical record for Resident B was reviewed on 01/07/2026 at 9:12 a.m. The resident's diagnoses included, but were not limited to, Bell's Palsy (sudden, temporary facial paralysis or weakness, usually on one side, caused by inflammation of the cranial nerve), cerebral aneurysm, and anxiety. The Annual Minimum Data Set (MDS) assessment, dated 12/4/25, indicated Resident B was cognitively intact. During an interview with Resident B on 1/5/26 at 1:48 p.m., they indicated they needed to be seen by the eye doctor. Resident B indicated their eyes were always bothering them, the resident always felt like something was in their eyes, they blinked a lot, and it was very painful. Resident B indicated she notified the nurse practitioner about it. During an interview with Divisional Director of Risk (DDR) on 1/8/26 at 11:49 a.m., they indicated Resident B had not been seen by the eye doctor since 2022. A physician's order, dated 5/20/22, indicated Resident B could consult optometry services. A plan of care, dated 9/2/25, indicated Resident B had impaired visual function related to Bell's Palsy and dry eyes. During an interview with DDR on 1/9/26 at 9:30 a.m., they indicated the facility does not have a policy regarding ancillary services. 3.1-39(a)(b)

Based on observation, interview, and record review, the facility failed to provide showers as scheduled for 1 of 4 residents reviewed for Activities of Daily Living (ADLs). (Resident G)Findings include:The clinical record for Resident G was reviewed on 1/7/2026 11:46 a.m. The resident's diagnoses included, but were not limited to, weakness, depression, and nicotine dependence.The admission Minimum Data Set (MDS) assessment, dated 12/18/25, indicated Resident G was cognitively intact and used a wheelchair for ambulation.During an observation and interview with Resident G on 1/6/25 at 11:25 a.m., he indicated he had not had a shower for weeks and staff had just been cleaning him up when they were changing him in the bed. Resident G's hair was observed being shoulder length, greasy and tangled. Resident G indicated it was his fault and should have asked for one.During an observation of Resident G on 1/7/26 at 11:28 a.m., his hair appeared greasy and tangled. Resident G indicated no one had come in to ask him if he wanted a shower and he thought his shower days were Wednesdays and Saturdays.During an observation and interview with Resident G on 1/8/25 at 9:41 a.m., Resident G indicated no staff had come in to offer him a shower and that he just needed to tell them. The resident had a strong, sweaty, body odor and greasy tangled hair were observed.The Electronic Health Record (EHR) indicated Resident G had a shower documented on 12/31/25. No showers or any other type of bathing was documented in EHR from 1/1/26 through 1/8/25. The EHR indicated there were no refusals of showers documented for Resident G.A plan of care, dated 9/26/24, indicated Resident G had Activities of Daily Living (ADL) deficit related to weakness and impaired mobility. The interventions included, but were not limited to, the resident requiring substantial/maximal assistance with helper doing more than half of the effort and 2 or more helpers were required with shower transfers.During an interview with Licensed Practical Nurse (LPN) 2 on 1/8/26 at 1:20 p.m., they indicated they did not know why Resident G had not had a shower in over 7 days. LPN 2 indicated it should trigger on her dashboard on the computer if a refusal or no care was done, so that was how she knew a follow up was needed and she did not receive any documentation regarding Resident G not receiving showers. LPN 2 indicated it was herself, also the unit manager, who was responsible to ensure residents were offered and given showers as scheduled or as needed.A Routine Resident Care policy was provided by the Divisional Director of Risk (DDR) on 1/9/26 at 9:20 a.m. It indicated .to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, needs. 3. Unlicensed staff: b. Routine care by a nursing assistant included, but is not limited to the following: i. Assisting or provides for personal care 1. Bathing.vii. A. Observing and documenting all aspects of care. 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident was seen by urology for 1 of 2 residents reviewed for catheter care. (Resident 111)Findings include: The clinical record for Resident 111 was reviewed on 01/07/2026 10:45 a.m. The resident's diagnoses included, but were not limited to, Spina Bifida (a birth defect where the spine and spinal cord don't close properly in early pregnancy) and obstructive and reflux uropathy (obstruction and backward flowing in the urinary tract). During an observation and interview with Resident 111 on 1/6/26 at 12:12 p.m., they indicated their urinary catheter always had a lot of sediment and the catheter leaks a lot due to it getting clogged up from thick sediment and bladder spasms. Resident 111 indicated they wake up two to three times a week needing a complete bed change because their catheter had leaked all over their bed due to being clogged. Resident 111's foley catheter tubing was observed with pale yellow urine with thick sediment. The Annual Minimum Data Set (MDS) assessment, dated 12/17/25, indicated Resident 111 was cognitively intact, had an indwelling catheter, and was always incontinent of urine. A plan of care, dated 1/16/23, indicated Resident 111 had an indwelling catheter related to obstructive uropathy and bladder spasms. A Telehealth progress note, dated 11/22/25, indicated Resident 111 had been seen for foley leaking. Per the nurse the resident had multiple episodes of catheter leaking when having bladder spasms. A urology consult was placed for assessment. A physician's order, dated 11/22/25, indicated for the resident to have a urology consult. A progress note, dated 12/23/25, indicated Resident 111 was seen for a follow-up positive urinalysis and was being sent for a urology consult. The Electronic Health Record (EHR) indicated no follow up was recorded until 1/6/26 at 9:51 a.m. A nurse's note indicated phoned urology for consult. During an interview with the Divisional Director of Risk (DDR) on 1/8/26 at 11:12 a.m., they indicated the urology order was placed 11/22/25, the facility faxed over the initial referral and face sheet, then we called urology. DDR indicated urology had them leave their name and number for a call back, but they never returned the call. The DDR indicated there was no documentation in the EHR until two days ago for the appointment to be made again and followed up on. During an interview with the Director of Nursing (DON) on 1/9/26 at 10:41 a.m., she indicated the unit manager was responsible to follow up on any consults made for residents. A Catheter Care policy was provided by DDR on 1/9/26 at 9:20 a.m. It indicated .It is the policy of this facility to provide resident care that meets the psychological, physical, and emotional needs and concerns of the residents. 3.1-41(a)(2)

Based on interview, observation, and record review, the facility failed to accurately transcribe admission order for Resident D, have pain medication available as ordered for Resident D, and failed to address pain for Resident H for 2 of 2 residents reviewed for pain control.Findings include:1 The clinical record for Resident D was reviewed on 1/7/2026 at 11:41 AM. The resident's diagnoses included, but were not limited to, chronic pain and respiratory failure. An admission Minimum Data Set Assessment, dated 12/25/2025, indicated that Resident D was cognitively intact, utilizes routine and as needed pain medication, and experienced pain occasionally. A care plan, dated 12/22/2025, indicated Resident D had chronic pain. The interventions included, but were not limited to, attempt non-pharmacological interventions, pharmacological interventions, and to report pain to the physician. During an interview with Resident D, on 1/6/2025 at 11:15 AM, the resident indicated when he first admitted to the facility in December of 2025 there was an issue with getting his pain medication as prescribed. Resident D denied having severe uncontrolled pain during that timeframe. Discharge orders used for admitting orders to the facility for Resident D, dated 12/18/2025, indicated the resident took methadone three times a day routinely. The medication administration record reflected a physician's order for Resident D, dated 12/18/2025, of methadone three times a day as needed for pain. No routine order for methadone was added on 12/18/2025. A physician's order, dated 12/19/2025, indicated Resident D to receive methadone three times a day as ordered. Review of the December 2025 Medication Administration Record indicated Resident D did not receive 15 scheduled doses of methadone for a reason of medication unavailable or was left blank. During an interview, on 1/8/2026 at 9:57 AM, LPN 2 indicated the facility has had issues getting methadone and similar medications for residents. During an interview, on 1/9/2026 at 12:43 PM, the DRR indicated it was the responsibility of the admitting nursing staff to assure the accuracy of admission orders. The nursing management team then conducts an additional review on the next business day. It was the expectation the nursing staff would notify the physician for unavailable medications. For Resident D, the medical director had not filled out the prescription correctly for methadone. The on-call provider was notified on 12/20/2025 and they had written a script on 12/21/2025, but it was not delivered until 12/22/2025. A policy entitled, Notification of Change of Condition, was provided on DRR on 1/9/2026 at 9:50 AM. The policy indicated, .It is the policy of the facility to provide resident centered care that meets the psychological, physical, and emotional needs, concerns of the residents. 2. The clinical record for Resident H was reviewed on 1/6/26 at 10:37 a.m. Her diagnoses included, but were not limited to, dementia, contusion of rib, and multiple fractures of rib, right side. The pain care plan, revised 12/10/25, indicated to administer non-pharmacological interventions and evaluate the effectiveness of interventions, initiated 7/4/25; and to provide medication per orders and evaluate effectiveness of medication, initiated 7/4/25. The 12/7/25 post fall evaluation, completed by RN (Registered Nurse) 5, indicated she experienced an unwitnessed fall on 12/7/25 at 9:45 a.m. The family/responsible party was notified of the fall on 12/7/25 at 9:55 a.m. The Pain/Skin section of the evaluation indicated she complained of pain on the right side of her back that was new to her. She was able to verbalize her pain level as a 5 on a scale of one to ten. Resident H described her pain as an ache and heavy. The evaluation did not indicate how Resident H's pain level of five was addressed. The physician's orders indicated to administer two 325 mg acetaminophen tablets by mouth three times a day for pain, starting 9/11/25. They indicated to administer two 325 mg tablets of acetaminophen by mouth every six hours as need for pain/fever, starting 9/11/25. There was no other as needed pain medication order in place when Resident H fell on [DATE] at 9:45 a.m. The December, 2025 MAR indicated the first regularly scheduled acetaminophen administration was administered in the morning on 12/7/25 for a pain level of three. There were no as needed administrations of acetaminophen administered on 12/7/25. The 12/7/25, 9:45 a.m., 10:00 a.m., 10:15 a.m., 10:30 a.m., 10:45 am., and 11:00 a.m., neurological assessments did not reference pain levels. The vitals section of the electronic health record included only one pain assessment on 12/7/25 prior to Resident H being sent to the hospital. It was a level of 3 in correlation with the regularly scheduled acetaminophen administration. The 12/7/25, 1:18 p.m. nurse's note, written by RN 5, indicated, res had unwitnessed fall in the morning [sic] with back hurts and a scratch on her ryt [sic] back and complains she feel pain when she takes breath her family notified and also DON [Director of Nursing] due to her family requested resident sent to ER with family for further evaluation. The note did not indicate any as needed pain medication was administered or any nonpharmacological interventions were implemented. RN 5 was not available for interview, as she was out of the country, and unable to be reached by telephone. On 1/8/26 at 2:03 p.m., an interview was conducted with CNA (Certified Nursing Assistant) 6, who found Resident H on the floor in her room on 12/7/25 at 9:45 a.m. after she fell. She indicated she was walking down the hall and saw Resident H sitting on the floor in her room with her back against her bathroom door. CNA 6 called for RN 5 to come down to the room. They both remained in the room for a while after assisting her up and into her chair. After getting her into her recliner, Resident H informed RN 5 that her rib cage was sore. CNA 5 was unsure how RN 5 addressed the pain. CNA 5 did not witness any administrations of pain medication to Resident H. The post fall evaluation, dated 12/7/25, completed by RN 5, indicated the physician was notified of the fall on 12/7/25 at 1:47 p.m. The content of discussion with physician section indicated, unwitnessed fall with no injury res. [resident] complain back hurts and abrasion noted on her right side of back transfer to ER due to family requested. An interview was conducted with Family Member 5 on 1/6/26 at 12:52 p.m. She indicated when Resident H fell on [DATE], Family Member H arrived at the facility within an hour of being notified. Upon arrival, Resident H was crying and complaining of pain on her right side. Family Member 5 insisted Resident H be sent to the emergency room. The nurse's note, dated 12/7/25 at 5:37 p.m., written by the DON indicated Resident H was transported to the emergency room at approximately 1:15 p.m. on 12/7/25. The 12/7/25 emergency department note indicated Resident H was seen by a provider at 1:36 p.m. on 12/7/25. She reported right rib and right abdominal pain, which was exacerbated by breathing. There was tenderness to palpation of the right ribs and abdomen. The discharge problem was contusion of rib and fracture of rib. The nurse practitioner note, dated 12/8/25, indicated she had a fall that resulted in an ER visit. Hospital found the patient has rib fracture of 8, 9, and 10. An interview was conducted with the DDR (Divisional Director of Risk) on 1/9/26 at 10:40 a.m. She indicated they had no verification Resident H's pain level of 5 on 12/7/25 was addressed. All they had was the December, 2025 MAR to verify she received her regularly scheduled acetaminophen for her pain level of three that morning. The Pain Management and Assessment policy was provided by the DDR on 1/8/26 at 12:00 p.m. It indicated, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the clinical staff to support the intent of 483.25 (k) that based on the comprehensive assessment of a resident, the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. There is no objective test that can measure pain. The clinician must accept the resident's report of pain. Clinical observations clarify information from the resident. Site of discomfort may direct the nurse to specific types of pain-relief measures. Break-through Pain Management.b. Pain that is above the routine pain and requires interventions along with the current pain management regime. c. May require, on occasion, adjuvant therapies including pharmacological and non-pharmacological interventions for enhancing pain relief .Documentation a. Medication pain relief and response. b. Non-pharmacological measures attempted and the resident response. This citation relates to Intake 2661565. 3.1-37(a)

Based on interview and record review the facility failed to provide a substitute at lunch as requested by the resident for 1 of 1 residents reviewed for nutrition (Resident 70).Review of the clinical record of Resident 70 on 1/07/2026 11:55 a.m., indicated the resident's diagnoses included, but were not limited to, vascular dementia, cerebral vascular disease, major depression disorder, adult failure to thrive and hypertension. The food preference assessment for Resident 70, dated 11/21/25, indicated the resident typically consumed salads. The resident requested salads for breakfast, lunch and dinner. The resident also liked fruit, chocolate milk, eggs, cheese, potatoes, fish, grilled cheese and peanut butter and jelly sandwiches. The Registered Dietician assessment for Resident 70, dated 11/26/25, indicated the resident Body Mass Index (BMI) was 15.9 indicating the resident was underweight. The resident did not have signs of of a swallowing disorder, oral/mouth problems and did not utilize adaptive eating equipment. The resident was not on a prescribed physician weight loss regimen. The resident's current body weight required increased nutrition to promote weight gain. The resident was malnourished. The care plan for Resident 70, dated 11/25/25, indicated the resident had protein calorie malnutrition, adult failure to thrive, dysphagia, vitamin b12 deficiency, iron deficiency anemia, Body Mass Index (BMI) underweight. The interventions included, but were not limited to, offer substitutions if provided meal was declined. The admission Minimum Data (MDS) assessment for Resident 70, dated 11/28/25, indicated the resident was severely impaired for daily decision making. The resident required set up only for eating. The physician recapitulation for Resident 70, dated January 2026, indicated the resident was ordered lacto-Ovo Vegetarian diet (excludes meat, but includes dairy and eggs diet), dysphagia advanced diet (moist and tender food) and thin liquids consistency. During an interview with Resident 70's family on 1/06/2026 at 10:32 a.m., the family member indicated the resident required more protein. The resident liked salads, but also liked eggs, fish and cream of wheat. The facility needed to offer the resident more choices to ensure she was receiving enough protein. During an interview with Resident 70, on 1/07/2026 at 1:09 p.m., she indicated she did not eat her salad for lunch today because she wanted something else. The resident indicated she wanted spaghetti with sauce. The resident asked the staff for spaghetti with sauce and was told the facility did not have it. The resident described the staff member she requested the substitute from. During an interview with CNA 1, on 1/7/26 at 1:18 p.m., the CNA indicated Resident 70 did request spaghetti with pasta sauce for lunch and she told the resident that the facility did not have that. CNA 1 indicated the resident only drank chocolate milk for lunch. During an interview with the Dietary Manager [NAME] on 1/8/26 at 11:40 a.m., she indicated she was not aware of a staff member requesting spaghetti and sauce for Resident 70 yesterday. The Dietary Manager verified with the dietary staff that the staff did not request spaghetti and sauce yesterday for lunch for Resident 70. The Dietary Manager indicated the facility had several substitutes at meal time. The Dietary Manager indicated the dietary department did have spaghetti and sauce available and would have made Resident 70 spaghetti and sauce yesterday if they had been aware after the main meal was completed. During an interview with the Regional Director of Clinical Operations on 1/9/26 at 10:42 a.m., indicated the facility did not have a policy for food substitutions, but there were several substitutions available daily. 1.3-21(a)(4)

Based on interview and record review, the facility failed to provide weekend activities, as preferred, for 2 of 4 residents reviewed for activities (Residents 13 and 71). This had the potential to affect 19 of 19 residents on the Reflections 1 Unit of the facility. Findings include: 1. The clinical record for Resident 71 was reviewed on 12/4/24 at 12:30 p.m. Her diagnoses included, but were not limited to, dementia. She resided on the Reflections 1 Unit, a memory care unit, of the facility. The activities care plan, revised 3/11/24, indicated she had a cognitive deficit that required supervised activities with staff. She enjoyed painting, coloring, small group events, and bingo. A goal was to show engagement in activities of interest through the next review. Two of the interventions were to encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities and to invite her to scheduled activities. 2. The clinical record for Resident 13 was reviewed on 12/4/24 at 12:30 p.m. His diagnoses included, but were not limited to, heart failure. He resided on the Reflections 1 unit in a room with Resident 71. The activities care plan, revised 10/5/23, indicated he enjoyed small group activities. The goal was for him to show engagement in activities of interest through the next review. Three of the interventions were to encourage him to participate in music and memory programs; encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities; and to provide activity materials of interest such as library books, word puzzles, and magazines. The 10/24/24 Quarterly Minimum Data Set (MDS) assessment indicated he was cognitively intact. An interview was conducted with Resident 13, on 12/4/24 at 12:31 p.m., in his room in the presence of Resident 71. He indicated the facility had no scheduled weekend activities, and he was bored with that. They had church service once a month on a weekend but would like to have it every Sunday. The December 2024 Reflections 1, Reflections 2, and Rosewood Units Activity Calendar was posted on the wall in the hallway outside of the dining room on the Reflections 1 Unit. It indicated the following weekend activities: Sunday, 12/1/24 - no activities scheduled, just a picture of candy canes, Saturday, 12/7/24 - Weekend Worksheet Packets, Sunday, 12/8/24 - Pics (Pictures) with Santa, Saturday, 12/14/24 - Weekend Worksheet Packets, Sunday, 12/15/24 - no activities scheduled, just a picture of holiday bells, Saturday, 12/21/24 - Weekend Worksheet Packets, Sunday, 12/22/24 - Weekend Worksheet Packets, Saturday, 12/28/24 - no activities scheduled, just a picture of a holiday mug, and Sunday, 12/29/24 - no activities scheduled, just a picture of gingerbread man. The Weekend Worksheet Packet for the Reflections 1 Unit was provided by the Infection Preventionist on 12/10/24 at 10:45 a.m. It included a stapled packet of four word searches and four coloring pages. An interview was conducted with Resident 13 and Resident 71 in their room on 12/10/24 at 11:27 a.m. Resident 13 looked over the Reflections 1 Weekend Worksheet Packet and indicated no one provided him this over the weekend. It looked familiar to him, but he hadn't received one of these for a long time. Resident 71 indicated she liked word searches and would do them if provided, preferably with Resident 13. An interview was conducted with Qualified Medication Aide (QMA) 5, who was working the Reflections 1 Unit, on 12/10/24 at 11:40 a.m. She indicated she sometimes worked the unit on weekends, and she'd seen coloring pages for residents before, but never a packet, nor had she seen anyone pass out a packet on the unit. She stated, Activities needs a lot of work. An interview was conducted with Certified Nursing Assistant (CNA) 6 and CNA 7 on 12/10/24 at 11:47 a.m. They indicated the facility needed more activities on the weekends. Activity staff were amazing, but only there Monday through Friday. On 12/9/24 at 12:16 p.m., an interview was conducted with Unit Manager (UM) 4, who managed the Reflections 1, Reflections 2, and Rosewood Units of the facility. She indicated there was a new Activity Director (AD) in the facility, who was working on having scheduled weekend activities. There used to be weekend packets for residents to do, that consisted of word searches, coloring, and some tactile simulations to pull out. The packet was different for each unit and not everyone received one. She occasionally worked on weekends and sometimes saw residents play Uno on the Reflections 1 Unit. On the Rosewood Unit, they watched a movie and had a snack or a game. None of it was scheduled and hadn't been in the past. She thought the facility was moving towards scheduled weekend activities. An interview was conducted with the AD on 12/9/24 at 2:02 p.m. She indicated she began working at the facility a week ago, and was told there were no weekend activities. There was church service the first Sunday of every month, but that was all she knew of on weekends. There was someone currently scheduled to be interviewed for weekends and evening activities. An interview was conducted with the Executive Director (ED) on 12/10/24 at 10:48 a.m. He indicated they were working on hiring someone for weekend activities. The Activities Program policy was provided by the Infection Preventionist on 12/10/24 at 10:22 a.m. It indicated, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .Procedure: I. The activity program is .b. Scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program .f. Reflect the schedules, choices and rights of the resident i. Are offered at hours convenient to the residents, including holidays and weekends. 3.1-33(a) 3.1-33(c)

Based on interview and record review, the facility failed to include a resident and a resident's representative in their care plan conferences for 2 of 5 residents reviewed for care planning. (Residents 13 and 104) Findings include: 1. The clinical record for Resident 13 was reviewed on 12/4/24 at 12:30 p.m. His diagnoses included, but were not limited to, heart failure. The 7/8/24 Annual, 10/2/24 Quarterly, and 10/24/24 Quarterly Minimum Data Set (MDS) assessments indicated he was cognitively intact. There was no information in the clinical record that indicated a care plan conference was held in coordination with any of the three above referenced MDS assessments. An interview was conducted with Resident 13 in his room on 12/4/24 at 12:42 p.m. He indicated he hadn't been invited to a care plan conference in the facility, but he would like to attend. An interview was conducted with Social Services Director (SSD) 2 on 12/6/24 at 10:45 a.m. She indicated she was responsible for coordinating care plan meetings for the residents on the unit. They were conducted every three months, beginning with the initial, then quarterly thereafter. They usually scheduled the next meeting at the current meeting. She had everything lined up so that meetings were held in line with quarterly assessments. They documented care plan meetings in the progress notes of the electronic health record (EHR). She remembered discussing laundry and Resident 13's wife at Resident 13's last care plan meeting. SSD 2 reviewed Resident 13's EHR at this time and indicated she did not see any documentation of an actual care plan meeting for him in July or October 2024, and suggested there may be documentation in a soft file in another office. She and the Unit Manger (UM) would have been the only staff present. On 12/6/24 at 12:22 p.m., an interview was conducted with SSD 2, who provided the, 10/9/24, handwritten Care Plan Notes for Resident 13 at this time. The notes indicated Resident 13, and his wife were in attendance. The notes were signed by SSD 2, but there was no signature for Resident 13. SSD 2 indicated she was unable to locate any care plan notes for July 2024. An interview was conducted with Resident 13 on 12/10/24 at 11:31 a.m. He indicated he did not recall having a care plan meeting on 10/9/24. He was able to sign his name, as he signed his name every time he withdrew money from his personal funds account and would have signed that he attended the care plan meeting, if asked. 2. The clinical record for Resident 104 was reviewed on 12/4/24 at 2:00 p.m. His diagnoses included, but were not limited to, Parkinson's disease, dementia, and intermittent explosive disorder. The 7/17/24 Quarterly and 9/12/24 Significant Change MDS assessments indicated he was severely cognitively impaired. There was no information in the clinical record that indicated a care plan conference was held in coordination with the two above referenced MDS assessments. An interview was conducted with Family Member 3 on 12/4/24 at 2:02 p.m. She indicated she hadn't been invited to a care plan conference in the facility yet. An interview was conducted with SSD 2 on 12/6/24 at 10:55 a.m. She indicated she invited Family Member 3 to Resident 104's care plan meetings, but she wasn't able to attend. SSD 2 did not document care plan invitation in the clinical record, but she invited Family Member 3 to his last care plan meeting. SSD 2 reviewed Resident 104's EHR and indicated she didn't see any documentation of an actual care plan meeting for him in September 2024, and suggested there may be documentation in a soft file in another office. She and the UM would have been the only staff present. On 12/6/24 at 12:22 p.m., an interview was conducted with SSD 2, who provided the, 10/4/24, handwritten Care Plan Notes for Resident 104 at this time. The notes indicated Family Member 3 was unable to attend the meeting and the only people in attendance were SSD 2 and the Unit Manager. SSD 2 indicated she was unable to locate any care plan notes for July 2024. An interview was conducted with Family Member 3 on 12/6/24 at 12:13 p.m. She indicated she did not recall being invited to a care plan meeting held on 10/4/24. She would have been able to attend, but didn't know anything about it. She tried to come to the facility two to three times a week, and moving forward, she would very much like to be invited to care plan meetings to be kept in the loop. The Plan of Care Overview policy was provided by the Executive Director on 12/6/24 at 12:00 p.m. It read, The facility will .vii. support and encourage resident/representative participation including but not limited to working cooperative to .3. schedule meeting to accommodate a resident's representative that may include conference calls, video conference sessions or live sessions .Attendees will sign and date care plan meeting agendas/documents. 3.1-35(d)(2)(B)

Based on interview, observation, and record review, the facility failed to ensure Resident 36's indwelling urinary catheter remained free of contact with the floor while in bed for 1 of 2 residents reviewed for indwelling urinary catheters. Findings include: The clinical record for Resident 36 was reviewed on 12/4/2024 at 1:45 p.m. The medical diagnoses included obstructive uropathy. A Quarterly Minimum Data Set assessment, dated 11/22/2024, indicated Resident 36 utilized an indwelling urinary catheter, dependent on staff assistance for toileting needs, and dependent on staff for transferring regarding activities of daily living. During an observation on 12/4/2024 at 12:45 p.m., Resident 36 was in bed with his urinary catheter drainage bag laying on the floor. During an interview on 12/4/2024 at 1:30 p.m., Certified Nursing Assistant (CNA) 7 indicated urinary catheter drainage bags should remain free of contact with the ground. During an observation on 12/10/2024 at 10:45 a.m., Resident 36 was in bed with his urinary catheter drainage bag laying on the floor. A policy entitled, Catheter Care, was provided by the Executive Director on 12/10/2024 at 12:30 p.m. The policy indicated to ensure .the collection bag is not on the floor . 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure misappropriation of residents' medication did not occur for 1 of 3 residents reviewed for medication administration. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/5/24 at 2:00 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebrovascular disease. An incident report, dated 7/24/24, indicated a discrepancy in the narcotic sign off sheet for Resident C that involved Registered Nurse (RN) 2. A physician order, dated 7/16/24, indicated to administer hydrocodone-acetaminophen (narcotic pain relief medication) 10-325 milligrams (mg) every four hours, scheduled, for pain. A controlled drug administration record, dated July 2024, for Resident C's hydrocodone-acetaminophen 10-325 mg tablet indicated the following discrepancies signed off by RN 2: - 7/17/24 at 8:00 a.m., the amount went from 79 to 77 tablets, - 7/19/24 in the morning., the amount went from 68 to 66 tablets, & - 7/22/24 at 8:00 a.m., the amount went from 48 to 46 tablets. A written statement by Qualified Medication Aide (QMA) 3, undated, indicated there were three open bottles of hydrocodone but only one was in use. QMA 3 reviewed the narcotic log and found a count error on several occasions and reported such to the Director of Nursing. A telephone interview conducted with RN 2, on 9/5/24 at 2:16 p.m., indicated he would remove two hydrocodone-acetaminophen 10-325 milligram tablets for Resident C. He would administer one to Resident C and take one for himself. There were five to six instances of RN 2 taking two tablets of narcotic pain medication to administer one to Resident C and keep one for himself. Resident C did not go without his narcotic pain medication. An interview conducted with the Executive Director (ED), on 9/5/24 at 12:50 p.m., indicated when QMA 3 noticed the discrepancy, they notified the ED and the Director of Nursing. The narcotic logs were reviewed, and all medication carts were audited to ensure no further concerns with residents' narcotic medications. The ED spoke with RN 2, and he admitted to taking Resident C's narcotic pain medication on more than one occasion. A policy titled Medication Controlled Drugs and Security, undated, was provided by the ED on 9/5/24 at 1:55 p.m. The policy indicated, .Procedure .d. Drug diversion will be treated as misappropriation of Resident Property and the Board of Nursing will be notified as appropriate for known drug diversions or suspected drug diversion after careful review and evidence collection A policy titled Abuse & Neglect & Misappropriation of Property, undated, was provided by the ED on 9/5/24 at 1:55 p.m. The policy indicated the following, .It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property .provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property The Past Noncompliance began on 7/17/24. The deficient practice was corrected on 7/24/24 after the facility implemented a systemic plan that included the following: audits completed of all medication carts that contained narcotic medication; nurses and qualified medication aides were educated of medication administration, misappropriation of property, and abuse policy; and medication was reordered from the pharmacy and billed to the facility to cover the cost of the medication. This citation relates to Complaint IN00439505. 3.1-28(a)

Based on interview and record review the facility failed to provide medications as ordered by the physician for 1 of 3 residents reviewed for medication administration. (Resident C) Finding include: During an interview with Resident C's family, on 6/24/24 at 12:35 p.m., indicated the resident did not receive all his medications as ordered by the physician when admitted to the facility on [DATE]. The resident was discharged on [DATE]. The clinical record of Resident C was reviewed on 6/25/24 at 12:40 p.m. The diagnoses included, but were not limited to, diabetes, severe protein calorie malnutrition, convulsions, sepsis, major depressive disorder, stiff man syndrome, hypotension, and pulmonary nodule. Review of the physician orders for Resident C, dated 11/23/24, indicated the resident was ordered and did not receive the following medications: tamsulosin 0.4 milligrams (mg) every morning (urinary retention medication), mirtazapine 15 mg at bedtime for depression, amoxicillin 500 mg; two capsules in the morning and at bedtime for an infection, midodrine 10 mg three times a day for hypotension, pantoprazole sodium 40 mg in the morning and at bedtime for digestive aid, and gabapentin 800 mg at bedtime for polyneuropathy. During an interview with the Regional Director of Clinical Operations, on 6/26/24 at 2:20 p.m., verified Resident C did not receive the medications as ordered by the physician and these medications were available in the Emergency Drug Kit (EDK) located in the facility. The floor nurse who admitted Resident C was responsible to obtain these medications out of the EDK and administer them to Resident C. The Emergency Pharmacy Service and Emergency kit policy provided by the Executive Director, on 6/26/24 at 3:19 p.m., indicated emergency pharmacy service was available 24 hours a day. Emergency needs for medication are met by using the facility's approved emergency medication supply. The provider pharmacy supplies emergency medication included, but were not limited to, emergency drugs and antibiotics. The nurse records the medication use from the emergency kit on the use form and seals the kit with a color- coded seal to indicate the need for replacement. This citation relates to Complaint IN00423037. 3.1-25(a)

Based on observation and interview, the facility failed to ensure that food was dated, out of date food was removed, and a storage scoop was not stored inside of a container with food. This had the affect 112 of 115 residents who resided in the facility. Findings include: A dietary observation, dated 9/6/2023 at 10:48 a.m., indicated in the dry food storage there was a large storage container with no date on the container, a container of cane sugar dated 1/5/2021, white rice in a container dated for 4/3/2021, flour in a container without a date, a box with an open plastic bag contained tea leaves without a date on it, and a portioning scoop was found inside of the brown sugar. Two additional scoops were hanging on the side of the rack with one labeled as flour with a brown granulated substance about an inch deep at the bottom of the hanging container. Numerous boxes were found in the middle of the floor of dry goods. An interview with Dietary Aide 2 on 9/6/2023 at 10:48 a.m. indicated that the dietary staff had not had time to stock the boxes of goods that were delivered on 9/5/2023. She further indicated that she did not believe the dates on the containers of rice and cane sugar were correct, because they would clean the containers when getting new products in but verified no other date was on any of the containers. She indicated she did not know the last time the scoops were cleaned or a rotation of cleaning for them. The dietary staff should be labeling all food items when they are opened. An observation of the large refrigeration unit on 9/6/2023 at 10:58 a.m., indicated three pitchers of lemonade with no date, a large container of iced tea with no date, a serving tray of cabbage with a date of 9/2/2023, a large serving tray of cooked macaroni and beef in a sauce with no date, a tray of Italian sausage with a date of 8/30/2023, and turkey with a date of 8/30/2023. An interview with Dietary Aide 2 on 9/6/2023 at 10:58 a.m. indicated that cabbage, macaroni noodles with beef in sauce, Italian sausage, and turkey had a used by date on them and should have all been pulled and disposed of prior to this observation. She indicated they usually do this every day, but they did not have time to do that this morning. She further indicated that all prepared drinks, iced tea and lemonade, should be labeled and dated when it is prepared. An observation of the front refrigeration unit on 9/6/2023 at 11:01 a.m., indicated seven bottles of sour cream with the use by date of 8/31/2023 and potato salad with no date. Dietary Aide 2 removed these items. An interview with the Director of Nursing on 9/13/2023 at 3:04 p.m., indicated that 112 of 115 residents received food from the kitchen. A policy entitled, Storage of Resident Food, was provided by the Executive Director on 9/12/2023 at 4:40 p.m. The policy indicated, .Foods will be stored in a closed container with sealable lids .Staff will date the container when good or beverages are brought into the facility .The dietary staff will monitor refrigeration storage areas for resident's food monitoring for outdated, unsafe, or otherwise food unfit for consumption . 3.1-21(i)(3)

Based on observation, interview and record review the facility failed to provide an ongoing activity program on the memory care unit for 7 of 9 resident's reviewed for activities (Resident 5, Resident 26, Resident 32, Resident 37, Resident 55, Resident 71 and Resident 77). Findings include: During an observation on 9/6/23 at 1:55 p.m., 6 residents were sitting in the common area, there were no activities occurring on the memory care unit. The TV was on with the volume turned down. Residents were observed talking to themselves. During an observation on 9/6/23 at 2:06 p.m., there were no activities occurring on the memory care unit. Resident 71 was wandering the memory care unit hallway and Resident 26 was wandering into the nursing station. There were no staff present. During an observation on 9/7/23 at 10:52 a.m., there were 6 residents sitting in the common area, there were no activities occurring on the memory care unit. During an observation on 9/7/23 at 1:47 p.m., there were no activities occurring on the memory care unit. Resident 55 and Resident 71 was wandering the memory care unit. During an observation on 9/8/23 at 10:54 a.m., there were 6 residents sitting in the common area, there were no activities occurring on the memory care unit. During an observation on 9/8/23 at 2:04 p.m., there were no activities occurring on the memory care unit. Resident 26 was wandering up and down the hallway and into other resident rooms. During an observation on 9/11/23 at 10:29 a.m., 6 residents were sitting in the common area, there were no activities occurring on the memory care unit. During an observation on 9/11/23 at 2:37 p.m., 7 residents were sitting in the common area, there were no activities occurring on the memory care unit. During an observation on 9/12/23 at 11:11 a.m., 6 residents were sitting in the common area, there were no activities occurring on the memory care unit. Resident 26 was wandering the memory care unit and in and out of other resident rooms. During an interview with CNA 1 on 9/12/23 at 11:13 a.m., indicated the memory care unit was her normal work area. CNA 1 indicated there were not enough activities on the memory care unit. The CNA's try to do things with the residents, but the memory care unit needed an assigned activity person. CNA 1 indicated the activity department did not take the memory care unit residents outside. 1.) During an observation on 09/07/23 at 10:53 a.m., Resident 5 was sitting by herself at the dining room table, the resident was anxious, crying and screaming there were no activities occurring on the memory care unit. During an observation on 09/07/23 at 12:38 p.m., Resident 5 was laying in bed screaming. There were no activities occurring. During an observation on 9/11/23 10:25 at a.m., Resident 5 was sitting in her geriatric chair talking to herself. There were no activities occurring. Review of the record of Resident 5 on 9/13/23 at 1:50 p.m., indicated the resident's diagnoses included, but were not limited to, schizophrenia, dementia, Parkinson disease, depressive disorder, intellectual disabilities, anxiety and osteoarthritis. The Annual MDS assessment for Resident 5, dated 3/1/23, indicated the resident was severely impaired for daily decision making. The activity assessment for Resident 5, dated 11/15/23, indicated the resident likes looking at magazines, colors, watches sports on TV, music, cooking/baking, sitting outdoors, family events 2.) Review of the record of Resident 26 on 9/13/23 at 1:31 p.m., indicated the resident's diagnoses included, but were not limited to, cerebral infarction, vascular dementia, hypertension and major depressive disorder. The Annual MDS assessment for Resident 26, dated 6/21/23, indicated the resident was severely impaired for daily decision making. It was very important for the resident to listen to music, be around animals, do her favorite activity and go outside. It was somewhat important for the resident to have books, newspapers, magazines, do things in groups of people and attend religious services. 3.) During an observation on 9/06/23 at 2:02 p.m., Resident 32 was sitting in the common area. There were no activities occurring on the memory care unit. During an observation on 9/07/23 at 11:03 a.m., Resident 32 was sitting in the common area with 6 other residents. there were no activities occurring on the memory care unit. Review of the record of Resident 32 on 9/12/23 at 11:40 a.m., indicated the resident's diagnoses included, but were not limited to, dementia with behavioral disturbance, paranoid personality disorder, psychotic disorder with delusions, major depression, cognitive communication deficit. The quarterly activity assessment for Resident 32, dated 1/7/23, indicated the resident preference was dogs, in the past the resident use to play bingo, read and exercised by walking, baked and cooked with family, keep up with the news, shopping/trips, parties and social events. The resident currently would sometimes do crafts, likes watching TV/ listening to music and spending time outdoors. The Significant Change Minimum Data Set (MDS) assessment for Resident 32, dated 8/15/23, indicated the resident was severely cognitively impaired for daily decision making. It was very important to listen to music, be around music, do her favorite activity, go outside to get fresh air and participate in religious services. It was somewhat important to have books, newspaper, magazines, do things in groups of people and keep up with the news. 4.) During an observation on 9/08/23 at 11:00 a.m., Resident 37 was sitting in the common area with 5 other residents. There were no activities occurring on the memory care unit. During an observation on 9/08/23 at 1:26 p.m., Resident 37 was laying in bed awake, there no activities occurring, no radio or no TV was on. During an observation on 9/11/23 at 10:31 a.m., Resident 37 was sitting in the common area with 5 other residents, the resident was hitting self in the face. There were no activities occurring on the memory care unit. Review of the record of Resident 37 on 9/13/23 at 12:45 p.m., indicated the resident's diagnoses included, but were not limited to, cerebrovascular disease, diabetes, anxiety, major depressive disorder and history of falling. The Significant Change MDS assessment for Resident 37, dated 6/5/23, indicated the resident was severely cognitively impaired for daily decision making. It was very important for the resident to have books, newspapers, magazine, music to listen to, be around animals, keep up with the news, do things in groups of people, do her favorite activity and go outside. 5.) During an observation on 9/8/23 at 1:29 p.m., Resident 55 was sitting in the common area holding a baby doll. There were no activities occurring on the memory care unit. Review of the record of Resident 55 on 9/12/23 at 12:35 p.m , indicated the resident's diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, psychotic disorder, diabetes, chronic kidney disease, hypertension, anxiety, chronic obstructive pulmonary disease and major depressive disorder. The Annual MDS assessment for Resident 55, dated 1/23/23, indicated the resident was severely cognitively impaired for daily decision making. It was very important to listen to music, be around pets, do things in groups and attend her favorite activity. It was somewhat important to participate in religious 6.) Review of the record of Resident 71 on 12:29 p.m., indicated the resident's diagnoses included, but were not limited to, psychosis, dementia, schizophrenia, chronic obstructive pulmonary disease, depressive disorder, hypertension, anxiety, insomnia and vitamin D deficiency. The Significant Change MDS assessment for Resident 71, dated 3/29/23, indicated the resident was severely impaired for daily decision making. The plan of care for Resident 71, dated 4/14/21, indicated the resident was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. The interventions included, all staff to converse with resident while providing care, invite the resident to activities, assist and escort activity functions and thank the resident for coming. The activity assessment for Resident 71, dated 9/24/22, indicated the resident liked dogs, cards, bingo, games, reading, exercise of walking, hunting/fishing, TV/music, shopping, going outside, gardening and social events. 7.) During an observation on 9/07/23 at 12:16 p.m., Resident 77 was laying in bed awake. there no activities occurring, no radio or no TV was on. During an interview with Resident 77's family member on 9/08/23 at 11:05 a.m., indicated when they visited Resident 77 they never seen any activities occurring on the memory care unit. Review of the record of Resident 77 on 9/13/23 at 1:20 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, osteoporosis, depressive disorder, anxiety disorder, cognitive communication deficit and chronic kidney disease. The Annual MDS assessment for Resident 77, dated 2/7/23, indicated the resident was severely cognitively impaired for daily decision making. It was very important for the resident to have books, newspapers, magazines, listen to music, do things in groups of people, do her favorite activities and participate in religious activities. It was somewhat important for her to be around animals, keep up with the news and go outside and get fresh air. During an interview with the Activity Director on 9/13/23 at 11:40 a.m., indicated the memory care unit did not have assigned activity staff, the one that was assigned on the memory care unit was no longer employed at the facility. The Activity Director indicated she attempted to spend one hour in the morning on the memory care unit and one hour in the evening. The memory care unit did not have an activity calendar at this time, when there was a activity aide assigned on the memory care unit, they have their own activity calendar. The activity program policy provided by the Director Of Nursing (DON) on 9/13/23 at 11:10 a.m., indicated the facility would provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The activity program was designed to encourage restoration to self care and maintenance of normal activity that is geared to the individual resident's needs, scheduled daily, consist small and large groups which were designed to meet the resident needs and interest of each resident. The activity program would include, but were not limited to, social activity, outdoor activities, activities away from the facility, religious programs, creative activities, intellectual and education activities, exercise and individualized activities. 3.1-33(a) 3.1-33(b)(1) 3.1-33(b)(2) 3.1-33(b)(3) 3.1-33(b)(4) 3.1-33(b)(5) 3.1-33(b)(6) 3.1-33(b)(7) 3.1-33(b)(8)

Based on observation, interview and record review the facility failed to have a care plan meeting and failed to develop a care plan to self administer medications for 2 of 6 residents reviewed for care planning (Resident 10 and Resident 64). Findings include: 1.) During an interview with Resident 10 on 9/06/23 at 1:39 p.m., indicated the facility had never had a care plan meeting to talk about her goals, needs and desires. The resident indicated she had the desire to discharge to an assisted living and other goals she needed the facility to assist her with that she would have talked to the facility about during a care plan meeting. During an interview with Social Services (S.S.) on 9/11/23 at 10:35 a.m., indicated the Social Service Director (S.S.D.) was responsible to ensure care plan meeting were completed. Care plan meetings were suppose to be completed every 3 months or with a change in condition. S.S. was unsure why one has not been completed for Resident 10. Review of the record of Resident 10 on 9/13/23 at 12:08 p.m., indicated the resident's diagnoses included, but were not limited to, psychosis, Alzheimer's disease, vascular dementia, bipolar disorder, chronic pulmonary disease, hypertension, major depressive disorder, arteriosclerotic heart disease, polyarthritis and chronic migraine. The Quarterly Minimum Data Set (MDS) assessment for Resident 10, dated 9/7/23, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. 45291 2. The clinical record for Resident 64 was reviewed on 9/13/2023 at 10:55 a.m. The medical diagnosis included chronic obstructive pulmonary disease. An Annual Minimum Data Set Assessment, dated for 6/29/2023, indicated that Resident 64 was cognitively intact. An interview and observation with Resident 64 on 9/7/2023 at 11:36 a.m. indicated that he had his nasal spray on the bedside table and that he would self-administer the medication. A physician order, dated for 12/10/2020, indicated Resident 64 could keep his nasal spray at beside. A self-administration assessment, dated for 3/20/2023, indicated Resident 64 was safe to self-administer his nasal spray. A care plan for self-administration of medications was added to Resident 64's chart on 9/12/2023. An interview with the Director of Nursing on 9/13/2023 at 2:35 p.m. indicated there was no previous care plan for self-administration of Resident 64's nasal spray. A policy entitled, Resident Self-Administration of Medication, was provided by the Director of Nursing on 9/13/2023 at 11:05 a.m. The policy indicated the care plan will be documented to contain the storage of the medication, responsible party for storage of the medication, documenting the administration of the drugs, and location of where the drugs will be administered. A policy entitled, Plan of Care Overview, was provided by the Director of Nursing on 9/13/2023 at 11:10 a.m. The policy indicated, .The purpose of the policy is to provide guidance to the facility to support the inclusions of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to their daily routine and goals to potentially return to a community setting .Residents/representatives will be informed of their PoC [plan of correction] in the most understandable manner possible .offered opportunities to voice their view .Gestures and actions will be recognized as methods to voice opinions .will have the right to participate in development and implementation of his/her own PoC including but not limited to .right to participate in goal establishment and outcomes . 3.1-35(a) 3.1-35(d)(1)

Based on observation, interview, and record review, the facility failed to ensure smoking materials were kept in a secure location, per facility policy, for 1 of 3 residents reviewed for smoking. (Resident 86) Findings include: 1. An observation and interview was conducted of Resident 86 on 9/7/23 at 3:36 p.m. There was a green lighter located on his bedside table. Resident 86 indicated he holds his own cigarettes and lighter. No facility staff told him he needed to turn his cigarettes and lighter into the facility. The clinical record for Resident 86 was reviewed on 9/11/23 at 2:58 p.m. The diagnoses included, but were not limited to, alcohol use with alcohol-induced persisting dementia, mood disorder, major depressive disorder, opioid abuse, in remission, and post-traumatic stress disorder. An admission minimum data set (MDS) assessment, dated 8/21/23, indicated Resident 86 was cognitively intact. A smoking assessment, dated 8/14/23, indicated Resident 86 utilized cigarettes, had a diagnosis of dementia, and did not have any adaptive equipment marked. The question to indicate if Resident 86 was independent with smoking was left blank. A smoking care plan, dated 8/15/23, indicated Resident 86 smoked cigarettes. The interventions listed to complete a smoking evaluation, encourage resident to express feelings regarding addiction, and obtain and monitor lab and/or diagnostic studies, as ordered. The smoking policy provided by the Director Of Nursing on 9/13/23 at 10:30 a.m., indicated the facility staff would secure smoking materials in a locked area when not in use by the resident for supervised smokers. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program related to mitigation efforts to minimize the potential for ants for 1 of 2 residents reviewed for environment. (Resident 30) Findings include: An observation conducted of Resident 30's room, on 9/6/23 at 3:10 p.m., noted open containers of food with food spillage located on the floor underneath her bedside table. An observation conducted of Resident 30, on 9/7/23 at 10:56 a.m., noted her bending over in attempt to make contact with the floor with her hands. Resident 30 indicated she was trying to kill the ants. There were approximately 8-10 ants crawling on the floor by Resident 30's feet and the lower part of her bedside table. There were open containers of food and drinks with spillage located on the floor. An observation conducted of Resident 30, on 9/8/23 at 9:40 a.m., noted a couple of ants on the floor and on the legs of her bedside table. There were open containers of food and drinks. Resident 30 indicated she woke up one morning with a container of applesauce left open overnight. There were ants crawling in the applesauce and they also lined her cup. She took a drink of the beverage before she noticed the ants were lining her cup. She wasn't sure if she drank any or not. The clinical record for Resident 30 was reviewed on 9/12/23 at 2:55 p.m. A quarterly minimum data set (MDS) assessment, dated 8/30/23, indicated Resident 30 was cognitively intact. An interview conducted with the Maintenance Director (MD), on 9/12/23 at 10:15 a.m., indicated he bought a bug killer from the store to use on site if needed. He contact the pest control company and they are going to treat Resident 30's room for ants. Resident 30's room hasn't been treated prior for ants. With ants it was due to leaving food out somewhere. The ants are back today in Resident 30's room, and he was going to spray her room today. The MD stated, we need to do a better job cleaning the room after meals. An interview conducted with the Executive Director (ED), on 9/12/23 at 12:10 p.m., indicated the pest control company was coming to spray Resident 30's room on 9/12/23. A policy titled Pest Control, dated 9/15/21, was provided by the ED on 9/12/23 at 4:40 p.m. The policy indicated the following, .B. If a problem should develop, the Environmental Services Director will contact [name of pest control company] for an additional visit .1. A problem list is hung at the nurse's station for [name of pest control company] personnel to review before starting so special attention can be given to this area 3.1-19(f)(4)

Based on interview and record review, the facility failed to follow-up with pharmacy recommendations and give a rationale for declining a gradual dose reduction (GDR) for 2 of 5 residents reviewed for unnecessary medications. (Resident 13 and Resident 57) Findings include: 1. The clinical record for Resident 13 was reviewed on 9/11/23 at 3:03 p.m. The diagnoses included, but was not limited to, multiple sclerosis, hemiplegia, and benign prostatic hyperplasia. A pharmacy recommendation, dated 3/10/23, indicated the following, .This resident is currently receiving OXYBUTYNIN ER [extended release] 24 hour medication 5 mg [milligrams] one tablet twice daily .24 hour dose medications should be given once daily .Recommendation .Please review and consider changing to OXYBUTYNIN ER 10 MG ONCE DAILY. The physician response indicated no changes and Urology to follow. Another pharmacy recommendation, dated 5/29/23, indicated the following, .This resident is currently receiving OXYBUTYNIN ER [extended release] 24 hour medication 5 mg [milligrams] one tablet twice daily .24 hour dose medications should be given once daily .Recommendation .Please review and consider changing to OXYBUTYNIN ER 10 MG ONCE DAILY. The physician response indicated no changes and Urology to follow. There was no documentation that the Urologist was contacted for the recommendations on 3/10/23 and 5/29/23. A visit summary, dated 3/21/23, indicated Resident 13 was seen for a kidney stone by a Urologist. The medication list had oxybutynin chloride listed for 5 milligrams twice daily for bladder spasm. There was no indication the medication was extended release. 15909 2. Resident 57's record was reviewed, on 9/11/23, at 10:23 a.m. The record indicated Resident 57 had diagnoses that included, but were not limited to, type 1 diabetes mellitus and inflammation of the esophagus. Current physician's orders included, but were not limited to: Omeprazole oral capsule, delayed release, 20 milligrams (mg) by mouth every morning and at bedtime for digestive health. A pharmacy recommendation, dated 5/29/23, indicated This resident is receiving a proton pump inhibitor (PPI), Omeprazole 20 mg BID (twice a day). Recommendations: Please consider changing to Omeprazole 20 mg once daily. Rationale for Recommendation: Dosing more frequent than once daily significantly increases the risk for adverse effects and medication cost. The risk of fracture was increased in patients who receive high-dose, defined as multiple daily doses. Due to the increased risk of Clostridium difficile infection, the manufacturer recommends use of the lowest dose for the shortest duration appropriate to the indication. The physician/prescriber's response was No change with no rationale for the response to decline the recommendation. During an interview, on 9/12/23 at 1:04 p.m., the Director of Nurses indicated the rationale for 5/29/23 was because he had grade D erosive esophagitis. She indicated she had spoken to the Nurse Practitioner, but the rational isn't documented anywhere. A policy titled Medication Regimen Review, revised 2/28/23, was provided by the Executive Director on 9/12/23 at 4:40 p.m. The policy indicated the following, .Policy .The pharmacist will report any irregularities to the attending physician, the facility's medical director and director of nursing, and these reports must be acted upon in a timely manner that meets the needs of the residents .4. Attending Physician or Non-Physician Practitioner (if state law allows) Responsibilities .b. If there is to be no change in the medication, the attending physician or non-physician practitioner if state law allows must document his/her rationale in the resident's medical record .d. If the attending physician fails or non-physician practitioner if state law allows to address the irregularity in a timely manner the director of nursing will escalate the concern to the medial [sic] director 3.1-25(i)

Based on interview and record review, the facility failed to ensure a plan of care was followed related to a resident's transfer status to where a resident (Resident M) was transferred with one person, without the utilization of a gait belt, and later identified with a subluxation to the right shoulder for 1 of 3 residents reviewed for accidents. The deficient practice was corrected by 6/2/23, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, education related to transfers and gait belt utilization, and audits related to transfers. Findings include: An incident reported to the Indiana Department of Health (IDOH) survey report system, dated 5/30/23, indicated Resident M was assessed by nursing and observed to have had a possible dislocation to the right shoulder. The type of injury noted was a right shoulder subluxation of the humeral head from the glenoid. The follow up to the investigation indicated that the transfer technique for Resident M should be reevaluated by therapy. The clinical record for Resident M was reviewed on 7/6/23 at 3:10 p.m. The diagnoses included, but were not limited to, epilepsy, anxiety disorder, severe intellectual disabilities, and cerebrovascular disease. A Quarterly Minimum Data Set (MDS) assessment, dated 12/29/22, indicated Resident M needed total assistance with 2 staff persons for transfers and bed mobility. A Quarterly MDS assessment, dated 3/31/23, indicated Resident M needed total assistance with 2 staff persons for transfers and bed mobility. An activities of daily living (ADL) care plan, initiated on 12/29/21 and revised on 3/10/22, indicated Resident M utilized a Broda chair for locomotion, dependent on 2 staff for bed mobility, and dependent on 2 staff for transfers utilizing a Hoyer lift that was revised on 6/8/23. A written statement for CNA 12, dated 5/31/23, indicated she transferred Resident M by holding onto the back of her pants and placed her arm underneath Resident M's arm, by herself. An interview conducted with Unit Manager (UM) 2, on 7/6/23 at 3:00 p.m., indicated she did a walkthrough of the unit where Resident M resides before she left for the day, on 5/29/23, and noted that Resident M was okay without concerns. She returned to work on 5/30/23 and noticed there was an x-ray obtained for Resident M that showed a partial dislocation to the right shoulder. Unit Manager 2 reviewed the nursing schedules to see who was working with Resident M on evening shift. There were 2 Certified Nursing Assistants (CNAs) working and CNA 12 was the one working with Resident M. When CNA 12 was interviewed she indicated, to UM 2, that she transferred Resident M without the utilization of a gait belt and by herself. CNA 12 transferred Resident M by taking one arm holding onto the back of Resident M's pants and the other arm went underneath Resident M's right arm and proceeded to transfer Resident M by herself. Resident M was a two staff assist with transfers prior to being evaluated by therapy and determined to need the utilization of a mechanical (Hoyer) lift. An interview conducted with CNA 4, on 7/7/23 at 11:22 a.m., indicated she had worked at the facility for approximately [AGE] years. In the past Resident M had been a 2 person assist with a stand and pivot transfer until recently. Resident M now needed the utilization of a Hoyer lift. A progress note, dated 5/29/23 at 9:00 p.m., indicated the following, .the CNA on duty noticed that Res' [Resident M's] R [right] shoulder has a partial dislocation (subluxation) while changing her clothes An x-ray result, dated 5/30/23, indicated an inferior subluxation of the humeral head from the glenoid. An emergency room (ER) note, dated 5/30/23, indicated the following, .XR [x-ray] of the R [right] shoulder obtained and radiologist reads it as subluxed [sic] but not dislocated .will d/c [discharge] back to her facility A policy titled Routine Resident Care, undated, was provided by Corporate Nurse on 7/7/23 at 9:40 a.m. The policy indicated the following, .Procedure .3. Unlicensed staff .a. Provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse .b. Routine care by a nursing assistant includes but is not limited to the following .iii. Assisting with ambulation, transfer, repositioning A policy titled Mechanical Lifts and Transfer, undated, was provided by Corporate Nurse on 7/7/23 at 9:40 a.m. The policy indicated the following, .Procedure .b. Manual lifting can cause injury to both resident and staff and should be avoided A document titled Using a Gait Belt, approval date of 9/10/22, was provided by Corporate Nurse on 7/7/23 at 9:40 a.m. The document indicated the following, .Using a gait belt while transferring or walking a patient will provide you and the patient increased safety and security. You can control a patient's balance and can keep the patient from falling by using a gait belt. You also decrease the chance of hurting your back. Always check the resident's Kardex to identify the type of transfer device to be used This Federal tag relates to Complaint IN00411601. 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse perpetrated by another resident, resulting in a fall and subsequent hip fracture, requiring a hospitalization , for 1 of 5 residents reviewed for abuse. (Residents S and T) Findings include: The Executive Director (ED) provided a copy of a state reportable incident report on, 2-10-23 at 10:45 a.m., dated 2-7-23, which indicated on 2-7-23 at 3:01 p.m., Resident T entered the room of Resident S while holding a folding chair and attempted to hit [name of Resident S]. [Name of Resident S] grabbed the chair and was pulled out of his seat, resulting in a fall .Staff immediately intervened and [name of Resident T] was placed on 1:1 [one to one] supervision .New order for x-ray for [name of Resident S]. It indicated the ED, Director of Nursing, Medical Doctor, local police department and family were notified and Resident T was sent out to an area geriatric-psychiatric facility for further evaluation and treatment, with Social Services to follow-up with both residents for a minimum of 72 hours and care plans to be revised as needed. In an interview with the ED on 2-10-23 at 9:15 a.m., he indicated both residents resided on the secured advanced dementia unit. He indicated Resident T struck Resident S with a folding chair. From the interviews, it doesn't sound like they were fighting, just near one another and he had picked the chair up and bumped him and [name of Resident S] fell backwards and ended up breaking his hip. The ED indicated Resident S was still hospitalized and expected to return to the facility soon. The ED indicated Resident T was sent out to a geriatric psychiatric facility the same evening and may not be returning to the facility as his family was considering relocating him to another facility. In an interview with CNA 5 on 2-10-23 at 10:33 a.m., she indicated she was working on the afternoon of 2-7-23 on the secured advanced dementia care unit with both Resident S and T, and was familiar with both residents. She recalled hearing loud voices coming from Resident S's room. When she entered the room, she observed Resident T jabbing a folding chair at Resident S, whom she found lying on the floor, adjacent to his bed with his head near the foot of the bed. She indicated Resident S was grabbing at the chair to keep from getting hit and yelling, 'Help me, stop hitting me', while I tried to get the chair away from Resident T. She recalled she was able to get the chair away from Resident T, while she was yelling to get the attention of the other staff on the unit. She recalled CNA 6 was down the hall in the nurse's station. She indicated CNA 6 arrived to assist her within 1-2 minutes. She indicated once she got the chair away from Resident T, she was able to redirect him out of the room. She indicated while Resident S was lying on the floor, it was obvious to her his leg did not look right and she wondered if it was broken, plus he seemed to be in a great deal of pain. She indicated she sent CNA 6 to get help from the other secured memory care unit. QMA 7, arrived soon after to help and check Resident S out. She indicated QMA 7 was able to get his vital signs and between the three of them, were able to get him back to bed. Around this time, LPN 8, the ED and the Social Worker arrived. She indicated initially, they said they weren't going to send him out, but would let the doctor know and probably get orders for in-house x-rays. Resident S was able to tell them he had been sitting in his room in a dining room chair and said he was just sitting there when the other resident came into his room, picked up the folding chair that was folded up and leaning against the wall and started hitting him with it. CNA 5 recalled not long after that, LPN 8 said she had talked to the telehealth physician and had orders to keep him here and get x-rays. CNA 5 indicated Residents S and T were ambulatory. She described Resident S as a resident who occasionally wandered, but tended to stay in his room. CNA 5 described Resident T as having a history of wandering and can be pretty confused at times. She shared, I heard that not long ago, he had given a CNA a black eye. I don't know that he's ever been rough with other residents, but he definitely has been that way with the employees. In an interview with CNA 9 on 2-13-23 at 10:55 a.m., she indicated she was familiar with Resident S and T as she had worked on the secured dementia care unit for over 5 years. She described Resident S as having some cognition issues, but seems higher functioning than some of the advanced dementia care unit residents, but does have some confusion at times and is easily redirectable if having confusion issues. She indicated he did not wander on the unit as he tended to stay in his room a lot. She could not recall any incidents of aggression with this resident. She recalled Resident T had a history of wandering at least daily or more often and this seemed to increase in the afternoons or evenings. He seemed to be searching for his wife or a way to get out of the unit. She indicated he had recently had Covid-19 and seemed to go downhill and seemed weaker after that. CNA 9 Indicated Resident T would be agitated at times and this seemed to correlated to his confusion and wandering. CNA 9 indicated she was not aware of any incidents of aggression aimed at staff or other residents. Normally, he seemed to be easily redirected. This incident was a shock to me, I was very surprised when I heard about it, because I was not aware [name of Resident T] had ever been physically aggressive to anyone. 1. The clinical record of Resident S was reviewed on 2-10-23 at 11:06 a.m. His diagnoses included, but were not limited to unspecified dementia with anxiety and diabetes. He was sent to an area hospital on 2-7-23 for further evaluation and treatment. He was admitted to that hospital on 2-7-23 for a fractured hip. He remained in the hospital as of the exit date of the survey on 2-13-23. 2. The clinical record of Resident T was reviewed on 2-10-23 at 11:32 a.m. His diagnoses included, but were not limited to, unspecified dementia with severe behavioral disturbances, anxiety and depression. Progress notes, dated 1-6-23, related to aggression towards staff, on that date. Upon notification to the psych services Nurse Practitioner, the resident was started on Depakote 125 milligrams three times daily, specific to the behaviors of aggression towards staff. In an interview with the ED on 2-13-23 at 12:32 p.m., he indicated Resident T had been physically aggressive towards one of the aides and had given her a black eye several weeks prior to the interaction with Resident S. Progress notes, dated 2-7-23 at 1:35 a.m., indicated Resident T was found lying on the floor of his room, between his bed and dresser at approximately 12:50 a.m. An assessment at this time revealed no injuries and no complaints of pain. Telehealth medical coverage was notified of the fall with no orders received. A follow up call was made by the telehealth medical coverage approximately one hour later. Notes indicated Resident T had no decline in mental status, but may be weaker than at baseline. Orders received at this time included to have the nurse practitioner to see the resident later in the day and to obtain lab work and a urinalysis. The urinalysis was obtained and the results indicated it was within normal limits. Resident T was care planned for the following behavior and care-related issues: -residing on a secured dementia unit, related to his diagnosis of dementia with behaviors of exit seeking, aggression, wandering and elopement risk. This care plan was developed on 10-18-22. Interventions to accomplish this included, but were not limited to, evaluate need for secured dementia unit; if needed, obtain order for such from physician, with appropriate diagnosis and include any exhibited behaviors, with consent of resident and/or representative; notify the medical provider and representative of any behavioral changes; offer snacks to redirect and redirect when appropriate with diversionary activities. -impaired cognitive function related to dementia with behaviors on 10-18-22 and updated on 1-26-23. Interventions for this issue included, but were not limited to, Observe/document/report to medical provider any changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. -having a behavior problem related to being combative with care, physical aggression, preferring to attempting to assist other residents with needs, such as locomotion or feeding, exit seeking, looking for his spouse, getting into others' personal space, pounding on table with his fists, swinging his cane and being combative or aggressive with staff. This care plan was developed on 10-18-22 and updated on 1-6-23 and 1-26-23. Interventions for this care plan included, but are not limited to approach and speak in a calm manner, consultation with behavioral health professionals, communicate with resident and/or representatives regarding behaviors and treatment, encourage active support from family and/or representatives, encourage participation activities of choice, monitor behavioral episodes and attempts to determine underlying cause and to intervene as necessary to protect the rights and safety of others. An intervention, dated 1-6-23, indicated a medication adjustment was conducted on 1-6-23. This Federal tag relates to Complaint IN00401246. 3.1-27(a)(1)

Based on interview, observations, and record review, the facility failed to provide adequate supervision for Resident 44 while in a Broda (tilt-in-space positioning chair) chair resulting in a fall with a major injury of multiple broken ribs, failed to provide a fall intervention of a colored call light for Resident 48 , failed to provide supervision for Resident 118 and 119 during smoking activities, and failed to update an elopement risk assessment for Resident 520 for 5 out of 6 residents reviewed for accidents and hazards. Findings include: 1. The clinical record for Resident 44 was reviewed on 7/19/22 at 12:04 p.m. Resident 44's diagnoses included, but not limited to, dementia with behavioral disturbance, anxiety disorder, and closed fracture of left femur neck with routine healing. An incident report regarding Resident 44 was received on 7/21/22 at 3:21 p.m. from ED (Executive Director). It indicated, on 7/3/22 at 1:01 p.m. During morning rounds, resident was found in dining room lying of left side. The immediate action taken indicated, a pain assessment was completed, the Medical Doctor, Executive Director, Director of Nursing and family was notified, and a new order to send Resident 44 out to the local emergency department for further evaluation and treatment. The type of injury was left eye laceration, fx [sic, fracture] along the posterior aspect of the right 7th-10th ribs and additional fx [sic] of the right 8th and 9th ribs. The preventive measures taken were to complete pain assessment, notify necessary persons, send the resident out to emergency room and upon return to: complete a skin assessment, have social services follow up for 3 days to ensure no psychosocial distress, physical therapy to evaluate, and the care plan to be reviewed and updated as appropriate. The follow up dated, 7/8/22, indicated, Resident 44 returned to the facility with no new orders from the hospital, to continue on hospice services for pain management and comfort care, social services to follow for 72 hours for possible psychosocial distress and noted the care plan had been updated. A nursing note dated 7/2/2022 at 6:10 a.m. indicated, This writer[sic] notified by CNA[sic, Certified Nursing Assistant) that resident was on the floor in dining room and bleeding. This writer [sic] to dining room and noted resident to be on the floor and next to his wheelchair. Laying slightly on his left side, there was a large amount of blood noted underneath resident's head. This writer assessed and noted it to be coming from a laceration next to residents left eye. Pressure put on wound immediately. No other immediate concerns noted at this time. Resident conts [sic, continues] to talk and interact with staff per his usual. 911 called. 911 transported res [sic, resident] to [sic, name of local hospital] ER[sic, emergency room ] for eval[sic, evaluation] et[sic, and] tx[sic, treatment], they were made aware he was a hospice pt[sic, hospice]. The emergency room notes were received on 7/25/22 at 2:55 p.m. from MDS (minimum data set coordinator) 62 and dated 7/2/22 at 7:01 a.m It indicated, Resident 44 presented to the emergency room after an unwitnessed fall at the facility. The report given to nursing staff was that the patient was found down in the dining room and felt that the patient tried to get up from his chair then fell . The chest/abdomen/pelvis CT (computed tomography) scan revealed fractures along the posterior aspect of the right 7th through 10th ribs and additional lateral fractures of the right 8th and 9th ribs. An interview with CNA 61 was conducted on 7/26/22 at 11:29 a.m. She indicated, she had just come in for her day shift on 7/2/22. The night shift staff were right by the units locked entry door. She stated, one staff person was about to take the trash out and another staff member was checking on the residents at that end of the hallway. She indicated, she walked down the hall and that's when she saw Resident 44 on the floor in the dining room next to his Broda chair and he was bleeding from his head. She asked him if he was ok and he replied oh, my head. She stated the Broda chair was in the tilted back position when he was found on the floor. She indicated, she hadn't heard any loud noises as she walked down the hall. She stated, she worked on the unit where Resident 44 resides quite often and was very familiar with Resident 44. She indicated, when Resident 44's Broda chair was in the reclined position she observed him sitting up in the chair as well as trying to stand up. Resident 44 also had falls with and/or without injury on the following dates: -4/4/22 at 1:37 p.m. while ambulating -5/11/22 at 4:53 p.m. from bed -5/18/22 at 2:15 p.m. from bed -6/3/22 at 9:50 p.m. from bed An interview with SSD (Social Services Director) 9 was conducted on 7/25/22 at 2:29 p.m. ED (Executive Director) was also present during the interview. SSD indicated, Resident 44 was declining in his health. She further indicated, she received an email from Resident 44's hospice provided which indicated Resident 44 was ordered the Broda chair for comfort and multiple falls. An interview with Resident 44's hospice LPN (licensed practical nurse) was conducted on 7/26/22 at 12:00 p.m. She indicated, she had been seeing for Resident 44 about once a week every week and some weeks twice since he has been on hospice service. She indicated, he was usually in his Broda chair either in an upright or reclined position. She indicated, Resident 44 was attempting to get up out of his Broda chair a lot during this visit and any attempt to get out of any chair would be considered dangerous for him. Neither Resident 44's hospice care plan, nor the facility's care plan addressed the need for increased monitoring and/or supervision for a resident with multiple falls. The facility failed to provide adequate supervision to prevent accidents. 2. The clinical record for Resident 48 was reviewed on 7/26/2022 at 11 a.m. The medical diagnoses included, but were not limited to, unspecified dementia and muscle weakness. A Quarterly Minimum Data Set Assessment, dated 5/25/2022, indicated that Resident 48 was cognitively impaired and needed assistance of staff for transferring and walking tasks. Resident had a history of falling during this review period. A fall care plan, last revised on 7/22/2022, indicated for Resident 48 to have a color code call light for a reminder to use a call light. An observation on 7/26/2022 at 10:36 a.m., indicated Resident 48 laying in bed with her call light clipped to the bottom sheet and covered with her top sheet, white blanket, and then a fleece blanket. The call light was a standard white button call light. CNA 30 assisted resident to stand with walker with stand by assistance. An interview with CNA 30 on 7/26/2022 at 10:39 a.m. indicated she wasn't familiar with Resident 48 and she wasn't aware of Resident 48 needing a special call light. She indicated the resident takes care of herself during the day. A policy entitled, Fall Prevention and Management, was provided by the Executive Director on 7/22/2022 at 10:27 a.m. The policy indicated, that .a fall investigation should begin ., the intradisciplinary team should review all information for the falls the next Daily Clinical meetings, and .A progress not of the discussion should be placed in the resident's chart . 3. The clinical record for Resident 118 was reviewed on 7/19/22 at 3:00 p.m. The diagnosis for Resident 118 included, but was not limited to, dementia. The resident was admitted on [DATE]. An Admission MDS (Minimum Data Set) assessment, dated 7/8/22, indicated Resident 118 was cognitively impaired. A smoking assessment dated [DATE] indicated Resident 118 needed supervision for smoking safety. 4. The clinical record for Resident 119 was reviewed on 7/19/22 at 3:15 p.m. The diagnosis for Resident 119 included, but was not limited to, [CONDITION(S)]. The resident was admitted on [DATE]. An Admissions MDS (Minimum Data Set) assessment, dated 7/8/22, indicated Resident 119 was moderately cognitive impaired. A smoking assessment dated [DATE] indicated Resident 118 needed supervision for smoking safety. An observation was made of Resident 118 and Resident 119's room on 7/19/22 at 3:00 p.m. Resident 118's bed was observed with a red lighter lying on the bed. Resident 119 indicated at that time, that her and her roommate (Resident 118) hold their own tobacco products and go outside and smoke. She indicated she was going back outside to smoke. Resident 118 was currently outside smoking. An observation was made of Resident 118 and Resident 119 in the courtyard on 7/19/22 at 3:11 p.m. The residents were observed outside sitting in chairs inside a two sided wall up against a door smoking. There were no staff present in the courtyard supervising the smoking activity. An interview was conducted with the Nurse Consultant on 7/19/22 at 3:19 p.m. She indicated Residents' 118 and 119 needed to be reassessed for smoking. The smoking assessments were conducted on admission. A smoking procedure and policy was provided by the Executive Director on 7/21/22 at 10:01 a.m. It indicated .Definition: .Supervised Smoker: A resident is unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling cigarette ash and extinguishing smoking materials and requires staff supervision when smoking. Policy: It is the policy of this facility to promote resident centered care by providing a safe smoking area for residents/patients that request to smoke and are capable of safe smoking behaviors either independently or with supervision unless facility is a designated non-smoking facility .8. Facility staff will: a. Secure smoking materials in a locked area when not in use by the resident/patient for supervised smokers . 5. The clinical record for Resident 520 was reviewed on 7/20/22 at 11:03 a.m. The Resident's diagnosis included, but was not limited to, Alzheimer's disease. She was admitted to the facility on [DATE]. An Admission Initial Evaluation, dated 7/13/22, indicated she was able to ambulate independently, without the use of a wheelchair or an assistive device. She had not displayed pacing with no course of action or direction, attempts to exit door, or wandering without a sense of purpose. A Behavior Note, dated 7/14/2022 at 5:45 p.m., read . Resident has been pacing the floor all day. Resident has tried getting outside multiple times and setting off alarms. Resident has been oriented to safety issues and to let staff know when she wants to go outside. Resident forgets this almost immediately. A SBAR (Situation, Background, Assessment and Recommendation) Communication Form, dated 7/14/22, indicated she was experiencing behavioral changes, described as pacing and intrusively entering other resident's rooms. On 7/20/22 at 1:00 p.m., Resident 520 was observed standing in the hallway by the community outdoor sitting area exit door. A staff member was walking through the courtyard and entered the door. She spoke briefly with Resident 520 and let her out into the sitting area. There were no staff members present in the sitting area. During an interview on 7/21/22 at 9:06 a.m., LPN (Licensed Practical Nurse) 20 indicated that Resident 520 was fairly new to the facility. She was a wanderer. She would wander around the facility and would get lost on the other unit. The staff would bring her back to her room. She was pleasantly confused. She did go outside to sit at times. During an interview on 7/21/22 at 9:00 a.m., Resident 520 indicated she had been at the facility for about 4 weeks. She was unsure of why she was there. She would go home when her family came to get her. During an interview on 7/22/22 at 11:37 a.m., SSD (Social Service Director) 7 indicated Resident 520 should have been reassessed for elopement risk after her change in behavior and that social services had not been made aware of her continued or intrusive wandering. She did not have a care plan for wandering or elopement risk. On 7/21/22 at 3:22 p.m., the Executive Director provided the Elopement Prevention Policy, last reviewed 4/20/17, which read . 1. Identify resident/[sic] patient who are at risk for elopement. a. All new admissions that are at risk for elopement will have interventions put into place immediately until further assessment is complete .b. Any resident/[sic] patient admitted who is cognitively impaired and can self-ambulate is considered an elopement risk until determined otherwise. c. Any resident/[sic] patient that has a change in condition that places them at risk for elopement . 3.1-45(a)(2)

Based on interview and record review, the facility failed to assess and document in sufficient detail regarding an alteration in skin integrity that was later identified as an unstageable pressure ulcer that resulted in a wound infection, hospitalization , and surgical intervention for 1 of 3 residents reviewed for pressure ulcers. (Resident J) Findings include: The clinical record for Resident J was reviewed on 9/17/20 at 12:18 p.m. The [DIAGNOSES REDACTED]. Resident J was admitted to the facility on [DATE]. An admission observation tool, dated 3/30/20, indicated 3 surgical incisions were present to Resident J's left hip, right hip and right thigh. No other skin alterations were noted upon admission. A physician order, dated 3/31/20, indicated the following, .Continue wound care orders from VA (Veterans Administration) An Admission Minimum Data Set (MDS) assessment, dated 4/6/20, indicated Resident J was at risk for pressure ulcer development and had no skin impairment marked upon admission. Resident J needed extensive assistance with 2 staff person for bed mobility, transfers, and toileting along with extensive assistance with 1 staff person for personal hygiene. A care plan for skin, initiated 3/31/20, indicated the following, .Potential for impaired Skin/tissue integrity .Moderate risk r/t (related to) restricted mobility, HX (history) of falling, [MEDICAL CONDITION] .Interventions/Tasks .Assess (name of Resident J's) skin weekly and PRN (as needed) A care plan for skin alteration, initiated 3/31/20, indicated the following, .Actual Alteration in Skin Integrity (Non-pressure) r/t (related to): Surgical Wound .Right hip .Right thigh .Left hip .Interventions/Tasks .Institute weekly Non-pressure Ulcer condition report .Monitor for signs and symptoms of infection and report to physician to obtain treatment Documents titled weekly skin check were reviewed for Resident J's stay at the facility. The following was noted: 4/6/20 comments of no new areas noted, 4/13/20 comments of no new skin issues, & 4/20/20 comments of no new areas noted. A physician order, dated 4/20/20, indicated the following, .Rt (right) Leg clean with saline treat with santyl (medicine that removes dead tissue from wounds so they can start to heal) and cover with kerlix one time a day for wound care A Nurse Practitioner (NP) Progress Note, dated 4/20/20, indicated Resident J had a right lower leg wound that was healing and present upon admission. There were measurements of 12 x 5 centimeters noted that appeared to be indicative of the documented [MEDICAL CONDITION] to the right lower leg. The note indicated small areas to foot and toes with measurements of 1 centimeter x 2 centimeters and 0.5 centimeters x 0.5 centimeters and documented area inflamed throughout. The NP notes were disordered with comments that were not specific to what the NP was explaining in regards to Resident J's status. The document was signed by NP 4. Another NP note, dated 4/23/20, indicated right lower leg with healing wound that was present upon admission. Santyl was ordered to the area with dressing and refer to wound care. Resident J was dependent on wheelchair and noted with poor strength. A physician order, dated 4/23/20, indicated the following, .Referral to facility wound care DR (doctor) A weekly skin check, dated 4/28/20, indicated a skin concern to Resident J's front right lower leg and outer left ankle. There was no description and/or measurements of the areas noted. There were no skin assessments that described the area(s) documented on Resident J's right lower leg, left outer ankle, and toes by the nurse practitioner and facility staff. There were no treatment orders identified for Resident J's area documented on the left outer ankle by facility staff and Resident J's toes by NP 4. There were no wound care notes per the physician order [REDACTED]. A weekly skin check, dated 5/1/20, indicated skin impairment to the front right lower leg and left outer ankle for Resident J. There were no description and/or measurements noted for the areas of skin impairment. Resident J was discharged on [DATE] to another skilled nursing facility (Facility 10). A Nursing Admission Assessment, dated 5/4/20, was completed by Facility 10. The document indicated Resident J had [MEDICAL CONDITION] to right lower extremity, outside calf. A skin assessment revealed Resident J had a stage 2 pressure ulcer to the right buttock measuring 2 x 1 centimeters, a stage 3 pressure ulcer to the front right lower leg measuring 15 x 5 centimeters, an unstageable pressure ulcer to the right heel measuring 6 x 2 centimeters, an unstageable pressure ulcer to the left heel measuring 7 x 5 centimeters, a stage 3 pressure ulcer to the right outside sole of foot measuring 3 x 3 centimeters, and another stage 3 pressure ulcer to the right outside sold of foot measuring 4.5 x 2.5 centimeters. A progress note, dated 5/7/20, indicated the following, .All wounds assessed and measured this shift .6 wounds in total noted. Bilateral heels have noted closed eschar. Right lateral foot 1 and 2 are eschared (sic) and wet, edges are open. #1 is unstageable and #2 is a stage 3. The right lateral leg is also eschared (sic) and soft, dark bloody drainage noted and attached eschar Hospital records, admitted [DATE], indicated Resident J was admitted to the hospital with [REDACTED]. The wound to the right leg had exposed muscles and tendons that were concerning for an infection. Resident J proceeded to have a right above the knee amputation while at the hospital. An interview conducted with the Regional Director of Clinical Operations (RDCO), on 9/18/20 at 11:30 a.m., indicated when a skin alteration is identified, the nurses are to assess the area and document such in the skin grid document. This occurs for pressure and/or non-pressure skin concerns. The facility has had a recent turnover in Medical Records staff and were unable to locate Resident J's closed chart during the complaint survey. An interview conducted with NP 4, on 9/18/20 at 2:28 p.m., indicated her progress notes are crazy looking and she was not sure why the documentation appeared disordered. Resident J should have had wound care orders from the hospital and been referred to the wound physician. She would have thought the wound physician would have seen Resident J. She recalled Resident J's lower right leg was red and inflamed but could not remember about him having open areas and the timeline related to such. A policy titled Skin Care & Wound Management, dated 7/2016, was provided by the Director of Nursing on 9/18/20 at 2:15 p.m. The policy indicated the following, .A pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction .The interdisciplinary team works with the resident/patient and/or family/responsible party to identify and implement interventions to prevent and and (sic) treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment .Prevention .1. Complete the Braden Scale on admission, weekly x3 (weeks), quarterly and with change of clinical condition .2. Complete an Admission Observation Tool .4. Develop a care plan with individualilzed interventions to address risk factors .6. Evaluate for consistent implementation of interventions and effectiveness .8. Communicate changes to the care giving team .Treatment .1. Select and complete the appropriate form .a. Pressure Ulcer Documentation. Complete for all pressure ulcers .b. Skin Impairment Documentation. Complete for all skin impairment issues that require measurement to indicate if healing is occurring .2. Review and select the appropriate treatment for [REDACTED]. Obtain a physician's orders [REDACTED]. Monitor and document progress .7. Evaluate effectiveness of interventions during the clinical meeting .9. Communicate changes to the caregiving team This Federal tag relates to Complaints IN 574 and IN 035. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to provide treatment and services for an indwelling urinary catheter to prevent the development of a urinary tract infection [MEDICAL CONDITIONS] for 1 of 2 residents reviewed for urinary catheters. (Resident 90) Findings include: The clinical record for Resident 90 was reviewed on 11/20/19 at 1:35 p.m. The [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set), dated 10/9/19, marked the use of an indwelling urinary catheter for Resident 90. A indwelling catheter care plan, revised 10/10/19, indicated the following, .(name of Resident 90) has (Indwelling) Catheter r/t (related to) Spinal cord injury, chronic obstructive [MEDICAL CONDITION] calculus of ureter and neuromuscular dysfunction of the bladder .Interventions/Tasks .Monitor for s/sx (signs and symptoms) of discomfort on urination and frequency .Monitor/document for pain/discomfort due to catheter .Monitor/record/report to MD for s/sx of UTI (urinary tract infection) A progress note, dated 7/21/19 at 12:29 a.m., indicated the following, .Writer went to administer MN (midnight) medication and BT (breathing treatment). Upon entering room, pt (patient) began to have dark yellow greenish emesis coming from mouth and sputum [MEDICAL CONDITION] .No output in cath (catheter) bag Resident 90's temperature was 103.2 at that time. There was no follow up in regards to Resident 90 not having any urine output on 7/21/19 at 12:29 a.m. A progress note, dated 7/21/19 at 8:37 p.m., indicated Resident 90 was sent out to the hospital per family request. Hospital records, dated 7/21/19 at 10:38 p.m., indicated Resident 90 was admitted due to a complicated UTI and [MEDICAL CONDITION] (a life-threatening complication of an infection). Resident 90's urinary catheter was changed with 1,500 milliliters of urine that appeared cloudy. A progress note, dated 7/22/19, indicated Resident 90's indwelling catheter was obstructed (from facility) with [MEDICAL CONDITION]. The indwelling catheter was removed and replaced in the intensive care unit with possible source of suspected urosepsis. A progress note, 7/23/19, indicated the physician mentioned changing Resident 90's indwelling catheter every few weeks could help. Resident 90 promptly defervesced and her leukocytosis (elevated white blood cell count) resolved after Foley (indwelling catheter) change and relief of obstruction. There were no orders related to urinary catheter care, output, and/or changing of the urinary catheter prior to hospitalization on [DATE]. Resident 90 returned to the facility on [DATE]. A physician order, dated 8/14/19, indicated the following, .foley cath (urinary catheter) change q3 (every 3) weeks The MAR (Medication Administration Record) for (MONTH) and (MONTH) of 2019, noted Resident 90's urinary catheter not being signed off as changed on 9/25/19 and 10/16/19. The progress notes of (MONTH) and (MONTH) of 2019, did not note any documentation related to catheter care and/or monitoring of such. A progress note, dated 10/1/19 at 3:59 a.m., indicated the following, .Resident started vomiting at 0100 (1:00 a.m.) [MEDICAL CONDITION] suctioning .Checked on resident at 0242 (2:42 a.m.), temp (temperature was 101.3 (high) .Rechecked resident at 0338 (3:38 a.m.), temp (temperature) 98.6 A progress note, dated 10/24/19 at 10:46 a.m., indicated the following, .Patient sent to (name of nearby hospital) ED (emergency department) for eval (evaluation) and treat d/t (due to) HR (heart rate) 156, Temp. (temperature) 100.3 .Patient has had no urine output on this shift Hospital records noted an admission date of [DATE] at 2:47 p.m. The hospital notes included the following, .was brought to the ER (emergency room ) from ECF (extended care facility) for fever, [MEDICAL CONDITION](elevated heart rate), suspected infection/sepsis .The ECF thought she had some decreased urinary output, but once foley (urinary catheter) was changed in the ER, there was an immediate 1L (liter) urine that came out, which looked dirty/infected Resident 90 was diagnosed with [REDACTED]. There were no orders implemented related to urinary catheter care, output, and/or changing of the urinary catheter prior to hospitalization on [DATE]. An interview conducted with Nurse Practitioner 18, on 11/19/19 at 10:54 a.m., indicated Resident 90 had recurrent urinary tract infections and is very fragile. An interview conducted with the Director of Nursing (DON), on 11/19/19 at 2:53 p.m., indicated there are urinary catheter orders that are implemented for such residents with urinary catheters. A policy titled Catheter Care, revised 5/1/17, was provided by Nurse Consultant 6 on 11/19/19 at 9:40 a.m. The policy indicated the following, .Policy .It is the policy of this facility to provide resident care that meets the psychosocial, physical and emotional needs and concerns of the residents .CAUTI (Catheter Associated Urinary Tract Infections) is the most common adverse event associated with indwelling urinary catheters .Procedure .I. Catheter Care at the bedside is performed to promote cleanliness and dignity and is performed by the nursing staff twice daily for residents who have an indwelling catheter .a. Chronic indwelling catheters should not be changed routinely but replaced only for reasons of obstructions or other malfunction or prior to initiating antimicrobial treatments for symptomatic urinary infections 3.1-41(a)(2)

A. Based on observation, interview and record review the facility failed to safely provide a bed bath to a totally dependent resident resulting in the resident falling out of bed and sustaining bruises and a facial laceration that required 7 sutures, for 1 of 4 residents reviewed for accidents (Resident B). B. Based on observation, interview, and record review, the facility failed to ensure a resident's inhaler was not left at her bedside for 1 of 1 resident reviewed. (Resident 206) Finding include: A. During an observation on 10/9/18 at 11:49 a.m., Resident B had a laceration with sutures above her left eye and had bruising on the entire left side of her face. During an interview with Resident B's family member on 10/10/18 at 10:03 a.m., indicated an CNA was giving the resident a bed bath and turned her too far and the resident face planted on the floor. The family member indicated it hurt the resident bad and she had to have stitches and she had facial bruising. Review of the record of Resident B on 10/11/18 at 2:34 p.m., indicated the resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment for Resident B, dated 8/27/18, indicated the resident was severely cognitively impaired for daily decision making. The resident was totally dependent of two people for bed mobility. The progress note for Resident B, dated 10/2/18 at 3:30 p.m., indicated upon entering the resident's room it was noted the resident was lying on the floor face down, the resident's bed was in a semi high position. The resident had been receiving a bed bath from a CNA and when the resident was turned toward the window the resident fell out of the bed. There was a large amount of blood on the floor. The resident had blood coming form her forehead and nose. The resident's left orbital area was very swollen. Emergency line was called to transport the resident to the hospital. The resident was not moved due to the inability to assess severity of injuries. Pressure was applied to the resident's forehead without moving her head. The emergency personal arrived and applied a neck brace to the resident for transport to the hospital. The local hospital emergency room report for Resident B, dated 10/2/18 at 4:15 p.m., indicated the resident rolled off the far side of the bed while being given a bath. The resident had a large laceration over her left eye. The resident was ordered a brain scan, chest x-ray, cervical spine scan, x-ray of her pelvis and shoulder STAT (immediately). The resident's laceration wound was closed with 7 sutures. The progress note for Resident B, dated 10/2/18 at 8:15 p.m., indicated the resident returned from the hospital with laceration above the left eye with 7 sutures, measuring 3.5 centimeters by 0.3 centimeters and an abrasion across the bridge of her nose. The fall investigation for Resident B (no date) indicated the resident fell out of bed on 10/2/18 at 3:30 p.m., and sustained head trauma, laceration above the left eye, left eye socket swelling and nose displaced. The resident was being given a bed bath by a CNA and fell from the other side of the bed and landed face down. The resident was sent to the emergency room for evaluation and treatment. The plan of care for Resident B, dated 2/9/18, indicated the resident was at risk for falls related to her [DIAGNOSES REDACTED]. There were no updated interventions since 9/28/17 until 10/15/18 of a bariatric bed. During an observation on 10/12/18 at 10:13 a.m., CNA 2 and CNA 3 provided Resident B a partial bed bath and incontinence care. CNA 2 and CNA 3 indicated the resident was totally dependent of two staff for bathing and turning in the bed, both CNA's indicated the resident was totally dependent of two staff with all of her care. During the observation Resident B did not assist in turning in bed or with the partial bed bath. During an interview with the Director Of Nursing (DON) on 10/15/18 at 1:15 p.m., indicated the root cause of Resident B's fall on 10/2/18 was there were no side rails on the bed and the bed was too small for the resident. The intervention implemented after the fall was a bariatric bed implemented. During an interview with CNA 4 on 10/15/18 at 2:21 p.m., indicated she was giving Resident B a bed bath on 10/2/18 by herself when the resident fell out of the bed. CNA 4 indicated the resident was on an air mattress without rails and when she went to turn the resident away from her to wash her other side she fell off the bed. During an interview with the Staff Development Coordinator on 10/16/18 at 2:55 p.m., indicated Resident B's bariatric bed was ordered on [DATE] and was put in place for the resident on 10/10/18. This indicated no interventions were implemented after the resident's fall on 10/2/18 for 8 days after the resident fell out of the bed. During an interview with the Regional Director Of Clinical Operations on 10/12/18 at 1:15 p.m., indicated the facility did not have a fall policy for what the protocol was after a resident fell . B. On 10/10/18 at 10:18 a.m., Resident 206 was observed to have a Breo Ellipta 100/25 - 100 [MEDICATION NAME] furoate (corticosteriod for an anti-[MEDICAL CONDITION] medication) and 25 micrograms vilanterol ([MEDICATION NAME] which relaxes muscles in the airways to improve breathing) inhaler on her overbed table. Resident 206 indicated the inhaler isn't left there usually, but the nurse left it there today. On 10/10/18 at 10:24 a.m., Qualified Medication Aid (QMA) 19 was passing medications on Resident 206's hall and said the inhaler should not have been at the bedside. QMA 19 went into the resident's room and removed the inhaler. Resident 206's record was reviewed on 10/11/18 at 3:03 p.m. and indicated [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment, dated 10/4/18, indicated Resident 206 was cognitively intact, does not walk, and has impairment on one side (right side) of upper and lower extremity in functional limitation in range of motion. Current physician's orders indicated an order for [REDACTED]. No medication self administration documentation was found in the resident's record. On 10/17/18 at 1:38 p.m., the Director of Nursing indicated there are no residents on that unit who self administer their medications. A policy and procedure for Medication Administration was provided by the Director of Nursing, on 10/15/18 at 11:09 a.m. The policy indicated, but was not limited to, Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care .cc. Do not leave medication at bedside 3.1-45(a)

Based on observation, interview and record review, the facility failed to monitor frequency of bowel movements (BM), provide interventions for constipation, notify the physician of a resident not having a bowel movement for 7 days, failed to administer PRN (as needed) medication for constipation resulting in 1 resident being hospitalized for [REDACTED].#182, Resident #169 and Resident #167). Findings include: 1.) During observation on 7/11/16 at 1:48 p.m., Resident #182 was laying in bed on his back with his eyes open, the resident did not respond verbally. During an interview with Resident #182's family member #1 on 7/12/16 at 11:41 a.m., indicated the resident had recently been discharged to the hospital. The family member indicated the facility had not been communicating about the resident's lack of bowel movements and the resident ended up with a fecal impaction and was throwing up bowel movement. The family member indicated the facility was not on top of the situation sufficiently. Review of the record of Resident #182 on 7/13/16, the resident's [DIAGNOSES REDACTED]. The Admission Minimum Data (MDS) assessment for Resident #182, dated 4/25/16, indicated the resident had no speech, was unable to make himself understood rarely/never and was severely impaired for daily decision making. The resident required extensive assistance of two people for bed mobility, transfers, toilet use and personal hygiene. The resident was unable to ambulate. The resident was always incontinent of his bowels and bladder. The resident's nutritional approach was a feeding tube (device inserted into the stomach to supply nutrition). The physician order [REDACTED]. The bowel movement record for Resident #182, dated May 2016, indicated the resident did not have a bowel movement on 5/4/16, 5/5/16 or 5/6/15. The May 2016 Medication Administration Record [REDACTED]. The physician order [REDACTED].#182 indicated the resident did not have a bowel movement on 6/19/16 and 6/20/16. The MAR indicated [REDACTED]. The bowel movement record dated from 6/28/16 to 7/4/16 indicated the resident not have a bowel movement, this indicated the resident went 7 days without a bowel movement. The MAR for Resident #182 indicated the resident did not receive the [MEDICATION NAME] suppository 10 mg as ordered by the physician on 6/28/16, 6/29/16, 6/30/16, 7/1/16, 7/2/16, 7/3/16 or 7/4/16. The progress note for Resident #182, dated 7/4/16 at 1:19 p.m., indicated the resident had vomited. The vomit had the appearance of tube feeding. The resident's tube feeding was put on hold and the resident will be monitored. The progress note was electronically signed by LPN #6. The progress note for Resident #182, dated 7/4/16 at 6:17 p.m., indicated the resident vomited again. The resident was placed on his left side, resident's lungs were clear. Suctioning equipment was hooked up at the bedside and the resident's mouth was suctioned, with nothing suctioned out at this time. The resident was being sent to the emergency room at this time per the Nurse Practitioner. The facility transfer to the hospital form for Resident #182, dated 7/4/16 at 6:32 p.m., indicated the resident was sent to the hospital for vomiting stool. The progress note for Resident #182, dated 7/4/16 at 7:00 p.m., indicated the local ambulance picked up the resident and transported him to the emergency room (ER). The Nurse Practitioner for Resident #182, dated 7/4/16 at 9:16 p.m., indicated she had been asked to see the resident for nausea and vomiting. The resident had problems with ileus (inability of the bowels to contract normally and move waste out of the body) in the past. I am unsure when his last BM was. The resident was not tolerating his tube feeding and his abdomen was firm. The resident's bowel sounds were hypoactive. The local ER note for Resident #182, dated 7/4/16 at 7:26 p.m., indicated the resident presented to the ER secondary to black tarry emesis. The resident had a history of [REDACTED]. The resident had [DEVICE] and does not take anything by mouth. The resident's family member #2 reported that he had a low grade fever for the past several days and had not been acting like himself. Today he began vomiting, and his emesis was black in color and smelled like stool. The family member reported the last time this occurred, he was found to be severely impacted with stool and had spent four days in the hospital getting enema and disimpactions. The abdomen/pelvis CT (x-ray computed tomography) scan for Resident #182, dated 7/4/17 12:00 a.m., indicated there were Marked [MEDICATION NAME] distention throughout the colon and moderate small bowel [MEDICATION NAME] distention. Large fecal impaction in the rectum. The discussion of ED (emergency department) course for Resident #182, dated 7/4/16, indicated [AGE] year old male who presented to the emergency department from the facility secondary to emesis. At the time of examination, the patient was found to be quite thin, dehydrated, and chronically ill-appearing. His abdomen was firm and distended and diffusely tender to palpation. The patient did have a couple episodes of dark brown emesis which was feculent smelling. The [DEVICE] was then aspirated with a large syringe, at which time a plug in the tubing dislodged and the [DEVICE] began draining dark brown stomach contents. Approximately 220 milliliters (ML) of fluid was suctioned from the patients stomach. I did attempt to manually disimpact the patient and was able to remove a moderate amount of clay consistency brown stool. The case was discussed with another physician and the resident was admitted for further treatment. The hospital discharge summary for Resident #182, dated 7/6/16, indicated the discharge [DIAGNOSES REDACTED]. The resident was admitted for fecal impaction and given mag [MEDICATION NAME] through PEG tube once vomiting controlled after gastric decompression in ER. Bowel function returned and patient stooled multiple times. Will need a more aggressive bowel regimen or reduced opiod use. Will start movantic to prevent further constipation. OK if patient has loose BM's- medication should not be stopped for this reason. Frequent changing and turning will be needed to prevent skin breakdown. Interview with the Assistant Director Of Nursing Services (ADNS) on 7/15/16 at 10:40 a.m., indicated she was unable to find documentation that Resident #182 received any PRN medication for constipation from 6/28/16 to 7/4/16. The ADNS indicated the facility does not have a bowel movement protocol. The ADNS indicated the CNA's and nursing staff chart BM's and report to the nurse if they have any concern. The ADNS indicated the physician would be notified if the resident had signs and symptoms of constipation. Interview with the Director Of Nursing Services (DNS) on 7/18/16 at 1:43 p.m., indicated Resident #182 did not receive any PRN's for constipation prior to his hospitalization on [DATE]. The DNS indicated the facility did not have an elimination policy or an elimination assessment policy. The DNS indicated in the daily report the dash board will say a resident had went without a BM after three days. The DNS indicated she was unsure what happened with Resident #182 during the time between 6/28/16 and 7/4/16 when the resident did not have bowel movement, the DNS indicated it was notification. When queried how did the facility assess what a normal bowel movement function would be for residents, the DNS indicated they ask the resident or their family. The DNS indicated the facility was aware that Resident #182 had a history of [REDACTED]. Interview with Resident #182 family member #2 on 7/18/16 at 3:06 p.m., indicated on 7/4/16 the resident stomach was firm/distended and the resident was vomiting. Family member #2 indicated the resident had been hospitalized prior to coming to the facility for constipation and the facility had been made aware of this. Family member #2 indicated on 7/4/16 they had requested LPN #6 to check and see when the resident had their last bowel movement. Family member #2 indicated then the facility called the NP and sent him to the hospital. Family member #2 indicated if the resident had not had a bowel movement by the third day, the facility needed to be doing something. Interview with LPN #6 on 7/18/16 at 4:08 p.m., indicated he was the nurse caring for Resident #182 on 7/4/16 when the resident was sent to the hospital. LPN #6 indicated a CNA had notified him that the resident had vomited. LPN #6 indicated the vomit appeared to look like tube feeding, so he raised the resident's head of the bed higher. LPN #6 indicated he had asked the resident if his stomach felt full and the resident shook his head yes. LPN #6 indicated it was not reported to him that the resident had not had a bowel movement for 6 days. LPN #6 indicated he would normally notify the physician if a resident had not had a bowel movement after 3 days. LPN #6 indicated normally residents would have a PRN medication for constipation and they were effective. 2. Resident #169's record was reviewed on 7/14/16 at 3:47 p.m. Her [DIAGNOSES REDACTED]. Resident #169's quarterly MDS assessment dated [DATE], indicated she was understood and had the ability to understand others. She was moderately impaired in her cognitive daily decision making skills. She required extensive assistance of 1 person for bed mobility, transfer, dressing, and toileting. She was continent of bowel. Resident #169's bowel movements documentation for May 2016 indicated she had not had a bowel movement May 13th, 14th, 15, 16th, and 17th. She had a hard constipated stool on May 18th, She had no bowel movement on May 19th. She had a hard constipated stool on May 20th. Resident #169's bowel movements documented for June 2016 indicated she had not had a bowel movement on June 11th, 12th, 13th, 14th, 15th, 16th, and 17th. She had a hard constipated stool on June 18th. She had no bowel movement on June 19th and 20th. Resident #169's bowel movements documented for July 2016 indicated she had not had a bowel movement on July 4th, 5th, 6th, 7th, 8th, 9th, and 10th. An interview with Unit Manager #13 on 7/18/16 at 4:31 p.m., indicated Resident #169 took Immodium daily. Resident #169 had not received any as needed medication to promote bowel stimulation because she had not had an order for [REDACTED]. 3. Resident #167's record was reviewed on 7/13/16 at 1:17 p.m. Physician's recapitulation orders, dated July 2016, indicated Resident #167 had [DIAGNOSES REDACTED]. A physician's telephone order, dated 4/13/16, indicated an order for [REDACTED]. The Medication Administration Records (MARs) indicated the [MEDICATION NAME] had been given every day from April 14, 2016 through July 14, 2016. A Quarterly Minimum Data Set assessment, dated 6/1/16, indicated Resident #167 had severe impairment in cognitive skills for daily decision making, required stand by assist with walking, and received a diuretic 7 times in the last 7 days. A Patient Nursing Evaluation, dated 6/17/16, indicated Resident #167 did not have Diuretic Use checked, and she had received [MEDICATION NAME] 20 milligrams by mouth every day in June, 2016. On 7/18/16 at 6:26 p.m., the DNS provided their Patient Assessment policy and procedure. The policy included, but was not limited to: A comprehensive, accurate, standardized, reproducible assessment of each patient's functional capacity and needs is conducted using the Resident Assessment Instrument (RAI), which directs the care of the patient based on his or her individual needs. Rationale: Patient data is collected and/or assessment forms and/or in an electronic medical record (e.g., Point Click Care (PCC)) to individualize and direct patient care .2. Assessment o the patient's needs is not limited to the content of the RAI. 3.1-37(a)

Based on interview and record review, the facility failed to ensure sexual abuse by a staff member did not occur towards 3 of 6 residents reviewed for sexual abuse resulting in mental anguish. (Resident #B, #C and #D) The Immediate Jeopardy began on the evening of 9-18-15 when Resident #B indicated she had been touched inappropriately in the chest area and CNA #2 exposed his penis to her. The Executive Director, the Director of Nursing and District Director of Clinical Operations were notified of the Immediate Jeopardy on 10-6-15 at 1:45 p.m. The Immediate Jeopardy was removed on 9-21-15 at 4:00 p.m., when CNA #2 was terminated from the facility and told never to return to the facility, 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: On 9-19-15 at 10:48 p.m., the facility emailed an initial report regarding an allegation of sexual abuse of a female resident by CNA #2 to the Indiana State Department of Health (ISDH), Long Term Care Division. It indicated on the evening of 9-19-15 at approximately 7:15 p.m., Resident #B indicated to CNA #1 that on 9-17-15 or 9-18-15, CNA #2, a male employee, had asked her if she was ready. Resident #B indicated she assumed he was referring to getting ready for bed. She continued, that CNA #2 then inappropriately touched her breasts while getting her undressed and then proceeded to expose his penis to her. She indicated CNA #2 then asked her to touch his penis. She indicated she yelled, No, at least twice. The report indicated CNA #2 then briefly laid on top of her, but no sexual intercourse took place. In a written timeline provided by the Executive Director (ED) on 10-2-15 at 9:20 a.m., and an updated timeline provided by the Corporate Nurse on 10-6-15 at 4:59 p.m., the timeline indicated the following information: -9-17-15 at 1:00 p.m. CNA #2 submitted a two week notification of resignation as a full time employee as he had secured a position elsewhere. He requested to become a PRN (as needed) staff member. CNA #2 worked on the long term care portion of the facility at that time. It indicated he was scheduled to work on 9- 17-15 and 9-18-15, then return to work until 9-21-15. -9-19-15 at 7:15 p.m. CNA #1 informed LPN #3 that Resident #B had made an abuse allegation. LPN #3 interviewed Resident #B in regards to the sexual abuse involving CNA #2. -9-19-15 at 7:35 p.m. LPN #3 notified the ED, Director of Nursing Services (DNS), the attending physician and the resident's family of the abuse allegation. -9-19-15 at 8:00 p.m. ED interviewed LPN #3 and CNA #1. -9-19-15 at 10:48 p.m. ED submitted abuse allegation report to ISDH. -9-20-15 (all day) Investigation conducted which included interviews with all alert and oriented female residents on the long term care unit regarding abuse. For non-alert and oriented females on the long term care unit, head to toe skin assessments were conducted. All residents on the transitional care unit were interviewed regarding abuse, as all were alert and oriented. Findings indicated another female resident, Resident #C, expressed a similar experience in which a male staff member had exposed his penis to her. Resident #B was able to identify the staff member by name. Resident #C was able to describe the male staff member. The investigation Indicated each resident had been interviewed multiple times with their interviews being consistent in details. Notifications were attempted to the family of Resident #C. The facility's administrative team met to review their investigational results and substantiated the sexual abuse allegation. CNA #2 was notified of suspension, pending results of the facility's investigation. Arrangements were made for CNA #2 to come into the facility the following day for an interview. Local police department was notified of the abuse investigation. -9-21-15 (all day) Staff interviews were conducted by management staff regarding the incident and included staff education regarding abuse policies. Resident #D was interviewed and identified as having a similar incident as Resident #B and #C. Interview with Resident #D indicated he and the alleged suspect had touched each other's penis, with nothing beyond that. The Medical Director, and attending physician for each of the three residents, was notified of the incidents. The POA/guardians of Resident #C and #D were notified of the allegations. Interviews were conducted with all alert and oriented male residents on the long term care unit regarding abuse. For non-alert and oriented males on the long term care unit, head to toe skin assessments were conducted. Interview conducted with CNA #2 by ED, DNS and two local police department's detectives. CNA #2 did not confess to any of the sexual abuse allegations. CNA #2 was notified his employment was immediately terminated and was not to enter onto facility property, not to communicate with any staff or residents. The ED filed Report of Reasonable Suspicion of a Crime Against a Resident. 9-22-15 (all day) Continued staff interviews were conducted by management staff regarding the incident and included staff education regarding abuse policies. Continued communication with families of the involved residents and with the local police department's detective. Counseling services met with each of the residents involved. ED filed a Consumer Complaint with the State Attorney General's office regarding incident and licensure of CNA #2. Follow up report emailed to ISDH. The Performance Improvement Committee met to review allegations of abuse. Care plans for the 3 affected residents were updated by 9-24-15 to reflect the potential for psychosocial distress. Education regarding abuse/abuse prohibition and reporting was provided to alert and oriented residents during a Resident's Council Meeting on 10-7-15. Additional written education on the same topic was distributed to all alert and oriented residents, as well as the family members of all residents. A. In an interview with Resident #B on 10-1-15 at 2:15 p.m., she indicated she had received care from CNA #2 previously with no concerns. She indicated the event of several weeks ago, was the first time any staff member had been inappropriate with her. She indicated the male staff member asked her if she was ready and she assumed he was referring to getting ready for bed for the evening. She indicated he inappropriately touched my chest (breasts). She indicated he also exposed his penis to her. In a phone interview with LPN #3 on 10-2-15 at 2:38 p.m., she indicated on the evening in question, CNA #1 told her she needed to talk with Resident #B. She indicated CNA #2 had pulled it out and then she clarified (meant) penis. LPN #3 indicated the resident told me the whole story, including (CNA #2) laying on top of her, but said they didn't have sex. LPN #3 indicated Resident #B specifically named (name of CNA #2). She indicated the resident was upset, but not distraught. Review of Resident #B's clinical record on 10-1-15 at 5:35 p.m., indicated her most recent quarterly Minimum Data Set assessment, dated 9-1-15, indicated she was cognitively intact. A Social Services note, dated 9-1-15, indicated she was cognitively intact, had normal vision and was able to understand and to be understood. B. In an interview with Resident #C on 10-1-15 at 2:27 p.m., she indicated an unknown male had exposed his penis to her over one month ago. She indicated she was unsure who the young, white male was or the exact date or time it occurred. She indicated she yelled, No, and he left her room and did not return. In review of the ISDH Reportable incident, submitted by the facility on 9-22-15, it indicated Resident #C had identified the male as CNA #2. It indicated CNA #2 had exposed himself by pulling out his penis and asking the Resident to touch it. The Resident states she told the CNA, 'No,' and that he left her room. Resident states that there was only one incident. Review of Resident #C's clinical record on 10-1-15 at 5:55 p.m., indicated her most recent Minimum Data Set assessment, dated 7-21-15, indicated she was cognitively intact. C. In an interview with Resident #D on 10-1-15 at 2:42 p.m., he indicated he had previously had a mutual relationship with CNA #2. He indicated CNA #2 was the one who initiated things, referring to the relationship. He indicated they only saw each other during CNA #2's work hours and were involved for a few weeks. He indicated CNA #2 was no longer employed at the facility. In review of the ISDH Reportable incident, submitted by the facility on 9-22-15, it indicated Resident #D had identified CNA #2 as the person he had a relationship with. He indicated this relationship included incidents in which CNA #2 had pulled his penis out and asked the resident to touch it, which he did, as well as CNA #2 touching Resident #D's penis. The report indicated Resident #D indicated there were multiple incidents, he could not quantify or be specific with dates. The Resident claims that some of the incidents included the Resident and CNA exposing themselves, both individuals having erections and ejaculations. Review of Resident #D's clinical record on 10-1-15 at 6:10 p.m., indicated his most recent Minimum Data Set assessment, dated 8-17-15, indicated he was moderately cognitively impaired. Review of CNA #2's employee file indicated he had been employed at the facility less than 2 months at the time of the abuse allegation. It indicated his orientation period included education on Resident's Rights and Abuse Prevention. Review of the Job Description for Certified Nursing Assistant, indicated CNA #2 signed this document during his orientation period. The job description indicated, Conducts job responsibilities in accordance with the standards set out in the Company's Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards. The ISDH Nurse Aide Curriculum, revised 3-21-14, indicated, Any sexual relationship with a resident is considered to be abuse. On 10-1-15 at 3:00 p.m., the ED provided a copy of a policy entitled, Abuse. This policy had a Release Date, of 7-28-14, and was identified as the current policy utilized by the facility. This policy indicated, Verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, neglect, and misappropriation of patient property is strictly prohibited. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown injuries of source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey agency and certification agency). Individuals are not hired when a history of abuse is known. Retribution against patients, staff or visitors who file reports is strictly prohibited. The Immediate Jeopardy that began on the evening of 9-18-15 was removed on 9-21-15 at 4:00 p.m., when CNA #2 was terminated from the facility and told never to return to the facility, completed their investigation, notified ISDH Long Term Care Division, notified the local police department, State Attorney General's office, completed staff inservice education and resident/family education on abuse/abuse prohibition. Post inservice interviews were conducted with staff and residents to verify understanding of what to do in the event of abuse. The 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 as the facility continued to provide re-education and reassurance to residents and families regarding their right to be free of abuse, knowledge of all types of abuse, procedures for reporting and protection against retaliation. This Federal tag relates to complaint IN 869. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to provide interventions to prevent 1 resident from acquiring an unstageable pressure ulcer on the heel for 1 of 5 residents reviewed for pressure ulcers in a sample of 14. (Resident #N) Findings include: During observation on 8/10/11 at 2:55 p.m., LPN #2 removed Resident #N's sock on his right foot. An oval shaped area black and approximately 3 cm (centimeters) x 4 cm area was observed on Resident #N's outer heel. The record of Resident #N was reviewed on 8/10/11 at 10:00 a.m. Resident #N's physician's orders [REDACTED]." Resident #N's MDS (Minimum Data Set), assessment dated [DATE], indicated the following: - makes self understood, usually understood - ability to understand, understands - bed mobility, total dependence with one person physical assist - transfer, total dependence with one person physical assist - walk in room, total dependence, two person physical assist - risk of pressure ulcers, yes - unhealed pressure ulcers, none Resident #N's care plan dated 8/3/11, indicated "problem, pressure area, goals, area will show signs and symptoms of improvement and intervention, skin prep per order, elevated heels off bed and monitor area for any changes." During interview with Unit Manager #1 on 8/10/11 at 11:15 a.m. Unit Manager #1 indicated Resident #N did not have a care plan for pressure areas until 8/3/11. Resident #N's "Pressure Ulcer Risk Assessment Tool" dated, 7/19/11, indicated a total score of 16 indicating Resident #N was at low risk for pressure ulcers. Resident #N's "Wound Progress Note/Reassessment", dated 8/5/11, indicated wound location, right heel, measurement 2.5 cm x 3.8 cm, type, pressure, stage unstageable (full thickness tissue loss in which the base of the ulcer is covered by eschar (tan, brown or black) in the wound bed). During interview with LPN #2 on 8/10/11 at 3:00 p.m. LPN #2 indicated Resident #N did not ambulate and residents that are in bed a lot and do not ambulate should have their heels floated off of the bed. LPN #2 also indicated if a resident heels were to be floated it should be on CNAs assignment sheet but the CNA assignment sheets were shredded after their use of that day so she did not know if the information to float Resident #N's feet was on the CNA assignment sheets before the area on his heel was discovered. The clinical record of Resident #N lacked evidence of Resident #N's heels being floated prior to the area on his heel found on August 3, 2011. During interview with Resident #N's family member on 8/10/11 at 7:00 p.m., they indicated during several visits with Resident #N they observed Resident #N in bed with his heels flat on the bed. A document provided by the Assistant Director of Nursing on 8/10/11 at 12:00 p.m., titled "Pressure Ulcer Prevention" dated 4/28/09, and indicated by the Assist Director of Nursing as the facility's current policy for pressure ulcers included but were limited to, use positioning techniques to keep the resident's heels off the bed and evaluate and individualize use of various devices to reduce or relieve pressure and/or reduce skin injuries that may result in pressure ulcers (i.e. heel protectors, and heel splints). This federal tag relates to complaint IN 524. 3.1-40(a)(1)