Every finding on record at Harcourt Terrace Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of dementia was provided effective person-centered dementia care and was not relocated to locked memory care unit without a documented reason which resulted in a resident-to-resident altercation for 2 of 2 residents reviewed for dementia care. (Resident H and G) This deficient practice resulted in an altercation between Resident H and G. Resident G received an intertrochanteric femur fracture (a broken hip around the upper thigh bone) which required surgical intervention.Findings include:An anonymous email, dated 5/3/25 at 4:52 p.m., indicated a resident-to-resident altercation occurred in which Resident G was pushed down by Resident H. Resident G complained of pain and required surgery. Facility management were not taking reports seriously, were hiding and sweeping concerns under the rug and were lying to families.A facility reported incident (FRI), dated 4/27/26 at 5:30 p.m., indicated Resident G walked by Resident H's room when the two residents made contact. Resident G fell to the floor. Resident G was sent to the emergency room for further evaluation due to right sided hip and leg pain. Resident G returned to the facility with a diagnosis of intertrochanteric femur fracture. After the facility investigation of the incident was completed, the fall was not witnessed. The root cause was determined to be Resident H was showing difficulty transitioning to a new environment (locked memory care unit). The report indicated both residents' families were aware of the incident.A facility document, dated 4/27/26, indicated the facility had failed to supervise a resident from intrusively wandering (Resident G), which had resulted in an injury after a resident-to-resident altercation.1. The clinical record for Resident H was reviewed on 5/19/26 at 9:50 a.m. The diagnoses included, but were not limited to, severe dementia with behavior disturbances, anxiety disorder, and psychotic disorder with delusions.Resident H was admitted to the facility on [DATE].The facility census history for Resident H indicated, on 4/22/26, an intra-facility transfer occurred in which the resident was moved to the locked memory care unit. On 4/28/26, a second intra-facility transfer occurred in which the resident was moved out of the locked memory care unit and back to the skilled unit. Resident H had previously remained in the same room since 2020.A care plan, initiated on 10/1/20 and dated as last reviewed 5/17/26, indicated Resident H had episodes of verbal and physical aggression towards staff and peers. Resident H was very particular about sticking to his own routine. Interventions included, but were not limited to, staff should approach Resident H in a calm manner, staff should not attempt to encourage the resident to make choices that he specified he did not want, such as food items, activity, or a change in his routine, and to allow Resident H to sit alone per the resident's preference. These interventions had been in place since May of 2023.A care plan, initiated on 10/26/20 and dated as last reviewed 5/17/26, indicated Resident H had experienced episodes of increased agitation due to not wanting to change his clothing or a change in his routine. Interventions included, but were not limited to, allow the resident to express his feelings and concerns and to approach the resident later. There were no new interventions dated after 10/26/20.A care plan, initiated 7/16/24 and dated as last reviewed 5/17/26, indicated Resident H could become aggressive when his trash was not emptied and his room was not cleaned a certain way. Interventions included, but were not limited to, empty resident's trash as needed and to encourage the resident to let staff know if his trash was full and needed emptied. There were no new interventions dated after 7/16/24.A care plan, initiated 7/17/24 and dated as last reviewed 5/17/26, indicated Resident H had episodes of agitation with staff during care, and at times could be very aggressive. Interventions included, but were not limited to, alternate staff as needed and to provide personal space as needed. There were no new interventions dated after 7/17/24.An annual Brief Interview for Mental Status (BIMS) assessment, dated 3/29/26, indicated Resident H had severely impaired cognition.A psychiatric progress note, dated 4/14/26, indicated per staff report, Resident H had remained at baseline. Staff had not reported any new or worsening behaviors.Resident H's activity participation log, from 4/1/26 to 4/21/26, indicated Resident H had attended twenty-two (22) out of twenty-five (25) activities.A physician's order, initiated on 4/21/26 and discontinued on 4/30/26, indicated Resident H could reside on a secure unit.A physician's order, initiated on 4/22/26 and discontinued on 5/5/26, indicated Resident H could have a stop sign placed on his door.A behavior event document, dated 4/27/26 at 4:30 p.m., indicated Resident H was involved in a resident-to-resident altercation in which Resident H had pushed a wandering resident to keep the resident from entering his room. The psychosocial change/stressor identified for the behavior was Resident H's new admission to the memory care unit. The intervention was to move Resident H back to his previous unit (skilled unit).A psychiatric progress note, dated 4/28/26, indicated according to the staff report, Resident H had recently moved to the memory care unit. Staff had reported Resident H appeared to enjoy the unit at first but had begun to have issues with a resident who intrusively wandered (Resident G), which led to a resident-to-resident altercation.An Interdisciplinary Team (IDT) progress note, dated 4/29/26 at 10:44 a.m., indicated Resident H was standing at the doorway of his room when Resident G walked by and attempted to enter the room. Resident H pushed Resident G away in attempt to redirect Resident G from his room. The root cause was Resident H had a diagnosis of dementia and Resident G was invading Resident H's space.A monthly behavioral health report, dated 5/10/26, indicated in the month of April, the only documented new or worsening behavior for Resident H was a peer-to-peer interaction. The completion of IDT reviews for the event was marked N/A, completion of care plan updates with effective interventions was marked N/A, staff education of interventions was marked N/A.During an interview, on 5/19/26 at 12:42 p.m., RN (Registered Nurse) 2 indicated since returning from the memory care unit, Resident H had been demonstrating increased aggression with the staff. RN 2 was not aware of the reason why the resident had been moved to the memory care unit. He had not been experiencing any new or worsening behaviors prior to the room change. However, within a few days after his room change, he had an altercation with another resident.During an interview, on 5/20/26 at 9:21 a.m., the Social Service Director (SSD) indicated Resident H liked things a certain way; his own space, to be in his room, did not like when people would enter his room and did not do well with change. Resident H's room change was discussed in the IDT (interdisciplinary team) morning meeting. Resident H's facility care companion had disagreed with a room change due to the resident being particular about his own space and not doing well with changes in his routine. Despite the disapproval, he was moved to the memory care unit the next day. The Social Service Director did not know the reason for Resident H's room change.During an interview, on 5/20/26 at 9:46 a.m., the Activity Director indicated she was not sure why the facility had moved Resident H's room. The housekeeping supervisor was Resident H's facility care companion. She had disagreed with moving the resident to the memory care unit. The resident liked his own personal space and being alone in his room.During an interview, on 5/20/26 at 9:50 a.m., the Housekeeping Supervisor indicated she was present in the meeting and had voiced to the interdisciplinary team Resident H liked his own private space.During an interview, on 5/20/26 at 12:40 p.m., the Minimum Data Set nurse indicated the facility, as a team, thought the resident would benefit from the Cottage (men's memory care unit) experience and would get him out of his room since Resident H had shown an increase in isolation.During an interview, on 5/20/26 at 2:03 p.m., Resident H's son indicated the Minimum Data Set nurse told him today, the room change was due to a decrease in Resident H's activity. The facility wanted him to come out of his room more often, so the facility moved him to a different room. Resident H's representative indicated he was not aware Resident H was involved in any resident-to-resident altercation.2. The clinical record for Resident G was reviewed on 5/19/26 at 10:25 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of the right femur, dementia, and Alzheimer's disease.A care plan, initiated 4/4/23 and dated as last reviewed 5/17/26, indicated Resident G was at risk of falls. Resident G would jog in the hallways or walk at a fast pace and had no spatial awareness, would approach others and get into their personal spaces. The care plan for falls did not include an approach for safety monitoring or supervision prior to the incident with Resident H.A care plan, initiated on 5/11/23 and dated as last reviewed 5/17/26, indicated Resident G demonstrated mood distress and behavioral symptoms as evidenced by frequent pacing in the hallways, inability to remain seated, and restlessness, likely related to his underlying cognitive/psychiatric condition and his impaired ability to self-regulate. The goal was Resident G would demonstrate reduced restlessness and pacing, with improved ability to engage in structured or supervised activities and maintain safety with staff support and redirection. Interventions included, but were not limited to, educating staff on resident specific behaviors and appropriate responses, encouraging Resident G to become involved with physical activities and social interactions, and work with Resident G to identify effective coping mechanisms. These interventions had been in place since 2025 and prior to the incident with Resident H.A care plan, initiated on 7/1/25 and dated as last reviewed 5/17/26, indicated Resident G demonstrated behavioral disturbances which placed him at risk for falls, injury, and environmental hazards. Interventions included, but were not limited to, offer structured activities or purposeful tasks (folding towels, organizing safe items, walking with staff, a fidget apron) to meet the need for movement and provide reassurance of safety and wellbeing. These interventions had been in place since 2025 and prior to the incident with Resident H.A care plan, initiated 9/9/25 and dated as last reviewed 5/17/26, indicated at times, Resident G would intrusively wander related to advanced cognitive impairment, resulting in the inability to recognize personal space. The resident had poor spatial awareness. The goal indicated Resident G would be maintained in a safe environment with reduced incidents of intrusive wandering, collisions, or altercations related to poor spatial awareness and intrusive wandering. Interventions included, but were not limited to, increasing supervision, offer/assisting Resident G to sit down in a dining chair, and address any immediate needs such as hunger, thirst, pain, boredom, loneliness, tiredness. These interventions had been in place since 2025 and prior to the incident with Resident H.An elopement risk assessment, dated 3/4/26, indicated Resident G was able to move freely throughout the unit, was often observed wandering aimlessly and without purpose, and intrusively wandered.An annual BIMS assessment, dated 3/29/26, indicated Resident G had severely impaired cognition.A behavior event, dated 4/27/26 at 4:30 p.m., indicated Resident G attempted to enter Resident H's room without invite. Staff had observed Resident G attempting to enter the other resident's room. The other resident who was standing at his door at that time attempted to prevent Resident G from entering his room. During the interaction, the wandering resident and the other resident lost their balance resulting in both falling to the floor.A physician communication tool, dated 4/27/26, indicated Resident G was complaining of right hip pain with movement.A progress note, dated 4/27/26 at 5:45 p.m., indicated Resident G was complaining of right hip/leg pain after a fall. The resident was grimacing and guarding the affected side upon assessment and was unable to bear weight. Emergency services were called and Resident G was transported to the hospital for further evaluation.A hospital document, dated 4/27/26, indicated Resident G was sent to the emergency room following a fall in his memory care unit, was complaining of right hip pain, and was unable to ambulate (walk). After further evaluation, Resident G was found to have a right intertrochanteric femur fracture. Resident G was taken to surgery for the fracture repair.An IDT progress note, dated 4/29/26, indicated Resident G attempted to enter Resident H's room without invite. The root cause identified was Resident G had a diagnosis of dementia and a history of intrusive wandering.During an interview, on 5/19/26 at 11:09 a.m., Resident G's wife and daughter were in the memory care unit sitting at a dining table with Resident G who was sitting in a Broda chair. The daughter indicated prior to the fracture, her dad was always on the move and wandering around the unit. The wife indicated, on 4/27/26, the facility had called to inform her Resident G had fallen and was being transported to the hospital after complaining of right hip/leg pain. The facility had not mentioned the fall was due to a resident-to-resident altercation and they (the wife and daughter) had still not been made aware of the details related to the fall. They had requested, from the facility, Resident G's records.During an interview, on 5/20/26 at 1:32 p.m., the Clinical Support Nurse indicated Resident G's fall was not witnessed. She acknowledged all the documentation had stated the event was witnessed and was a result of a resident-to-resident altercation but indicated after the facility investigation, it had been determined Resident G's fall was not witnessed.During an interview, on 5/21/26 at 12:50 p.m., the Executive Director (ED) indicated during the facility investigation of the incident, the fall was found to have been unwitnessed and indicated Resident G and Resident H were not provided with the appropriate supervision/monitoring to prevent the incident.During an interview, on 5/21/26 at 11:45 a.m., the Clinical Support Nurse indicated the facility did not have a policy regarding resident-to-resident altercations.A current facility policy, titled Resident Rights, dated as last revised 10/2023 and received from the Clinical Support Nurse on 5/21/26 at 9:40 a.m., indicated .The facility must protect and promote the rights of each resident.Receive services in the facility with reasonable accommodation of resident needs.The resident has a right to care in an environment that promotes maintenance or enhancement of each resident's quality of life. The resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.This citation relates to Intake 3002127.410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on interview and record review, the facility failed to ensure a relocation planning conference meeting was held with the resident's responsible party and the Executive Director prior to moving the resident onto a locked memory care unit and prior to moving the resident out of the locked memory care unit and back to the skilled unit for 1 of 1 resident reviewed for transfers. (Resident H)Findings include:During an interview, on 5/19/26 at 1:05 p.m., Resident H's resident representative indicated due to his profession, he was unable to visit Resident H often but the last time he went to the facility to visit, all Resident H's belongings were gone, and Resident H was not in his room. He asked a staff member where Resident H was and was told the dementia unit. Resident H's son explained he had not been to the dementia unit before and did not know where the unit was, so he asked the staff member how to get there. To get to the dementia unit, he had to go through two sets of locked doors. When he entered the men's dementia unit and found Resident H's room, there was a stop sign across the door frame. He was concerned because he thought Resident H's health had worsened since he had been moved to a dementia unit and a stop sign was blocking the entrance to his room. Resident H had been residing in the same room on the skilled unit since he was admitted to the facility. He had not been informed by the facility as to why Resident H was moved to the dementia unit.Resident H's son was also unaware Resident H had since been moved back to his previous room on the skilled unit until speaking with the surveyor.The clinical record for Resident H was reviewed on 5/19/26 at 9:50 a.m. The diagnoses included, but were not limited to, severe dementia with behavior disturbances, anxiety disorder, and psychotic disorder with delusions.Resident H was admitted to the facility on [DATE].The facility census history for Resident H indicated, on 4/22/26, an intra-facility transfer occurred in which the resident was moved to the locked memory care unit. On 4/28/26, a second intra-facility transfer occurred in which the resident was moved out of the locked memory care unit and back to the skilled unit. Resident H had previously remained in the same room since 2020.A care plan, initiated 5/19/23 and dated as last reviewed 5/17/26, indicated Resident H's son lived nearby, but he was not available to visit or receive resident's calls as much as the resident would like. Interventions included, but were not limited to, the resident was able to call his son after 6:00 p.m., or afterwards. There were no new interventions dated after 5/19/23.A physician's order, initiated on 4/21/26 and discontinued on 4/30/26, indicated Resident H could reside on a secure unit.An Intra-Facility Transfer Notice of Room Change document, dated 4/21/26 at 2:08 p.m., and completed by the Social Service Director, indicated Resident H was being moved from the skilled unit to the memory care unit. The transfer took place on 4/21/26. The reason for the transfer was to transition to the Cottage (men's memory care unit). The option to waive the right for 48-hour notice, the right for a relocation planning conference, the right to receive the notice in writing, and the acknowledgement the legal representative/responsible party had received notice were all check marked.The contact number for the legal representative and the date of notification were not marked. A progress note, dated 4/21/26 at 12:56 p.m., indicated the Executive Director (ED) notified Resident H's responsible party of the room move to the all-male dementia unit and the responsible party was agreeable to the move.The progress note documented by the ED did not include any information regarding why the move was occurring, whether the option to tour the unit was given, whether Resident H's responsible party was offered or refused the right to waive 48-hour notice, a relocation planning conference, or to receive the notice in writing.An Intra-Facility Transfer Notice of Room Change document, dated 4/28/26 at 1:41 p.m., and completed by the Social Service Director, indicated Resident H was being moved from the memory care unit to the skilled unit. The transfer took place on 4/28/26. The option to waive the right for 48-hour notice, the right for a relocation planning conference, and the right to receive the notice in writing were all check marked. The acknowledgement of legal representative or responsible party was marked N/A.Documentation of a progress note related to the notification to Resident H's responsible party for the room change was not located in the electronic health record.During an interview, on 5/20/26 at 1:16 p.m., the ED indicated she contacted Resident H's son by telephone for the first room change and left a voice message regarding the second room change. Resident H was moved to the locked memory care unit because the facility had noticed an increase in self-isolation by staying in his room and he was not participating in activities he normally would. Prior to an intra-facility transfer, the family would be notified why the room change was occurring, and a planning conference would be held with the resident and/or responsible party.During an interview, on 5/20/26 at 9:21 a.m., the Social Service Director indicated when room changes are considered, the resident and/or responsible party should be informed prior to and agree to the room change. After consent was obtained, the resident would be moved, and social services would follow up with the resident for several days to ensure the resident was transitioning well. Resident H had a low cognition and would be unable to consent or agree to a room change. Resident H's son was the resident's responsible party. The Social Service Director did not know the reason for Resident H's room change.During an interview, on 5/20/26 at 12:06 p.m., the Social Service Director indicated this morning, she and the Minimum Data Set (MDS) nurse conducted Resident H's quarterly care plan meeting via telephone. Resident H's son had asked about his father's dementia diagnosis and wanted to know why he was moved to the memory care unit. The process for non-emergent intra-facility transfers was to notify and explain the reason for the move to the responsible party, answer any questions, tour the unit and room with the responsible party, obtain consent prior to the transfer, observe the resident on the new unit, and document the process in the resident's record.During an interview, on 5/20/26 at 12:40 p.m., the Minimum Data Set (MDS) nurse indicated when the room change for Resident H was considered, the facility looked for roommate compatibility and area compatibility. Resident H's room change was not an emergent need.During an interview, on 5/20/26 at 2:03 p.m., Resident H's son indicated he attended a care plan meeting with the Social Service Director and the MDS nurse earlier today. He had asked about his father's diagnosis of dementia and room change. He was told by the MDS nurse the room change was due to a decrease in his activity and the facility wanted him to come out of his room more often, so the facility moved him to a different room. Again, he indicated he had not been contacted or informed about a room change prior to the visit to the facility in April when he found his father and belongings were not in the room on the skilled unit and the facility documents should not indicate he had been notified.During an interview, on 5/21/26 at 12:50 p.m., the ED indicated Resident H's son was difficult to contact and did not visit very often. She had called him and left a voicemail about the room change. She did not have documentation for the message.A current facility policy, titled Resident Rights,' dated as last revised 10/2023 and received from the Clinical Support Nurse on 5/21/26 at 9:40 a.m., indicated .The facility must protect and promote the rights of each resident.Receive written notice.before the resident's room.in the facility is changed.Refuse to transfer to another room in the facility; if the purpose of the transfer is solely for the convenience of staff.The resident and/or resident representative has the right to be notified of the following.a change in room.A current facility policy, titled Intra Facility Transfers/Roommate Notification Policy, dated as last revised 11/2017 and received from the Clinical Support Nurse on 5/21/26 at 9:40 a.m., indicated .Intra-facility transfers will be initiated if only one or more of the following exists.The move is necessary for medical reasons.the move is necessary for the welfare of the residents or other residents.Notice will be given to the resident who is moving at least 48 hours prior to the move.An intra-facility transfer form will be completed prior to the room change. Information included in form are the following.Reason for the transfer.Name, address and telephone number of the local and state long term care ombudsman.Notification of the transfer will be made to the resident and/or representative and recorded on the intra facility form. The legal representative may be notified by phone prior to the transfer which shall be recorded on the intra facility transfer form. The resident/representative will receive the notice in writing unless they waive their right to do so.This citation relates to Intake 3002127.410 IAC (Indiana Administrative Code) 3.1-12(a)(18)410 IAC (Indiana Administrative Code) 3.1-12(a)(19)410 IAC (Indiana Administrative Code) 3.1-12(a)(20)410 IAC (Indiana Administrative Code) 3.1-12(a)(21)410 IAC (Indiana Administrative Code) 3.1-12(a)(22)410 IAC (Indiana Administrative Code) 3.1-12(a)(23)410 IAC (Indiana Administrative Code) 3.1-12(a)(24)

Based on observation, interview, and record review, the facility failed to ensure the same size tracheostomy canula was kept at bedside as ordered for 1 of 1 resident reviewed for respiratory care. (Resident B)Findings include:During an observation, on 4/1/26 at 11:21 a.m., Resident B had a tracheostomy.The clinical record for Resident B was reviewed on 4/1/26 at 12:00 p.m. The diagnoses included, but were not limited to, chronic respiratory failure and sleep apnea.A physician's order, dated 2/2/26, indicated the tracheostomy type and size was a Bivona tracheostomy XL 7 (a silicone, wire-reinforced, extra-length tracheostomy tube deigned for adult patients who require deeper airway access).A physician's order, dated 2/2/26, indicated to keep a small tracheostomy canula and the same size tracheostomy canula at bedside.During an interview, on 4/1/26 at 11:25 a.m., RN 2 indicated the tracheostomy canula stored at the bedside was a size 6. She would have to check to see if the facility stored the same size canula at bedside.During an interview, on 4/1/26 at 11:30 a.m., the Minimum Data Set (MDS) Coordinator indicated Resident B had a size 6 canula at bedside and she would have to check if the facility stored the same size canula at bedside.During an interview, on 4/1/26 at 1:10 p.m., the Director of Nursing (DON) indicated the same size canula just needed to be stored in the facility but not stored at the bedside. She observed the physician's order which indicated the same size canula should be stored at the bedside. She indicated the facility did not have a policy for tracheostomies.410 IAC (Indiana Administrative Code) 3.1-47(a)(4)

Based on interview and record review, the facility failed to ensure speech therapy was initiated and provided to a resident who admitted to the facility with a diagnosis of dysphagia (swallowing disorder) and on a therapeutic diet for 1 of 3 residents reviewed for therapy services. (Resident E)Findings include: The clinical record for Resident E was reviewed on 3/30/26 at 11:05 a.m. The diagnoses included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (inability to produce speech), and dysarthria (motor speech disorder which impairs control of the muscles used for speech).Resident E was admitted , on 1/14/26 at 11:08 a.m., from a rehabilitation (rehab) hospitalThe rehab hospital Discharge summary, dated [DATE], indicated speech-language pathology evaluated the patient for dysphagia and communication deficits. The patient was found to have mild oral phase deficits, characterized by right anterior loss and pocketing, intermittent cough with thin liquids and solids, and impulsivity during feeding. The patient was continued on a dysphagia diet with 1:1 supervision for all meals due to an aspiration risk. The speech therapist recommended ongoing monitoring for signs of aspiration or pulmonary compromise. A team conference was held on 1/7/26 and indicated the modified barium swallow study remained unchanged and the diet was a minced/moist diet. Discharge to a skilled nursing facility (SNF) was set for 1/14/26. A dysphagia diet was ordered as IDDSI (International Dysphagia Diet Standardization Initiative which is a global standard for classifying texture-modified foods and thickened liquids for individuals with swallowing difficulties) thin/IDDSI 0 (IDDSI Level 0, termed Thin, refers to liquids that flow freely like water, milk, or juice), 1:1 or close supervision, alternate sips/liquids and SMALL bites, no straws, minced and moist/IDDSI 5 (IDDSI Level 5, termed minced and moist, refers to food which is soft and moist but with no liquid leaking or dripping from the food. Food which has been mashed or minced before serving and biting was not required). Resident E's discharge self-care functional abilities for eating were supervision or touching assistance.A facility admission observation, dated 1/14/26 at 12:26 p.m., indicated Resident E's current health problems included swallowing difficulties.A physician's order, dated 1/14/26 at 11:30 a.m. and discontinued 1/14/26, indicated a regular diet.A physician's order, dated 1/14/26 at 8:33 p.m. and discontinued 1/27/26, indicated a soft bite-sized diet.A care plan, dated 1/15/26, indicated the resident required assistance with eating related to dysphagia and dysarthria.An admission Minimum Data Set (MDS) assessment, dated 1/21/26, indicated the resident required partial to moderate assistance with eating.A progress note, dated 1/23/26 at 12:57 p.m., indicated the nurse was called to the dining room due to the resident coughing and vomiting. Resident E continued to eat and cough. A therapy evaluation was triggered.A progress note, dated 1/26/26 at 12:10 p.m., indicated the resident was eating lunch and had thick secretions, coughing, and emesis. Speech therapy was to evaluate Resident E due to an event on 1/23/26.A physician's order, dated 1/27/26, indicated speech therapy to evaluate and treat.A physician's order, dated 1/27/26, indicated speech therapy to treat five (5) times a week for ten (10) weeks for swallowing dysfunction and oral functions for feeding.A physician's order, dated 1/27/26 at 11:10 a.m., indicated pureed diet. During an interview, on 3/31/26 at 2:45 p.m., the Director of Nursing (DON) indicated speech therapy was usually ordered for residents upon admission for worsening dysphagia or modified diets. She indicated she believed the resident's dysphagia had been stable or improving.During an interview, on 3/31/26 at 11:55 a.m., Speech Therapist 6 indicated when a resident was admitted with dysphagia and on a modified diet, speech therapy should be notified to evaluate. The facility had not ordered speech therapy when Resident E was admitted . The facility did not offer a minced and moist diet. Normally, speech therapy would determine the diet substitution for a diet which was not offered. A soft and bite-sized diet would be considered an upgraded diet status from minced and moist and should not be made without a speech therapy evaluation.During an interview, on 3/30/26 at 12:30 p.m., Resident E's daughter indicated her father had swallowing difficulties from a stroke which had gotten worse. He was in a rehabilitation hospital in December and then admitted to the facility on [DATE] for continued therapy. She had filed a grievance with the facility, on 1/20/26, related to the facility leaving her father unattended while eating. Her father required close supervision for all meals.A current facility policy, titled Diet Orders, dated 8/25 and provided by the Executive Director (ED) on 3/31/26 at 3:54 p.m., indicated .If a resident admits with orders for either a Mechanical Soft or Minced and Moist diet, please complete a nursing to therapy referral for Speech Therapy to review to ensure most appropriate diet is provided.This citation relates to Intake 2738953.410 IAC (Indiana Administrative Code) 16.2-3.1-23(a)(1)

Based on interview and record review, the facility failed to ensure a provided diet was comparable and compatible to the diet ordered from a rehabilitation hospital on admission for 1 of 3 residents reviewed for therapeutic diets. (Resident E)Findings include:The clinical record for Resident E was reviewed on 3/30/26 at 11:05 a.m. The diagnoses included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (inability to produce speech), and dysarthria (motor speech disorder which impairs control of the muscles used for speech).Resident E was admitted , on 1/14/26 at 11:08 a.m., from a rehabilitation (rehab) hospitalThe rehab hospital Discharge summary, dated [DATE], indicated speech-language pathology evaluated the patient for dysphagia and communication deficits. The patient was found to have mild oral phase deficits, characterized by right anterior loss and pocketing, intermittent cough with thin liquids and solids, and impulsivity during feeding. The patient was continued on a dysphagia diet with 1:1 supervision for all meals due to an aspiration risk. The speech therapist recommended ongoing monitoring for signs of aspiration or pulmonary compromise. A team conference was held on 1/7/26 and indicated the modified barium swallow study remained unchanged and the diet was a minced/moist diet. Discharge to a skilled nursing facility (SNF) was set for 1/14/26. A dysphagia diet was ordered as IDDSI (International Dysphagia Diet Standardization Initiative which is a global standard for classifying texture-modified foods and thickened liquids for individuals with swallowing difficulties) thin/IDDSI 0 (IDDSI Level 0, termed Thin, refers to liquids that flow freely like water, milk, or juice), 1:1 or close supervision, alternate sips/liquids and SMALL bites, no straws, minced and moist/IDDSI 5 (IDDSI Level 5, termed minced and moist, refers to food which is soft and moist but with no liquid leaking or dripping from the food. Food which has been mashed or minced before serving and biting was not required). Resident E's discharge self-care functional abilities for eating were supervision or touching assistance.A facility admission observation, dated 1/14/26 at 12:26 p.m., indicated Resident E's current health problems included swallowing difficulties.A physician's order, dated 1/14/26 at 11:30 a.m. and discontinued 1/14/26, indicated a regular diet.A physician's order, dated 1/14/26 at 8:33 p.m. and discontinued 1/27/26, indicated a soft bite-sized diet.A document, titled Complete IDDSI Framework Detailed definitions 2.0, dated 2019, indicated a minced and moist diet included small lumps equal to or less than 4 millimeters (mm) wide by 15 mm long and required minimal chewing while a soft and bite-sized diet included 15 mm by 15 mm pieces and required regular chewing and tongue control. A soft and bite-sized diet according to IDDSI would be an IDDSI Level 6.A care plan, dated 1/15/26, indicated the resident required assistance with eating related to dysphagia and dysarthria.An admission Minimum Data Set (MDS) assessment, dated 1/21/26, indicated the resident required partial to moderate assistance with eating.A progress note, dated 1/23/26 at 12:57 p.m., indicated the nurse was called to the dining room due to the resident coughing and vomiting. Resident E continued to eat and cough. A progress note, dated 1/26/26 at 12:10 p.m., indicated the resident was eating lunch and had thick secretions, coughing, and emesis. A physician's order, dated 1/27/26 at 11:10 a.m., indicated pureed diet. During an interview, on 3/30/26 at 12:30 p.m., Resident E's daughter indicated her father had swallowing difficulties from a stroke which had gotten worse. He was in a rehabilitation hospital in December and then admitted to the facility on [DATE] for continued therapy. She had filed a grievance with the facility, on 1/20/26, related to the facility leaving her father unattended while eating. Her father required close supervision for all meals.During an interview, on 3/31/26 at 11:55 a.m., Speech Therapist 6 indicated the facility did not offer a minced and moist diet. Speech would determine a diet substitution for a diet not offered. A soft and bite-sized diet would be considered an upgraded diet from minced and moist.A current facility policy, titled Nursing Admission/Return admission Policy and Procedure, dated 12/25 and provided by the ED (Executive Director) on 3/31/26 at 3:54 p.m., indicated .Transcribe the admission orders from the original orders.Diet-transcribe the diet using the correct terminology.A current facility policy, titled Diet Orders, dated 8/25 and provided by the ED on 3/31/26 at 3:54 p.m., indicated . Available Diets: Regular, Puree.Ground Meat.Soft & Bite Sized.If the physician orders a diet not consistent with the diets offered by the facility (above), nursing can utilize the diet terminology in the chart below.Order-Mechanical Soft* Interpretation-Soft & Bite Sized, Order-Minced and Moist* Interpretation-Puree .If a resident admits with orders for either a Mechanical Soft or Minced and Moist diet, please complete a nursing to therapy referral for Speech Therapy to review to ensure most appropriate diet is provided.This citation relates to Intake 2738953.410 IAC (Indiana Administrative Code) 16.2-3.1-21(a)(3)

Based on interview and record review, the facility failed to ensure medications were disposed of in a secure and safe method to prevent diversion and/or accidental exposure for 1 of 3 residents reviewed for pharmacy services. (Resident E)Findings include:The clinical record for Resident E was reviewed on 3/30/26 at 11:05 a.m. The diagnoses included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (inability to produce speech), and dysarthria (motor speech disorder which impairs control of the muscles used for speech).Resident E was admitted , on 1/14/26 at 11:08 a.m., from a rehabilitation (rehab) hospitalThe rehab hospital Discharge summary, dated [DATE], indicated speech-language pathology evaluated the patient for dysphagia and communication deficits. The patient was found to have mild oral phase deficits, characterized by right anterior loss and pocketing, intermittent cough with thin liquids and solids. Medications were to be crushed in puree form.A Medication Administration Record, dated 2/7/26 at 7:27 a.m., indicated the following medications were marked as not administered due to the resident's condition:a. aspirin (a non-steroidal anti-inflammatory medication)b. vitamin D3 (a vitamin supplement)c. lactulose (a liquid laxative used to reduce blood ammonia levels)d. methylphenidate (a scheduled II controlled substance)e. sennosides-docusate sodium (a laxative)f. rifaximin (an antibiotic medication)g. polyethylene glycol (a laxative)A controlled substance record indicated one (1) tablet of rifaximin was signed out on 2/7/26 at 8:00 a.m., by RN 5.The controlled substance record did not indicate the tablet was disposed of or wasted with a second nurse.During an interview, on 3/31/26 at 11:00 a.m., Unit Manager 4 indicated RN 5 had informed her Resident E did not receive his medications on 2/7/26 due to his condition and RN 5 had thrown all the medications in the trash in his room. Unit Manager 4 indicated medications were not supposed to be thrown in the trash in resident's room. Unit Manager 4 had taken a second staff member into the room and verified two (2) pills were found in the trash can. There were only 2 pills found in the trash out of the 6 pills ordered for that morning. There was no liquid medications found in the trash can. The controlled substance had not been destroyed with a second nurse.During an interview, on 4/1/26 at 2:00 p.m., RN 5 indicated she did not administer any medications to the resident that morning.An employee communication form, dated 2/8/26, indicated RN 5 received a written warning for inaccurately signing out medications as given and not destroying medications per policy.A skills competency nursing checklist, titled Medication Administration (Medication Pass Procedure), revised 4/2025 and provided by the Director of Nursing (DON) on 4/1/26 at 2:35 p.m., indicated .Wasted, dropped or discarded medications disposed of in Drug Buster disposal system.Administration and inventory of controlled substances were documented according to facility policy.A current facility policy, titled Controlled Substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction), dated 10/25 and provided by the DON on 4/1/26 at 11:49 a.m., indicated .all unused medication will be destroyed by.a witnessing licensed nurse.destruction will be documented on the resident's Controlled Substance Record.This citation relates to Intake 2738953.410 IAC (Indiana Administrative Code) 16.2-3.1-25(e)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-25(o)

Based on interview and record review, the facility failed to ensure medications were administered, labs were obtained, and admission orders were transcribed according to the physician's orders for 2 of 3 residents reviewed for quality of care. (Resident J and E)Findings include: 1. During an interview, on 3/30/26 at 11:00 a.m., Resident J indicated on the morning of 2/7/26, the facility staff did not give him his insulin medication. The clinical record for Resident J was reviewed on 3/30/26 at 11:30 a.m. The diagnoses included, but were not limited to, type 2 diabetes, anemia, and hypertension A physician's order, dated 12/2/25, indicated to administer 16 units of lispro insulin three (3) times a day with meals. The Medication Administration Record (MAR) indicated, on 2/7/26, the 7:30 a.m. dose was not administered. During an interview, on 3/31/26 at 11:55 a.m., Unit Manager (4) indicated due to the resident's preference, Resident J did not want her to administer his insulin the morning of 2/7/26. She passed the medication administration responsibility onto another nurse. During an interview, on 3/31/26 at 12:31 p.m., Licensed Practical Nurse (LPN) 3 indicated she was not informed she was supposed to take care of Resident J until it was too late. He did not refuse his insulin for her. The dose was not administered because she was told too late and he did not get his 7:30 a.m. dose. During an interview, on 4/1/26 at 1:10 p.m., the Director of Nursing (DON) indicated the facility did not have a medication administration policy. They had a skills validation checkoff. A facility skills competency document, titled Medication Administration, dated April 2025 and received from the DON on 4/1/26, indicated .Medications administered within 60 minutes before and/or after time ordered or within the 4 hour time range (if on time ranges).The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right Time. 2. The clinical record for Resident E was reviewed on 3/30/26 at 11:05 a.m. The diagnoses included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (inability to produce speech), and dysarthria (motor speech disorder which impairs control of the muscles used for speech). a. The rehab hospital Discharge summary, dated [DATE], indicated Resident E had been assessed for hypercalcemia (high level of calcium in the blood), hyponatremia (low level of sodium in the blood), and hyperammonemia (high level of ammonia in the blood) and to continue to monitor labs levels. Resident E was admitted , on 1/14/26 at 11:08 a.m., from a rehabilitation (rehab) hospital. A lab report, dated 1/16/26, indicated the resident's sodium was 132 (low) and calcium was 12.5 (high). A physician's progress note, dated 1/19/26, indicated the resident was seen for hypercalcemia, hyponatremia, and elevated ammonia levels. The plan was to repeat a comprehensive metabolic panel lab test in one (1) week. A physician's order, dated 1/19/26, indicated to repeat an ammonia and comprehensive metabolic panel lab test on 1/26/26. A lab report, dated 1/30/26, indicated the quantity of blood was insufficient to obtain lipid or thyroid test results. The report did not indicate a comprehensive metabolic panel or ammonia level was ordered or obtained. The clinical record did not contain results for a repeat comprehensive metabolic panel or ammonia level after the initial results on 1/16/26. An emergency room note, dated 2/7/26 at 9:51 a.m., indicated Resident E was admitted to the hospital for diagnoses of acute respiratory failure with hypoxia, hypercalcemia, acute renal insufficiency, and hypernatremia. A hospital history and physical, dated 2/7/26 at 12:26 p.m., indicated the Resident E's abnormal lab values included, but were not limited to sodium, potassium, and calcium. b. The rehab hospital Discharge summary, dated [DATE], indicated speech-language pathology evaluated the patient for dysphagia and communication deficits. The patient was found to have mild oral phase deficits, characterized by right anterior loss and pocketing, intermittent cough with thin liquids and solids, and impulsivity during feeding. The patient was continued on a dysphagia diet with 1:1 supervision for all meals due to an aspiration risk. Discharge to a skilled nursing facility (SNF) was set for 1/14/26. A dysphagia diet was ordered and included 1:1 or close supervision, alternate sips/liquids and SMALL bites, medications crushed in puree, and no straws. Resident E was admitted , on 1/14/26 at 11:08 a.m., from a rehabilitation (rehab) hospital. A physician's order, dated 1/14/26, indicated may crush appropriate medications and mix with applesauce or other food sources as needed. The electronic medical record did not include orders for 1:1 or close supervision for meals, alternating sips of liquids with small bites, medications needed to be crushed in puree, or no straws. During an interview, on 3/30/26 at 12:30 p.m., Resident E's daughter indicated her father had swallowing difficulties from a stroke which had gotten worse. He was in a rehabilitation hospital in December and then admitted to the facility on [DATE] for continued therapy. She had filed a grievance with the facility, on 1/20/26, related to RN 5 placed an uncrushed pill in her father's mouth and not in applesauce. Her father required his medications to be crushed in applesauce. During an interview, on 3/31/26 at 11:00 a.m., Unit Manager 4 indicated a physician's order indicating the nurse may crush medications was not the same as an order to always crush the medications. She did not believe the resident received his medications crushed. A current facility policy, titled Nursing Admission/Return admission Policy and Procedure, dated 12/25 and provided by the Executive Director on 3/31/26 at 3:54 p.m., indicated .The admitting nurse must review the pre-admission assessment, history and physical, hospital discharge summary.and physician orders.Transcribe the admission orders from the original orders. This citation relates to Intake 2738953 and 2742060. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to protect a resident's right to be free from verbal abuse and intimidation (Resident B) by another resident (Resident C) for 1 of 4 residents reviewed for abuse.Findings include:During an observation and interview, on 3/30/26 at 11:04 a.m., Resident B was lying in bed, covered with a sheet and had a back scratcher resting on the right side of the bed next to him. Resident B indicated he had no complaints regarding the staff, but Resident C cussed at him last evening (3/29/26) while a nurse was providing tracheostomy care for him. Resident C was his old roommate and now lived in the room across the hall from him. Resident C yelled and cussed at him for no reason.During an observation and interview, on 3/31/26 at 12:18 p.m., Resident B was lying in bed, covered with a sheet and had a back scratcher resting on the right side of the bed next to him. His right hand was resting on the back scratcher. Resident B indicated it bothered him when Resident C talked s**t and threatened him because the attacks were always unprovoked. Resident B indicated he did not get out of bed and Resident C always came into the doorway of his room. If the staff questioned Resident C about the altercation, Resident C claimed to the staff he was stopping by to see Resident B's roommate. Resident B indicated, on 3/29/26, Resident C threatened to come into his room and kick his a**. Resident B indicated since Resident C lived across the hall; Resident C had to pass his room every time Resident C left his own room. Resident B indicated he had been having trouble staying asleep at night because Resident C was allowed to come and go from the facility at all hours of the night, would return to the facility drunk, and Resident C could bring a weapon back with him or enter his (Resident B) room while he was sleeping and bonk him on the head with something, and there would be nothing he (Resident B) could do about it.During an interview, on 3/31/26 at 12:18 p.m., Anonymous Staff Member 7 indicated Resident C would yell and cuss at a lot of staff and residents, but the behavior was particularly bad towards Resident B. Anonymous Staff Member 7 did not know why Resident C did not like Resident B.During an interview, on 3/31/26 at 2:21 p.m., Resident B's daughter indicated Resident B called her in the evening, on 3/30/26, and told her Resident C had come to his room yelling and cussing at him. This was the third incident she had been made aware of. Resident B told her Resident C had threatened to beat him up. Resident B's daughter indicated the facility allowed Resident C to come and go from the facility whenever he would like and she was concerned about her dad's safety since there were now threats of physical harm. Her dad was bed bound and was unable to protect himself. She and Resident B were concerned about Resident C bringing a weapon into the facility and indicated the facility would have no way of knowing until it was too late. Resident C was a danger to not only her dad but other residents as well. Staff had no control over Resident C. Her dad had mentioned to her he was worried about what Resident C could do to him, so her dad kept a back scratcher next to him for protection.During an interview, on 3/30/26 at 2:31 p.m., the Executive Director (ED) indicated when Resident B arrived three months ago, he and Resident C were roommates for a very short time. Resident C did not want a roommate and there were problems between the two residents from the beginning. Resident C did not qualify to be in the facility because he was independent and did not require any assistance for activity of daily living but refused to look for another living situation because he did not want to pay to live anywhere. There were suspicions Resident C had returned to the facility intoxicated. The police had to be called because Resident C returned to the facility, staff reported Resident C smelled of alcohol, was yelling, being verbally aggressive to staff and yelling at other residents. The ED indicated the facility had lost staff due to Resident C's behaviors and Resident C did whatever he wanted and everyone knew it.During an interview, on 3/31/26 at 3:39 p.m., the Social Service Director indicated Resident C had a history of becoming disruptive and aggressive about having a roommate. When Resident B returned from the hospital, on 1/30/26, he was placed in a room with Resident C. Resident C was not happy about having a roommate and having to move his belongings to one side of the room. Resident C was then moved into a room across the hall and had become angry when his T.V. wasn't working properly after he moved rooms. Since the issue with Resident C's T.V., every time Resident C passed Resident B's room there was an altercation. A couple of days ago (3/29/26), Resident C was yelling at Resident B from the doorway of Resident B's room. Resident B reported Resident C threatened to beat his a**. Early Monday morning (3/30/26), Resident C heard the nurse in the room with Resident B talking about getting cleaned up and started yelling at Resident B calling him a fat a** and continued to make threats. There were other residents who did get along with Resident C who could possibly move rooms to allow Resident B to move further away from Resident C. She had mentioned the idea of room changes three different times during the morning IDT (interdisciplinary team) meetings, but the idea was always rejected. The first time she suggested this was after following up with Resident B after the first altercation on 2/3/26. She believed the suggestion was turned down because the facility was trying to make Resident C uncomfortable so the resident would want to live somewhere else but believed everyone else (residents) were uncomfortable due to the disruptions Resident C caused.During an interview, on 3/31/26 at 3:55 p.m., the ED indicated Resident B complained to his daughter about Resident C and claimed he was threatened. Resident B's daughter called the facility, reported the incident, and stated Resident C was verbally aggressive to her father. The ED informed the daughter her father had an [NAME] and was claiming he denied being bothered by the altercation when the ED spoke with Resident B about what had happened. The ED believed Resident B was an aggressor too. The ED indicated the nurse was attempting to suction Resident B's tracheostomy when Resident B was being verbally aggressive with the nurse. Resident C had overheard the conversation and entered the doorway to Resident B's room and started yelling at Resident B saying, you take up all the nurse's time and no one else can get help. The ED indicated Resident C was sticking up for the staff member. Resident B and the daughter had been offered to move rooms several times, but they both refused. The ED indicated she believed moving rooms would not make a difference because of the way the building was set up. Resident C wanted to stop in Resident B's room to say hi to Resident B's roommate and the roommate had the right to be visited by other residents. Resident B had never been bothered by Resident C yelling, cussing, and name calling in the past, but now, for the first time, it bothered him. The ED indicated that a resident must have physical or psychosocial distress from an interaction to qualify as a resident-to-resident event. She would expect staff to separate the residents and document the incident. The event would be documented in the aggressor's record and social services would complete resident follow-ups regardless of admitted distress.During an interview, on 4/1/26 at 9:46 a.m., Resident B's daughter voiced safety concerns for all the residents in the facility. Resident B's daughter indicated after the second altercation between Resident B and Resident C, she requested a room change but indicated no one wanted to move her father's room. The ED had asked her about changing rooms yesterday during the telephone call but claimed none of the other residents wanted to move closer to Resident C. Resident B's daughter indicated this was the first time the facility was considering a room change but also claimed there would always be opportunities for Resident C to be around Resident B. At first, Resident B was okay with Resident C entering his room to see his roommate, but when the verbal aggression was a constant problem, Resident B started telling Resident C to stop coming in. Resident C was verbally aggressive to Resident B all the time, even when staff were present and providing care for her father. Resident B was too proud of a man to admit being bothered by another man's behaviors and threats.During an interview, on 4/1/26 at 12:28 p.m., the Director of Nursing (DON) indicated Resident B had never admitted to being bothered by Resident C until now and believed it was Resident B's daughter who was bothered by the altercation and not actually Resident B. Until now, there have never been reports of threats from Resident C. The DON indicated per the federal regulations, Resident C yelling, cussing and calling Resident B names was not considered abuse because Resident B was not admitting psychosocial distress.During an interview, on 4/1/26 at 1:27 p.m., Resident B indicated the ED had asked if he wanted to move to another room when she spoke with him yesterday (3/31/26). Resident B felt since Resident C caused the issues, Resident C should be the one to move and because of that, he told the ED he did not want to move rooms. Resident B also wanted to let people know if something happened to him, he was not the aggressor.1. The clinical record for Resident B was reviewed on 3/30/26 at 1:16 p.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, anxiety, depression, and morbid obesity.A care plan, dated 1/30/26, indicated Resident B displayed signs and symptoms of mood distress as evidenced by finding little interest or pleasure in doing things, decrease in sleep, increase in fatigue, and trouble concentrating and to encourage Resident B to verbalize feelings, concerns, fears, and to clarify misconceptions.A care plan, dated 2/27/26, indicated Resident B was at risk of depression and to allow Resident B to express feelings and frustration and for staff to offer validation and support.A progress note, dated 2/4/26, indicated the Social Service Director was following up with Resident B. Resident B indicated he had an issue with his last roommate (Resident C) coming in and out of his room after Resident C moved out of the room they had shared. Resident B indicated he was happy in the facility before his hospital stay but since returning from the hospital, he has been unhappy. During the follow-up interview with Resident B, Resident C started yelling, cursing and calling the resident names from the hallway. Resident B became upset and shouted back at Resident C. The Social Service Director closed the door and was able to talk to Resident B until he became calm.A psychiatric visit note, dated 3/19/26, indicated Resident B had a history of anxiety. Resident B described experiencing low mood, trouble sleeping, worry, irritability, and nervousness.A psychiatric visit note, dated 3/23/26, indicated Resident B would like to go home and reported he had been dealing with depression and anger.2. The clinical record for Resident C was reviewed on 3/30/26 at 1:48 p.m. The diagnoses included, but were not limited to, alcohol abuse, anxiety, and insomnia.A behavior event, dated 1/15/26, indicated Resident C was informed he would be getting a new roommate. Resident C indicated he did not want a roommate and anyone they placed in his room, he would make it very uncomfortable for them. Staff educated Resident C about proper notification of receiving a new roommate and he was asked to try and get along with the new roommate. Resident C indicated he did not care about the facility policy or reason for the facility to place a new roommate in his room and stated he would not tolerate another roommate. Resident C's current roommate was removed from the room and taken to another location in the facility.A progress note, dated 1/27/26, indicated Resident C was very irritated and appeared to be under the influence. Resident C was going in and out of other resident's rooms being disrespectful and using vulgar language.A progress note, dated 2/25/26, indicated Resident C was standing outside of a resident's room encouraging the resident to cuss out a different resident.A wellness visit note, dated 3/11/26, the Nurse Practitioner indicated per nursing staff reports, Resident C had been returning to the facility intoxicated.A behavior event, dated 3/13/26, indicated Resident C had returned to the facility, appeared to be intoxicated, was yelling at the staff so what if I'm drunk. As Resident C was propelling himself to his room, he stopped in the doorway of Resident B's room and started yelling at Resident B saying, his big a** lays in the bed all f***ing day not doing s**t, talking on the phone about me all the time. Staff made several attempts to redirect Resident C before the verbal altercation stopped. The document indicated this behavior affected other residents.A progress note, dated 3/27/26, indicated the DON, ED, SSD, unit manager, and Medical Director spoke with Resident C regarding returning to the facility intoxicated, as evidence by, Resident C voiced being drunk and his behaviors. Resident C was provided with a policy for education on the matter. Resident C became upset and said, leave me alone about this b******t.Documentation by the nurse regarding the witnessed verbal altercation, on 3/29/26, was not located in Resident B and/or Resident C's clinical record.Documentation of what had occurred requiring police involvement was not located in Resident B and/or Resident C's clinical record.There was no behavior contracts located in Resident C's clinical record. A plan which ensured Resident B's safety had not been put into place by the facility.A current facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated as last revised 3/2026 and received from the ED on 3/30/26 at 10:26 a.m., indicated .to provide each resident with an environment that is free from abuse.This includes but is not limited to verbal abuse, physical abuse, mental abuse.will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents.Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Verbal abuse-The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents.within their hearing distance.This includes.verbal threats of harm by resident to resident.Mental abuse-verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering.This includes.resident to resident if it appears to be willfully directed to a specific resident.Examples of mental abuse include but are not limited to.harassing a resident, mocking, insulting, ridiculing .yelling.with the intent to intimidate.threatening resident.Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect.These symptoms include but are not limited to.Aggressive and/or catastrophic reactions of residents.outbursts or yelling out.difficulty in adjusting to new routines.Abuse includes.Resident to resident abuse of any type.Types of abuse.Verbal abuse.Mental abuse.Resident to Resident Abuse.Any individual who witnesses resident-to-resident abuse will immediately separate and protect the residents involved.Staff member(s) will maintain the resident initiating the abuse under direct supervision until the initial investigation is complete and resident safety is maintained.The individual who witness the abuse will report the situation immediately to his/her supervisor and Executive Director. In the event a behavior management plan is unsuccessful, or if the team feels that the inappropriate behavior poses a risk to other residents, the facility reserves the right to transfer/discharge the resident following the transfer/discharge policy .Based on the root cause, ED/Designee will determine how care provision will be changed.All residents will be protected from physical and psychological harm during and after the allegation and investigation. This will include.Responding immediately to protect the alleged victim and protect the integrity of the investigation.Provide increased supervision of the alleged victim and other residents.Implement room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.Provide emotional support and counseling to the resident during and after the investigation if needed .In cases where an altercation has occurred but does not meet the criteria for reporting, the facility must meet the following requirement.Providing care and services according to acceptable standards of practice to prevent harm as a result of resident-to-resident altercations .It is the responsibility of every employee.to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director A current facility policy, titled Resident Rights, dated as last revised 2/2019 and received from the ED on 3/30/26 at 10:26 a.m., indicated .This facility recognizes that each resident has the right to a dignified existence.This facility will protect and promote the rights of each resident.410 IAC (Indiana Administrative Code)3.1-27(a)(1)410 IAC (Indiana Administrative Code)3.1-27(b)

Based on observation, interview and record review, the facility failed to ensure refrigerated items were labeled with a received dated and disposed of by the discard date in 2 of 2 reach-in refrigerators reviewed in the kitchen. This deficient practice had the potential to affect 81 of 81 residents who received food from the kitchen. Findings include:During an observation and interview, on 1/5/26 at 9:47 a.m., five (5) gallons of 2% milk were in the reach-in refrigerator and did not a have a receive date label. Culinary manager 12 indicated she would place received dates on them. During an observation and interview, on 1/5/26 at 9:50 a.m., there was one (1) cottage cheese container which had a use by date of 12/29/25 and another cottage cheese container which was not labeled with a received date and had a best by date of 12/28/25. Neither had been discarded. Culinary manager 12 indicated both containers should have been discarded.During an interview, on 1/9/26 at 10:36 a.m., the Director of Nursing indicated there were no residents in the building with a nothing by mouth (NPO) diet. A current facility policy, titled Labeling and Dating, dated 5/2018 and received from the Director of Nursing on 1/8/25 at 11:25 a.m., indicated .Any refrigerated opened item that has not been cooked can be stored for 7 days. Label with the date item is placed in storage and the date of discard - add 6 to today's date. *Examples: canned fruit, cottage cheese, sour cream, yogurt and milk 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure staff wore the appropriate Personal Protective Equipment when entering isolation rooms and to ensure a 2-Step tuberculosis test was documented as completed in the recommended timeframe for 4 of 8 residents and 1 of 5 new employees reviewed for infection control. (Resident 44, 48, 53, 56 and Activity Assistant 7)Findings include:During a telephone interview, on 1/6/26 at 8:30 a.m., a resident's family member indicated one of their concerns was the facility had a Covid outbreak and the staff were not wearing PPE such as gowns and masks when entering the rooms.1. During an observation, on 1/5/26 at 10:53 a.m., an isolation cart was observed outside the residents' room and signs indicated the room was a droplet/contact precaution isolation room. The sign indicated, in addition to standard precautions, everyone must wear a gown, an N95 Respirator (a specific mask), eye protection, and gloves. The room was a double occupancy room shared by Resident 44 and 48.During an observation, on 1/5/26 at 3:31 p.m., QMA 6 was observed to enter the room wearing a surgical mask only.During an interview, on 1/5/26 at 3:33 p.m., QMA 6 indicated she did not have a reason why she did not use the PPE required to enter the room.a. The clinical record for Resident 48 was reviewed on 1/9/26 at 9:21 a.m. The diagnoses included, but were not limited to, basal cell carcinoma of the skin, dementia with other behavioral disturbance, and schizoaffective disorder. A nursing progress note, dated 12/27/25 at 9:09 p.m., indicated the resident was on Covid precautions due to exposure.b. The clinical record for Resident 44 was reviewed on 1/5/26 at 10:54 a.m. The diagnoses included, but were not limited to, coronary artery disease, hypertension, and anemia.The resident was documented to be Covid positive until 1/6/26.2. During an observation, on 1/5/26 at 10:40 a.m., an isolation cart was observed outside the residents' room and signs indicated the room was a droplet/contact precaution isolation room. The sign indicated, in addition to standard precautions, everyone must wear a gown, an N95 Respirator (a specific mask), eye protection, and gloves. The room was a double occupancy room shared by Resident 53 and 56.During an observation, on 1/5/26 at 3:27 p.m., CNA 4 was observed entering the residents' room wearing a surgical mask and gloves. CNA 4 was not observed to use a gown, N95 mask, or eye protection.During an interview, on 1/5/25 at 3:39 p.m., CNA 4 indicated she was not aware both residents were positive for Covid and thought it was only Resident 53.a. The clinical record for Resident 53 was reviewed on 1/5/26 at 10:40 a.m. The diagnoses included, but were not limited to, alcohol dependence with alcohol-induced persisting dementia, 2019-nCoV acute respiratory disease, and major depressive disorder.A physician's order, dated 12/28/25, indicated Resident 53 was on droplet precautions for Covid 19 until 1/6/26.b. The clinical record for Resident 56 was reviewed 1/9/26 at 9:09 a.m. The diagnoses included, but were not limited to, Alzheimer's dementia, hyperlipidemia, and major depressive disorder.A physician's order, dated 12/28/25, indicated Resident 53 was on droplet precautions for Covid 19 until 1/8/26.3. The employee records were reviewed on 1/7/26 and 1/8/26.Activity Assistant 7 was hired on 3/26/25. The employee received the first tuberculosis test on 2/24/25 at 12:00 p.m. The results were read on 2/26/25 at 2:00 p.m.The employee received the second tuberculosis test on 4/8/25 at 1:00 p.m. The results were read on 4/10/25 at 2:00 p.m.During an interview, on 1/8/26 at 11:03 a.m., the Director of Nursing indicated the wrong date was documented on the form for the tuberculosis second step test.During an interview, on 1/8/26 at 3:11 p.m., the Director of Nursing indicated new employees were to have a first step tuberculosis test and then between 1-3 weeks later the second tuberculosis test. She indicated the wrong date was documented on the form it should have been documented as completed in March, not April. During the exit conference, on 1/9/26 beginning at 11:17 a.m., the Director of Nursing indicated the wrong date was documented on the tuberculosis testing paperwork. The facility was unable to provide additional documentation.A current facility policy, titled Standard and Transmission-Based Precautions (Isolation) Policy, dated as last revised in 2/2025 and received from the Director of Nursing on 1/7/26 at 11:10 a.m., indicated .DROPLET/CONTACT PRECAUTIONS.is used to designate transmission-based precautions beyond droplet precautions for residents who meet criteria for transmission-based precautions associated with COVID-19, which includes the use of N-95 respirator.Use of Personal Protective Equipment.HCP (health care provider) should wear an N95 or higher-level respirator, eye protection (i.e., goggles or face shield that covers the front and sides of the face), gloves and gown.A current facility policy, titled Tuberculosis Control Program, dated as last revised 1/2022 and received from the Director of Nursing on 1/8/26 at 3:07 p.m., indicated .maintain a program to identify suspected or known TB infection or disease in residents and staff 3.1-18(b)(2)3.1-18(h)

Based on observation, interview and record review, the facility failed to ensure medication carts were free from loose pills, medications contained pharmacy labels, opened medications were labeled with the date the medication was opened, unopened medications which required refrigeration were stored properly, expired medications were not stored in the medication cart, and damaged medication packaging was not secured with tape for 2 of 2 medication carts reviewed for medication labeling and storage. (Willow Bend 2/Moving Forward cart and Augustes Cottage CB cart)Findings include:1. During an observation, on 1/8/26 at 10:03 a.m., the [NAME] Bend 2/Moving Forward medication cart had the following:a. Breztri Aerosphere inhalation (an aerosol respiratory inhaler) with 25 of 28 administrations remaining did not contain a pharmacy label, was not in the medication packaging, and was missing an open date.b. Latanoprost eye drops with instructions to keep the medication refrigerated until it was opened did not have an open date and the sealed medication cap was still present on the bottle.c. An opened haloperidol (an antipsychotic medication) 2 mg/ml (milligram per milliliter) bottle with no open date.d. An opened bottle of nitroglycerin (a medication used for chest pain) with no open date and without a pharmacy label.e. Bisacodyl 5 mg tablets with 26 of 33 doses remaining expired on 10/1/25.f. Fluticasone nasal spray was opened and missing an open date.g. Saline mist nasal spray was opened and was missing an open date.h. Azelastine nasal spray was opened and was missing an open date.i. In the bottom left drawer, there were 3 loose pills.j. Lispro (insulin) with an open date of 1/6/26. The medication seal cap was still present on the bottle with instructions to keep the medication refrigerated until it was opened.k. In the narcotic lock box, there were 3 medication cups with medications present in the cups. Written on medication cup 1 was a room number, written on medication cup 2 were initials, and there was no writing on medication cup 3. A blister pack of PRN (as needed) hydrocodone-acetaminophen (a controlled medication to control pain) was damaged and pocket 6 with the dose present was secured closed with clear tape.l. Sucralfate (a medication for ulcers) 1gm/10ml (gram per milliliter) and with 9 ml remaining was missing an open date.During an interview, on 1/8/26 at 10:16 a.m., LPN (Licensed Practical Nurse) 15 indicated the latanoprost eye drops were delivered on 1/6/26 during the night shift. The medication bottle had a second lid under the seal cap, and she was not sure if the bottle had been opened because the seal cap could be snapped back into place. The medication would be refrigerated until it was opened, and the bottle did not have an open date. LPN 15 was observed to write the date 1/8/26 on the bottle during the interview with the surveyor.In the same medication drawer, a second bottle of latanoprost for the same resident had the seal cap removed from the bottle was dated to have been opened on 1/8/26.During an interview, on 1/8/26 at 10:42 a.m., the ADON (Assistant Director of Nursing) indicated the 3 medication cups with medications present should not have been stored in the cart, expired medications were to be pulled out of the medication carts, unopened medications with instructions to be kept refrigerated would be stored per the instructions on the medication bottle, and when a nurse opened a new medication for administration they would write the date the medication was opened.During an interview, on 1/8/26 at 11:09 a.m., RN (Registered Nurse) 17 indicated the 3 medication cups were in the narcotic lock box because the residents were not in their rooms when she attempted to administer the medications.2. During an observation, on 1/8/26 at 11:29 a.m., Augustes Cottage CB medication cart had the following:a. In the bottom left drawer, there were 2 loose pills.b. In the narcotic lock box, a blister pack of lorazepam (a controlled medication for anxiety) contained clear tape on pocket 15, and the medication was not present in the pocket. A blister pack of tramadol (a controlled medication to control pain) contained clear tape on pocket 7, and the medication was not present in the pocket.During an interview, on 1/8/26 at 11:34 a.m., QMA (Qualified Medication Aide) 20 indicated he did not put the tape on the back of the blister packs, and the medications should have been disposed of.During an interview, on 1/9/26 at 11:02 a.m., the DON (Director of Nursing) indicated the facility followed their medication pass procedure and the facility did not have a policy for medication administration.A document, titled Medication Administration (Medication Pass Procedure), dated as last revised 4/2025 and received from the DON on 1/9/26 at 10:36 a.m., indicated .Procedure for all medications.Medications are not administered if the prescription label is missing.Medications administered are not expired. Medications with shortened expiration dates (e.g., insulin, eye drops) have date opened on the medication or label.A current facility policy, titled Medication Storage and Expiration Policy, dated 11/2024 and received from the DON on 1/8/26 at 3:07 p.m., indicated .The facility should store medications and monitor expiration dates of medications consistent with applicable state and federal laws and regulations.Once any medication is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications.Facility staff should record the date opened on the primary medication container (vial, bottle inhaler) when the medication as a shortened expiration date once opened.Expired medications should be stored separately from other medications until destroyed or returned.Facility staff may record the calculated expiration date based on date opened on the primary medication container.When an ophthalmic solution or suspension has a manufacturer shortened beyond the use date once opened, facility staff should record the date open.Facility should destroy and reorder medications with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions.Medications should be stored in accordance with manufacturers' recommendations.Medications for each resident should be stored in the containers in which they were originally received.Medications that are expired, discontinued.should be stored separately, away from use, until destroyed or returned to the provider.Effect of Non-Compliance: May result in receipt of a federal deficiency.3.1-25(j)3.1-25(k)(1)3.1-25(k)(2)3.1-25(k)(3)3.1-25(k)(4)3.1-25(k)(5)3.1-25(k)(6)3.1-25(k)(7)3.1-25 (o)

Based on observation, interview and record review, the facility failed to document a resident's behaviors or distress which required the increase or addition of a psychotropic medication or the non-pharmaceutical interventions used to treat the behaviors for 1 of 5 residents reviewed for unnecessary medications. (Resident 72)Findings include:During an observation, on 1/5/26 at 10:57 a.m., Resident 72 was in bed with her eyes closed and her arm hanging off the bed. During an observation, on 1/5/26 at 2:47 p.m., Resident 72 was in bed with a flat effect and was speaking very slowly. During an observation, on 1/6/26 at 10:05 a.m. and 1:57 p.m., Resident 72 was in her bed with her eyes closed. During an observation, on 1/7/26 at 11:01 a.m. and 2:20 p.m., Resident 72 was asleep in her bed. During an observation, on 1/8/26 at 10:59 a.m., Resident 72 was lying on her side asleep in her bed. During an observation, on 1/9/26 at 10:38 a.m., Resident 72 was slowly ambulating to the bathroom without assistance. The clinical record for Resident 72 was reviewed on 1/7/25 at 12:01 p.m. The diagnoses included, but were not limited to, vascular dementia with anxiety, depressive disorder, anxiety disorder, opioid dependence, chronic pain, severe bipolar disorder with psychotic features, Wernicke's encephalopathy, insomnia, and alcohol dependence in remission. A physician's order, dated 10/16/24, indicated to administer sertraline (an antidepressant medication) 150 milligrams (mg) once a day. A physician's order, dated 12/18/24 and discontinued 5/20/25, indicated to administer Depakote Sprinkles (a seizure medication also used to treat manic episodes related to bipolar disorder) 125 mg twice a day. A physician's order, dated 5/20/25, indicated the Depakote Sprinkles increased to 250 mg twice a day. A physician's note, dated 8/5/25 at 5:37 p.m., indicated Resident 72 and staff denied needs at the time and had no concerns. The resident was walking in the hall with her water bottle to get more ice water. The current prescribed medications include Depakote Sprinkles 125 mg twice a day and 150 mg of sertraline once a day. The note indicated there were no problems with behaviors per the nursing documentation and there was no plan for medication changes or additions. The physician's note did not reflect the increase of the Depakote Sprinkles from 125 mg twice a day to 250 mg twice a day which occurred on 5/20/25. A psychiatric nurse practitioner progress note, dated 8/13/25, indicated Resident 72 was assessed in her room and was resting soundly in bed. She was not easily aroused by name or touch. The staff reported the resident was at her neurocognitive baseline and was not displaying acute changes in mood or worsening depression. The plan was to continue current medications and to plan discontinuation of the Depakote Sprinkles at a future visit. A nursing progress note, dated 8/14/25 at 1:59 p.m., indicated Resident 72 came to the nurses' station multiple times to ask for water, ice, or a soft drink. A nursing progress note, dated 8/15/25 at 10:20 p.m., indicated Resident 72 had no changes in mood or behavior throughout the shift. A nursing progress note, dated 8/17/25 at 11:29 a.m., indicated Resident 72 had shown no signs or symptoms of obsessive-compulsive behavior during the shift and appeared comfortable. A nursing progress note, dated 8/17/25 at 8:37 p.m., indicated Resident 72 had shown no signs or symptoms of obsessive-compulsive behavior during the shift and appeared comfortable. A nursing progress note, dated 8/18/25 at 2:12 p.m., indicated Resident 72 was in her room resting with no new behaviors noted during the shift. A nursing progress note, dated 8/19/25 at 3:07 p.m., indicated Resident 72 was in her room resting with no new behaviors noted during the shift. A nursing progress note, dated 8/21/25 at 12:48 p.m., indicated Resident 72 was at the nurses' station multiple times asking for ice. An interdisciplinary team behavior note, dated 8/22/25 at 1:21 p.m., indicated Resident 72 had been exhibiting repetitive behaviors. The immediate interventions were to offer the resident reminders she had ice in her room and to provide ice as requested. A nursing progress note, dated 8/25/25 at 2:25 p.m., indicated Resident 72 had been given ice during the shift and had not exhibited any signs of repetitive behaviors. A nursing progress note, dated 8/25/25 at 10:28 p.m., indicated Resident 72 was in her room resting with no new behaviors noted this shift. An acute care physician's progress note, dated 8/27/25, indicated the physician did not have any plan to adjust the resident's medications for dementia, bipolar, depression, or anxiety. It did not indicate any increase in behaviors or psychotic symptoms. A physician's order, dated 9/2/25, indicated the Depakote Sprinkles 250 mg was increased from twice a day to three (3) times a day. A physician's order, dated 9/2/25, indicated olanzapine (an atypical antipsychotic medication) 2.5 mg at bedtime was added to Resident 72's medication regimen. The physician's order for sertraline 150 milligrams once a day was changed to 50 mg once a day, on 9/10/25. On 10/7/25, the sertraline was then increased to 100 mg once a day. A psychiatric nurse practitioner progress note, dated 9/16/25, indicated the staff had reported an increase in attention-seeking behaviors. Resident 72 was calm and cooperative, denied depression, anxiety or hallucinations. The resident was now on an antipsychotic medication, olanzapine, which had started before the psychiatric visit. There were no progress notes, assessments or events documented in the electronic medical record to indicate Resident 72 had displayed psychotic behaviors, dangerous behaviors, hallucinations, delusions, or incidents where the resident was in distress, not redirectable, or warranted the increase of medication or the addition of an antipsychotic medication. During an interview, on 1/8/26 at 11:35 a.m., the Director of Nursing (DON) indicated the facility's procedure was to hold an interdisciplinary team (IDT) meeting with clinical staff and social work to discuss new medications or medication changes. The facility could not provide any further documentation of increased behaviors, or the non-pharmaceutical interventions attempted. During an interview, on 1/7/25 at 9:35 a.m., LPN 15 indicated behaviors were documented in the notes, and the physician should be informed. A current facility policy, titled Psychotropic Management, dated as revised 7/2025 and provided by the DON on 1/8/26 at 3:08 p.m., indicated .A psychotropic drug is any drug that affects brain activities associated with mental process and behavior.Anti-psychotics; Anti-depressant; Anti-anxiety; and Hypnotic .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition.Prior to initiating a psychotropic medication, an assessment by the IDT/prescriber will be made of the resident including other potential causes of the behavior, as well as non-pharmacological interventions that have been attempted. Symptoms and therapeutic goals must be clearly documented prior to initiating or increasing.Prescribers should consider the potential risks, benefits and outcomes of psychotropic medications before prescribing.they should consult with the resident/responsible party to review the indication for use potential risks and benefits and respond to questions.For antipsychotic medications, diagnoses alone do not.warrant the use.Antipsychotic medications may be indicated if: a. behavioral symptoms present a danger to the resident or others; b. expressions or indications of distress that are significant distress to the resident; c. Non-pharmacological approaches have been attempted, but did not relieve the symptoms which are presenting a danger or significant distress. 3.1-3(w) 3.1-26(a)

Based on observation, interview and record review, the facility failed to ensure furnishings remained in a safe and homelike condition in 1 of 1 dining room observed for environment. (Men's Memory Care Unit)Findings include:During an observation, on 1/5/26 at 11:58 a.m., a dining table placed in front of the nursing station and close to the window was observed to have approximately one quarter of the laminate coating torn off which exposed a composite board surface. A male resident was seated at the spot where the cover was missing and was running his hand on the loose material. There was no debris around the resident to indicate he had removed the table laminate.During an observation, on 1/6/26 at 12:11 p.m., the table was observed in use and in the same condition.During an interview, on 1/7/26 at 8:26 a.m., LPN 9 indicated she was not sure if the table had been reported to maintenance.During an interview, on 1/7/26 at 8:27 a.m., LPN 19 indicated she would put another maintenance request in for the table and the tabletop was peeled off last night (1/6/26).During an observation and interview, on 1/7/26 at 8:40 a.m., Maintenance Supervisor 14 examined the torn tabletop and indicated he was not aware of the concern until this morning. He indicated there could be potential for cuts depending on how someone moved their hand across the table. During an interview, on 1/7/26 at 2:05 p.m., the Director of Nursing indicated the facility did not have a policy on maintaining furnishings or a homelike environment. A current facility document, titled Maintenance Supervisor, updated 12/2014 and received from the Director of Nursing on 1/7/26 at 2:05 p.m., indicated .The Maintenance Supervisor is responsible for providing maintenance services to create a safe, sanitary, and homelike environment for residents, staff and the public 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure oxygen was set on the correct liter flow according to the physician's order for 1 of 4 residents reviewed for respiratory care. (Resident 62)Findings include:During an observation, on 1/6/26 at 10:10 a.m., Resident 62 was receiving oxygen, and it was set between 3 and 3.5 liters. During an observation, on 1/7/26 at 9:07 a.m., Resident 62 was receiving oxygen, and it was set on 3 liters. During an interview, on 1/7/26 at 9:10 a.m., Licensed Practical Nurse (LPN) 11 indicated she changed the setting from 3 liters of oxygen to 2 liters of oxygen. It was supposed to be on 2 liters of oxygen according to the physician's order.The clinical record for Resident 62 was reviewed on 1/6/26 at 12:15 p.m. The diagnoses included, but were not limited to, chronic respiratory failure and sleep apnea. A physician's order, dated 10/22/20, indicated to administer 2 liters of oxygen continuously when the resident was not wearing a BiPAP (Bilevel Positive Airway Pressure) machine. A care plan, dated 10/22/20, indicated the resident had the potential for impaired gas exchange and to administer oxygen at 2 liters as ordered. A vitals tab located in the electronic medical record indicated Resident 62 had the following oxygen documentation:On 12/10/25, 3 liters were administered.On 12/11/25, 3 liters were administered.On 12/12/25, 3 liters were administered.On 12/15/25, 3 liters were administered.On 12/24/25, 3 liters were administered.On 12/26/25, 3 liters were administered.During an interview, on 1/7/26 at 9:11 a.m., the Assistant Director of Nursing (ADON) indicated Resident 62 was supposed to be administered 2 liters of oxygen according to the physician's order.During an interview, on 1/7/26 at 12:17 p.m., the Director of Nursing (DON) indicated the facility used the medication administration policy for their oxygen policy.A current facility policy, titled Medication Administration (Medication Pass Procedure), dated as last revised on 4/2025 and received from the Director of Nursing on 1/7/26 at 12:17 p.m., indicated .The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right Time 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) tracking assessment was transmitted as required for 1 of 1 resident reviewed for MDS. (Resident 12)Findings include:The clinical record for Resident 12 was reviewed on [DATE] at 1:56 p.m. The diagnoses included, but were not limited to, dementia, heart failure, and generalized anxiety.A nursing progress note, dated [DATE], indicated Resident 12 had expired with his family at the bedside.The MDS tracking assessment for the death in the facility was not located in the medical record. During an interview, on [DATE] at 2:18 p.m., MDS Coordinator 1 indicated the assessment for death in the facility needed to be completed in seven days. If the assessment was not completed in seven days, it would be late. The resident should have had the MDS completed by [DATE].During an interview, on [DATE] at 12:18 p.m., the Director of Nursing indicated the facility did not have a policy for MDS. During an interview, on [DATE] at 9:36 a.m., MDS Coordinator 1 indicated the facility used the Resident Assessment Instrument manual for MDS.Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual ([DATE]) was retrieved on [DATE] from Centers for Medicare and Medicaid Services at CMS.gov. The guidance indicated the death in facility tracking record must be completed when the resident died in the facility or when LOA (leave of absence). It must be completed within 7 days after the resident's death, which was recorded in item A2000. It must be submitted within 14 days after the resident's death, which was recorded in item A2000. It may not be combined with any other type of assessment.3.1-31(b)

Based on interview and record review, the facility failed to ensure the Ombudsman was notified of residents' discharge for 2 of 4 residents reviewed for hospitalization. (Resident 21 and Resident 73)Findings include:The clinical record for Resident 73 was reviewed on 1/6/26 at 9:42 a.m. The diagnoses included, but were not limited to, hypertension, Alzheimer's dementia, and major depressive disorder. The clinical record indicated Resident 73 was discharged to a psychiatric facility on 10/29/25. There was no documentation to indicate the Ombudsman was notified of the transfer/discharge in the clinical record. The list of residents on the transfer/discharge notification to the Ombudsman, for October, November and December 2025, was reviewed on 1/6/26 at 3:50 p.m. Resident 73 was not found to be listed on the documents. 2. The clinical record for Resident 21 was reviewed on 1/7/26 at 11:47 a.m. The diagnoses included, but were not limited to, dementia, syncope and collapse, and hypertension. The clinical record indicated Resident 21 was discharged from the facility to the hospital on 3/7/25 and returned to the facility on 3/10/25. Resident 21 also discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation to indicate the Ombudsman was notified of the transfer/discharge in the clinical record. The list of residents on the transfer/discharge notification to the Ombudsman, for September, October, November and December 2025, was reviewed and did not include Resident 21. During an interview, on 1/8/26 at 2:00 p.m., the Executive Director (ED) indicated the list of residents on the monthly discharge summary was every resident's discharge the Ombudsman was notified of. During an interview, on 1/8/26 at 3:45 p.m., Social Service 2 indicated when the Ombudsman was notified of discharges, a discharge summary report was pulled for the month, and the list of residents was populated automatically. Social Service 2 did not add or remove residents from the list and was not sure why the residents were not included in the discharge summary report. A document, titled Family of Social Service Administration, last updated October 2024, indicated .CMS requires nursing facilities to notify the Long-Term Care (LTC) Ombudsman of the majority of residents' transfers and discharges .When a resident is transferred on an emergency basis to an acute care facility and expected to return, the SLTCO must be notified. Information from facilities regarding emergency transfers should be provided in a monthly list to the SLTCO, which should include residents' names, dates of transfer, facilities to which residents were transferred, and reasons for the transfers The facility did not have a policy related to Ombudsman notification. 3.1-12(a)(6)(A)(iv)

Based on interview and record review, the facility failed to ensure a resident or the resident's representative was informed of the risks and benefits of a medication, all available treatment options, and to document their chosen treatment option for 3 of 5 residents reviewed for unnecessary medications. (Resident 72, 73 and 24)Findings include:1. The clinical record for Resident 72 was reviewed on 1/7/25 at 12:01 p.m. The diagnoses included, but were not limited to, vascular dementia with anxiety, depressive disorder, anxiety disorder, opioid dependence, chronic pain, severe bipolar disorder with psychotic features, Wernicke's encephalopathy, insomnia, and alcohol dependence in remission. A physician's order, dated 10/16/24, indicated to administer sertraline (an antidepressant medication) 150 milligrams (mg) once a day. A physician's order, dated 12/18/24 and discontinued 5/20/25, indicated to administer Depakote Sprinkles (a seizure medication also used to treat manic episodes related to bipolar disorder) 125 mg twice a day. A physician's order, dated 5/20/25, indicated the Depakote Sprinkles increased to 250 mg twice a day. A physician's note, dated 8/5/25 at 5:37 p.m., indicated Resident 72 and staff denied needs at the time and had no concerns. The resident was walking in the hall with her water bottle to get more ice water. The current prescribed medications include Depakote Sprinkles 125 mg twice a day and 150 mg of sertraline once a day. The note indicated there were no problems with behaviors per the nursing documentation and there was no plan for medication changes or additions. The physician's note did not reflect the increase of the Depakote Sprinkles from 125 mg twice a day to 250 mg twice a day which occurred on 5/20/25. A psychiatric nurse practitioner progress note, dated 8/13/25, indicated Resident 72 was assessed in her room and was resting soundly in bed. She was not easily aroused by name or touch. The staff reported the resident was at her neurocognitive baseline and was not displaying acute changes in mood or worsening depression. The plan was to continue current medications and to plan discontinuation of the Depakote Sprinkles at a future visit. An acute care physician's progress note, dated 8/27/25, indicated the physician did not have any plan to adjust the resident's medications for dementia, bipolar, depression, or anxiety. It did not indicate any increase in behaviors or psychotic symptoms. A physician's order, dated 9/2/25, indicated the Depakote Sprinkles 250 mg was increased from twice a day to three (3) times a day. A physician's order, dated 9/2/25, indicated olanzapine (an atypical antipsychotic medication) 2.5 mg at bedtime was added to Resident 72's medication regimen. The physician's order for sertraline 150 milligrams once a day was changed to 50 mg once a day, on 9/10/25. On 10/7/25, the sertraline was then increased to 100 mg once a day. A new order document, dated 9/2/25 at 10:56 a.m., indicated Resident 72's representative was notified of an increase in Depakote Sprinkles, decrease in sertraline, and the start of olanzapine. Documentation of a discussion related to alternative measures, risks vs. benefits, or black box warnings for olanzapine was not included in the document. A psychiatric nurse practitioner progress note, dated 9/16/25, indicated the staff had reported an increase in attention-seeking behaviors. Resident 72 was calm and cooperative, denied depression, anxiety or hallucinations. The resident was now on an antipsychotic medication, olanzapine, which had started before the psychiatric visit. An informed consent explaining the risk verses benefits of the prescribed psychotropic medication use, associated black box warnings for the prescribed psychotropic medications, and/or alternative treatment options to the resident's representative could not be found in the electronic health record. During an interview, on 1/8/26 at 11:35 a.m., the Director of Nursing (DON) indicated the facility's procedure was to hold an interdisciplinary team (IDT) meeting with the clinical staff and social services to discuss new medications or medication changes. The psychiatric provider often talked with the resident and family before starting medications, but she did not know who spoke with the resident's representative this time. There were no consents or documentation of anyone talking with the resident and her representative about alternative measures, risks versus benefits, or the black box warnings for any of the medication changes in September and October. The facility could not provide any further documentation of resident or family education or consent. 2. The clinical record for Resident 73 was reviewed on 1/7/26 at 8:33 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, altered mental status, and hyperlipidemia. A physician's order, dated 11/12/25, indicated to administer risperidone (an antipsychotic) 0.25 mg twice a day for dementia with severe agitation. A physician's order, dated 12/5/25, indicated to administer escitalopram oxalate (an antidepressant) 20 mg once a day. An informed consent explaining the risk verses benefits of the prescribed psychotropic medication use, associated black box warnings for the prescribed psychotropic medications, and/or alternative treatment options to the resident's representative could not be found in the electronic health record. During an interview, on 1/7/26 at 11:10 a.m., the Director of Nursing indicated the facility did not have informed consents for the medications. 3. The clinical record for Resident 24 was reviewed on 1/6/26 at 1:56 p.m. The diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, and insomnia. A care plan, dated 10/22/25, indicated Resident 24 was at risk for adverse side effects related to the use of psychotropic medications; antianxiety, antidepressant, and hypnotics. A physician's order, dated 10/22/25, indicated to administer buspirone (an antianxiety medication) 7.5 mg three times a day. A physician's order, dated 11/20/25, indicated to administer Trazodone (an antidepressant medication) 50 mg twice a day. A physician's order, dated 11/11/25 and an increase in dosage dated 12/10/25, indicated to administer Zoloft (an antidepressant medication) 100 mg once a day. An informed consent explaining the risk verses benefits of the prescribed psychotropic medication use, associated black box warnings for the prescribed psychotropic medications, and/or alternative treatment options to the resident's representative could not be found in the electronic health record. During an interview, on 1/7/26 at 12:17 p.m., the DON indicated informed consents would be obtained by the resident or resident representative after receiving a physician's order and before initiating the medication. The facility did not obtain informed consents for Resident 24's prescribed psychotropic medications. During an interview, on 1/7/26 at 1:58 p.m., the DON indicated the facility did not have a policy related to obtaining informed consent but followed the interdisciplinary psychotropic medication new/changed order review guide. A facility document, titled IDT Psychotropic Medication New/Changed Order Review, undated and received from the DON on 1/7/26 at 2:05 p.m., indicated .Any New Or Increase of a psych medication.ex: Antidepressants, Anxiety, Antipsychotic, Mood Stabilizer, Hypnotic, PRN, and medication used to treat a bx [behavior] symptom or mood.Clinical indication for medication use.List non pharmacological interventions attempted prior.Expected benefits from medication use.Potential risks from medication use discussed with resident or resident representative.Black box warning for medication.Discussion of warning held with resident or resident responsible party.Name of resident or responsible party and their response to risk/benefit/alternatives.Informed consent documentation: indication for use.Non Pharmacological interventions attempted (the burden for this is on the IDT, NOT the psych provider! You should have these well documented in the plan of care, and IDT Behavioral Review and the Monthly Behavior Summary.Expected benefits.Potential risks.Resident/RP response. A current facility policy, titled Psychotropic Management, dated as last revised 7/2025 and received from the DON on 1/8/26 at 3:08 p.m., indicated .A psychotropic drug is any drug that affects brain activities associated with mental process and behavior.Anti-psychotics; Anti-depressant; Anti-anxiety; and Hypnotic.Prior to initiating a psychotropic medication, an assessment by the IDT/prescriber will be made of the resident including other potential causes of the behavior; as well as non-pharmacological interventions that have been attempted.The IDT Psychotropic New/Increase Order observation in Matrix should be used for increases or initiation of psychotropic medications.Prescribers should consider the potential risks, benefits and outcomes of psychotropic medications before prescribing.they should consult with the resident/responsible party to review the indication for use potential risks and benefits and respond to questions. 3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure Activity of Daily Living (ADL) care was provided in a safe and comfortable manner for 2 of 3 residents reviewed for ADL care. (Resident B and C)Findings include:A facility reported incident, dated 9/22/25, indicated a staff member had a concern regarding a resident who was treated roughly by a QMA (Qualified Medication Aide).1. The clinical record for Resident B was reviewed on 9/23/25 at 1:45 p.m. The diagnoses included, but were not limited to, dementia with other behavioral disturbances, Alzheimer's disease, generalized anxiety disorder, pain, difficulty in walking, and cognitive communication deficit.A care plan, dated 11/8/22, indicated Resident B required assistance with ADLs including bed mobility and transfers. The interventions included, but were not limited to, assist with bed mobility, transfers, and locomotion/ambulation as needed.A facility document, titled Employee Communication Form, dated 9/19/25, indicated QMA 1 was terminated from the facility for a violation of resident rights related to disregarding resident safety.During an interview, on 9/22/25 at 4:03 p.m., LPN 6 indicated QMA 1 had taken Resident B to the shower room and gave her a shower on 9/15/25. QMA 1 brought the resident back to her room with the resident sitting on the seat of her rollator walker and pushing the resident from the shower room to her bed. LPN 6 heard QMA 1 talk loudly at Resident B to get up, get up, get up. When LPN 6 arrived at the doorway of Resident B's room, she observed QMA 1 attempting to put the resident to bed. LPN 6 felt QMA 1 was being rough with Resident B. LPN 6 told QMA 1 there was a better way to assist the resident to bed, to step out of the room, and she would finish placing Resident B in the bed.During an interview, on 9/22/25 at 7:29 p.m., QMA 1 indicated she had taken Resident B to the shower room and pushed her back to her room with the resident sitting on the seat part of her rollator walker. QMA 1 asked Resident B to stand up, so she could place her in bed, but the resident refused. QMA 1 lifted her up with both her arms under the resident's armpits and placed her on the bed. LPN 6 was standing in the doorway watching her place the resident to bed and told QMA 1 she had been rough with the resident, to step out of the room, and LPN 6 finished placing Resident B in the bed. QMA 1 indicated she did not use a gait belt to transfer the resident onto the bed. During an interview, on 9/23/25 at 11:30 a.m., the Clinical Support nurse indicated QMA 1 did not use a gait belt to transfer the resident from the walker to the bed, and she did not follow the facility policy and procedure.2. The clinical record for Resident C was reviewed on 9/23/25 at 2:15 p.m. The diagnoses included, but were not limited to, Parkinson's disease, vascular dementia, osteoporosis with current pathological fracture, and pathological fracture of the right ankle.A care plan, dated 11/19/20, indicated Resident C had impaired mobility related to the diagnosis of Parkinson's disease and required assistance with ADLs. The interventions included, but were not limited to, assist with incontinence care and observe for signs of pain.A care plan, dated 7/12/23, indicated Resident C was at risk of pain. The interventions included, but were not limited to, leg brace with open knee per order and observe for nonverbal signs of pain: changes in breathing, vocalizations, crying, teeth clenched, changes in posture and sad/worried face.During an interview, on 9/22/25 at 1:50 p.m., the Executive Director indicated QMA 7 was suspended pending investigation related to Resident C's care and had returned to work. Since Resident C fractured her ankle, she required two people to assist with bed mobility and transfers.During an interview, on 9/22/25 at 2:09 p.m., CNA 4 indicated she heard Resident C crying while QMA 7 was providing care. Resident C was being held over toward the wall with QMA 7's hand against her back while she provided incontinence care. Resident C had previously rolled out of bed and broke her ankle and had been more difficult to care for. Resident C needed two caregivers when turning her in the bed because she yelled and cried out in pain whenever she was touched. CNA 4 stopped QMA 7 and immediately told the nurse. During an interview, on 9/22/25 at 4:30 p.m., QMA 7 indicated she was trying to change Resident C's brief. Resident C yelled out while QMA 7 was changing her. She stopped providing care and was going to go tell the nurse Resident C was in pain when CNA 4 walked into the room and told her to stop the care. CNA 4 went and reported her to the nurse, and she was suspended. She was able to come back to work. A current facility policy, titled Ambulation with walker, dated 2/2010 and provided by the Director of Nursing on 9/23/25 at 2:29 p.m., indicated Place the gait belt around the resident's waist. 8. Place walker in front of resident as close to the bed as possible. 9. Have the resident grasp both arms of the walker. 10. Brace the leg of the walker with your foot and place your hand on top of the walker. 11. Assist the resident to stand on count of three.Walk slightly behind and to the affected side of the resident holding onto the gait belt.Remove the gait belt A current facility policy, titled Resident [NAME] of Rights, dated 12/17 and provided by the Director of Nursing on 9/22/25 at 1:50 p.m., indicated .The resident has the right to be treated with consideration, respect and recognition of their dignity and individuality .The resident will have the right to the following.Refuse any treatment or service, including medication This citation relates to Intake 2621869.3.1-38(a)(2)(B)

Based on interview and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed for resident rights. (Resident B)Findings include:A facility reported incident, dated 9/22/25, indicated a staff member had a concern regarding a female resident who was treated roughly by a QMA (Qualified Medication Aide) during care on 9/15/25 at 8:01 p.m. The clinical record for Resident B was reviewed on 9/23/25 at 1:45 p.m. The diagnoses included, but were not limited to, dementia with other behavioral disturbances, Alzheimer's disease, generalized anxiety disorder, pain, difficulty in walking, and cognitive communication deficit.A care plan, dated 10/19/23, indicated Resident B refused medications and ancillary services. The interventions included, but were not limited to, offer other staff as needed, provide Resident B with safety and redirect the resident as needed.A care plan, dated 10/19/23, indicated Resident B had a hearing loss. The interventions included, but were not limited to, facing the resident when speaking, obtain the resident's attention before speaking, speak clearly, and adjust tone as needed. A facility document, titled Employee Communication Form, dated 9/19/25, indicated QMA 1 was terminated from the facility for a violation of resident rights related to disregarding resident safety.During an interview, on 9/22/25 at 4:03 p.m., LPN 6 indicated QMA 1 had taken Resident B to the shower room and gave her a shower on 9/15/25. QMA 1 brought the resident back to her room with the resident sitting on the seat of her rollator walker and pushing the resident from the shower room to her bed. LPN 6 heard QMA 1 talk loudly at Resident B to get up, get up, get up. When LPN 6 arrived at the doorway of Resident B's room, she observed QMA 1 attempting to put the resident to bed. LPN 6 felt QMA 1 was being rough with Resident B. LPN 6 told QMA 1 there was a better way to assist the resident to bed, to step out of the room, and she would finish placing Resident B in the bed.During an interview, on 9/22/25 at 7:29 p.m., QMA 1 indicated she had taken Resident B to the shower room and pushed her back to her room with the resident sitting on the seat part of her rollator walker. QMA 1 asked Resident B to stand up, so she could place her in bed, but the resident refused. QMA 1 lifted her up with both her arms under the resident's armpits and placed her on the bed. LPN 6 was standing in the doorway watching her place the resident to bed and told QMA 1 she had been rough with the resident, to step out of the room, and LPN 6 finished placing Resident B in the bed.During an interview, on 9/23/25 at 11:30 a.m., the Clinical Support nurse indicated QMA 1 was terminated because she did not understand Resident B should not have been placed in bed when she did not get up off her walker. The facility did not find QMA 1 abusive to the resident, but she did violate her resident rights. A current facility policy, titled Resident [NAME] of Rights, dated 12/17 and provided by the Director of Nursing on 9/22/25 at 1:50 p.m., indicated .The resident has the right to be treated with consideration, respect and recognition of their dignity and individuality .The resident will have the right to the following.Refuse any treatment or service, including medication This citation relates to Intake 2621869.3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure a clean, sanitary, and homelike environment was provided for 1 of 12 rooms reviewed for environment. (room [ROOM NUMBER]) Findings include: During an observation, on 7/2/25 at 9:18 a.m., room [ROOM NUMBER] had an old urine smell to it. There were approximately 7 different flies in the room. 2 flies were crawling on top of Resident B as he was sleeping. There were also 2 flies in his cup of juice and a sock on his bedside table. The bedside commode had a very small amount of dark yellow urine in the basin. In room [ROOM NUMBER]'s bathroom, there was a dried, dark drown substance smeared on the toilet with 2 flies crawling on the substance. There was also a puddle of liquid on the floor with dark yellow liquid on the trash can liner. Resident B and C resided in room [ROOM NUMBER]. The clinical record for Resident B was reviewed on 7/2/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia, osteoarthritis, and encephalopathy (a brain disease which could cause confusion). A current care plan, last revised on 6/20/25, indicated Resident B required assistance with toileting due to decreased mobility, weakness, and incontinence. Interventions included, but were not limited to, assistance with incontinence care as needed. The clinical record for Resident C was reviewed on 7/2/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease stage 3, and depressive episodes. A current care plan, last revised on 5/13/25, indicated Resident C required assistance with toileting due to decreased mobility, weakness, incontinence, and the diagnoses of dementia. Interventions included, but were not limited to, assistance with incontinence care as needed. During an interview, on 7/2/25 at 9:25 a.m., Qualified Medication Assistant (QMA) 2 indicated there were several flies in the room. Staff were supposed to clean out the basin after each use of the bedside commode. During an interview, on 7/2/25 at 9:35 a.m., Certified Nursing Assistant (CNA) 3 indicated there was usually a liner placed in the bedside commode and staff would change it after each use. When CNA 3 went into the bathroom, she was observed to shoo away a fly and indicated the dark brown substance on the toilet appeared to be feces. During an interview, on 7/2/25 at 9:38 a.m., Housekeeper 4 indicated she was not sure the last time the bathroom was cleaned. She was usually just a fill in and it appeared to her that the dark brown substance on the toilet appeared to be feces. During an interview, on 7/2/25 at 10:10 a.m., the Executive Director (ED) indicated the housekeepers cleaned up messes, but the CNAs could clean up if the resident had an incontinence episode. During an interview, on 7/2/25 at 12:15 p.m., the ED indicated they did not have a policy which included providing a homelike environment, but it was a mission for the facility. A current facility policy, titled Resident Rights, dated as last reviewed on 7/2023 and received from the Director of Nursing on 7/2/25 at 11:50 a.m., indicated .All staff members recognize the right of residents at all times and residents assume their responsibilities to enable dignity, wellbeing, and proper delivery of care This citation relates to Complaint IN00462246. 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure effective person-centered dementia care was provided to a resident with known physically aggressive behaviors for 2 of 5 residents reviewed for dementia care. (Residents H and J) This deficient practice resulted in an altercation between Resident H and J. Resident J received a fractured left wrist and a laceration above his right eye. The deficient practice was corrected on 7/10/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A facility document, titled Indiana State Department of Health Survey Report System, indicated on 7/2/24 at 9:30 p.m., Resident J complained of arm pain after an interaction with Resident H. Resident J received a fractured ulna (left wrist bone) during the altercation with Resident H. Resident H was sent to a psychiatric hospital for evaluation and treatment. A facility document, titled Event Report, dated 7/1/24 at 7:00 p.m., indicated Resident H was in the dining room hitting other residents in the face. He was removed from the dining room and redirected to his room. He was given medication, then he calmed down. There were other residents affected by his behavior. The other residents were redirected to their rooms to ensure safety. The interventions put into place to prevent another behavior were to administer medications as ordered, redirect to his room, and 15-minute checks for increased surveillance. The facility's investigation indicated an altercation between Residents H and J occurred, on 7/1/24 at approximately 7:00 p.m., on the men's memory care cottage. Staff on the unit were interviewed and no one witnessed the altercation. CNA 2 heard a noise down the hall, went to determine what it was, and observed Residents H and J in the hallway talking to one another. Resident J was asking Resident H to get away from him and indicated Resident H had hit him causing the laceration to his face. On 7/2/24, Resident J complained of left arm pain and the nurse observed his arm to be swollen. X-ray results indicated he had a fractured left wrist. 1. The clinical record for Resident H was reviewed on 7/23/24 at 10:29 a.m. The diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies, psychotic disorder with delusions due to known physiological conditions, schizophrenia, generalized anxiety disorder, major depressive disorder, sleep disorders, and other symptoms and signs involving cognitive functions and awareness. A care plan addressed the resident enjoyed dancing, riding motorcycles, boating, camping and hunting. The approaches included, but were not limited to, 10/23/23, staff would provide the resident with opportunities to utilize strengths, staff would provide the resident with the needed materials to practice his strengths. A care plan addressed the resident enjoyed the following types of activities. He enjoyed reading magazines, loved dogs and listening to music such as classic rock, country and 80's music. He enjoyed watching the local news and westerns on TV. He enjoyed outside activities but had a history of eloping during outside activities. He enjoyed reminiscing on his past experiences. He was in the Army. The approaches included, but were not limited to, 10/23/23, give verbal reminders to resident to remind him of activities of his interest, provide assistance to activities as needed, provide independent supplies for room as needed. A nursing progress note, dated 10/23/23 at 12:40 a.m., indicated Resident H was being very combative. The nurse attempted to redirect the resident, but he went into the TV room, attempted to open the window, and became very combative. He went to the unit's back door and started pushing on it and was redirected to his room. The resident came from his room and as the nurse was walking the resident hit the nurse with a punch. The nurse asked the resident kindly to go get some rest, but the resident went to the nurse's cart and began removing medication cups from the cart and throwing them on the floor. The nurse redirected him to his room, then he came out of his room with a foot pedal in his hand, hiding it at his back, and began swinging it at the nurse, while she was washing her hands in the dinner area sink. The nurse hurriedly came behind the resident, took the foot pedal from him, and redirected him to his room. A nursing progress note, dated 10/27/23 at 12:50 a.m., indicated the resident was going into other residents' rooms. He was redirected by staff to go back to his room. The resident came out of his room walked down the hallway, grabbed the pill crusher off the nurses' cart and attempted to hit staff with it. Staff were unable to get the pill crusher from the resident, so 911 was called. The resident went back to his room. A care plan addressed the problem of the resident exhibited cognitive impairment as evidenced by the resident was severely impaired. The approaches included, but were not limited to, 10/27/23, encourage participation in daily activities particularly regarding orientation, socialization and stimulation, encourage social interaction, give the resident choices throughout the day regarding decisions as able to do so, provide simple instructions and repeat as needed. A nursing progress note, dated 10/30/23 at 8:13 a.m., indicated the resident continued to wander into other residents' rooms. A nursing progress note, dated 10/31/23 at 1:26 p.m., indicated the resident was observed removing the mop from the housekeeping cart. The staff member asked the resident for the mop back and grabbed the handle of the mop, then the resident grabbed the staff member's hand in an aggressive manner and squeezed. The nurse asked the resident calmly to show the staff member how to use the mop and he demonstrated how to use it, then she asked if she was able to use it and he provided the nurse with the mop and walked away. A nursing progress note, dated 11/7/23 at 7:03 a.m., indicated the resident continued to be combative toward peers and staff. The resident attempted to physically hit staff and was involved in several verbal altercations with peers. The resident had to be redirected by staff several times, refused care/hygiene attempts, and was being closely supervised by staff. A nursing progress note, dated 11/7/23 at 2:09 p.m., indicated the resident continued to wander around the unit, going in and out of other residents' room at times and continued to be combative with staff. The resident was given personal space when he became aggressive. A care plan addressed the problem the resident would engage in verbal and/or physical aggression towards staff and/or other residents. He may throw furniture, break items, and try to fight staff members. The approaches included, but were not limited to, 11/7/23, staff members would offer the resident an appropriate activity of the resident's preference, staff members would offer the resident personal space to help the resident calm down, staff members would redirect the resident as needed. A care plan addressed the problem the resident had episodes of intrusive wandering and aggressive episodes toward staff members when providing redirection from other residents' room. The approaches included, but were not limited to, 11/07/23, door identifier to reorient the resident to his room. 11/8/23, staff will offer the resident an activity of their choice. A care plan addressed the problem the resident had signs and symptoms of mood distress. He had a diagnosis of Lewy body dementia and received an antipsychotic medication. Approaches included, but were not limited to, 11/10/23, administer medications and monitor and record effectiveness, encourage the resident to become involved with physical activities and social interactions, obtain a psych consult or psychosocial therapy. A nursing progress note, dated 11/11/23 at 7:30 p.m., indicated the resident spent part of the shift in his room asleep and later came out just before midnight and began pushing and banging on the unit exit door, and depressing the door latch. Any attempt to redirect the resident, he would ball his fist up and attempted to drive his knee into anyone who tried to redirect him. He did this on several occasions and had to be re-redirected. The resident did not take re-direction well and any attempt to further assess the resident failed. A nursing progress note, dated 11/18/23 at 8:41 a.m., indicated Resident H was observed walking the halls and carrying a foot pedal for a wheelchair. He struck another resident with the foot pedal then another resident in a different room began to insert himself into the situation causing Resident H to become even more agitated. He swung the foot pedal even more, refused redirection, continued to carry the foot pedal around and banged it on the walls. The other resident moved away from the initial conflict and allowed Resident H to wander around giving him space to vent. The intervention was somewhat effective. A care plan addressed the problem the resident would engage in verbal and/or physical aggression towards staff and/or other residents. He may throw furniture, break items, and try to fight staff members. The approaches included, but were not limited to, 11/20/23, staff members would monitor the resident closely to prevent any unsafe episodes. 11/20/23, staff members would offer a snack/beverage of his interest. A social service progress note, dated 11/22/23 at 9:16 a.m., indicated the Social Worker met with the resident to check his psychosocial status. Resident H indicated he missed his twin brother who has passed away. His daughter was called to ask her to bring pictures of his brother in and the psychiatric physician was asked to evaluate and treat the resident. A nursing progress note, dated 11/24/23 at 2:08 p.m., indicated the resident was transported for a psychiatric evaluation by ambulance. A care plan addressed the problem the resident had difficulty making himself understood. Approaches included, but were not limited to, the following: 11/28/23, allow the resident time to speak and avoid interruption, provide a quiet, non-hurried environment, free of background noises and distractions, remind the resident to speak slowly and clearly, repeat what the resident said to validate. A psychiatric hospital note indicated Resident H was admitted on [DATE] and discharged on [DATE], for aggression and paranoia. His coping strategies were walking around, singing and dancing, having a snack, sitting with staff and peers, and he liked helping others or being social. A nursing progress note, dated 12/13/23 at 9:39 p.m., indicated Resident H returned to the facility from a psychiatric hospital stay. He was confused and required extra time and guidance with directions. A psychiatric progress note, dated 12/19/23, indicated Resident H was being seen for his initial visit with the psychiatric physician services to assess his current psychiatric status. He had multiple psychiatric hospitalization s with the most recent one on 11/24/23. He was admitted to the facility on [DATE]. He was referred to the psychiatric physician services for management of dementia with behaviors. He was cognitively impaired, speech and thought processes were disorganized and nonsensical. The nursing staff reported the resident had been agitated and physically aggressive towards other residents. Prior to the hospitalization , he threatened to use a foot pedal and pill crusher towards another resident. A nursing progress note, dated 12/30/23 at 11:51 a.m., indicated the nurse was in the common area of the unit when she heard a noise like glass breaking. A CNA called her to the man cave area of the memory care-secured unit where Resident H had picked up a chair and used it to break out a window, then he threw a cup of lemonade on the nurse. The physician was called, and a new order was given for Haldol (an antipsychotic medication) 5 mg (milligrams) for one dose. A psychiatric progress note, dated 1/2/24, indicated Resident H was being seen for a routine follow-up visit to assess his current psychiatric status. The nursing staff reported he had been intrusively wandering and was easily agitated. He had physical aggression and threw a chair through a window on his memory care-secured unit. He was confused at his baseline and his speech was disorganized. Past psychiatric hospitalization s included, but were not limited to, 8/4/23 to 10/16/23 and 11/24/23 to 12/13/23. A nursing progress note, dated 1/9/24 at 3:23 p.m., indicated the resident threw water from the mop on other residents, but he was able to be redirected to his room. A psychiatric progress note, dated 2/5/24, indicated Resident H was being seen for mood and behavioral issues. He was minimally cooperative with the mental status examination. He was positive for visual hallucinations. His insight and judgement were severely impaired. A social service progress note, dated 2/15/24 at 12:21 p.m., indicated the resident was seen by the psychiatric physician. The resident demonstrated confusion with agitation and aggressive behavior, which had been disruptive to the residents on the male memory care-secured unit. A psychiatric progress note, dated 2/20/24, indicated Resident H was being seen to assess his current psychiatric status. His speech was disorganized. He had a history of inpatient psychiatric admissions for psychosis. A nursing progress note, dated 2/26/24 at 4:55 a.m., indicated the resident was found sitting on his roommate's legs. They were fully clothed. The incident appeared to be both the residents' ideas because both residents were observed attempting to get up from a sitting position. They both appeared confused and Resident H was taken to another room. A nursing progress note, dated 2/26/24 at 1:38 p.m., indicated the resident took a mop from the housekeeping staff and hit the staff in the head with the mop. He attempted to hit other residents with the mop but was redirected by staff. A psychiatric general note, dated 2/26/24, indicated Resident H was being physically aggressive towards staff and another resident. His behavior was disruptive and non-pharmacological interventions attempted three times but were ineffective. A telephone order for Haldol 5 mg now for one dose. A nursing progress note, dated 2/27/24 at 9:35 p.m., indicated Resident H was intrusively wandering into another resident's room, while the resident was lying down. The resident got up and began to make contact with the resident. Both residents were scuffling with each other. The residents were separated, and Resident H was redirected and was administered a PRN (as needed) medication. A psychiatric progress note, dated 2/28/24, indicated Resident H was being seen to assess his current psychiatric status. The nursing staff indicated the resident continued to exhibit physical aggression. He was restless and intrusive. The Haldol given on 2/26/24, was effective. A nursing progress note, dated 3/1/24 at 2:16 p.m., indicated the staff was attempting to provide care to the resident and the resident refused. As staff was walking away to allow a cool-off period, the resident made contact with the staff's shoulder. The staff redirected the resident and allowed him personal space to cool-off. A psychiatric general note, dated 3/1/24, indicated Resident H was delusional, hitting staff and barricading himself in his room. He pushed the medication cart into the nurse. A Haldol dose was given and was effective. Haldol was scheduled to be given for three days. He may benefit from a psychiatric stay for further evaluation if the current medication regimen was ineffective. A social service progress note, dated 3/1/24 at 2:18 p.m., indicated the Social Worker notified Resident H's daughter regarding the resident being admitted for an inpatient psychiatric stay. The resident's daughter agreed. A nursing progress note, dated 3/1/24 at 6:49 p.m., indicated the resident was sent to the psychiatric hospital for evaluation and treatment. A psychiatric hospital note indicated Resident H was admitted on [DATE] and discharged on [DATE], for agitation with physical aggression. While hospitalized , the hospital staff reported he displayed behaviors of increased intrusive wandering and physical aggression with staff. He had delusions and believed staff members were trying to harm or kill him. He refused his medications on occasion and became combative depending on the staff member's approach. He was in others' space at times. The staff members had tried to redirect the resident using redirection and reassurance, without success in improving his behaviors. An Interdisciplinary Team (IDT) progress note, dated 3/19/24 at 9:22 a.m., indicated the resident entered another resident's room and started pushing chairs around, then he tried to throw a chair. Staff redirected him several times to get him out of the resident's room. A care plan addressed the problem the resident would engage in verbal and/or physical aggression towards staff and/or other residents. He may throw furniture, break items, and try to fight staff members. The approaches included, but were not limited to, 3/19/24, the resident would continue to be seen by psychiatric services. 3/20/24, weighted blanket as needed for anxiety. A psychiatric progress note, dated 3/21/24, indicated the resident was being seen for mood and behavioral issues. The staff reported the resident demonstrated irritability and aggressive behavior toward staff. During the session, he presented himself as depressed, minimally cooperative, and when asked if he was getting along with others, he shook his head no and pointed to a staff member in the room. An IDT progress note, dated 3/29/24 at 10:02 a.m., indicated Resident H entered another resident's room and put on that resident's shoes. That resident told Resident H to take off his shoes, then Resident H hit the other resident and he fell on the floor during the altercation. Staff redirected the two residents and escorted Resident H to his own room. A nursing progress note, dated 4/4/24 at 12:19 a.m., indicated the resident was walking up and down the unit hallway and opening some of the residents' doors and waking them up. The residents were complaining about his intrusiveness, and he was repeatedly redirected, but he would not comply with any attempts to redirect him. He balled his fist up to hit whoever tried to redirect him. He would not comply with any attempts at redirection. He was offered snacks and juices to drink, which he ate it all up, then started walking again and intruded into things and other residents' rooms. He got on the floor twice and got himself up out of anger. As he continued to walk up and down the hallway, he attempted to pull the side rails from the walls. He went to the man cave sat for a while, then got a wheelchair and started rolling it. He ran the wheelchair into the nurses' station door and ran the wheelchair into a CNA. He was redirected. A PRN order for Haldol was ordered, but not given because the resident went to his room as he was redirected to do so and fell asleep. Any attempts to get his vitals, he balled his fist up as if he was going to hit the staff members. A psychiatric progress note, dated 4/4/24, indicated the resident was being seen for mood and behavioral issues. The resident was being seen due to staff request. The staff reported Resident H had pushed a wheelchair into staff and had been wandering into other residents' rooms. A nursing progress note, dated 4/6/24 at 2:00 p.m., indicated the resident wandered up and down the hallway after lunch and was found in another resident's room. He had taken some of that resident's candy. When the nurse asked the resident to come out of the resident's room, he threw the candy down on the floor and walked out of the room. He would not allow the CNAs to help change him. A nursing progress note, dated 4/8/24 at 1:44 p.m., indicated Resident H went into another resident's room and slept in his bed. He would not come out. He refused to allow the nurse to take his vitals for his weekly skin assessment. He eventually went to his room and laid down. A psychiatric progress note, dated 4/9/24, indicated the resident was being seen to assess his current psychiatric status. Staff reported he was physically aggressive at times. A psychiatric progress note, dated 4/18/24, indicated the resident was being seen for mood and behavioral issues. The staff reported Resident H had been pulling railings off the walls. The resident had a maladaptive communication and comprehension issue, which negatively impacted his treatment. A nursing progress note, dated 5/8/24 at 10:02 a.m., indicated the resident came out of his room for breakfast and while staff was passing out trays he made contact with the staff member's face twice. He then went into another resident's room and made contact with the resident. When redirected he went into the hallway and made contact with a different resident's stomach. A nursing progress note, dated 6/2/24 at 1:34 p.m., indicated the resident was walking around, being aggressive, trying to fight staff and a resident. The physician was called, and an order was given for Zyprexa (an atypical antipsychotic medication) 2.5 mg. The medication was given, and the resident appeared to be a little calmer. A nursing progress note, dated 6/5/24 at 2:30 p.m., indicated the resident was intrusively wandering, then became combative with another resident when staff attempted to redirect him out of the resident's room. He was also combative with staff members and became physically violent with staff members while using current interventions to remove him from the resident's room. The staff were unable to redirect the resident safely. He was allowed to remain inside the resident's room with the door closed. A nursing progress note, dated 6/5/24 at 3:45 p.m., indicated the resident was given as needed (PRN) medication ordered by the psychiatric physician. The resident became aggressive while staff were checking on him for safety and he proceeded to punch the staff member in the face. For safety measures pending an evaluation by a psychiatric hospital, the resident was placed on one-on-one supervision. The resident continued to barricade himself in his room and refused to come out of room. A psychiatric progress note, dated 6/6/24, indicated Resident H was being seen for mood and behavioral issues. The staff reported the resident recently engaged in physical aggression with two other residents. The staff reported nothing appeared to trigger the aggressive behavior. A psychiatric hospital note indicated Resident H was admitted on [DATE] and discharged on [DATE], for confusion and aggression. His coping strategies were socializing and interacting with staff and participating in activities he was able to follow. A care plan addressed the problem the resident would engage in verbal and/or physical aggression towards staff and/or other residents. He may throw furniture, break items, and try to fight staff members. The approaches included, but were not limited to, 6/6/24, offer cool down period as needed for behaviors. 6/6/24, PRN medication as ordered. A nursing progress note, dated 6/19/24 at 1:48 p.m., indicated Resident H returned from a psychiatric hospital stay. The resident was pleasant. A psychiatric progress note, dated 6/20/24, indicated the resident was being seen for mood and behavioral issues. The staff reported Resident H just returned from a week psychiatric stay due to his combative behaviors. A nursing progress note, dated 6/22/24 at 1:31 p.m., indicated the resident was wandering into another resident's room. A Qualified Medication Aide (QMA) attempted to redirect the resident to his room when he balled his fist up and made contact with the QMA's face. The nurse heard the QMA's scream for help and assisted the QMA with the redirection of the resident to his room. While assisting the resident to his room, he showed signs of aggravation. A nursing progress note, dated 6/22/24 at 10:29 p.m., indicated a staff member attempted to get a urinalysis on the resident, but he showed signs of agitation, and he refused his medication in the evening. A psychiatric progress note, dated 6/25/24, indicated the resident was being seen to assess his current psychiatric status. He had multiple hospitalization s. He recently returned from a psychiatric hospital stay where he was admitted for agitation and physical aggression towards staff and other residents. A care plan addressed the problem the resident had episodes of intrusive wandering and aggressive episodes toward staff members when providing redirection from other residents' room. The approaches included, but were not limited to, 6/25/24, allow the resident space and validate his frustrations. 6/25/24, approach the resident calmly when assisting him away from other residents' rooms. 6/25/24, offer assistance to resident to his room/bathroom and dining room when he was wandering aimlessly in the hallway. A significant change Minimum Data Set (MDS) assessment, dated 6/26/24, indicated Resident H had physical behavioral symptoms which placed others at a significant risk for physical injury. The resident wandered and significantly intruded on the privacy or activities of others. A nursing progress note, dated 7/2/24 at 7:26 a.m., indicated the resident continued his intrusive wandering into other residents' rooms. When attempting to redirect the resident, he would become aggressive, and ball up his fist up to strike. He was presently calm, snacks were provided, and he was walking throughout the unit dinner area and hallway with no issues at that time. A nursing progress note, dated 7/2/24 at 8:47 a.m., indicated the resident was being combative and attempting to hit staff members and other residents. A one-time order for Haldol 5 mg was given. A nursing progress note, dated 7/2/24 at 9:38 a.m., indicated the resident was observed sitting in the man cave and was observed grabbing another resident's walker by the activities area. The staff member went to tell the nurse and heard a loud noise. The nurse observed Resident H lying on his back near the couch and lift. The resident got himself off the ground and into a chair. He had complaints of back pain, and a knot was observed on the back of his head. His blood pressure (BP) was 69/46 and a manual BP was 78/48. He became less alert and non-reactive to the sternum rub. The resident was sent out by 911 to the hospital. A nursing progress note, dated 7/2/24 at 9:40 p.m., indicated the resident returned from the hospital and was placed on one-on-one supervision until he was able to be evaluated by psychiatric services or transferred out to a psychiatric hospital. An Interdisciplinary Team progress note, dated 7/2/24 at 8:00 a.m., indicated Resident H was being combative with peers. The immediate interventions were redirection, separation and assist to assigned room. The root cause of his behavioral expression was he was unable to voice his wants and needs effectively, had a diagnosis of dementia, psychotic disorder, schizophrenia, and over stimulation. The resident did not believe his peers belonged in his home. The preventative interventions related to the above root cause was determined to be redirecting the resident to his room and belongings, redirecting the resident to activities going on at that time, assess the resident for unmet needs, order obtained for Risperidone (an antipsychotic medication) and Haldol, the resident was to be checked by the behavioral and medication review, and continue 15-minute checks for increased surveillance. A nursing progress note, dated 7/3/24 at 5:07 p.m., indicated Resident H was transferred to a psychiatric hospital. A care plan addressed the problem the resident had episodes of intrusive wandering and aggressive episodes toward staff members when providing redirection from other residents' room. The approaches included, but were not limited to, 7/2/24, assist the resident to a less stimulating environment (he enjoyed being outside or in his room) and offer one on one conversation (he enjoyed talking about his old motorcycles). 7/3/24, the resident was to have a private room. A care plan addressed the problem the resident would engage in verbal and/or physical aggression towards staff and/or other residents. He may throw furniture, break items, and try to fight staff members. The approaches included, but were not limited to, 7/2/24, dim lights and/or assist resident to less stimulating location such as outdoor patio or his room and validate his frustrations. 7/3/24, 15-minute checks. 2. The clinical record for Resident J was reviewed on 7/23/24 at 2:05 p.m. The diagnoses included, but were not limited to, dementia with agitation, fracture of the lower end of the left ulna, secondary malignant neoplasm of the brain, malignant neoplasm of part of the bronchus or lung, and weakness. An admission MDS assessment, dated 6/10/24, indicated the resident did not display any physical or verbal type of behavior toward other residents or staff. He did display wandering type behavior which significantly intruded on the privacy and activities of others. A physician's progress note, dated 7/2/24, indicated Resident J was seen for left lower arm pain. The resident reported getting in an altercation with another resident. He had pain and swelling to his left forearm and the area was tender to touch. A surgical consult, dated 7/10/24, indicated Resident J presented in the physician's office for a wrist injury, which he injured approximately two and a half weeks ago. He experienced pain and limited use of his left wrist. X-rays indicated he had a fractured left wrist. He was placed in a splint for the next four weeks. During an interview, on 7/19/24 at 2:38 p.m., Resident J indicated Resident H and two other men were in his room and Resident H was sitting on his bed. He told the men to get out of his room. The next thing he knew Resident H and him was wrestling on the bed in his room. When he got up, he had pain in his left wrist. During an interview, on 7/23/24 at 2:41 p.m., Employee 3 indicated there were no activities after 5:00 p.m. The facility was low on activity staff, and they tried to fill in with CNAs who had a day off when they were able to. Some days when there were no activity staff available, the CNAs on the memory care unit were responsible for completing the activities for the day. Resident H responded better when he was doing one-on-one activities. During an interview, on 7/23/24 at 3:31 p.m., CNA 4 indicated Resident H wandered into other residents' rooms. He hit staff and resisted care at times. He did not take redirection well. She was scared of him because he would use his balled-up fist and hit the staff during care. He fought with almost all the residents on the memory care unit. Staff did not do any activities after 5:00 p.m. He was very hard to care for because of his combativeness. During an interview, on 7/23/24 at 3:45 p.m., RN 5 indicated Resident H did wander intrusively into other residents' room. He was combative with the staff. He was strong and quick with his fists. The deficient practice was corrected by 7/10/24, after the facility implemented a systemic plan that included the following actions: Resident H was admitted to an inpatient psychiatric unit for treatment, all residents' safety was ensured, residents were interviewed for abuse, skin assessments were completed on residents, staff were in-serviced on abuse prevention and behavior management and interventions, 1:1 observations collected daily and reviewed by the IDT team for any concerns or changes needed to the plan of care. This citation relates to Complaint IN00437935. 3.1-37(a)

Based on record review and interview the facility failed to investigate an allegation of resident to resident sexual abuse to ensure further potential abuse was prevented from Resident B for 2 of 2 residents reviewed for sexual abuse. (Resident C and D) The Immediate Jeopardy began on (MONTH) 15, 2019, when the facility failed to investigation allegation of resident to resident sexual abuse and subsequently a second sexual abuse occurred by the same resident ( Resident B). The Administrator, Director of Nursing and Regional Nurse Consultant were notified of the Immediate Jeopardy on (MONTH) 30, 2019 at 3:20 p.m. The Immediate Jeopardy was removed on 5/1/19, but the non compliance remained at a lower scope and severity level of pattern, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview, with the Director of Nursing (DON) on 4/30/19 at 12:00 p.m., she indicated she was aware of the sexual allegation on 4/15/19. She started an investigation consisting of interviewing staff and Resident B. She felt Resident B was interviewable despite the resident's cognitive status being severely impaired. Because Resident B indicated to the DON he did not touch Resident C, the DON unsubstantiated the allegation within 2 hours and therefore did not feel it was a reportable because there was not a finding. She also indicated because of Resident B's statement she felt like it did not happen. When the written statement from CNA 1 was requested at this time, she indicated she could not locate the original statement and therefore could not provide it. In an interview, on 4/30/19 at 1:48 p.m., CNA 1 indicated she was working on the all male cottage on 4/15/19 and was walking past Resident B and C's room (they were roommates). She indicated she observed Resident C in Resident B's bed on his back and Resident B in his chair that was turned towards the bed and Resident B was playing with Resident C's genitals. She immediately went to the nurse on duty and reported what she had seen. At that point she also told this allegation to CNA 2 that she was working with at that time. They both went into Resident's B and C's room to change Resident C's brief. At that time, she indicated CNA 2 asked Resident C if he had been touched to which the resident nodded his head yes and when CNA 2 then asked where he had been touched Resident C took her hand in his and placed it on top of his genitals. Again CNA 1 indicated she told the charge nurse and the unit manager who requested her to put her statement in writing, she indicated she did and handed it to the unit manager. She indicated she had been a CNA for [AGE] years with dementia experience and knew to report any type of abuse she witnessed to the nurse on duty. During an interview, on 4/30/19 at 1:20 p.m., the Administrator indicated any sexual abuse should be investigated immediately. She indicated the event on 4/15/19 was not investigated and no intervention were put in place to prevent the sexual abuse from occurring again. A statement from CNA 2 dated 4/20/19 (not timed), indicated about 10:45 a.m., Resident D wandered into Resident B's room and was sitting in a recliner. Resident B was standing in front of Resident D and was playing with Resident D's penis. The LPN 2 was informed and she redirected Resident D and LPN 2 stated Patient doesn't appear to recall occurrence A Reportable occurrence to the Indiana State Department of Health indicated on 4/20/19 at 1:11 p.m., Resident B had intimate contact, by touch with Resident D. 2. The record review for Resident B was completed on 4/30/19 11 a.m. [DIAGNOSES REDACTED]. A plan of care dated 4/4/19 indicated the resident had sexually offensive behaviors. The MDS (Minimum Data Set) Assessment, dated 1/29/19, indicated the resident was cognitively impaired. Progress notes for 4/15/19 did not indicated any event of sexually inappropriate touching with Resident C. 3. The record for Resident C was reviewed on 4/30/19 at 11:15 p.m. [DIAGNOSES REDACTED]. A plan of care dated 1/11/17 indicated Resident C wandered into others rooms and laid himself in other beds. The MDS assessment, dated 2/13/19, indicated the resident was severely cognitively impaired. There were no progress notes on 4/15/19 that indicated he was inappropriately sexually touched by Resident B. An Observation Detail noted dated 4/16/19 at 3:59 p.m., indicated Resident C was moved from room [ROOM NUMBER] (shared with Resident B) to room [ROOM NUMBER] due to room mate incompatibility. 4. The record for Resident D was reviewed on 4/30/19 at 11:30 p.m. [DIAGNOSES REDACTED]. The MDS assessment, dated 1/29/19, indicated the resident was severely cognitively impaired. An Event report dated 4/20/19 at 1:11 p.m., resident had increased wandering into a peers room. The record Resident D did not contain written documentation of the inappropriate sexually touching by Resident B on 4/20/19. A policy revised on 6/18, provided by the Executive Director on 4/30/19 at 1:58 p.m., titled, Abuse Prohibition, Reporting, and Investigation, indicated .Policy: It is the policy of (name of facility) to provide each resident with an environment that is free from abuse This includes but is not limited to .sexual abuse Investigation: The Executive Director is the designated individual responsible for coordination all efforts in the investigation of abuse allegations In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services Resident to Resident Abuse: 4. The staff member in charge will initiate the investigation immediately 5. The executive Director will be notified immediately of the report and the initiation of the investigation 9. It is the responsibility of the Administrator/Director of Nursing to report abuse, or allegations of abuse, immediately within 2 hours to the Indiana State Department of Health via the gateway system Reporting/Response: 4. It is the responsibility of every employee of (name of company) to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to .the Executive Director 7. The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long Term Care Incident Report Policy. The Immediate Jeopardy that began on 4/15/19 was removed on 5/1/19 when the facility ensured monitoring of residents with 1:1, and frequent checks, completed full body assessments, resident interviews, staff interviews and family interviews. Staff education was completed on prevention, identification, investigation and reporting of abuse. The Immediate Jeopardy was removed on 5/1/19, but the non compliance remained at a lower scope and severity level of pattern, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated on the abuse policy and there was a need for ongoing monitoring for compliance. This Federal tag relates to Complaint IN 244. 3.1-28(d)

Based on record review and interview the facility failed to prevent resident to resident when Resident C and D were touched sexualually by Resident B for 2 of 2 residents reviewed for sexual abuse (Resident C and Resident D). Resident C was inappropriately sexual touched by Resident B and subsequently 5 days later, Resident D was inappropriately sexually touched by Resident B. The Immediate Jeopardy began on (MONTH) 15, 2019, when Resident B was observed to touch Resident's C genitals while Resident C was lying in Resident B's bed. The Administrator, Director of Nursing and Regional Nurse Consultant were notified of the Immediate Jeopardy on (MONTH) 30, 2019 at 3:20 p.m. The Immediate Jeopardy was removed on 5/1/19 at 4:30 p.m., but the non compliance remained at a lower scope and severity level of pattern, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. An incident report form dated 4/15/19 (identified date of incident), provided by the Administrator on 4/30/19 at 11 a.m., indicated on 4/26/19 during the course of the investigation of a separate incident, it was reported by a staff member Resident B was touching Resident C's genital area. An Internal/Resident Event Investigation dated 4/15/19, not timed, indicated Resident C was found in Resident B's bed with only a brief on. There was no further information on the form. A written statement dated 4/22/19 (untimed) by Social Service Support, indicated during her interview with CNA 1, CNA 1 indicated a week ago she had observed Resident C laying on his back with his brief down and Resident B was playing with his private area. She indicated she had notified the Unit Manager and she was asked to write a statement, which she did and gave to the Unit Manger. During an interview, with the Director of Nursing (DON) on 4/30/19 at 12:00 p.m., she indicated she was aware of the sexual abuse allegation on 4/15/19. She started an investigation consisting of interviewing staff and Resident B. She felt Resident B was interviewable despite the resident's cognitive status being severely impaired. Because Resident B indicated to the DON he did not touch Resident C, the DON unsubstantiated the allegation within 2 hours and therefore did not feel it was a reportable because there was not a finding. She also indicated because of Resident B's statement she felt like it did not happen. When the written statement from CNA 1 was requested at this time, she indicated she could not locate the original statement and therefore could not provide it. During an interview, with the unit manager on 4/30/19 at 12:30 p.m., she indicated CNA 1 reported to the nurse on 4/15/19 she thought Resident B was touching Resident C because his hand was over Resident's C brief. CNA 1 reported to her Resident C was in Resident B's bed with only a brief on and Resident B was standing or leaning over him from his recliner touching Resident C inappropriately. The unit manager indicated this was a serious allegation so she immediately reported this to the Administrator and the DON. During an interview, on 4/30/19 at 12:51 p.m., CNA 2 indicated she was working with CNA 1 on 4/15/19 when she reported to her she just caught Resident B playing with Resident C's penis. She also indicated CNA 1 reported this to the nurse prior to discussing it with her. At that point CNA 2 indicated she and CNA 1 went into the resident's room where Resident B was in his own bed with his brief secured in place. CNA 2 indicated she asked Resident C if he had been touched and he nodded his head yes, next she asked him where and at that point she indicated Resident C took her hand and placed it on his penis. She indicated she was not interviewed by management pertaining to the allegation at that time other than the Unit manager asking her if she thought Resident B would do that. During an interview, on 4/30/19 at 1:16 p.m., LPN 3 indicated she was the nurse on duty on 4/15/19 and CNA 1 reported to her another resident was in another resident's bed and was touching the other resident. She indicated she then went into the room with CNA 1 and Resident B was observed to be in his recliner. Resident C had a brief on and it was falling down. She and CNA 1 cleaned and dressed Resident C then LPN 3 indicated she reported to the unit manager what CNA 1 had reported to her. She verbally told the unit manager and did not give a written statement. When asked if she felt Resident B was interviewable she replied I do not know. During an interview, on 4/30/19 at 1:20 p.m., the Administrator indicated any sexual abuse should be reported to her immediately and an investigation immediately started there after as well as reporting this to the Indiana State Department of Health. She indicated this did not appear to be sexual abuse by what was reported to her, therefore a thorough investigation and reportable was not completed. She was not aware of the sexual touching until after another sexual touching incident was reported to have occurred on 4/20/19 In an interview, on 4/30/19 at 1:48 p.m., CNA 1 indicated she was working on the all male cottage on 4/15/19 and was walking past Resident B and C's room (they were roommates). She indicated she observed Resident C in Resident B's bed on his back and Resident B in his chair that was turned towards the bed and Resident B was playing with Resident C's genitals. She immediately went to the nurse on duty and reported what she had seen. At that point she also told this allegation to CNA 2 that she was working with at that time. They both went into Resident's B and C's room to change his brief. At that time, she indicated CNA 2 asked Resident C if he had been touched to which the resident nodded his head yes and when CNA 2 then asked where he had been touched Resident C took her hand in his and placed it on top of his genitals. Again CNA 1 indicated she told the charge nurse and the unit manager who requested her to put her statement in writing, she indicated she did and handed it to the unit manager. She indicated she had been a CNA for [AGE] years with dementia care experience and knew to report any type of abuse she witnessed to the nurse on duty. In a written statement, dated 4/23/19 the Administrator indicated she recalled hearing the Unit Manager had been given a written statement from CNA 1 and the statement was then given to the DON for review. She was not notified of anything further and no investigation was completed on this event. It had always been the facility internal practice for the DON to notify her immediately if there was an allegation of abuse or reportable of any kind for the facility. 2. A statement from CNA 2, dated 4/20/19 (not timed), indicated about 10:45 a.m., Resident D wandered into Resident B's room and was sitting in a recliner. Resident B was standing in front of Resident D and was playing with Resident D's penis. The LPN 2 was informed and she redirected Resident D and LPN 2 stated Patient doesn't appear to recall occurrence A Reportable occurrence to the Indiana State Department of Health indicated on 4/20/19 at 1:11 p.m., Resident B had intimate contact, by touch with Resident D. The record review for Resident B was completed on 4/30/19 11 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively impaired. A plan of care dated 4/4/19 indicated the resident had sexually offensive behaviors. A plan of care 4/22/19 indicated the resident was involved with inappropriate sexually touching a peer. Progress notes for 4/15/19 did not indicated any event of sexually inappropriate touching with Resident C. An Event note for 4/20/19 at 1:11 p.m., indicated Resident B had intimate contact with Resident D who had entered Resident B's room. A behavior note dated 4/22/19 at 5:41 p.m. indicated on 4/20/19 Resident B was involved in sexual inappropriate contact with Resident D. The resident voiced he had increased thoughts of sexual nature. Progress notes dated 4/23/19 indicated the Resident B was discharged to Psychiatric Hospital for care. The record for Resident C was reviewed on 4/30/19 at 11:15 p.m. [DIAGNOSES REDACTED]. A plan of care dated 1/11/17 indicated Resident C wandered into others rooms and laid himself in other beds. The MDS assessment,dated 2/13/19, indicated the resident was severely cognitively impaired. There were no progress notes on 4/15/19 that indicated he was inappropriately sexually touched by Resident B. An Observation Detail noted dated 4/16/19 at 3:59 p.m., indicated Resident C was moved from room [ROOM NUMBER] (shared with Resident B) to room [ROOM NUMBER] due to room mate incompatibility. The record for Resident D was reviewed on 4/30/19 at 11:30 p.m. [DIAGNOSES REDACTED]. The MDS assessment,dated 1/29/19, indicated the resident was severely cognitively impaired. An Event report dated 4/20/19 at 1:11 p.m., resident had increased wandering into a peers room. The record Resident D did not contain written documentation of the inappropriate sexually touching by Resident B on 4/20/19. A policy revised on 6/18, provided by the Executive Director on 4/30/19 at 1:58 p.m., titled, Abuse Prohibition, Reporting, and Investigation, indicated .Policy: It is the policy of (name of facility) to provide each resident with an environment that is free from abuse This includes but is not limited to .sexual abuse Investigation: The Executive Director is the designated individual responsible for coordination all efforts in the investigation of abuse allegations In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services Resident to Resident Abuse: 4. The staff member in charge will initiate the investigation immediately 5. The executive Director will be notified immediately of the report and the initiation of the investigation 9. It is the responsibility of the Administrator/Director of Nursing to report abuse, or allegations of abuse, immediately within 2 hours to the Indiana State Department of Health via the gateway system Reporting/Response: 4. It is the responsibility of every employee of (name of company) to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to .the Executive Director 7. The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long Term Care Incident Report Policy. The Immediate Jeopardy that began on 4/15/19 was removed on 5/1/19 when the facility ensured monitoring of residents with 1:1, and frequent checks, completed full body assessments, resident interviews, staff interviews and family interviews. Staff education was completed on prevention, identification, investigation and reporting of abuse. The Immediate Jeopardy was removed on 5/1/19, but the non compliance remained at a lower scope and severity level of pattern, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated on the abuse policy and there was a need for ongoing monitoring for compliance. This Federal tag relates to Complaint IN 244. 3.1-27(a)(1)

Based on record review and interview the facility failed to asses a known worsening wound and notify the physician for possible change in treatment timely for 1 of 3 residents reviewed for skin conditions. (Resident B). Resident B had a worsening wound to her Left Lower Extremity, and the wound was not assessed and the physician notified for treatment when the wound had increased drainage. The resident was admitted to the hospital for an amputation. Findings include: The record for Resident B was reviewed on 5/18/2017 at 3:00 p.m. [DIAGNOSES REDACTED]. Resident cognition indicated resident B was severely impaired. A care plan dated 4/13/2017 for Resident B indicated resident had impaired skin integrity, open areas, and left lower extremity (LLE) [MEDICAL CONDITION], left medial foot and left lateral foot. Target goal was for wound to heal without complications by 7/19/2017. Interventions included, but were not limited to, assess wound weekly documenting measurements and description, notify MD of worsening or no change in wound or for signs of infection,and observe for signs and symptoms of infection: redness, pain, drainage, malodorous drainage, fear, and increase in size/depth of wound. A care plan dated 7/11/2012 for Resident B indicated resident was at risk for further skin breakdown due to decreased mobility. Target Goals was to be free from skin breakdown 6/22/2017. Interventions included but were not limited to assess and document skin condition weekly and as needed. Notify MD of abnormal findings. A nursing progress note dated 4/26/2017 at 10:42 p.m., indicated resident post ATB with no adverse reactions. Wound care completed to LLE this shift. LLE has no signs and symptoms (s/s) of infection no warmth to area, or abnormal drainage and no odor, but wounds are black and hardened and not healing properly. Wound care team will assess resident tomorrow morning. A nursing progress note dated 4/27/2017 at 5:18 p.m., indicated IDT (interdisciplinary team) wound review, resident noted with neurotic wounds to LLE including left posterior calf, left lateral calf and left heel. MD notified and ordered to have resident evaluated at (Name of Hospital) Wound Center. New treatment orders obtained, (Name of Hospital) Wound Clinic contacted and appointment scheduled for 5/1/2017 at 10:00 a.m. Care plan and profile updated at this time. A nursing progress note dated 4/29/2017 at 4:31 p.m., indicated wound dressing was changed per order. A nursing progress note dated 4/30/2017 at 3:20 p.m., indicated increased drainage to left posterior calf noted during dressing change. Skin discoloration on LLE. Resident has wound care scheduled for tomorrow 5/1/17 at 10 a.m. A wound clinic report dated 5/1/2017, received from the DON on 5/18/2017 at 3:34 p.m., indicated LLE dry gangrene lateral calf to 5th toe, tender red swollen, dorsal foot with slough and [MEDICAL CONDITION]. Wet appearing gangrene there. The skin temperature was warm. There was moderate [MEDICAL CONDITION]. Sensory perception is decreased. Dorsalis Pedis pulses were taken by doppler and are present. Posterior Tibial pulses were taken by doppler and were absent. Patient here for initial visit, exam shows signs of [MEDICAL CONDITION]. There was ongoing [MEDICAL CONDITION] and skin had gangrene (dry and possibly wet as well). Patient needs vascular evaluation, IV antibiotic, pain control. Prognosis for healing was poor due to gangrene. Suspect likely to require amputation. Risks if left un treated include worsening pain, infection,[MEDICAL CONDITION], death. Arranged to admit to the hospital. An emergency admit report on 5/1/2017, received from the DON on 5/18/2017 at 4:40 p.m., indicated Resident B was directly admitted to hospital from the wound clinic, full thickness necrosis from the proximal and lateral malleolus and her foot. This was full thickness necrosis including the subcutaneous fat and dermis. Operating hospital procedure note on 5/2/2017, received from the DON 5/18/2017 at 4:40 p.m., indicated the leg was unreconstructable, evaluation leg was ischemic with large necrotic areas throughout the leg with full thickness skin lose, starting recommendation was for an amputation. Patient tolerated procedure. During an interview on 5/22/2017 at 4:10 p.m., with the Director of Nursing, she indicated nursing progress notes did not indicate on 4/28/2017 and 4/29/2017, an assessment of the wound occurred. On 4/30/2017, after the wound assessment, the MD was not notified of the increased and new wound drainage. She indicated the 4/27/2017 wound measurement skin weekly event was not completed. The last assessment competed was 4/20/2017. During an interview on 5/22/2017 at 4:10 p.m., with the Assistant Director of Nursing, she indicated nursing progress notes did not indicate on 4/28/2017 and 4/29/2017 an assessment of the wound occurred. On 4/30/2017 after the wound assessment, the MD should have been notified of the wound drainage observation. She indicated the 4/27/2017 wound measurement skin weekly event was not completed. The last assessment completed was 4/20/2017. She indicated the family was aware of the residents condition. This Federal tag related to complaint IN 771. 3.1-37(a)

Based on record review and interview the facility failed to notify the Physician (MD) of a change in a resident skin condition for 1 of 3 residents reviewed for skin conditions. (Resident B). Resident B had increased drainage to a worsening wound and was admitted to the hospital for and amputation. Findings include: The record for Resident B was reviewed on 5/18/2017 at 3:00 p.m. [DIAGNOSES REDACTED].Resident cognition indicated resident B was severely impaired. A care plan dated 4/13/2017, indicated the resident had impaired skin integrity, open areas, and left lower extremity (LLE) [MEDICAL CONDITION], left medial foot and left lateral foot. Target goal was for wound to heal without complications by 7/19/2017. Interventions included, but were not limited to, assess wound weekly documenting measurements and description, notify MD of worsening or no change in wound or for signs of infection, and observe for signs and symptoms of infection: redness, pain, drainage, malodorous drainage, fear, and increase in size/depth of wound. A care plan dated 7/11/2012, indicated the resident was at risk for further skin breakdown due to decreased mobility. Target Goals was to be free from skin breakdown by 6/22/2017. Interventions included but were not limited to assess and document skin condition weekly and as needed. Notify MD of abnormal findings. A nursing progress note dated 4/26/2017 at 10:42 p.m., indicated the resident was post ATB with no adverse reactions. Woundcare completed to LLE this shift. LLE has no signs and symptoms (s/s) of infection no warmth to area, or abnormal drainage and no odor, but wounds are black and hardened and not healing properly. Wound care team will assess resident tomorrow morning. A nursing progress note dated 4/27/2017 at 5:18 p.m., indicated IDT (interdisciplinary team) wound review, resident noted with neurotic wounds to LLE including left posterior calf, left lateral calf and left heel. MD notified and order received to have resident evaluated at (Name of Hospital) Wound Center. New treatment orders obtained, (Name of Hospital) Wound Clinic Contacted and appointment scheduled for 5/1/2017 at 10:00 a.m. Care plan and profile updated at this time. A nursing progress note dated 4/29/2017 at 4:31 p.m., indicated wound dressing changed per order. A nursing progress note dated 4/30/2017 at 3:20 p.m., indicated increased drainage to left posterior calf noted during dressing change. Skin discoloration on LLE. Resident has wound care scheduled for tomorrow 5/1/17 at 10 a.m. A wound clinic report dated 5/1/2017, received from the DON on 5/18/2017 at 3:34 p.m., indicated LLE dry gangrene lateral calf to 5th toe, tender red swollen, dorsal foot with slough and [MEDICAL CONDITION]. Wet appearing gangrene there.The skin temperature was warm. There was moderate [MEDICAL CONDITION]. Sensory perception was decreased. There is ongoing [MEDICAL CONDITION] and skin has gangrene (dry and possibly wet as well). Patient needs vascular evaluation, IV(intraveneous) antibiotic, pain control. Prognosis for healing is poor due to gangrene. Suspect likely to require amputation. Risks if left un treated include worsening pain, infection,[MEDICAL CONDITION], and death. Arranged to admit to the hospital. An emergency admit report on 5/1/2017, received from the DON on 5/18/2017 at 4:40 p.m., indicated Resident B was directly admitted to hospital from the wound clinic, full thickness necrosis from the proximal and lateral malleolus and her foot. This was full thickness necrosis including the subcutaneous fat and dermis. Operating hospital procedure note on 5/2/2017, received from the DON 5/18/2017 at 4:40 p.m., indicated the leg was unreconstructable, evaluation leg was ischemic with large necrotic areas throughout the leg with full thickness skin lose, starting recommendation was for a though knee versus above the knee amputation. Patient tolerated procedure. During an interview on 5/22/2017 at 4:10 p.m., with the Director of Nursing, she indicated on 4/30/2017after the wound assessment indicated increased drainage, the MD was not notified of the change in wound condition. During an interview on 5/22/2017 at 4:10 p.m., with the Assistant Director of Nursing, she indicated the MD should have been notified of the wound drainage observation on 4/30/17. This Federal tag related to complaint IN 771. 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure hydration needs were met to prevent significant dehydration and hospital admission for 1 of 3 residents reviewed for hydration needs. (Resident B) Finding includes: The record for Resident B was reviewed on 4/14/16 at 10:23 a.m. [DIAGNOSES REDACTED]. Admission assessment, dated 3/28/16, indicated the residents oral mucous was moist and intact and was a full code. Progress notes, dated 3/28/16, indicated the resident was alert and oriented x 2, and was able to verbalize needs and wants to staff, able to take medications without difficulty, and the family was very involved. A 3/29/16 hydration assessment indicated the resident needed assistance with food and fluids and the resident needed individualized interventions to meet fluid needs and if the intake of fluids provided decreased, then the physician would be notified. A plan of care, dated 3/29/16, indicated the resident was at risk of fluid imbalance, with approaches that included, but were not limited to, encourage fluids, record intake, and notify the physician of dry mucous membranes, change in mental status and poor skin tugor. A plan of care, dated 3/30/16, indicated the resident refused his medication or spit them out at times, with approaches that included, but were not limited to, staff will attempt various methods of administration per doctors orders to help the resident take his medications. A nutrition assessment, dated 4/5/16 at 11:23 a.m., from the Dietician, indicated the resident required cueing and staff assistance during meals. The resident's fluid intake was low, less than 1000 milliliters per day. After discussion with he residents daughter who inquired about oral supplements, it was recommended to provide Ensure Plus 237 milliliters at 10 a.m., and 2 p.m., and increase fluids to provide additional 240 milliliters between meals to promote adequate hydration. Physician orders, dated 4/6/16, indicated Ensure plus 237 milliliters twice a day at 10 a.m., and 8 p.m., and offer 240 milliliters of fluid at 10 a.m., 2 p.m., and 8 p.m. The April 2016 Medication Administration Record [REDACTED] The record indicated the following amounts of fluids consumed daily, and daily amounts were not totaled by the facility to ensure fluid needs were met. 4/3/16 840 milliliters 4/4/16 340 milliliters 4/5/16 500 milliliters 4/6/16 170 milliliters 4/7/16 797 milliliters 4/9/16 765 milliliters 4/10/16 540 milliliters A progress note, dated 4/10/16 at 6:58 p.m., indicated, Resident daughter came in due to the visitors, calling her complaining resident did not look right to them Vital signs were taken and blood pressure was 110/63, pulse was 88 and heart rate was 18, pulse oximetry was 95 % and blood sugar was 144. Resident appeared to be in no distress .due to the family demanding the resident be sent out, resident was sent out 911. On 4/10/16 at 6:40 p.m., a Physician Communication Tool indicated the resident was a full code, skin was warm and dry, he was alert and oriented and confused, the problem uncertain, patient deteriorating and family requested A event note, dated 4/10/16 and timed 7:02 p.m., indicated at 6:17 p.m., the resident was in bed, was pocketing medications in his mouth and talked resident into swallowing his medications and under note their effectiveness documented was not effective. The note indicated the physician was notified and the daughter was notified. Interventions included educate resident on swallowing meds. A (Name of Hospital) emergency room note, dated 4/10/16, indicated the resident had a temp of 100.1 degrees Fahrenheit (F), had reminence of medications on tongue and roof of mouth upon arrival, had altered mental status and somnolence. He was found unresponsive at the Nursing Home and his mouth was dry, and his tongue was coated with yellow film. He was given 1000 milliliters of fluid intravenous over 1 hour at 7:35 p.m., and at 8:49 p.m. (Name of Hospital) laboratory report, dated 4/10/16, indicated the resident's chloride was 119 (high, normal 96-106), Sodium was 153 (high, normal 135-145) his BUN (Blood Urea Nitrogen) was 91 (high, normal 7-20), Creatinine was 4.02 (high, normal 0.7-1.2). A (Name of Hospital) physician note, dated 4/10/16, indicated the resident was significantly dehydrated and the resident would be admitted to the hospital on the Progressive care unit. The resident was hypernatremic (high sodium) and hyperchloremic (high chloride) and had a total body free water deficit was 3.5 liters. The note indicated the resident had apparently has been pocketing food in his mouth and had Acute [MEDICAL CONDITION] secondary to dehydration. Additional information was requested regarding Resident B's intakes and delay in implementing hydration recommendations on 4/18/16 at 10:50 a.m. On 4/18/16 at 12:10 p.m., the DON indicated she had no further information to provide. This Federal tag relates to complaint IN 967. 3.1-46(b)

Based on interview and record review, the facility failed to prevent a fall resulting from a staff to resident behavioral interaction resulting in the resident sustaining a fractured right hip and being hospitalized for [REDACTED]. (Resident E) Findings include: Resident E's record was reviewed on 2/26/16 at 2:18 p.m. [DIAGNOSES REDACTED]. Annual MDS (Minimum Data Set) Assessment, dated 12/20/15, indicated the resident's BIMS (Brief Interview Mental Status) was a 15. The resident had a Care Plan, dated 1/20/15, which indicated he had a behavior he exhibited verbal aggressive behaviors of yelling out and cursing at staff and he had a [DIAGNOSES REDACTED].#2 provide Resident personal space during acute periods The resident had a Care Plan, dated 2/6/15, which indicated he had a behavior of periods of physical aggression as evidenced by attempting and throwing items and hitting others with his wheelchair. Approaches included, but were not limited to, .2/6/15--Intervention #2 provide personal space when appropriate The resident had a Care Plan, dated 2/11/15, which indicated he had periods of refusing care as evidenced by refusing medications and care usually when upset regarding other factors. Approaches included, but were not limited to, 2/11/15--Do Not Challenge-Inform Physician . 2/11/15--re-approach at later time. A document titled A Fall Event, dated 2/17/16 at 11:57 p.m., indicated the resident had a witnessed fall. Prior to the fall according to the aide the resident was running in the hallway and fell back when he grabbed at the door. He was sitting on the floor in the hallway when the nurse observed him on the floor. He complained of left hip pain and was sent to the emergency room . A Progress note, dated 2/18/16 at 12:18 a.m., indicated Writer was passing medication in another hallway when aid told writer resident was running in hallway and fell . Aid said resident was upset that his bathroom was dirty and pacing down the hallway and got upset when Aid bought a coke and cookies for residents room mate. Writer can confirm that resident had walked down and back the hallway that the writer was currently passing meds. Resident had stopped writer to complain that the aid had not cleaned the mess his room mate had made in their bathroom. Shortly after the resident had left aid had told writer that the resident had fallen. When writer approached resident, resident was sitting on the hallway floor scooting to his room. Resident said he had fallen on his surgical hip and couldn't get up and requested 911 and police be called. Writer helped resident to side railing and at the request of the resident, brought his rolling walker from his room. Resident was not using his walker at the time of the accident. Resident had said aid had pushed him. Writer contacted DON (Director of Nursing) and 911. Police were also contacted at the request of the resident. However, resident has a behavior history that correlates with aid's story. Behavior eval (evaluation) will be conducted when resident returns. Resident was sent to ER (emergency room ) for further evaluation Writer will contact ER for evaluation. A report sent to the ISDH (Indiana State Department of Health) indicated an incident occurred on 2/17/16 at 10:46 p.m., Resident E was involved with CNA #6. The resident indicated he was pushed by an aide. He had a hip fracture. The follow up section of the report indicated the investigation was completed and showed the resident was exhibiting behaviors at the time of the fall and he fell on his own. An interview with the resident, dated 2/17/16, indicated Resident E had given his roommate four cokes and his roommate had repaid three cokes back to him. CNA #6 bought his roommate a coke when other aides would not do it. She placed the coke on the roommate's table and Resident E took the can of coke from his roommate's table and headed toward the library. CNA #6 followed him and grabbed a hold of the can of coke and both of them had their hands on the can of coke. Resident E indicated CNA #6 used a judo-wrestling move on him and flipped him over her back and then took the can of coke and he landed on the hip he had already had replaced. He could not move after that and yelled for help. A statement from LPN #7, dated 2/17/16, indicated he was passing medications on another hallway when a resident came down the hall yelling about his bathroom. He saw the resident head back toward his room. Shortly after that the aide came and got him and told him the resident was running down the hall and fell He assessed the resident and found him sitting on the floor scooting to his room. The resident indicated he fell on his hip and was in pain. The resident added that the aide had pushed him. 911 was contacted and the resident was sent to ER. A statement written by CNA #6, indicated Resident E was acting up because his roommate used the restroom and he indicated his roommate made a mess in the restroom. After that she got the resident's roommate a coke and some cookies, then the resident started yelling at her to get out of his room and he snatched the coke and cookies out of her hand. Resident E threw the cookies on the floor and started walking out to the restroom in the back room. Once he got to the restroom door he stopped to open the soda and that was when CNA #6 tried reaching for the coke. CNA #6 indicated she did not know if Resident E turned really fast and she was not sure if he tripped because his feet were not fast enough. She indicated as soon as he hit the floor she went to get LPN #7. She indicated she did not touch him. She indicated the resident was being verbally abusive to her since the restroom incident in his room prior to getting the coke and cookies for his roommate. A telephone interview from CNA #6, dated 2/18/16, indicated the DNS (Director of Nursing Services) and ED (Executive Director) contacted her and she indicated she had taken the resident's roommate to the restroom and told him to turn on the light when he was finished. Resident E was upset because the toilet was dirty and there was S*** everywhere. CNA #6 went to get Resident E's roommate a nighttime snack and when she returned the resident started yelling at her to get out of his room. Resident E took the beverage and indicated his roommate owed him. CNA #6 indicated as she was reaching for the coke the resident proceeded to pull his arm back and he fell on the floor. She immediately went to get the charge nurse. The resident indicated the CNA #6 pushed him. CNA #6 denied pushing or touching the resident. A Hospital Consultation Note, from (Name of Hospital) dated 2/18/16 at 7:27 a.m., indicated the resident presented to the hospital with right hip pain that began immediately after an injury, which occurred as he reported being thrown down by a worker at his facility, causing him to fall onto his right hip. The note indicated the resident's X-ray report of the right hip indicated he had a fracture of the right hip. The note indicated he was going to be treated nonoperatively. During an interview on 2/26/16 at 10:34 a.m., Resident E indicated CNA #6 was going to purchase a coke for his former roommate and he told her that the other CNA's did not purchase the cokes for him because he made a mess with them in the room and he did not want him to have one either. He indicated she went ahead and got one for him anyway. He indicated after she purchased the coke for him and gave it to his former roommate, Resident E grabbed it off his roommates table and he walked to the library with the coke. CNA #6 grabbed the coke in the library and he and CNA #6 were wrestling over the coke. He indicated she had taken the coke out of his hands by performing a wrestling move. Resident E indicated both of them had a hold of the coke can and the wrestling move flipped the coke over her body and he was holding onto the coke can and that move threw him over her back and his body went along with the coke and he landed flat on his right hip on the tile floor in the library. He indicated his right hip had already been replaced. He indicated he had written this CNA up before, but did not elaborate why he had written her up. He indicated his roommate owed him 4 cokes, which he had given him prior to that day and he should have been made to pay him back before the aides bought his roommate any cokes. During an interview on 2/26/16 at 3:25 p.m., CNA #6 indicated Resident E's roommate was going to use the restroom and Resident E started acting up. Resident E indicated to her that whatever mess his roommate made she had to clean up. Resident E's roommate put on his light and she got him ready for bed and Resident E got loud with her. CNA #6 indicated Resident E's roommate threw the toilet paper and soap on the floor and she picked up the toilet paper and soap off the floor. She went and got the resident's roommate a coke and snacks and the resident told her to get out of the room and he tried to push her and she moved. Resident E grabbed the snacks and the coke and threw the snacks on the floor and took the coke and headed to the library. Resident E went to the bathroom in the back hallway and tried to open the coke. She indicated she told Resident E to give it back and she tried to reach for the coke and he turned and lost his balance and fell backwards. She went to get LPN #7 and told him that Resident E fell . She indicated she was suspended and the facility called her and told her she could come back to work, but she never came back to work. CNA #6 indicated she did not want to come back to work because she had trouble with Resident E before and the facility was stressful and she did not want to deal with him and the facility anymore. She indicated she had seen him crushing his pills in his room and reported it to the nurse and he had harassed her since then by taking her linen barrel at the end of the hall and he came into a resident's room while she was caring for that resident. Also, he placed a cup of juice in front of a resident's door, so she would kick it and spill it everywhere when she came out of the room. During an interview on 3/01/16 at 8:57 a.m., LPN #5 with the DNS (Director of Nursing Services) in attendance. LPN #5 indicated she expected CNA #6 to walk with the resident and explain to the resident the coke was not his and it was his roommates. The DNS indicated she thought CNA #6 thought she was protecting the roommate by trying to get the coke back for him. LPN #5 indicated she would have expected CNA #6 to let Resident E go knowing he had behaviors to prevent him from having another behavior that evening. This Federal tag relates to Complaint IN 705. 3.1-45(a)(1)

Based on interview and record review, the facility failed to discover diabetic ulcers on the left heel and left toes until the ulcers were necrotic (Death of body tissue, which occurs when too little blood flows to the tissue) for 1 of 1 residents reviewed for skin conditions, which were non-pressure related. (Resident C) Findings include: Resident C's record was reviewed on 2/29/16 at 12:02 p.m. [DIAGNOSES REDACTED]. The resident had a Care Plan, dated 6/16/15, indicating she was at risk for skin breakdown due to decreased mobility, [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) with [MEDICAL TREATMENT], DM malnutrition, debility, [MEDICAL CONDITION] and dementia. Approaches included, but were not limited to, .Assess and document skin condition weekly and as needed, Notify MD (Medical Doctor) of any changes . An IDT (Interdisciplinary Team) progress note, dated 7/30/15 at 3:45 p.m., indicated a skin assessment was completed on the resident and she was noted to have boggy (spongy) heels. A document titled Weekly Summary, dated 8/17/15 at 3:48 p.m., indicated the resident's skin integrity had no current skin altercations. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events (Name of Company) Non-Pressure Wound Skin Event, dated 8/27/15 at 8:04 a.m., indicated the left heel wound was a new area, which was facility acquired with an original noted date of 8/27/15. The wound type was a diabetic ulcer with a status of FTW (Full Thickness Wound). The wound measured 2.0 x 3.5 x 0.1 cm (centimeters). The wound color was 100% black. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 8/27/15 at 8:06 a.m., indicated the left 1st, 4th and 5th toes on the left foot were new areas, which were facility acquired with an original noted date of 8/27/15. The wound types were diabetic ulcers with a status of FTW. The wound measurements indicated generalized. The wound colors were 100% black. A Wound Clinic document, dated 8/27/15 at 9:26 a.m., indicated the resident had a left lateral heel and toe wounds due to suspected vascular disease with known diabetes. The note indicated that visit was the initial consult for several necrotic toe wounds and a heel wound and the wounds were consistent with emboli showering. The note indicated the resident indicated she had increasing pain over the last week. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/3/15 at 8:03 a.m., indicated the left heel wound was an existing area, which was facility acquired with an original noted date of 8/27/15. The wound type was a diabetic ulcer with a status of FTW. The wound measured 2.0 x 1.9 x 0.1 cm. The wound color was 75% black and 25% [MEDICATION NAME]. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/3/15 at 8:23 a.m., indicated the left 1st, 4th and 5th toes on the left foot were existing areas, which were facility acquired with an original noted date of 8/27/15. The wound types were diabetic ulcers with a status of FTW. The wound measurements indicated generalized. The wound colors were 75% black and 25% [MEDICATION NAME]. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/10/15 at 8:17 a.m., indicated the left heel wound was an existing area, which was facility acquired with an original noted date of 8/27/15. The wound type was a diabetic ulcer with a status of FTW. The wound measured 2.0 x 2.5 x 0.1 cm. The wound color was 100% necrotic. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/10/15 at 7:59 a.m., indicated the left 1st, 4th and 5th toes on the left foot were existing areas, which were facility acquired with an original noted date of 8/27/15. The wound types were diabetic ulcers with a status of FTW. The wound measurements indicated generalized including the entire 5th toe and plantar of the 1st and 4th toes (bottom of the toes). The wound colors were 100% black. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/17/15 at 6:59 a.m., indicated the left heel wound was an existing area, which was facility acquired with an original noted date of 8/27/15. The wound type was a diabetic ulcer with a status of FTW. The wound measured 1.0 x 1.5 x 0.0 cm. The wound color was black. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/17/15 at 6:59 a.m., indicated the left 1st, 4th and 5th toes on the left foot were existing areas, which were facility acquired with an original noted date of 8/27/15. The wound types were diabetic ulcers with a status of FTW. The wound measurements indicated generalized. The wound colors were black. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/24/15 at 6:58 a.m., indicated the left heel wound was an existing area, which was facility acquired with an original noted date of 8/27/15. The wound type was a diabetic ulcer with a status of FTW. The wound measured 0.8 x 1.0 x 0.0 cm. The wound color was black. The document titled IDT (Interdisciplinary Team) Weekly Update Skin Events(Name of Company) Non-Pressure Wound Skin Event, dated 9/24/15 at 6:59 a.m., indicated the left 1st, 4th and 5th metatarsals on the left foot were existing areas, which were facility acquired with an original noted date of 8/27/15. The wound types were diabetic ulcers with a status of FTW. The wound measurements indicated generalized. The wound colors were black. On 3/1/15 at 8:47 a.m., with the Director of Nursing Services (DNS) and LPN #5 in attendance, they were notified of the concern of the resident's diabetic ulcers on her left heel and left 1st, 4th and 5th toes being found when they were necrotic (black). Further information was requested to indicate if these wounds were discovered any earlier than when they were necrotic. The DNS indicated they would look into this. During an interview on 3/1/15 at 3:48 p.m., with LPN #5 and the CEC (Clinical Education Coordinator) in attendance, the CEC indicated they were continuing to work on the black wound issue. During an interview on 3/1/16 at 5:00 p.m., the DNS indicated the resident's left heel wound and left toe wounds were discovered on 8/27/15, when a skin sweep was completed. A current policy titled Skin Management Program, dated 6/2014 with a revised of 1/2016, was provided by the DNS on 3/1/16 at 3:45 p.m., indicated POLICY: It is the policy of (Name of Company) to assess each resident to determine the risk of potential skin integrity impairment, upon admission, quarterly, annually and with significant change. Residents will have a skin assessment completed no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment. PROCEDURE: 1. A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and weekly This Federal tag relates to Complaint IN 411. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a dependent resident did not develop pressure areas, in that when a resident was identified as requiring extensive assistance upon staff for areas of Activities of Daily Living, including turning, bed mobility and repositioning the nursing staff failed to immediately identify areas of bruising (deep tissue injury) to the resident's lower legs and feet which resulted in pressure ulcers for 1 of 4 residents reviewed for pressure ulcers in a sample of 6. (Resident "D"). Findings include: 1. The record for Resident "D" was reviewed on 05-13-15 at 10:15 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's MDS (Minimum Data Set Assessment), dated 03-13-15 indicated the resident had cognitive impairments and required extensive assistance of 2+ staff members with transfer, bed mobility and toileting. In addition, the assessment indicated the resident was not steady with surface to surface transfers, and not steady when moving from a seated to a standing position, walking, turning around and moving on and off the toilet with stabilization only staff assistance. The resident was identified "at risk for pressure ulcers," but at the time of the assessment, had no identified pressure ulcers or unstageable areas in regard to deep tissues injury. A review of the resident's current plan of care, originally dated 02-18-12, indicated the resident was at risk for skin breakdown due to [MEDICAL CONDITION], incontinence, impaired mobility, confusion, hypertension and dementia. Interventions to this plan of care included, "assess and document skin condition weekly and as needed. Notify the MD (Medical Doctor) of abnormal findings as needed, and assist resident to reposition every two hours." A review of the Progress notes indicated the resident had an unwitnessed fall on 04-16-15 at 2:15 a.m., and subsequently began to display a change in condition. Documentation indicated the resident began to display increase agitation, and eventually a decrease in meal consumption. The physician assistant progress notes, dated 04-21-15 indicated the resident with "agitation, staff notes pt. (patient) resisting care more agitated/confused than normal." The physician orders [REDACTED]. The results of the complete blood count, dated as "collected" on 04-22-15, indicated the resident had increased white blood cell count with a result of 18.1 with a normal range of 4.5 - 10.8. A subsequent physician assistant notation, dated 04-22-15 indicated "worsening agitation, dysphagia, noted to have worsening change in mental status with agitation. Unable to obtain urine. Pt's behavior worsening and now not swallowing meds or food." The physician instructed the nursing staff to "start [MEDICATION NAME] (an antibiotic) empirically." The physician notation dated 04-24-15, indicated the resident "found to be confused earlier this week - not eating or drinking. No fever, no diarrhea, no cough. Has been agitated refusing urinalysis (in and out catheterization)." The physician ordered a repeat to the complete blood count as well as the basic metabolic profile. The result of the complete blood count indicated an increase to the white blood cell count with a result of 20.6 with normal ranges of 4.5 - 10.8. The resident was again seen by the physician assistant on 04-27-15 and again on 04-28-15 and indicated the resident had persistent altered mental status "more than normal, still combative, still not taking much PO (by mouth)." A review of the "Shower Report," dated 04-23-15 indicated a "complete bed bath given - resident tolerated well, but combative at times." A section of the report instructed the certified nurses aide to "circle problem areas and check all boxes as needed." The report lacked information related to changes or concerns to the resident's skin. The 04-28-15 "Shower Report," indicated the resident "refused a shower" but lacked information if a bed bath was performed and also lacked any "circled areas" of skin concerns. The Nursing Weekly Assessment, dated 04-28-15 indicated the resident had a skin tear to the left lower leg and groin and had physician orders [REDACTED]. A review of the Progress Notes, dated 04-29-15 indicated the resident's condition did not show any improvement, and the family member requested the resident be transported to the local area hospital for evaluation and assessment. A review of the Hospital record on 05-11-15 at 9:00 a.m., indicated the following: During an evaluation in the emergency room , the resident was found with "multiple pressure areas." The physician "History and Physical," dated 04-29-15, DTI's (deep tissue injury's - ("an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body and restricts blood flow in the tissue causing the tissue to die")), over lat. (lateral) foot and medial right foot without exudate. [DIAGNOSES REDACTED] (redness). Tenderness. One inch skin tear over R (Right) knee - not infected, superficial. Bandaged sore over L (Left) med. (medial) ankle. Impression/Assessment: Leg wounds - Wound care - pressure wounds." "Adult Patient Profile," dated 04-29-15, "Completely dependent" for "ambulation, transferring, toileting, bathing dressing." "Document Skin Report", dated 04-30-15, titled "wound/skin evaluation," indicated the resident with "altered mental status, and multiple pressure ulcers." WOUND #1 Pressure - Suspected Deep Tissue Injury 3 cm (centimeters) in length by 2 cm in width - Right foot proximal wound - skin intact. WOUND #2 Pressure - Suspected Deep Tissue Injury 4.5 cm. in length by 1.5 cm in width - - right medial mid foot - skin intact. WOUND #3 Pressure - Suspected Deep Tissue Injury 2.5 cm in length by 1.5 cm in width - Right Medial foot - Distal. WOUND #4 Pressure - Suspected Deep Tissue Injury 2.5 cm in length by 1.5 cm in width - Right Medial Heel - skin intact. WOUND #5 Pressure Suspected Deep Tissue Injury 2 cm. in length by 2 cm in width - Left Lateral Distal Foot - Skin Intact. WOUND #6 - Pressure Suspected Deep Tissue Injury 4 cm in length by 3 cm in width - Left Lateral Mid Foot - Skin intact. WOUND #7 Pressure - Suspected Deep Tissue Injury 4 cm in length by 3 cm in width - Left Lateral Heel - Skin Intact. WOUND #8 Pressure - Suspected Deep Tissue Injury 5 cm in length by 1 cm in width - Suspected Deep Tissue Injury - Left Lateral malleolus (ankle) - Skin Intact.. WOUND #9 Pressure - Unstageable 1 cm in length by 2.5 cm in width by 0.1 cm in depth - Left Medial malleolus - Skin Intact. WOUND #10 Pressure - Unstageable 2 cm in length by 1 cm in width by 0.1 cm in depth 100 % Yellow Slough - Left Medial Proximal Ankle - Skin Broken. WOUND #11 - Left lateral knee wound skin open with 50 % yellow slough and 50 % pink. A review of the Hospital Case Management Report dated 04-29-15, indicated the following: "Patient does not speak or ambulate. Patient comes into the emergency room with abnormal labs (laboratory blood work). His (family member) demanded he be brought in based on his long term care facilities lack of urgency. The (family member) states that he has bruises and scrapes/abrasions on both legs, which I verified, and requested pictures be taken for medical records." "Evidence Collected 04-29-15 at 1520 (3:20 p.m.) - Photography: Body." The Hospital Nutrition Assessment, dated 04-30-15 indicated, "Pt. (patient) with [MEDICAL CONDITION] non-pitting to bilateral legs/feet on 04-29. Skin issues: L (left) knee abrasion, bilateral skin abrasions, L lower inner leg ulceration, R (right) medial foot pressure ulcer. L lateral foot & L ankle pressure ulcer, bilateral heels boggy." During interview on 05-11-15 at 8:30 a.m., the Hospital Registered Nurse indicated the resident was admitted with areas identified as deep tissue injuries to both lower legs and feet. During observation on 05-11-15 at 8:40 a.m., with the Hospital Registered Nurse, the resident was observed laying on his back. The Registered Nurse moved the bedsheet to one side, to expose the resident's lower legs. Waffle boots which had been applied to both lower legs/feet were removed. Observation of the right foot included three dark purple areas of bruising, one of which was actively bleeding. During this observation the Hospital Registered Nurse indicated the area started "bleeding over the weekend." In addition there was bruising to the resident's heel. There were areas along the resident's right shin, too numerous to count, were observed with scabs. An observation of the resident's left foot revealed an abrasion to the left lower leg, a pressure ulcer to the malleolus and adjacent to the malleolus, bruising along the outer aspect of the residents foot, and heel. There were numerous abrasions along the right shin with scabbing present. The licensed nurse indicated the area to the left ankle was a deep tissue injury with a pressure ulcer on the malleolus. The side of the resident's foot was observed with multiple dark purple areas, which the licensed nurse also identified as deep tissue injuries. During an interview on 05-14-15 at 4:00 p.m., the Director of Nurses verified the weekly assessment lacked information related to the condition of the resident's skin in regard to pressure ulcers or a deep tissue injury. This Federal tag relates to the investigation of Complaint IN 848. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to assess a resident in regards to pain and bowel concerns, which resulted in severe pain and fecal impaction for 1 of 4 residents reviewed for care concerns. (Resident C) Finding included: On 3/11/15 at 3:30 p.m., the record review for Resident C was completed. [DIAGNOSES REDACTED]. On 3/11/2015 at 4:01 p.m., CNA #1 and LPN #2 were observed transferring resident via a stand up lift. The resident was taken to the bathroom and transferred via a stand up lift from the wheelchair to the toilet. On 3/11/2015 at 4:16 p.m., Resident C was grimacing indicating her bottom hurt. CNA #1 indicated she was not aware of any open areas on the resident's bottom. The resident indicated she had been having problems with her bowels lately and sometimes it felt as if she was going to have surgery when she had a bowel movement (BM). CNA #1 applied barrier cream to the area. The resident indicated after the barrier cream was applied her bottom felt better. LPN #2 asked the resident, during transfer when she complained of pain, if she wanted to stop and she would say yes. They would stop, then when they needed to continue with care they asked her permission to start again and she would indicate it was all right. Resident C was observed on 3/12/2015 at 9:38 a.m., getting therapy to her left hand and the resident indicated to the therapist at that time she was having pain in her bottom. The therapist indicated she would reposition her. On 3/12/2015 at 10:35 a.m., the resident indicated to LPN #3 that her bottom was hurting. CNA #4 and CNA #5 were observed transferring Resident C on 3/12/2015 at 10:52 a.m., from her bed to the wheelchair and the wheelchair to the toilet. CNA #5 went to change the bedding and it was observed to have some bowel movement smearing on the incontinence pad. On 3/12/2015 at 11:12 a.m., CNA #4 and CNA #5 left Resident C on the toilet with the call light in her hand. CNA #5 indicated the resident had a few small pieces of hard BM in her brief. Resident C complained of pain in her bottom again. CNA #5 was observed leaving the resident and indicated she needed to get sheets for the bed due to their being food in the bed. On 3/12/2015 at 11:16 a.m., the resident was complaining off and on again of discomfort, CNA #5 asked at that time if she was all right. CNA #5 told her she was going to leave for a moment and get something else and ensured the resident had the call light in her hand. About 11:19 a.m., after CNA # 5 left the room , the resident started moaning loudly. She was also yelling to go get CNA #5 and calling out loudly while on the toilet. On 3/12/2015 at 11:21 a.m., the Clinical Consultant Specialist (CCS) came in and started helping her. CNA #5 and an unidentified CNA were assisting to clean up the resident. The resident's stools were observed as very dark in appearance. On 3/12/15 at 11:30 a.m., LPN #3 came into the room and asked the resident where she hurt. The resident told LPN #3 her tailbone hurt. LPN #3 indicated at that time, she had been in a couple of times this morning and the resident had complained of pain and LPN #3 had repositioned her a couple of times. During an interview on 3/12/15 at 1:25 p.m., the CCS indicated a bowel assessment was completed. The CCS indicated the Physician's Assistant (PA) had indicated upon her assessment the resident had active bowel sounds and hard stool in her rectum. The CCS indicated the PA digitally removed the stool and had a large amount of soft stool. The CCS indicated the resident was also given an enema to assist in the removal of remaining soft stool and the resident's stool had a greenish tint to it, which was from the iron the resident received. On 3/12/2015 at 2:46 p.m., LPN #2 indicated if a resident complained of pain he would possibly do a pain assessment. He indicated he had not done a bowel assessment due to the fact that she had soft smearing in her brief and had indicated she had a bowel movement recently. He also indicated that the resident had soft smearing, which indicated she was not constipated. LPN #2 indicated the pain was more related to the high cushion on the toilet, which the family had requested be placed on the toilet, since the resident spent a lengthy amount of time sitting on the toilet. He also indicated this caused discomfort because of the way the resident was weak on the left side and the fact she had to be lifted higher in the transfer sling in order to get up on top of the toilet cushion. He indicated CNA #1 had not reported any pain to the nurse because he was in the room, but that aids were expected to report pain to the nurse. LPN #2 indicated he felt that the pain was more from the transfer and that was why he had tried to stop the transfer, but the resident had indicated to go ahead. LPN #2 also indicated the resident had problems with constipation in the past and that was one of the concerns the family had communicated to him upon admission. During an interview on 3/12/2015 3:08 p.m., the CCS indicated she expected the nurse to assess the resident if a resident complained of pain, when it was explained to her that the resident indicated she had pain feeling like she was going to have surgery when having a bowel movement. A progress note dated 3/12/15 at 11:45 a.m., indicated, "Resident was complaining of pain in her bottom while on toilet. Resident had just had pain medication within the last hour. After resident was transferred to bed, smear of dark stool noted on incontinence pad. Resident bowel sounds assessed and active in all quads. Abdomen distended and firm, but this is usual for resident per report of charge nurse. NP (Nurse Practitioner) in building and contacted to assess resident and notified of assessment.... " This progress note had a note to indicate it had been edited. The progress note dated 3/12/15 at 11:56 a.m., indicated, "...Per report of NP at bedside. Resident had soft stool in the rectal vault that was manually removed by the NP. She stated that stool did not appear black and tarry but greenish as she is on iron. She stated there was no indication for hemacult (test to check for blood in the stool) due to the color. Enema administered.... " This progress note had a note to indicate it had been edited. The original version indicated, "...Per report of NP at bedside. Resident has hard stool in the rectal vault that was manually removed by the NP. She stated that stool did not appear black and tarry but greenish as in she is on iron., She stated there was no indication for hemacult (sic) due to the color. Enema administered...." The progress note dated 3/12/15 at 12:07 p.m., indicated, "Present during assessment of resident pain and bowel status. NP asked resident if she would like assistance in removing stool to rectum and resident consented. NP ordered enema due to soft stool higher up, Resident tolerated enema well with initial small results. No further complaints of pain after resident received enema...." The Physicians Assistant document titled, "HMC Comprehensive Assessment" dated 3/12/15 at 11:45 a.m., indicated, "...fecal impaction...patient complaining of rectal pain and constipation with associated abdominal pain-aching, bilateral lower quadrant, constant...physical exam...abdomen: positive bowel sounds, soft, tender to palpation large amount black green soft stool removed from rectal vault increased soft stool palpated higher up no bright red blood per rectum. Assessment: 1) Fecal impaction manual disimpaction performed fleets enema, add stool softener...." This Federal tag relates to complaint IN 541. 3.1-37(a)

Based on observation, interview and record review, the facility failed to have interventions in place to prevent possible infection for a wound and to prevent and place interventions to avoid the digression of a wound from moisture associated skin damage to an an unstageable pressure wound for 1 of 2 residents reviewed for pressure wounds. (Resident R) Findings include: On 1/27/15 at 2:55 p.m., the record review for Resident R was completed. Resident had [MEDICAL CONDITION], adult failure to thrive, pressure ulcer, incontinence of bowel and bladder (inability to hold urine or feces) and chronic pain. The events page indicated : 8/29/14-the resident had a new area that was not present on admission 1 centimeter (cm) x 1 cm, current treatment Duoderm. 10/3/14-The Assistant Director of Nursing (ADON) documentation indicated the resident had a right gluteal moisture associated skin damage area which measured 2.0 cm x 2.5 cm x 0.1 cm. 10/7/14-The ADON's documentation indicated the resident had a moisture associated skin damage area which measured 2.5 cm x 3.0 x 0.1 cm. There was a new physician's orders [REDACTED]. 10/21/14-The ADON's documentation indicated the resident had a right gluteal moisture associated skin damage area which measured 1.5 cm x 8.0 x 1 cm. Treatment therahoney and [MEDICATION NAME]. 10/28/14-The ADON's documentation indicated the resident had a right gluteal moisture associated skin damage area which measured 2.8 cm x 2.5 cm x 0.1 cm. Treatment therahoney and [MEDICATION NAME]. 11/4/14-The ADON's documentation indicated the resident had a right gluteal moisture associated skin damage area which measured 3.5 cm x 1.5 cm x 0.1 cm. Treatment therahoney and [MEDICATION NAME]. 11/12/14-The ADON's documentation indicated the resident had a right gluteal moisture associated skin damage area which measured 2.5 cm x 2.5 x 0.1 cm. Treatment therahoney and [MEDICATION NAME]. 11/18/14-The ADON's documentation indicated the resident had a right gluteal moisture associated skin damage area which measured 3.5 cm x 1.8 cm x 0.1 cm. Treatment therahoney and [MEDICATION NAME]. 11/25/14-The ADON's documentation indicated the resident had an unstageable area which measured 3.5 cm x 4 x 0.1 cm The physician ordered to discontinue current treatment and to cleanse the right gluteal area with normal saline, pat dry, apply Santyl (a wound agent that removes dead skin tissue) to open area, cover with [MEDICATION NAME] (a wound covering). Composure mattress. (special mattress for pressure areas) 12/2/14-The ADON's documentation indicated the resident had a right gluteal unstageable pressure area which measured 3.0 cm x 5.0 cm x 0.1 cm. 12/8/14 -The physician discontinued the Santyl order and apply 0.25 % Dakins (an anti infection dressing) solution to fluffed gauze and place in wound bed. Swab peri wound with skin prep and cover with [MEDICATION NAME] dressing. 12/9/14-The ADON's documentation indicated the resident had a right gluteal unstageable pressure area which measured 2.2 cm x 3.8 cm x 0.8 cm . The physician also had an order to discontinue the composure mattress to a low air loss mattress (a mattress which uses air to provide less pressure to body areas). 12/16/14-The ADON's documentation indicated the resident had a right gluteal unstageable pressure area which measured 1.8 cm x 3.5 cm x 1 cm. 12/23/14-The ADON's documentation indicated the resident had a right gluteal Stage IV pressure area which measured 3 cm x 3.2 cm x 1.8 cm. 12/30/14-The ADON's documentation indicated the resident had a right gluteal Stage IV pressure area which measured 2.1 x 1.2 cm. The physician ordered a wound treatment of [REDACTED]. 1/6/15 -The ADON's documentation indicated the resident had a right gluteal Stage IV pressure area which measured 1.5 cm x 1.8 cm x 1.5 cm. 1/10/15-The physician discontinued the silver alginate and corded to cleanse area with normal saline, pat dry, apply Dakins 0.25 % solution to fluffed gauze, pack wound bed. Skin prep peri wound and cover with [MEDICATION NAME]. Change daily and as needed. 1/13/15-The ADON's documentation indicated the resident had a right gluteal Stage IV pressure area which measured 2 cm x 2.5 cm x 3.5 cm. 1/19/15-The ADON's documentation indicated the resident had a right gluteal Stage IV pressure area which measured 2.5 cm x 3 cm x 3 cm. The physician changed the wound order to cleanse wound with sterile water, moisten fluffed gauze with [MEDICATION NAME] gel and loosely pack wound , swab area around wound with skin prep and cover with ABD pad and Medifix tape. 1/26/15 -The ADON's documentation indicated the resident had a right gluteal Stage IV pressure area which measured 2.6 cm x 2.3 cm x 3.5 cm. The wound clinic was seeing the resident for her right gluteal wound and indicated,"...12/8/14...Location: Right gluteal fold...Duration: Began as excoriation several weeks ago, Deterioration last week...Right Gluteal fold is a Necrotic (dead tissue) Tissue (unstageable) Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.2 cm length x 3.8 cm width, by 0.8 cm depth...Undermining ( a separation of tissue from the surface of the edge of the wound) has been noted...Limit up in wheelchair to meals only...1/19/15...Right Gluteal fold is a Stage 4 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encourage measurements are 2.5 cm length x 3 cm width x 3 cm depth...Undermining has been noted...The wound is deteriorating...." The resident was not being off loaded and laid down after meals as ordered by wound clinic as evidenced by observation on 1/26/2015 at 10:37 a.m., resident was observed in the main dining room with her eyes closed. An observation on 1/28/15 at 10:30 a.m., the resident was observed with her eyes closed and was sitting in her room by her bed in her Broda chair. At 11:30 a.m., the resident was observed playing Bingo for an activity. At 12:35 p.m., the resident was in main dining room for lunch. On 1/28/2015 10:52 a.m., LPN #4, LPN #5, and RN #8 were present for a dressing change. LPN #4 assisted resident onto her side to start to remove the dressing. The old undated and unmarked dressing was removed. The dressing was a small square of adhesive with a pink color to outside and non adhesive bandage on the other side. Two pieces of gauze were removed. The resident told LPN #4 and LPN #5 her back and legs hurt. The dressing was stopped at that time. LPN #5 rolled the plastic incontinence pad that had been lying on top of the low airloss mattress underneath of the resident, and tucked it underneath of the resident and placed her on her back. The wound was open and had no dressing to cover it. On 1/28/15 at 1:00 p.m., the final dressing change was completed. The resident was observed lying on her left side with wound open to air and the plastic incontinence pad laying underneath of her. LPN #4 used sterile water to clean the wound. LPN #4 then took [MEDICATION NAME] soaked gauze soaked with sterile water, fluffed the gauze and placed it into the wound. She then applied skin prep around peri wound and covered with a large white ABD pad, then secured the pad with a large piece of Medifix tape. She indicated at that time these were the current orders. On 1/29/15 at 4:50 p.m., the Director of Nursing indicated she expected the nurse to have the wound covered with some sort of dressing after the old dressing was removed. She indicated leaving the wound open on the incontinence pad could potentially cause infection of the wound. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure a dressing change was completed without potential for infection for 1 of 2 residents observed for a dressing change (Resident C) and failed to ensure effective pain management was provided for 2 of 2 residents reviewed for pain management resulting in Resident C complaining of pain throughout and after a wound dressing change. (Resident C and R) Findings include: 1. Resident C's record was reviewed on 1/27/15 at 10:51 a.m. [DIAGNOSES REDACTED]. The resident's recapititulation (recap) orders dated January 2015, included, but were not limited to, the following: 6/13/13--[MEDICATION NAME] (a non-narcotic pain medication) 325 mg (milligrams) Take two tablets (650 mg) by mouth every six hours as needed for moderate pain 12/9/14--[MEDICATION NAME] (a pain medication) 50 mg take one tablet by mouth twice daily as needed. 12/10/14--Keflex (An antibiotic medication) 500 mg (milligrams) by mouth three times a day for 10 days for right lower extremity (RLE) wound. 12/12/14--[MEDICATION NAME] 50 mg take one tablet by mouth three times a day. 1/19/15--RLE wound--Cleanse the wound with normal saline (wound cleanser). Apply Santyl (an ointment medication that removes the dead tissue from the wound) to the wound bed. Top the wound with hydrogel (a gel medication applied to the wound to aid in the prevention of the wound drying out) gauze. Apply [MEDICATION NAME] (an ointment applied around the wound as a skin protector) to periwound. Cover the wound with an ABD (abdominal) pad and Kerlix (gauze wrapping). Change daily and as needed if soiled or dislodged. 1/27/15--[MEDICATION NAME]/APAP (a narcotic pain medication) 5/325 mg one tablet by mouth 30 minutes prior to wound treatment daily for pain. An "Infection Control Individual Report" dated 12/10/14 at 10:52 a.m., indicated the resident had redness and swelling to the RLE. She was ordered Keflex 500 mg by mouth for 10 days on 12/10/14. A "Non-Pressure Wound Skin Evaluation Report" dated 1/20/15 at 2:00 p.m., indicated the resident had a full thickness wound to her RLE caused by trauma, which was not present on admission to the facility. The wound origination date was 12/9/14. The wound measured 7.5 cm (centimeters) x 5.5 cm x 0.3 cm. The wound bed color was 100% red granulation (the pink/red, moist tissue, which fills the open wound when it begins to heal). The wound had a small amount of serosanguineous (light red to pink, thin, watery and normal during the [MEDICAL CONDITION] stage of healing) drainage. A Wound physician progress notes [REDACTED].#1 Right, Anterior Lower Leg is a Full Thickness Trauma Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 7.5cm length x 5.5cm width x 0.3cm depth...The patient reports a wound pain of level 3. The wound is deteriorating... Wound Orders: Wound #1 right, Anterior Lower Leg... Cleanse wound bed with NS (normal saline). Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze, then cover with dry gauze and secure daily and PRN (as needed), soiled-Cover with ABDS & Kerlix. Change daily & PRN... Ulcer of lower limbs, except pressure ulcer, Ulcer of calf--Deteriorated with slightly larger dimensions but no slough or odor today. change to Santyl for chemical maintenance (sic) debridement, hydrogel for moist wound healing & to decrease pain when dressing removed...." A Wound physician progress notes [REDACTED].#1 Right, Anterior Lower Leg is a Full Thickness Trauma Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 7.5cm length x 5.5cm width x 0.3cm depth...The patient reports a wound pain of level 3. The wound is deteriorating (getting worse)... Ulcer of lower limbs, except pressure ulcer, Ulcer of calf--Deteriorated with slightly larger dimensions but no slough or odor today...." A physician progress notes [REDACTED].. Resident has wound to RLE-recent I & D (Incision and Drainage)... Review of Systems:.. Symptom Management:.. Pain Location: RLE... Pain description: Intermittent Pain Triggers: Dressing changes Pain Treatments: Medications Pain Duration: Three weeks up to two months... Opioid Use for Pain: No...." Nursing progress notes reviewed for RLE wound dressing changes from 12/9/14 to 1/27/15, and the resident had 35 dressing changes completed. She complained of pain during the dressing changes at the following times these number of times: Whenever the wound area was touched--1 time Packing of the wound--7 times Removal of the dressing--5 times General pain during the dressing change--10 times The resident's MAR's (Medication Administration Records) were reviewed from 12/9/14 to 1/27/15, for pain medication administration. The resident's MAR indicated [REDACTED] [MEDICATION NAME] 50 mg--5 times [MEDICATION NAME]-0 times The resident's MAR indicated [REDACTED] [MEDICATION NAME]--0 times [MEDICATION NAME]--1 time, which was 1/27/15, after her wound dressing was changed. On 1/27/15 at 10:55 a.m., LPN #1 was observed changing Resident C's RLE wound dressing. She placed her clean supplies on a towel barrier on the resident's bed. She washed her hands. She placed the resident's RLE onto a clean incontinence pad edge of the bed. At that time, Resident C indicated to LPN #1 her RLE was tender. LPN #1 opened her dressing supplies on the clean towel barrier and got her supplies ready for the dressing change. She tore two pieces of tape and placed them on the resident's nightstand, then dated and initialed them. She got her empty trash bag ready on the nightstand and took a pair of scissors out of the plastic bag, which she had used to bring the dressing supplies down to the resident's room. She placed the pair of scissors on the clean towel barrier with the clean supplies without wiping them off. She donned clean gloves at that time. LPN #1 removed the old dressing by cutting it off with the pair of scissors then she laid the scissors back on the clean towel barrier field without cleaning the scissors. The old 4 x4 gauze dressings were lying on top of the wound and the dressings were stuck to the edges of the resident's wound due to being dried along the edges of the resident's wound. The resident indicated to the nurse at that time when she removed the dressings "Ouch, that hurts." LPN #1 indicated to the resident at that time she was being as gentle as she could be and she would be done in a minute. The resident had a furrowed brow and grimaced when LPN #1 removed the dressings from the resident's RLE. She threw the old dressing in the trash. The old 4 x 4 gauze pads covering the wound had a moderate amount of brownish red drainage on them. She irrigated the wound with normal saline in a syringe without changing her gloves. The resident indicated to LPN #1 at that time the wound was tender and LPN #1 indicated at that time to the resident, she was being as gentle as she could be. LPN #1 indicated at that time, she had medicated the resident at 10:00 a.m., with her routine [MEDICATION NAME]. The resident indicated at that time, the pain medicine helped a little bit, but her leg was still hurting. The wound was approximately the size of an orange. The wound bed was red with white slough along the lateral outside edge of the wound. LPN #1 removed her gloves and washed her hands, then donned clean gloves. LPN #1 applied Hydrogel onto one 4 x 4 gauze dressing, then laid it back on the open package. LPN #1 squeezed Santyl ointment into the middle of the wound, then used one sterile cotton tipped applicator and smeared it around the entire wound. She started in the middle where the glob of ointment was and continued to smear the Santyl around in a circular motion four times, while crossing over the inside of the wound. The resident indicated at that time, the wound bed was hurting and LPN #1 indicated at that time, she was being as gentle as she could be and she was almost finished with the dressing. The resident was observed with furrowed brows and facial grimacing during that time She pulled the 4 x 4 gauze smeared with Hydrogel gauze apart into a flat circle and used a sterile cotton tipped applicator and applied it to Resident C's wound. The resident indicated at that time, her wound bed was hurting. LPN #1 indicated at that time to the resident, she was being as gentle as she could. The resident was observed with facial grimacing and furrowed brows while LPN #1 was packing the wound with the Hydrogel gauze. LPN #1 applied [MEDICATION NAME] ointment around the periwound with a sterile tipped applicator, then covered the wound with an ABD pad. She wrapped the Kerlix gauze around the ABD pad and secured it with tape. The resident indicated at that time, as the LPN #1 was applying the [MEDICATION NAME] to the edges of the wound and wrapping the RLE with the Kerlix gauze that her leg was hurting. LPN #1 indicated that she was just about done with the dressing change. The resident was observed with facial grimacing and furrowed brows throughout these two steps of the dressing change. LPN #1 did not stop during the wound dressing change to medicate the resident with any as needed pain medication. She cleaned up her trash and removed her gloves. Resident C indicated to LPN #1 while she was cleaning her trash up after the dressing change that her RLE continued to hurt. She washed the pair of scissors with soap and water, then washed her hands. During an interview on 1/27/15 at 11:29 a.m., LPN #1 indicated she should have removed her gloves, then irrigated resident C's RLE with normal saline. She indicated she had cleansed her scissors with alcohol before she went into the room. She indicated she should have applied the Santyl by starting in the middle of the wound and worked her way out towards the outside of the wound. She indicated she should not have placed the pair of scissors on the clean towel barrier next to her clean supplies after she cut the old dressing off the resident's RLE. LPN #1 indicated the 4 x 4 gauze dressings that she removed from the wound should not have been laid on top of the resident's wound. She indicated the resident had not normally had that much pain when her wound dressing was changed, but the old dressing was dried around the wound edges and it stuck to her wound when she tried to remove it. LPN #1 indicated she normally would have stopped and medicated the resident having pain during a dressing change, then finished the dressing, but she had pre-medicated Resident C, so she thought she would be okay throughout the dressing change. On 1/27/15 at 11:30 a.m., LPN #1 was observed asking Resident C at the nurses station if she was still having RLE pain and the resident indicated at that time she was having pain. At that time, LPN #1 medicated the resident with her as needed [MEDICATION NAME] pain medication. During an interview on 1/28/15 at 1:15 p.m., the DNS (Director of Nursing Services) indicated LPN #1 should have removed her gloves and washed her hands after she removed the old dressing on 1/27/15, then cleansed Resident C's RLE wound. She indicated LPN #1 should have placed the pair of scissors on a dirty field, not the clean field after cutting the old dressing off her RLE wound. The DNS indicated LPN #1 should have applied the Santyl with a gauze from the inside of the wound to the outside of the wound and the Hydrogel gauze should have been fluffed when she applied it to the resident's RLE wound. During an interview on 1/28/15 at 5:45 p.m., the DNS indicated LPN #1 should have stopped doing the dressing change and medicated the resident, waited for the medication to take effect, then resumed with the dressing change. A current policy titled "Dressing Change (Incision or Wound)" dated 09/2012, provided by the DNS on 1/28/15 at 3:33 p.m., indicated "Procedure Steps:.. 6. Put on gloves. 7. Remove old dressing from residents and put directly in trash receptacle. 8. Remove gloves and discard. 9. Perform hand hygiene. 10. Put on gloves. 11. Initiate wound care according to the physician order:.. a) cleanse away debris or drainage from the wound... 13. Remove gloves and discard. 14. Perform hand hygiene. 15. Put on gloves. 16. Apply new dressing according to the physician orders...." 2. On 1/27/15 at 2:55 p.m., the record review for Resident R was completed. [DIAGNOSES REDACTED]. The care plan dated 7/13/11, indicated the resident was at risk for pain related to chronic pain, knee pain, Gout ([MEDICAL CONDITION] condition of the joints), H/O (history of) pain related to [MEDICAL CONDITION]. Administer meds as ordered, assist/encourage to reposition frequently, document effectiveness of prn (as needed) medications, notify MD if pain is unrelieved, worsening or having break thru pain as needed, observe for changes in day to activities, observe for changes in sleep pattern, observe for changes in sleep pattern. Observe for non verbal signs of pain, changes in breathing, vocalizations, mood/behavior changes, eyes change expression, sad/worried face, crying, teeth clenched, changes in posture, offer non pharmacological interventions such as quiet environment, rest, shower, back rub, reposition. On 1/27/15 at 2:00 p.m., CNA #1 and CNA # 2 were observed transferring Resident #47 with a Hoyer lift from her broda chair into her bed. The CNA's placed the Hoyer pad underneath the resident, transferred her and positioned her in bed. The resident had facial grimacing and a furrowed brow while the CNA's were transferring her. CNA #2 told the resident they were going to remove her pants and clean her up. CNA #1 and CNA #2 moved the resident to her left side and to the other while removing her pants. The resident yelled out at as CNA #1 pulled on the left side of pants, and CNA #2 pulled on the right side of the pants and pulled them down underneath of the resident's knees. Then CNA #1 and CNA #2 continued care by pulling off the resident's brief, unfastening it on the left side and pulling the brief down without taking the seam off of the right side. As they turned to reposition her on her right side the resident indicated "that hurts." She was yelling, had facial grimacing and her eyebrows were furrowed. On 1/28/15 at 11:20 a.m., LPN # 4 indicated during interview, the CNA's completing the transfer and care should have reported the complaints of pain to her. LPN # 4 indicated she had not been notified of the resident's complaints of pain A document titled "Pain Management" dated 1/03, with revision dates of 12/03, 1/06, 1/08, 3/10 and 9/2013 was provided by the Assistant Director of Nursing on 1/29/15 at 11:15 a.m. The policy indicated, "...It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keep the resident as comfortable and pain free as possible...." 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a dressing change was completed without potential for infection for 1 of 2 residents observed for a dressing change (Resident C) and failed to ensure effective pain management was provided for 2 of 2 residents reviewed for pain management resulting in Resident C complaining of pain throughout and after a wound dressing change. (Resident C and R) Findings include: 1. Resident C's record was reviewed on 1/27/15 at 10:51 a.m. [DIAGNOSES REDACTED]. The resident's recapititulation (recap) orders dated January 2015, included, but were not limited to, the following: 6/13/13--[MEDICATION NAME] (a non-narcotic pain medication) 325 mg (milligrams) Take two tablets (650 mg) by mouth every six hours as needed for moderate pain 12/9/14--[MEDICATION NAME] (a pain medication) 50 mg take one tablet by mouth twice daily as needed. 12/10/14--Keflex (An antibiotic medication) 500 mg (milligrams) by mouth three times a day for 10 days for right lower extremity (RLE) wound. 12/12/14--[MEDICATION NAME] 50 mg take one tablet by mouth three times a day. 1/19/15--RLE wound--Cleanse the wound with normal saline (wound cleanser). Apply Santyl (an ointment medication that removes the dead tissue from the wound) to the wound bed. Top the wound with hydrogel (a gel medication applied to the wound to aid in the prevention of the wound drying out) gauze. Apply [MEDICATION NAME] (an ointment applied around the wound as a skin protector) to periwound. Cover the wound with an ABD (abdominal) pad and Kerlix (gauze wrapping). Change daily and as needed if soiled or dislodged. 1/27/15--[MEDICATION NAME]/APAP (a narcotic pain medication) 5/325 mg one tablet by mouth 30 minutes prior to wound treatment daily for pain. An "Infection Control Individual Report" dated 12/10/14 at 10:52 a.m., indicated the resident had redness and swelling to the RLE. She was ordered Keflex 500 mg by mouth for 10 days on 12/10/14. A "Non-Pressure Wound Skin Evaluation Report" dated 1/20/15 at 2:00 p.m., indicated the resident had a full thickness wound to her RLE caused by trauma, which was not present on admission to the facility. The wound origination date was 12/9/14. The wound measured 7.5 cm (centimeters) x 5.5 cm x 0.3 cm. The wound bed color was 100% red granulation (the pink/red, moist tissue, which fills the open wound when it begins to heal). The wound had a small amount of serosanguineous (light red to pink, thin, watery and normal during the [MEDICAL CONDITION] stage of healing) drainage. A Wound physician progress notes [REDACTED].#1 Right, Anterior Lower Leg is a Full Thickness Trauma Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 7.5cm length x 5.5cm width x 0.3cm depth...The patient reports a wound pain of level 3. The wound is deteriorating... Wound Orders: Wound #1 right, Anterior Lower Leg... Cleanse wound bed with NS (normal saline). Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze, then cover with dry gauze and secure daily and PRN (as needed), soiled-Cover with ABDS & Kerlix. Change daily & PRN... Ulcer of lower limbs, except pressure ulcer, Ulcer of calf--Deteriorated with slightly larger dimensions but no slough or odor today. change to Santyl for chemical maintenance (sic) debridement, hydrogel for moist wound healing & to decrease pain when dressing removed...." A Wound physician progress notes [REDACTED].#1 Right, Anterior Lower Leg is a Full Thickness Trauma Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 7.5cm length x 5.5cm width x 0.3cm depth...The patient reports a wound pain of level 3. The wound is deteriorating (getting worse)... Ulcer of lower limbs, except pressure ulcer, Ulcer of calf--Deteriorated with slightly larger dimensions but no slough or odor today...." A physician progress notes [REDACTED].. Resident has wound to RLE-recent I & D (Incision and Drainage)... Review of Systems:.. Symptom Management:.. Pain Location: RLE... Pain description: Intermittent Pain Triggers: Dressing changes Pain Treatments: Medications Pain Duration: Three weeks up to two months... Opioid Use for Pain: No...." Nursing progress notes reviewed for RLE wound dressing changes from 12/9/14 to 1/27/15, and the resident had 35 dressing changes completed. She complained of pain during the dressing changes at the following times these number of times: Whenever the wound area was touched--1 time Packing of the wound--7 times Removal of the dressing--5 times General pain during the dressing change--10 times The resident's MAR's (Medication Administration Records) were reviewed from 12/9/14 to 1/27/15, for pain medication administration. The resident's MAR indicated [REDACTED] [MEDICATION NAME] 50 mg--5 times [MEDICATION NAME]-0 times The resident's MAR indicated [REDACTED] [MEDICATION NAME]--0 times [MEDICATION NAME]--1 time, which was 1/27/15, after her wound dressing was changed. On 1/27/15 at 10:55 a.m., LPN #1 was observed changing Resident C's RLE wound dressing. She placed her clean supplies on a towel barrier on the resident's bed. She washed her hands. She placed the resident's RLE onto a clean incontinence pad edge of the bed. At that time, Resident C indicated to LPN #1 her RLE was tender. LPN #1 opened her dressing supplies on the clean towel barrier and got her supplies ready for the dressing change. She tore two pieces of tape and placed them on the resident's nightstand, then dated and initialed them. She got her empty trash bag ready on the nightstand and took a pair of scissors out of the plastic bag, which she had used to bring the dressing supplies down to the resident's room. She placed the pair of scissors on the clean towel barrier with the clean supplies without wiping them off. She donned clean gloves at that time. LPN #1 removed the old dressing by cutting it off with the pair of scissors then she laid the scissors back on the clean towel barrier field without cleaning the scissors. The old 4 x4 gauze dressings were lying on top of the wound and the dressings were stuck to the edges of the resident's wound due to being dried along the edges of the resident's wound. The resident indicated to the nurse at that time when she removed the dressings "Ouch, that hurts." LPN #1 indicated to the resident at that time she was being as gentle as she could be and she would be done in a minute. The resident had a furrowed brow and grimaced when LPN #1 removed the dressings from the resident's RLE. She threw the old dressing in the trash. The old 4 x 4 gauze pads covering the wound had a moderate amount of brownish red drainage on them. She irrigated the wound with normal saline in a syringe without changing her gloves. The resident indicated to LPN #1 at that time the wound was tender and LPN #1 indicated at that time to the resident, she was being as gentle as she could be. LPN #1 indicated at that time, she had medicated the resident at 10:00 a.m., with her routine [MEDICATION NAME]. The resident indicated at that time, the pain medicine helped a little bit, but her leg was still hurting. The wound was approximately the size of an orange. The wound bed was red with white slough along the lateral outside edge of the wound. LPN #1 removed her gloves and washed her hands, then donned clean gloves. LPN #1 applied Hydrogel onto one 4 x 4 gauze dressing, then laid it back on the open package. LPN #1 squeezed Santyl ointment into the middle of the wound, then used one sterile cotton tipped applicator and smeared it around the entire wound. She started in the middle where the glob of ointment was and continued to smear the Santyl around in a circular motion four times, while crossing over the inside of the wound. The resident indicated at that time, the wound bed was hurting and LPN #1 indicated at that time, she was being as gentle as she could be and she was almost finished with the dressing. The resident was observed with furrowed brows and facial grimacing during that time She pulled the 4 x 4 gauze smeared with Hydrogel gauze apart into a flat circle and used a sterile cotton tipped applicator and applied it to Resident C's wound. The resident indicated at that time, her wound bed was hurting. LPN #1 indicated at that time to the resident, she was being as gentle as she could. The resident was observed with facial grimacing and furrowed brows while LPN #1 was packing the wound with the Hydrogel gauze. LPN #1 applied [MEDICATION NAME] ointment around the periwound with a sterile tipped applicator, then covered the wound with an ABD pad. She wrapped the Kerlix gauze around the ABD pad and secured it with tape. The resident indicated at that time, as the LPN #1 was applying the [MEDICATION NAME] to the edges of the wound and wrapping the RLE with the Kerlix gauze that her leg was hurting. LPN #1 indicated that she was just about done with the dressing change. The resident was observed with facial grimacing and furrowed brows throughout these two steps of the dressing change. LPN #1 did not stop during the wound dressing change to medicate the resident with any as needed pain medication. She cleaned up her trash and removed her gloves. Resident C indicated to LPN #1 while she was cleaning her trash up after the dressing change that her RLE continued to hurt. She washed the pair of scissors with soap and water, then washed her hands. During an interview on 1/27/15 at 11:29 a.m., LPN #1 indicated she should have removed her gloves, then irrigated resident C's RLE with normal saline. She indicated she had cleansed her scissors with alcohol before she went into the room. She indicated she should have applied the Santyl by starting in the middle of the wound and worked her way out towards the outside of the wound. She indicated she should not have placed the pair of scissors on the clean towel barrier next to her clean supplies after she cut the old dressing off the resident's RLE. LPN #1 indicated the 4 x 4 gauze dressings that she removed from the wound should not have been laid on top of the resident's wound. She indicated the resident had not normally had that much pain when her wound dressing was changed, but the old dressing was dried around the wound edges and it stuck to her wound when she tried to remove it. LPN #1 indicated she normally would have stopped and medicated the resident having pain during a dressing change, then finished the dressing, but she had pre-medicated Resident C, so she thought she would be okay throughout the dressing change. On 1/27/15 at 11:30 a.m., LPN #1 was observed asking Resident C at the nurses station if she was still having RLE pain and the resident indicated at that time she was having pain. At that time, LPN #1 medicated the resident with her as needed [MEDICATION NAME] pain medication. During an interview on 1/28/15 at 1:15 p.m., the DNS (Director of Nursing Services) indicated LPN #1 should have removed her gloves and washed her hands after she removed the old dressing on 1/27/15, then cleansed Resident C's RLE wound. She indicated LPN #1 should have placed the pair of scissors on a dirty field, not the clean field after cutting the old dressing off her RLE wound. The DNS indicated LPN #1 should have applied the Santyl with a gauze from the inside of the wound to the outside of the wound and the Hydrogel gauze should have been fluffed when she applied it to the resident's RLE wound. During an interview on 1/28/15 at 5:45 p.m., the DNS indicated LPN #1 should have stopped doing the dressing change and medicated the resident, waited for the medication to take effect, then resumed with the dressing change. A current policy titled "Dressing Change (Incision or Wound)" dated 09/2012, provided by the DNS on 1/28/15 at 3:33 p.m., indicated "Procedure Steps:.. 6. Put on gloves. 7. Remove old dressing from residents and put directly in trash receptacle. 8. Remove gloves and discard. 9. Perform hand hygiene. 10. Put on gloves. 11. Initiate wound care according to the physician order:.. a) cleanse away debris or drainage from the wound... 13. Remove gloves and discard. 14. Perform hand hygiene. 15. Put on gloves. 16. Apply new dressing according to the physician orders...." 2. On 1/27/15 at 2:55 p.m., the record review for Resident R was completed. [DIAGNOSES REDACTED]. The care plan dated 7/13/11, indicated the resident was at risk for pain related to chronic pain, knee pain, Gout ([MEDICAL CONDITION] condition of the joints), H/O (history of) pain related to [MEDICAL CONDITION]. Administer meds as ordered, assist/encourage to reposition frequently, document effectiveness of prn (as needed) medications, notify MD if pain is unrelieved, worsening or having break thru pain as needed, observe for changes in day to activities, observe for changes in sleep pattern, observe for changes in sleep pattern. Observe for non verbal signs of pain, changes in breathing, vocalizations, mood/behavior changes, eyes change expression, sad/worried face, crying, teeth clenched, changes in posture, offer non pharmacological interventions such as quiet environment, rest, shower, back rub, reposition. On 1/27/15 at 2:00 p.m., CNA #1 and CNA # 2 were observed transferring Resident #47 with a Hoyer lift from her broda chair into her bed. The CNA's placed the Hoyer pad underneath the resident, transferred her and positioned her in bed. The resident had facial grimacing and a furrowed brow while the CNA's were transferring her. CNA #2 told the resident they were going to remove her pants and clean her up. CNA #1 and CNA #2 moved the resident to her left side and to the other while removing her pants. The resident yelled out at as CNA #1 pulled on the left side of pants, and CNA #2 pulled on the right side of the pants and pulled them down underneath of the resident's knees. Then CNA #1 and CNA #2 continued care by pulling off the resident's brief, unfastening it on the left side and pulling the brief down without taking the seam off of the right side. As they turned to reposition her on her right side the resident indicated "that hurts." She was yelling, had facial grimacing and her eyebrows were furrowed. On 1/28/15 at 11:20 a.m., LPN # 4 indicated during interview, the CNA's completing the transfer and care should have reported the complaints of pain to her. LPN # 4 indicated she had not been notified of the resident's complaints of pain A document titled "Pain Management" dated 1/03, with revision dates of 12/03, 1/06, 1/08, 3/10 and 9/2013 was provided by the Assistant Director of Nursing on 1/29/15 at 11:15 a.m. The policy indicated, "...It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keep the resident as comfortable and pain free as possible...." This Federal tag relates to complaint IN 279. 3.1-37(a)

Based on interview and record review, the facility failed to assess a resident with a prior history of wounds after a significant change in condition which resulted in the hospitalization and amputation below the knee for 1 of 3 resident's reviewed for non pressure wounds in a sample of 9. (Resident B) Findings include: The record review for Resident B was completed on 6/2/14 at 2:00 P.M. [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Cleanse BLE with sterile water , apply silver alginate, apply ABD pads and wrap with Kerlix, change daily and as needed due to soiling or dislodgement. An order dated 3/28/14 indicated physical therapy would do wound treatment and four layer compression weekly on Tuesdays and Fridays. The physical therapy documentation indicated: 3/25/14-"... Wound evaluation to BLE venous stasis ulcers. Wound debridement (cleaning of dead skin) provided to improve tissue growth and dressings changed as per ordered. 4 layer compression applied to BLE to decrease [MEDICAL CONDITION] (swelling) and improve skin integrity. Patient and nursing staff were given instructions/education on wound goals/status and plan of care. The patient exhibits venous stasis ulcers to Bilateral lower legs with severe [MEDICAL CONDITION]/hyperpigmentation (skin very dark in color) and maceration (breakdown of skin due to moisture). 1. Right big toe 1.3 x 2.1 with 80% slough with mild serosanginous drainage. 2. Right shin 4.7 x 5.4 with 90% red 10% pink with moderate serous drainage...." 3/28/14- a note indicated the resident tolerated and completed active wound treatment to BLE wounds as per ordered. No pain. Applied compression wraps-4 layer to BLE to decrease [MEDICAL CONDITION]. Patient/nursing staff education provided. 4/1/14- a note indicated the BLE dressing were changed with Xeroform and 4-layer compression wraps. Indicated the patient exhibited venous stasis ulcers to BLE that show improvement with current treatment. Measurements were not taken during this treatment period. 4/4/14- Completed and tolerated active wound treatment to BLE wounds as per ordered. BLE showed decreased [MEDICAL CONDITION], decreased maceration, wound beds are red. No complaints of pain. Applied compression wraps #1, 2, and #4 to BIL lower legs to decrease [MEDICAL CONDITION] and improve skin integrity. Patient/nursing staff education was provided. 4/8/14-The patient exhibited venous stasis ulcers x multiple small areas to both lower legs characterized by 100% red, no maceration, minimal non [MEDICAL CONDITION], superficial and minimal serous drainage. 4/11/14- No documentation regarding wounds was found. 4/15/14- BLE [MEDICAL CONDITION] dressing change. 4/18/14- Changed resident's bilateral LE dressings and caregiver education on dressing changes and identifying changes during resident's LOA (leave of absence). 4/22/14- no documentation regarding dressing change. The patient exhibited lesser venous ulcers to Right lower leg which are 100% red, no maceration, slight non-[MEDICAL CONDITION] with zero drainage. 4/30/14-"BLE [MEDICAL CONDITION] dressing changes today...." The progress notes from nursing was reviewed from March through May and there was no documentation of the venous stasis ulcers. The weekly skin checks from nursing were reviewed from March through May and they only indicated some [MEDICAL CONDITION] to bilateral lower extremities, there was no documentation regarding stasis ulcers or any redness to the lower extremities. In an interview with the Director of Nursing Services (DNS) on 6/3/14 at she indicated they were not tracking the bilateral lower extremity wounds and that therapy had the only documentation of the wounds on the legs. On 5/3/14 at 3:15 P.M., the progress notes indicated ., "... became lethargic to name,. Temperature 102.6, pulse 89, respirations 18-24, blood pressure 134/67, pulse oxygen level 96%, and blood sugar 181. The physician was notified and orders obtained for immediate labs, chest-X-ray and intravenous (IV) fluids. Also gave Tylenol for fever. 8:30 P.M. the resident was more alert and talking, but still not at normal baseline. Temperature remains elevated at 101.8 Tylenol for fever repeated. 11:20 P.M. Scab on back of neck healing no signs or symptoms of infection. Buttock wound continues to improve. Bilateral feet dressings changed small amount of serous drainage on both areas. No complaints of pain with dressing changes...." 5/4/14- 3:10 A.M. "...Resident had a left arm midline catheter placed and IV fluids started at 125 milliliter/hour. Patient was alert and up in chair Resident given [MEDICATION NAME] (antibiotic)1 gram intramuscularly. Resident has no complaints of pain or discomfort. Temperature 98.9 will continue to monitor. Dressing change done to left and right 2nd toes . no complaints of pain or discomfort, no signs or symptoms of infection noted. 2:06 P.M.- New orders for immediate blood cultures, a urinary and sputum (spit) culture. IV [MEDICATION NAME] (antibiotic) 1 gram twice daily and Aztreoman (antibiotic)2 grams three times daily. Treat fever over 100.5, vitals every 30 minutes or as needed if resident had low blood pressure 2:28 P.M.- wife notified of new orders. 8:39 P.M.- vitals were monitored temperature remained high but stable, heart rate equally high but stable. The oxygen, respiratory rate and blood pressure remained within normal limits. 9:42 P.M. DNS notified regarding increased temperature. 9:45 P.M. Patient was assessed all evening for vital signs. Temperature remained increased after Tylenol was given. Patient seemed alert but having trouble with communication during the shift related to falling asleep in the middle of tasks or questions. Patient dressing changes were completed during this shift. Patient having trouble staying awake or following instructions. 5/5/14- 2:46 A.M.- resident condition changed, resident was lethargic, was on IV Aztreoman 2 grams TID, vitals were abnormal, notified physician, called spouse and left a voice message, notified, DNS- left voice message. Resident was sent to hospital via ambulance...." The hospital records dated 5/5/14 indicated the resident's admitting [DIAGNOSES REDACTED]. A doctor indicated on his hospital consultation note dated 5/5/14 2:12 P.M., "...Reason for consultation : Right leg infection...Upon further investigation, he apparently has a white count of 30,000. He has an INR of 5.6 at the time and he was on [MEDICATION NAME] for [MEDICAL CONDITION]. His right leg appears to be grossly infected with [MEDICAL CONDITION] that has gone beyond the knee joint into his right thigh area. he has bilateral lower extremity ulcerations, most likely related to venous disease...." A Nurse Practitioner indicated in her hospital consultation note dated 5/5/14 9:50 P.M., "...there was [MEDICAL CONDITION] that was extending up to distal foot and toes...." The surgery report dated 5/8/14 indicated, "...Diagnosis: [REDACTED]." The record between 5/3/14 and 5/5/14 had no indication the compression wraps were removed and the bilateral extremities were assessed as the resident was declining with lethargy, high temp and unstable vital signs. The last skin assessment performed was on 5/2/14 by the nursing staff. On 6/5/14 at 2:00 P.M., the Director of Nursing indicated the weekly skin sheets dated 5/2/14 and the notes that physical therapy provided were the only documentation she had to provide regarding Resident B's legs. This Federal tag relates to the Investigation of complaint IN 537. 3.1-37(a) .

Based on observation, record review and interview the facility failed to ensure residents did not acquire pressure ulcers, in that when dependent residents entered the facility without a pressure ulcer, acquired pressure ulcers which progressed in size and to Stage 3 and unstageable ulcers and required additional interventions by a contracted wound specialist to aide in the resolution of the area. This deficient practice effected 2 of 3 residents reviewed with pressure ulcers in a sample of 6. (Residents "F" and "E"). Findings include: 1. The record for Resident "F" was reviewed on 09-11-13 at 10:50 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set assessment, dated 09-02-13, indicated the resident had no cognitive impairment and also indicated the resident required extensive assistance with transfer, bed mobility, toileting and hygiene. The assessment indicated the resident did not have a pressure ulcer. The resident's current plan of care, originally dated 06-13-13 indicated the resident had ADL (activities of daily living) Functional / Rehabilitation Potential. "Self care deficit related to decreased mobility, hx (history) [MEDICAL CONDITION] with hemi ([MEDICAL CONDITION]), hemicraniectomy, [MEDICAL CONDITION]." After the Initial tour of the facility, on 09-11-13 at 9:30 a.m., the Director of Nurses indicated the resident was recently assessed with [REDACTED]. A review of physician orders, dated 08-27-13 instructed the nursing staff to apply [MEDICATION NAME] to the buttocks qs (every shift) for redness. A subsequent physician order, dated 09-01-13 instructed the nursing staff to apply [MEDICATION NAME] to bilateral buttocks two times a day. A review of the resident "shower sheets," dated 08-28-13, 08-31-13 and 09-04-13 lacked indication the resident's wound had declined. The "shower report," clearly prompts the CNA (certified nurse aide) to "circle problem area and check all boxes as needed." A subsequent plan of care, dated 09-05-13 indicated the condition of the resident's buttocks had declined and noted as "Problem - Resident has impaired skin integrity: Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) and Unstageable to left buttocks." A progress note, dated 09-06-13 at 10:54 a.m. indicated "wound rounds with NP (nurse practitioner), DNS (Director of Nursing Services), MDS (Minimum Data Set) and DM (Dietary Manager) at bedside. Resident followed weekly related to impaired skin integrity to left buttocks. #1 left superior buttock: area is Unstageable and suspected DTI (deep tissue injury) with scant sero-sanguineous drainage, no odor noted. Periwound skin is normal, no s/s (signs or symptoms) of infection noted. NP recommends to change tx. (treatment) to left buttock to [MEDICATION NAME] powder with [MEDICATION NAME]. A review of the resident's clinical record, contained a progress note dated by the local wound care company, dated 09-06-13 which indicated the following:"Location: left buttocks, Severity: Stage 3 DTI. Duration 08-28-13. Context: wounds are a result of pressure. Complaints and symptoms: Patient complains of gastrointestinal: bowel incontinence, [MEDICAL CONDITION]: urinary incontinence, musculoskeletal: deformities, muscle weakness, neurological one sided weakness." "Wound #1 Left superior buttock is a suspected deep tissue injury pressure ulcer and has received a status of not healed. Measurements are 1.4 cm (centimeters) length by 1.2 cm depth with an area of 1.68 sq. (square) cm. There is a scant amount of sero-sanguineous drainage noted which has no odor. General notes: 60% DTI." "Wound #2 left inferior buttocks is a stage 3 pressure ulcer and has received a status of not healed. Measurements are 1.2 cm length by 0.9 cm width by 0.1 cm depth with an area of 1.08 sq cm and a volume of 0.108 cubic cm. There is a small amount of serosanguineous drainage noted which has no odor." "Plan - wound #1 apply [MEDICATION NAME] powder to affected area(s) followed by application of [MEDICATION NAME] or equivalent to area(s) every shift and PRN (as needed), incontinence. Wound #2 left inferior buttocks - apply [MEDICATION NAME] powder to affected area(s) followed by application of [MEDICATION NAME], or equivalent to area(s) every shift and PRN, incontinence." "Assist with turning every two hours." During an interview on 09-12-13 at 9:45 a.m. the resident indicated "I've been up in this chair (wheelchair) since about 6:30 a.m. I think I got those bedsores because they didn't turn me." When interviewed if the resident could turn self in bed, the resident responded "No." When interviewed if the resident had been changed, checked for incontinence or position had been changed since early this morning, the resident responded "no." Upon completion of this interview the resident was taken for therapy. An interview on 09-12-13 at 9:55 a.m., Certified Nurse Aide #8 indicated she had been assigned to the resident "this morning. I haven't had to do anything for (resident) she'll let me know if she needs to be changed." 2. The record for Resident "E" was reviewed on 09-11-13 at 11:10 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's MDS, dated [DATE] indicated the resident had no cognitive impairment, and required extensive assistance with two staff member for bed mobility, transfer, toileting and hygiene. The assessment indicated the resident was always incontinent of bowel and frequently incontinent of bladder and further indicated the resident did not have pressure ulcers. The resident's current plan of care, originally dated 07-09-13 indicated the resident required assistance with ADLS's related to status [REDACTED]. Approaches to this plan of care included "assist with transfers as needed, incontinent care as needed, provide shower two times per week, partial bath in between." After the Initial tour of the facility, on 09-11-13 at 9:30 a.m., the Director of Nurses indicated the resident was recently assessed with [REDACTED]. A progress note, dated 09-06-13 at 11:45 a.m., indicated the resident "followed weekly related to impaired skin integrity to left buttocks. Area appears as stage 3 pressure ulcer that is 100 % granulation with scant sero-sanguineous drainage and no odor noted. NP (nurse practitioner) recommends to d/c (discontinue) current tx. (treatment) and start [MEDICATION NAME] powder and [MEDICATION NAME] every shift and prn." A review of the clinical record included a progress note from the local contracted wound care company and dated 09-06-13, which indicated the following:"Location: left buttocks. Severity: stage 3. Duration 09-02-13. Context: wound is a result of pressure. Modifying factors: fecal incontinence, urinary incontinence and debility. Needs assistance with repositioning, needs assistance with transfers. Complaints and symptoms: gastrointestinal: bowel incontinence, [MEDICAL CONDITION]: urinary incontinence, muscluloskeletal: muscle weakness, neurological: weakness, psychiatric: depression." "Neurological: Diminished sensation in lower extremities." "Wound #1 left buttock is a Stage 3 pressure ulcer and has received a status of not healed. Measurements are 0.8 cm length by 0.7 cm width by 0.1 cm depth with an area of 0.56 sq cm and a volume of 0.056 cubic cm. There is a scant amount of sero-sanguineous drainage noted which has no odor. The wound margin is well defined.""Plan: wound #1 left buttocks - [MEDICATION NAME] - apply [MEDICATION NAME] powder to affected area(s) followed by application of [MEDICATION NAME] or equivalent to area(s) every shift and PRN incontinence. Off loading: turn every two hours. Pressure ulcer stage 3 - diligent offloading. Full incontinence of feces - contain. Keep pt. (patient) clean and dry with wounds free from contamination. Functional urinary incontinence - same as above. Assist patient with turning and repositioning every two hours." A review of the resident "shower sheets," dated 09-03-13 and 09-07-13 indicated "circled" areas of concern on the residents perineum and lower buttocks, and the 09-10-13 shower report indicated the resident "refused a shower," but lacked identification of skin areas of concern. The shower report contained an area for the "charge nurse signature," and prompted the nurse "all skin problems must be assessed and documented by the charge nurse. Any shower refusal must be recorded with a second attempt tried." The resident's current plan of care, originally dated 09-05-13, indicated the "resident has impaired skin integrity: Stage 3 left buttocks." Interventions to this plan of care included "treatment as ordered, turn and reposition every two hours." During an interview on 09-11-13 at 2:00 p.m., the resident indicated "I've been in these briefs so long - I've been using them since I came here in June 2013. Once I got up yesterday around 11:00 a.m., I stayed up in this chair until 5:00 p.m. The other day I got up around 11:00 a.m., and stayed up until 9:00 p.m. I don't wet much so they don't have to do too much for me." During an observation on 09-12-13 at 8:15 a.m., the resident was observed seated in bed with the head of the bed elevated and her breakfast tray positioned on the over bed table. The resident remained seated upright in bed until 10:45 a.m., at which time a skin assessment was requested. The resident, with the assistance of the CNA #8, was turned to the right side. The resident had indentations present across bilateral hips and spanned across her buttocks. This Federal tag relates to Complaint IN 457. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review and interview the facility failed to ensure a resident did not acquire a pressure ulcer, in that when a dependent resident entered the facility without a pressure ulcer, acquired an ulcer which progressed in size and required additional interventions by a contracted wound specialist to aide in the resolution of the area. This deficient practice affected 1 of 4 residents reviewed with pressure ulcers in a sample of 9. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 08-19-13 at 8:50 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. At the time the resident was admitted to the facility, the previous Extended Care Facility included a physician's "History and Physical," dated 04-13-13, in which the resident had "slit ulcers under each breast - slight slough" and included the physician orders [REDACTED]. A facility "observation report," dated 04-19-13 indicated the resident was alert to time, place and person, and had lower body and right handed weakness and did not have a pressure ulcer. The resident's skin was intact. A review of the Admission Minimum Data Set assessment, dated 04-22-13, indicated the resident required extensive assistance with bed mobility, and transfer. In addition the resident was frequently incontinent of bowel and bladder, had physical limitations to one side and did not have a pressure ulcer at the time of the assessment. A plan of care, dated 04-23-13 indicated the resident had the "potential for skin breakdown related to decreased mobility and urinary and bowel incontinence." Interventions to this plan of care included, "turn and reposition at least every 2 hours and as needed, positioning wedge in bed to aid in positioning, assist resident with toileting and pericare after each incontinent episode, pressure reducing/redistribution cushion in chair/wheelchair." The Director of Nurses provided documentation, the Resident Care sheet, dated 04-23-13 in regard to the resident, where the resident was without a pressure ulcer. A nurse progress note, dated 04-28-13 indicated the resident had "redness to left buttocks." The nurses received physician orders [REDACTED]. A report, titled "Event Report," dated 04-29-13 indicated the resident was assessed with [REDACTED]. The report indicated the tissue had "granulation (pink or red tissue with shiny, granular appearance), with no drainage noted." A physician order [REDACTED]. (evaluate) and tx. (treat) - bottom OA (open area)." A progress note dated 05-10-13 indicated the resident had a "wound to left buttocks and measured 1.7 cm by 2.3 cm by 0.1 cm with scant amount of serosanguinous drainage. Resident assessed by (name of wound care company) due to poor response to previous treatment." Review of the contracted wound care company report, dated 05-10-13, indicated the following: "Wound #1 location: left buttocks...is a result of pressure. Modifying factors included fecal and urinary incontinence, DM (diabetes mellitus), [MEDICAL CONDITION] and debility, with diminished sensation in lower extremities. Wound left buttocks Stage 3 (Full thickness of skin is lost, exposing the subcutaneous tissue - presents as a deep crater with/without undermining tissue) pressure ulcer has received a status of not healed. Measurements are 1.7 cm length by 2.3 cm in width by 0.1 dm depth with scant amount of serosanguinous drainage noted which has no odor." A subsequent plan of care, dated 05-13-13 indicated the "resident has h/o (history of) impaired skin integrity" pressure area left buttock." Interventions to this plan of care included "incontinent care as needed, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, turn and reposition every two hours, treatment as ordered." The wound care report, dated 05-17-13 indicated the area remained a Stage 3 pressure ulcer which measured "1.2 cm in length by 1.4 cm in width by 0.1 cm in depth with scant amount of sero-sanguineous drainage noted which has no odor." Further review of the consultant wound care report, dated 05-24-13, the area was assessed as "not healed" and measured "1.1 cm in length by 2.1 cm in width by 0.1 cm in depth." The 05-31-13 report indicated the area was "not healed" and measured "1.8 cm in length by 1.7 cm in width by 0.2 cm in depth. The wound is deteriorating." Instructions to the nursing staff included "keep pt (patient) clean and dry without stool or urine in the wound. Staff education regarding proper dressing placement was provided." The 06-14-13 report indicated the pressure ulcer was "healed," however presented with "fragile epithelium." On 07-26-13 the local wound care consultant assessed the resident and indicated the "Wound #2 - patient presents with open area on buttocks - is a result of pressure," and located on the resident's "coccyx." The area was noted as a "Stage 3 pressure ulcer" and measured "0.2 cm in length by 0.2 cm in width by 0.1 cm in depth." The "plan" included "[MEDICATION NAME] - cleanse wound are with mild soap and water, rinse thoroughly. dry. apply [MEDICATION NAME] or equivalent to wound area once per shift and PRN (as needed), incontinent. Off Loading - wedge cushion or pillow/s for positioning in bed and turn every 2 hours." The 08-02-13 report indicated the resident's pressure ulcer was "healed." Observation on 08-19-13 at 9:45 a.m., the resident was observed lying in bed. With permission of the resident a body assessment was conducted with the Director of Nurses. During this assessment, the resident indicated she was unable to turn herself in bed without the help of the nursing staff. The resident was turned to the left side. The resident's buttocks and coccyx were observed without open or pressure areas noted. A subsequent observation on 08-19-13 at 3:00 p.m., the resident was seated upright in bed. The resident indicated her spouse "cleaned me up and got me dressed, that was about noon. I just got back in bed a few minutes ago." When questioned if the nursing staff checked or provided incontinent care after being transferred back to bed the resident indicated "no." With permission of the resident, an assessment was conducted with the Director of Nurses. The resident was turned to the right side. Although the previous pressure ulcerated areas were not opened, the resident was found to be incontinent of urine, and had not received additional nursing care for approximately 3 hours from the time the resident's spouse assisted the resident with daily care. This Federal tag relates to Complaint IN 954. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review the facility failed to ensure residents received services to prevent further skin breakdown, in that when residents were identified and assessed with [REDACTED]. (Resident "C" and "A") Resident C had multiple open skin areas that deteriorated and increased in size. Findings include: 1. The record for Resident "C" was reviewed on 05-09-13 at 1:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. During an interview on 05-09-13 at 9:05 a.m., the resident was observed laying in bed and indicated the night shift nurse had not provided treatment to the areas on the posterior thighs. "They're suppose to do it every shift, and no one came in to do it last night." A request was made for the resident to turn in order to observe the areas. The resident had 4 areas which included 2 on the right posterior thigh, one area on the left posterior thigh, one area on the right thigh and scattered areas on the left buttocks and right lower posterior ankle area. The areas did not have a dressing in place. The areas appeared circular and did not have a dressing applied to any of the areas. During this observation the resident indicated "they can't use any tape on me because I'm allergic to it." The record for Resident "C" was reviewed on 5/9/13 at 1 p.m. Review of the resident's clinical record indicated the resident received services of a local wound care company and the latest "progress note details," dated 04-26-13, indicated the "wounds are a result of [MEDICAL CONDITION]," and indicated the following assessment and measurements: "Wound #2 right posterior, superior upper leg full thickness dermatologic / rash - not healed. Measurements are 1 cm length by 2.3 centimeters width by 0.1 centimeters in depth. The wound is deteriorating." "Wound #4 left posterior upper leg full thickness dermatologic / rash. Not healed. Measurements are 1 centimeters length by 1.5 centimeters width by 0.1 centimeters depth. The wound is deteriorating." "Wound #5 right inferior upper leg full thickness dermatologic / rash. Not healed. Measurements are 1 centimeters length by 0.7 centimeters in width by 0.1 centimeters depth. There is a scant amount of drainage noted which has no odor. The patient reports a wound pain of level 2. The wound is deteriorating." "Wound #6 right medial upper leg full thickness. Not healed. Measurements are 2 centimeters length by 3 centimeters in width by 0.1 centimeters depth. The wound is deteriorating." The wound care specialist "plan," dated 04-26-13, included the use of "1:1:1 mix of [MEDICATION NAME], 0.025 % [MEDICATION NAME], and 2% [MEDICATION NAME] to affected areas every shift and cover with alevyn foam." In addition was a recommendation, by the wound care specialist on 04-26-13, included "off loading for all wound and to "upgrade w/c (wheelchair) cushion - upgrade to ROHO (brand of cushion)." Observation on 05-09-13 at 11:15 a.m., with the Director of Nurses in attendance, verified the resident's wheelchair had not been upgraded with the recommended cushion. Interview on 05-09-13 at 1:25 p.m., the Therapy Director indicated a ROHO cushion had not been ordered "but we can get one." A request was made to re-measure the resident's wounds. On 05-09-13 at 2:00 p.m., the Director of Nurses provided documentation which indicated the following measured areas: "Right inferior thigh 2.0 centimeters by 1.1 centimeters by 0.2 centimeters." This was an increase in size from the 4/26/13 measurments."Right Superior thigh 2.6 centimeters by 2.4 centimeters by 0.1 centimeters." This was an increase in size from the 4/26/13 measurement. "Left thigh 1.6 centimeters by 1.4 centimeters by 0.1 centimeters." This was an increase in size from the 4/26/13 measurements. 2. The record for Resident "A" was reviewed on 05-08-13 at 11:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04-05-13, indicated the resident was frequently incontinent of bowel and bladder. In addition the resident required extensive assistance with bed mobility. A subsequent MDS, after the resident returned to the facility for a hospitalization , dated 05-02-13 indicated the resident's bowel and bladder status had declined and was assessed as "always incontinent of bowel and bladder." Review of the Resident's plan of care, originally dated 04-06-13, indicated the resident "is incontinent due to debility." An "approach" to this plan of care included "assist with incontinent care as needed, check every 2 hours for incontinence." A subsequent plan of care, originally dated 04-06-13 indicated the "resident is at risk for skin breakdown due to decreased mobility, incontinence...." "Approach's" to this plan of care included "incontinent care as needed using peri wash and moisture barrier, assess and document skin condition weekly and as needed, assist/encourage resident to reposition frequently." Review of a Progress Note, dated 05-03-13 at 11:40 a.m., indicated the resident "has 5 fluid filled blisters on right inner thigh, we will leave them open to air until they rupture, then we will reevaluate." Observation on 05-08-13 at 1:05 p.m., the resident was observed lying in bed, slightly positioned to the right side. A request was made to check the resident for incontinence. Licensed Nurse employee #7 and Certified Nurse Aide (CNA) employee #6 removed the bedspread and turned down the sheet to the resident's ankles. During this observation a piece of linen was observed positioned between the resident's upper thighs. When questioned about the use of the pillowcase between the resident's thighs, the Licensed Nurse indicated the use was to prevent skin to skin contact. CNA #6 verified he placed the pillowcase between the resident's thighs. CNA #6, with the assistance of the Licensed Nurse removed the pillowcase. The pillowcase had been folded lengthwise, and was saturated with urine approximately 3/4 of the area of the pillowcase which extended from the resident's upper thighs to the lower back/buttocks. Upon removal of the pillowcase an open area was observed on the resident's right upper thigh. A request was made for the Assistant Director of Nurses (ADON) to measure the area. The ADON indicated the area had previously been five little blisters and indicated the area now measured 1.5 centimeters in width and .5 centimeters in length. The ADON indicated the nurses were suppose to keep a pillow between the resident's upper thighs for positioning and allow the area to be open to air. During an observation on 05-09-13 at 8:00 a.m., the resident was observed lying on her back in bed. A request was made to check the resident for incontinence and skin care. CNA employee #8 folded back the bed linen. During this observation a pillowcase was observed positioned between the resident's upper thighs. A request was made for the ADON to observe the resident. The ADON verified the pillowcase was not suppose to be used for the resident. The ADON re-measured the area, previously identified as "little blisters" and indicated the area measured 1.5 centimeters in width and .6 centimeters in length. This Federal Tag relates to Complaint IN 215. 3.1-37(a)

Based on observation, record review and interview the facility failed to ensure the resident's plan of care and/or physician orders [REDACTED]. (Resident's "A", "F", "B", "D", "E" and "C"). Findings include: 1. The record for Resident "A" was reviewed on 12-17-12 at 1:53 p.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. These [DIAGNOSES REDACTED]. admission orders [REDACTED]. The record also indicated the resident received oxygen therapy at 2 liters per nasal canula and c-pap (continuous positive air pressure) at bedtime per physician order [REDACTED]. In addition the resident had a physician order, dated 11-25-12 for the nursing staff to monitor oxygen saturation levels every shift. The record indicated the following: "11-27-12 at 10:36 p.m. - Resident awake and alert. Resident had occational <sic> nonprodective <sic> cough. Resident has o2 (oxygen) at 2 liters/nasal cannuli <sic> and wears c-pap at bedtime." "11-28-12 at 4:45 p.m. - Re;c <sic> resident in bed hob (head of bed) up. Resident struggling to breath c-pap applied O2 sat. between 83 (%) - 84 (%). Resident has HX. history) [MEDICAL CONDITIONS] on o2 at 2 l (liters) per nc (nasal canula). NP (nurse practitioner) notified, new order rec;d <sic> Assessment done, some wheezing noted. Resp (respiratory therapist) here, inservice on the c-pap done. Staff spoke with family. Staff cont;d <sic> to monitor o2 (oxygen) sat (saturation) 88 (%) - 91 (%)." "11-29-12 at 6:01 a.m. - Resident resting in bed with c-pap machine on, o2 level range between 88 - 91 when on c-pap. Resident was made comfortable and bed adjusted to level when airway is open and resident is able to breathe easily." "11-29-12 at 2:18 p.m. - At about 9:00 a.m. resident was c/o (complains of) sob (shortness of breath). Writer checked o2 sats 77 % ra (room air) Resident had taken off O2, once O2 was on res. (resident) O2 sat. increased to 93% on 2L O2. Writer retrieved another nurse for more advice, she said she was ok now. Res. was also c/o c-pap machine not giving enough O2, res. had (family member) bring in c-pap machine from home, (family member) connected c-pap machine and res. said (resident) was fine. Res. (family member) was cleaning her up and writer told (family member) to let me know when (resident) was done, writer wanted to check O2 sat, et (and) (family member) was at 96 % 2 L O2. After stand up writer was informed that res. could not use c-pap from home. Writer informed resident et (family member) of the situation. Writer switched <sic> (resident) back to the other c-pap machine et resident was fine. About 1:00 p.m. CNA (certified nurse aide) informed writer that resident could not breathe well. Writer did VS (vital signs) all w/n/l/ (within normal limits) BP (blood pressure) 138/72, P (pulse) 82, R (respirations) 24 O2 sat 93 % T. (temperature) 97.6 Writer asked for the Unit manager to help with c-pap straps. Res. was sating at 96 % and fading in et out of conscienceous <sic> et c/o chest pains. Writer retrieved NP for more advice called 911. Sent to (name of local area hospital) ER (emergency room ) for eval (evaluation) and Tx. (treatment)." The record lacked documentation the physician was notified for clarification of the [MEDICATION NAME] order in regard to frequency and the resident never received the treatment. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the record lacked documentation the nursing staff failed to inform the physician the oxygen saturation levels had not been conducted as ordered for each nursing shift. A review of the Hospital record on 12-17-12 at 9:00 a.m. indicated the resident was assessed with [REDACTED]. The emergency room physician indicated the resident had complaints of "mid sternal - [MEDICAL CONDITION] pain and shortness of breath since lunch, difficulty breathing last night (off c-pap times 5 days), had c-pap last night but shortness of breath worsened today. Not receiving breathing treatments since at ECF (extended care facility) times 3 days with inspiratory and expiratory wheezing and rhonchi anterior." Interview on 12-17-12 at approximately 1:00 p.m., a concerned family member indicated the nursing staff didn't get the c-pap machine in "right away and once they got it they didn't know how to use it. (Resident) wasn't getting breathing treatments either." 2. The record for Resident "F" was reviewed on 12-19-12 at 10:50 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. At the time of admission, the resident required "assistance with bathing, dressing and toileting and maximum assistance with mobility." The record indicated on 10-09-12 at 1:01 p.m. the "resident has been laothorgic <sic> this shift, not able to help self do anything, Md (medical doctor) order cbc (complete blood count), bmp (basic metabolic profile) c x r (chest xray) et (and) [MEDICATION NAME] (inhalation therapy) three times a day times 3 days." The nurses notes further indicated on 10-09-12 at 7:15 p.m. "lab (laboratory) results came back abnormal. New order were given ..." Review of the physician orders [REDACTED]." The nursing staff received a subsequent order dated 10-10-12 which instructed them to take the oxygen saturation level during the middle of the night to see if "sat (oxygen saturation level)" drops below 90 %. In and out cath (catherization) to obtain ua c & s." Review of the nurses notes dated 10-10-12 at 1:53 p.m. indicated "res. alert but doesn't want to open eyes or mouth. res. wants to lay in bed during shift and doesn't want to get up." Nurses note 10-10-12 at 3:56 p.m. - as a late entry indicated the resident had an "witnessed fall on 10-09-12" and although the resident did not hit head the physician ordered blood work. "Chest xray showed mild [MEDICAL CONDITION] vascular congestion in both lower lung fields. MD notified and order to check O2 sat and UA." Nurses note 10-10-12 at 9:19 p.m. indicated the write "called MD to give update on res. res was acting more lethargic and out of it than the night before. chest xray showing mild [MEDICAL CONDITION] vascular congestion in both lower lung fields. MD was notified and the following orders were put into place. O2 sat during middle of night to see if sat drops below 90 % in and out cath to obtain UA C & S per MD." Nurses note 10-10-12 at 9:39 p.m. Rec;d <sic> resident in bed, responsive to tactile stimulation. Resident only took sip of water encouragement given. Refused diet staff assist ed <sic> as needed, incontinent of bowel et bladder. Total care with ADL's (activities of daily living) refused medication vitals WNL no wheezing noted staff cont;d to monitor." Nurses note 10-11-12 at 5:53 a.m. "Resident in bed would no <sic> wake up to open eyes to take medication. No respond <sic> to tactile stimulation vitals WNL, will continue to monitor." Nurses note 10-11-12 at 11:56 a.m. "Resident in bed responsive to touch. Resident didn't eat or take any medication for this writer. Res. didn't open eyes or response <sic> to my voice. Called Md for instruction. writer was advised by the NP to call the family et advise them of the situation and see if they wanted (resident) to go to the hospital. Family said yes, send to (name of local area hospital) ER for eval et tx." A subsequent nurses note dated 10-12-12 at 9:58 a.m. indicated the resident had been admitted to the hospital and to the intensive care unit. Although the nursing staff had physician orders [REDACTED]. In addition, the record lacked documentation the family had been kept informed of the continued decline of the resident's condition until 10-11-12. Interview on 12-19-12 at 1:15 p.m., the Administrator confirmed the physician orders [REDACTED]. 3. The record for Resident "B" was reviewed on 12-17-12 at 1:30 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The clinical record indicated the resident had fluctuating capillary blood glucose levels, and on 11-05-12 the physician instructed the nursing staff to "refer to Endocrinologist." The resident's blood glucose levels continued to fluctuate through 11-22-12, when the resident was sent to the local area hospital for evaluation. The record lacked information or documentation the resident was referred to the Endocrinologist for evaluation and possible treatment. Review of the resident's minimum data set assessment, dated 09-19-12 indicated the resident required extensive assistance with toileting, hygiene and was frequently incontinent. The resident's plan of care dated 10-04-11 indicated the resident had a "self care deficit." A "goal" to this "problem" indicated the "resident will be clean, neatly groomed and dressed appropriately daily ... ." Interventions included "incontinent care as needed, provide oral care at least two times daily, provide shower two times per week, and partial bath in between." A subsequent plan of care dated 08-12-12 indicated "problem - resident has h/o (history of) impaired skin integrity to lt. (left) ankle and rt. (right)ankle." Interventions to this plan of care included Notify MD of worsening or no change in wound or for signs of infection, incontinent care as needed, assess wound weekly documenting measurements and description, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound." When the resident was evaluated at the local area hospital emergency roiagnom on [DATE], the hospital record indicated the resident was assessed with [REDACTED]." Additional hospital notation dated 11-22-12 indicated the "patient was "unclean/has poor oral hygiene, poor skin condition/decubitus ulcers, ulcers on testicles, and extreme diaper rash." During record review on 12-19-12 at 9:30 a.m., the "shower report" dated 11-21-12 indicated the resident had "redness and raw" noted. The comment section of this report indicated "redness with no open areas." Interview on 12-19-12 at 1:10 p.m. the Assistant Director of Nurses indicated the physician should have been notified for a treatment order. "I was not made aware that on 11-21-12 the area was red or raw. If I had know, yes it would have required the doctor to be notified for a treatment order." 4. The record for Resident "D" was reviewed on 12-19-12 at 9:40 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident was treated by a local wound care company. The record indicated the resident had a plan of care dated 11-21-12 which indicated the "resident was at risk for skin breakdown due to impaired mobility, slides down in chair/bed, diabetes, [MEDICAL CONDITION], incontinence, confusion, [MEDICAL CONDITION] and pressure area to the sacrum." Interventions to this plan of care included "preventative treatment as ordered." Review of a physician order [REDACTED]." The resident was assessed by the local wound care specialist on 12-14-12 and indicated a change in the "plan - Cleanse wound bed with normal saline and pat dry. Apply barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze, then cover with dry gauze and secure daily and PRN soiled." Observation on 12-19-12 at 10:30 a.m., licensed nurse employee #8 indicated she was preparing to complete the dressing change to the resident's pressure ulcer. During this observation, the resident was lying on back in bed fully dressed. The licensed nurse with the help of a CNA turned the resident to the right side, pulled slacks to ankles, removed one side of the incontinent brief, exposing the resident's buttocks. The resident did not have a dressing to the pressure ulcer. The licensed nurse then cleansed around the pressure ulcer two times with a gauze which had been soaked in normal saline. The nurse then applied the Santyl followed by [MEDICATION NAME] and a dry dressing had been secured with tape. Review of the medication/treatment record for 12-2012, contained the order as dated 12-07-12 and not the current order from the wound care specialist. 5. The record for Resident "E" was reviewed on 12-18-12 at 10:30 a.m. [DIAGNOSES REDACTED]. In addition the resident had a gastrostomy feeding tube, an indwelling catheter, a rectal tube and a [MEDICAL CONDITION]. These [DIAGNOSES REDACTED]. Review of the "Temporary Admission Care Plan," dated 12-17-12 at 3:35 p.m., indicated the resident "has potential for fluid deficit r/t (related to) risk factor identified on hydration risk assessment." Interventions to the plan of care included "assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine cracked lips, cry mucus membranes and electrolyte imbalance)." Upon admission the resident was assessed with [REDACTED]." Upon review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"200 ml every six hours." Interview on 12-19-12 at 8:25 a.m., licensed nurse employee #7 verified the order as "200 c.c. (cubic centimeters) every 4 hours." Observation on 12-19-12 at 9:55 a.m., with the Director of Nurses in attendance the resident's skin was again assessed. The urine in the resident's catheter tubing was dark and appeared concentrated. Interview on 12-19-12 at 1:00 p.m., the Director of Nurses verified the color of the resident's urine. The nursing staff failed follow the physician order [REDACTED]. of free water [MEDICATION NAME]. Review of the metabolic profile collected on 12-19-12 at 7:36 a.m. with the results received at the facility on 12-19-12 at 13:55 (1:55 p.m.) indicated the resident's sodium level was 153 (normal range of 126 - 146), BUN (blood urea nitrogen) at 30 (normal range 7 - 18). In addition, the resident had a physician order, dated 12-18-12 at 7:00 p.m. which instructed the nursing staff to "keep (oxygen) saturation level above 90 %, oxygen at 5 liters with 28 % humidity to keep saturation greater than 90 %, change [MEDICATION NAME] (a respiratory treatment) to every 4 hours [MEDICAL CONDITION] perform an oxygen saturation level every shift." The nursing staff failed to monitor the resident's oxygen saturation level on 12-19-12 at 8:00 a.m. and 12:00 p.m. Observation on 12-19-12 at 2:30 p.m., with the Assistant Director of Nurses in attendance with resident had a change in condition in which the current oxygen saturation level was 85 %. 6. The record for Resident "C" was reviewed on 12-17-12 at 12:50 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's minimum data set assessment, dated 10-02-12 indicated the resident required total care of the nursing staff of all aspect of activities of daily living. Review of the resident's plan of care dated 10-03-12 indicated the resident was "NPO (nothing by mouth) and needs extra care to mouth." Interventions to this plan of care indicated "oral care every shift and prn (as needed." Observation on 12-19-12 at 2:30 p.m., the resident was assessed. During this assessment, the resident's lips were dry and slightly cracked. When the resident opened mouth "strings of thick mucus" were observed between the surface of the upper and lower lips. The resident had a subsequent plan of care dated 07-27-12 which indicated "resident has an open areas <sic> to right and left buttock." Intervention to this plan of care included "blue chux on bed, and turn side to side while in bed." The resident had a subsequent current plan of care dated 10-03-12 in which the resident was assessed with [REDACTED]." Interventions to this plan of care included "assist/encourage resident to reposition frequently, use of positioning wedge while in bed to promote side to side positioning." Observation on 12-18-12 the resident remained on back from 10:30 a.m. until 1:00 p.m. Additional observation on 12-19-12 the resident remained slightly turned to left side with a pillow positioned under the left upper arm, from 8:30 a.m. thru 2:30 p.m. This Federal tag relates to complaints IN 799, IN 868 and IN 015. 3.1-35(g)(2)

Based on record review and interview, the facility failed to thoroughly assess, treat, and ensure care was provided for a resident with a significant change in condition, with changes in level of consciousness and vital signs, for 1 of 2 residents who died and were reviewed for the prevention of death (Resident #116). Findings include: Resident #116's record was reviewed on [DATE] at 2:22 P.M. Resident #16 was admitted to this facility on [DATE]. Resident #116's [DIAGNOSES REDACTED]. Resident #116 had been in another rehab facility following a stroke which occurred in May of 2012. This stroke affected the right side of his body. While at this facility he developed complications and was sent to an acute care hospital due to a mental status change and was treated for [REDACTED]. The hospital's transfer report dated [DATE] indicated both issues were resolved over the course of the hospital stay and Resident #116 was transferred to Harcourt Terrace in stable condition on [DATE] to continue rehabilitation from the stroke. A Speech Therapy (ST) note dated [DATE] indicated Resident #116's goal was to complete self-care and activities of daily living (ADLs) with minimal assistance within the home in order to return home safely with his spouse. His rehabilitation potential was good due to he was independent in prior activities of daily living and self care and his improving medical condition. A Physical Therapy (PT) discharge summary dated [DATE] indicated his prognosis for further progress was good. A Speech Therapy (ST) note dated [DATE] indicated Resident #116's prognosis for further progress was good due to the strong support of his significant other. A Social Service Note dated [DATE] indicated a meeting was held with Resident #116, his wife, and IDT (interdisciplinary team). During this meeting Resident #116's wife was informed of the progress being made in therapy and the goals still to accomplish. Resident #116's wife indicated in this meeting she wanted her husband home even if he was unable to be independent. She was considering retiring to care for her husband. A nurses note dated [DATE] indicated Resident #116 was alert and oriented, but hard to understand related to dysphagia, A nursing note dated [DATE] indicated Resident #116 was alert to self only. A nurse's noted dated [DATE] indicated Resident #116 was alert to self and environment, ambulated by wheelchair, was able to make needs known, and was in a happy mood that shift. A care plan dated [DATE] indicated Resident #116 was a full code, had support from family, and his wife visited almost daily since admission. Discharge plans were for him to return home with his wife. Resident #116 had chosen to have life sustaining measures with approaches that included to call the emergency ambulance as needed and notify MD and family of condition changes. A nurse's note dated [DATE] at 2:15 P.M. indicated, "Resident is less responsive than normal. BP (blood pressure) ,[DATE] P (pulse) 64 02 sat (oxygen saturation) on RA (room air) 93% Resp (respirations) 26. No signs of acute pain. Opens eyes when nae (sic) is called. Answering service for (DR. named) called at this time. Awaiting return call from (Nurse Practitioner (NP) named)." A telephone order dated [DATE] at 3:00 P.M. indicated the NP gave orders to check Resident #116's vitals every 4 hours for 24 hours. This order indicated the problem was a change in LOC (level of conscience) and the intervention was the above order. The next two nursing notes were recorded as late entries on [DATE] at 2:46 P.M. and 2:53 P.M. The late entry recorded on [DATE] at 2:46 P.M. for [DATE] at 3:34 P.M. indicated, "Resident is responding to voice and touch. He is pulling hand and arm away." The late entry dated [DATE] at 2:53 P.M. for [DATE] at 7:52 P.M. indicated, "Resident has some juice to drink, he is a little more cooperative at this time VS (vitals) are WNL (within normal limits), respirations unlabored, resting at this time." The vitals record indicated on [DATE] at 7:49 P.M. Resident #116's vitals were: blood pressure ,[DATE], pulse 72, respirations 20, and oxygen saturations were 96%. The next nursing note dated [DATE] at 12:00 A.M. indicated, "Res in bed asleep with HOB (head of bed) elevated. no s/sx (signs or symptoms) of distress/discomfort noted. res bed low with landing mat at bedside call light in reach, no behavior/agitation noted. spoke with wife earlier to inform her of res status. concerns of res not eating food during meal time." The vitals record indicated on [DATE] at 12:15 A.M., Resident #116's vitals were: blood pressure ,[DATE], respirations 20, no oxygen saturation was documented, no pulse was documented. According to the vitals document, the facility utilizes the acceptable ranges for blood pressure of 90-,[DATE]-90. The next vitals documented were at 2:15 A.M. pulse was 48, blood sugar was 362 mg/dl, and temperature was 97.7. Oxygen saturation or blood pressure were not documented. The next nurse's note was dated [DATE] at 3:08 A.M. This note indicated, "res in bed with HOB elevated. CNA (Certified Nursing Assistant) reported res breathing with difficulty, writer went in to assess res et (and) respirations ,[DATE] per min. Accu check 362 mg/DL, writer put res on 2 L (Liters) oxygen per nursing measures. MD notified writer awaiting return call. upon awaiting return call from MD writer unable to obtain respiration no chest movement removed from bed et placed on hard surface CPR initiated per writer/nursing staff 911 called. after EMT (Emergency Medical Technicians) arrives et continued CPR writer called on-call manager to notify of res status. family/wife notified et family states they are on the way to facility spoke with (NP named)/(Dr. named) on call and order to release body to mortuary of choice, death certificate completed et given to mortician. Dr from (hospital named) to sign off on time of death per EMT personnel." During an interview on [DATE] at 2:20 P.M., the facility's corporate clinical nurse consultant was asked to provide the resident's entire chart including doctor orders, doctor notification, care plans, hot charting, event charting, observation documents, progress notes, documentation of vitals, and any information regarding care given to Resident #116 when the first abnormal blood pressure was noted on [DATE] at 7:49 P.M. through 2:15 A.M. when his pulse was documented as 48 beats per minute prior to his [MEDICAL CONDITION]. During an interview on [DATE] at 2:51 P.M., the facility's corporate clinical nurse consultant indicated the doctor had not been notified of the abnormal blood pressure. Documentation of a pulse taken at that time or an oxygen saturation level was not available. During an interview on [DATE] at 10:06 A.M., the NP, who was notified of Resident #116's level of consciousness change and gave the order to monitor vitals every 4 hours for 24 hours, was questioned of her expectations of the vitals she expected the nurse to monitor. She replied, "Temp, respirations, pulse, 02 sats, and if it was due to a neurological change, neuro checks." She indicated she could not remember the call or exactly what she was told. When questioned if she would have intervened if she had been notified of Resident #116's blood pressure dropping from ,[DATE] at 7:49 P.M. to ,[DATE] at 12:15 A.M., she replied, "If he was awake and talking with no other symptoms, I would have ordered stat labs. It just depended on what they told me. If he was not, I would have just sent him to the hospital." During an interview on [DATE] at 2:11 P.M., the supervisor at the funeral home where Resident #116's body was taken indicated the death certificate listed the causes of death as: a. stroke on left brain, b. essential hypertension, c. diabetes mellitus type II, d. acute [MEDICAL CONDITION]. Cause of death part two: [MEDICAL CONDITION] localized six years. He indicated an autopsy was not done. During an interview on [DATE] at 10:30 A.M., the Executive Director (ED) and the Director of Nursing (DON) reviewed the information surrounding Resident #116's death. The DON indicated it would depend on what was going on with the resident which vitals he would have expected the nurse to obtain. He did not feel oxygen saturation was a necessary vital. He indicated a pulse should have been taken and the doctor should have been notified of the abnormal blood pressure. There was not documentation of a mental status at the time of the abnormal vitals, but if the resident was being monitored for a change in mental status, the DON indicated "then maybe not neurological checks but at least mental status assessments would be expected." The ED indicated none of the staff who documented on this resident at the time in question were still employed, therefore not available for interviews. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to notify the family and/or the physician for 1 of 36 residents reviewed for physician/family notification of a significant change. This change had the potential for requiring physician intervention which could have prevented his death (Resident #116). Findings include: Resident #116's record was reviewed on [DATE] at 2:22 P.M. Resident #16 was admitted to this facility on [DATE]. Resident #116's [DIAGNOSES REDACTED]. Resident #116 had been in another rehab facility following a stroke which occurred in May of 2012. This stroke affected the right side of his body. While at this facility he developed complications and was sent to an acute care hospital due to a mental status change and was treated for [REDACTED]. The hospital's transfer report dated [DATE] indicated both issues were resolved over the course of the hospital stay and Resident #116 was transferred to Harcourt Terrace in stable condition on [DATE] to continue rehabilitation from the stroke. A nurses note dated [DATE] indicated Resident #116 was alert and oriented, but hard to understand related to dysphagia, A nursing note dated [DATE] indicated Resident #116 was alert to self only. A nurse's noted dated [DATE] indicated Resident #116 was alert to self and environment, ambulated by wheelchair, was able to make needs known, and was in a happy mood that shift. A care plan dated [DATE] indicated Resident #116 was a full code, had support from family, and his wife visited almost daily since admission. Discharge plans were for him to return home with his wife. Resident #116 had chosen to have life sustaining measures with approaches that included to call the emergency ambulance as needed and notify MD and family of condition changes. A nurse's note dated [DATE] at 2:15 P.M. indicated, "Resident is less responsive than normal. BP (blood pressure) ,[DATE] P (pulse) 64 02 sat (oxygen saturation) on RA (room air) 93% Resp (respirations) 26. No signs of acute pain. Opens eyes when nae (sic) is called. Answering service for (DR. named) called at this time. Awaiting return call from (Nurse Practitioner (NP) named)." A telephone order dated [DATE] at 3:00 P.M. indicated the NP gave orders to check Resident #116's vitals every 4 hours for 24 hours. This order indicated the problem was a change in LOC (level of conscience) and the intervention was the above order. The next two nursing notes were recorded as late entries on [DATE] at 2:46 P.M. and 2:53 P.M. The late entry recorded on [DATE] at 2:46 P.M. for [DATE] at 3:34 P.M. indicated, "Resident is responding to voice and touch. He is pulling hand and arm away." The late entry dated [DATE] at 2:53 P.M. for [DATE] at 7:52 P.M. indicated, "Resident has some juice to drink, he is a little more cooperative at this time VS (vitals) are WNL (within normal limits), respirations unlabored, resting at this time." The vitals record indicated on [DATE] at 7:49 P.M. Resident #116's vitals were: blood pressure ,[DATE], pulse 72, respirations 20, and oxygen saturations were 96%. The next nursing note dated [DATE] at 12:00 A.M. indicated, "Res in bed asleep with HOB (head of bed) elevated. no s/sx (signs or symptoms) of distress/discomfort noted. res bed low with landing mat at bedside call light in reach, no behavior/agitation noted. spoke with wife earlier to inform her of res status. concerns of res not eating food during meal time." The vitals record indicated on [DATE] at 12:15 A.M., Resident #116's vitals were: blood pressure ,[DATE], respirations 20, no oxygen saturation was documented, no pulse was documented. According to the vitals document, the facility utilizes the acceptable ranges for blood pressure of 90-,[DATE]-90. The next vitals documented were at 2:15 A.M. pulse was 48, blood sugar was 362 mg/dl, and temperature was 97.7. Oxygen saturation or blood pressure were not documented. The next nurse's note was dated [DATE] at 3:08 A.M. This note indicated, "res in bed with HOB elevated. CNA (Certified Nursing Assistant) reported res breathing with difficulty, writer went in to assess res et (and) respirations ,[DATE] per min. Accu check 362 mg/DL, writer put res on 2 L (Liters) oxygen per nursing measures. MD notified writer awaiting return call. upon awaiting return call from MD writer unable to obtain respiration no chest movement removed from bed et placed on hard surface CPR initiated per writer/nursing staff 911 called. after EMT (Emergency Medical Technicians) arrives et continued CPR writer called on-call manager to notify of res status. family/wife notified et family states they are on the way to facility spoke with (NP named)/(Dr. named) on call and order to release body to mortuary of choice, death certificate completed et given to mortician. Dr from (hospital named) to sign off on time of death per EMT personnel." During an interview on [DATE] at 2:20 P.M., the facility's corporate clinical nurse consultant was asked to provide the resident's entire chart including doctor orders, doctor notification, care plans, hot charting, event charting, observation documents, progress notes, documentation of vitals, and any information regarding care given to Resident #116 when the first abnormal blood pressure was noted on [DATE] at 7:49 P.M. through 2:15 A.M. when his pulse was documented as 48 beats per minute prior to his [MEDICAL CONDITION]. During an interview on [DATE] at 2:51 P.M., the facility's corporate clinical nurse consultant indicated the doctor or family had not been notified of the abnormal blood pressure. During an interview on [DATE] at 10:06 A.M., the NP, who was notified of Resident #116's level of consciousness (LOC) change and gave the order to monitor vitals every 4 hours for 24 hours, was questioned if she would have intervened if she had been notified of Resident #116's blood pressure dropping from ,[DATE] at 7:49 P.M. to ,[DATE] at 12:15 A.M. She replied, "If he was awake and talking with no other symptoms, I would have ordered stat labs. It just depended on what they told me. If he was not, I would have just sent him to the hospital." She indicated she did not remember the call or what they told her. During an interview on [DATE] at 10:30 A.M., the Executive Director (ED) and the Director of Nursing (DON) reviewed the information surrounding Resident #116's death. The DON indicated the doctor should have been notified of the abnormal blood pressure. The ED indicated none of the staff who documented on this resident at the time in question were still employed, therefore not available for interviews. A current facility policy provided by the corporate nurse consultant on [DATE] at 3:50 P.M. indicated: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely and effective intervention occurs. . .Acute Medical Change-any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. the licensed nurse in charge will notify the physician. . . The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met. 3XXX,[DATE](a)