Every finding on record at Harrison Terrace

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by Resident F hitting Resident G in the eye for 2 of 5 residents reviewed for abuse. (Resident F and Resident G). The deficient practice was correct on 5/7/26 prior to the start of the survey, and therefore past noncompliance. Findings include: 1. The clinical record for Resident F was reviewed on 6/03/26 at 9:30 a.m. The diagnosis included but was not limited to: dementia (decline in mental ability) and delusional disorder (beliefs that are not reality).A quarterly Minimum Data Set (MDS) Assessment, dated 4/30/26, indicated Resident F was cognitively impaired. The resident had no upper or lower extremity impairments. She independently ambulated with walker. 2. The clinical record for Resident G was reviewed on 6/03/26 at 10:00 a.m. The diagnosis included but was not limited to: dementia (decline in mental ability).An admission MDS Assessment, dated 2/12/26, indicated Resident G was cognitively impaired.A nursing note for Resident F, dated 5/6/26 at 12:00 p.m., indicated Registered Nurse (RN) 5 was at the medication cart putting away medications when Resident F approached the medication cart and asked RN 5 what did she do with her clothing. During that time, Resident F had scratched RN 5 on the side of her neck. RN 5 responded to resident that her clothing was in her room or in the laundry. Resident F returned to her room.A behavioral event for Resident F, dated 5/6/26 indicated the resident was exhibiting physical aggressive behavior toward RN 5. The resident accused RN 5 of taking her clothes, and scratched RN 5 on the side of her neck. The interventions that were provided at the time of incident were redirection and reported to resident her clothes were in her room.A nursing note for Resident F, dated 5/6/26 at 1:26 p.m., indicated Resident F was in the dining room eating her lunch meal. She approached Resident G accusing her of stealing her dress. During the altercation, Resident F punched Resident G in her left eye. A behavioral event for Resident F, dated 5/6/26, indicated Resident F had a behavior of physical assault. Resident F had approached Resident G accusing her of stealing her clothing. Resident F punched Resident G with closed fist in her left eye. Resident F was placed on 1:1 [one on one] staff supervision.A reportable incident to the Indiana Department of Health, dated 5/6/26, indicated Resident F had made physical contact with Resident G. The follow up: Resident G was moved to another unit.The investigation for the reportable incident between Resident F and Resident G was provided by the Director of Nursing on 6/3/26 at 9:00 a.m. The investigation included but was not limited to the following:A written statement by Certified Nursing Assistant (CNA) 2, dated 5/7/26 indicated, I was passing out chips to the resident's in the dining room. I started to hear yelling and heard 'I'll hit you dead in your mouth!' So I turned around and saw [Resident F] in [Resident G]'s face standing over [Resident G]. So as I was about to get in between Resident F quickly hit [Resident G] twice in her face. It happened so fast. I then got in between and broke it up. I told [Resident F] to go into her room and I got [Resident G] a cold rag and ice for her eye and then checked on [Resident F] in her room.An interview was conducted with Social Services Director on 6/3/26 at 10:46 a.m., indicated Resident F and Resident G had been roommates a few months ago. Resident F at times would get confused about the clothing in the closet. She had false belief the clothing was all hers. It was hard for her to recognize the barrier in between the closet to separate her clothing from Resident G's clothing. Resident F had requested to be moved to another room to be closer to the dining room.An observation was made of Resident F sitting in the dining room on 6/3/26 at 10:52 a.m. The resident was speaking with another resident. Resident F stood up and ambulated independently with her walker and left the dining room. An observation was made of Resident G on 6/3/26 at 11:42 a.m. The resident was observed in her room sitting in her wheelchair. During that time, Resident G indicated A girl hit me with her hand in my eye. I had her blouse on and didn't know it.An interview was conducted with CNA 2 on 6/3/26 at 11:50 a.m. She indicated she was passing ice chips to the residents in the dining room. She heard arguing between Resident F and Resident G. Resident F was upset and stated Resident G had taken her dress. CNA 2 went to intervene and Resident F hit Resident G in her face. The incident happened fast.An interview was conducted with the Director of Nursing on 6/3/26 at 11:56 a.m. She indicated after the incident on 5/6/26 between Resident F and Resident G. Resident G was moved to a new unit and an action plan was put in place. An abuse policy was provided by the Director of Nursing on 6/3/26 at 12:09 p.m. It indicated, .Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion.American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents, consultants, volunteers, staff, or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals.Definitions/Examples of Abuse: Willful, used in the definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury or harm. Physical Abuse - A willful act against a resident by another resident, staff member, or other individual (s). Examples may include but not be limited to hitting, slapping, punching, and choking.This deficient practice was corrected on 5/7/26 after the facility implemented a systemic plan that included the following actions: assessment of all residents with abusive behaviors; care plans audited, reviewed and updated, all staff in-serviced on abuse and how to respond to abusive behaviors, observation rounds of dining rooms during meals to be completed daily on alternating shifts to monitor for adequate staff supervision, Quality Assurance and Performance Improvement (QAPI) behavior management tool will be completed weekly times 4 weeks and monthly for 6 months to ensure system compliance.This citation is related to Intake 3020842.410 IAC (Indiana Administrative Code) 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the implementation of a care in pairs intervention that were put in place for behavior management for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/2/26 at 1:30 p.m. The diagnoses included, but were not limited to, dementia (decline in mental ability) and psychotic and mood disturbance (emotional disturbances combined with detachment of reality).An admission Minimum Data Set (MDS) Assessment, dated 4/16/26, indicated Resident B was cognitively impaired. A behavior care plan, dated 4/13/26, indicated Resident B would become aggressive with staff, hitting them, yell and/or curse, become combative with redirection and may make threatening statements towards his peers.and staff. At times will turn on his call light, when staff arrive to help, he responds with insults, inappropriate, foul language, and delusional thinking. Resident would state that he owns the facility and that people are using his name to purchase things. Resident will also yell out and believe that he is a part of a conversation when he hears others engaging with each other. The interventions included but were not limited to: care in pairs (more than one staff member was to provide care to Resident B).A behavior care plan for Resident B, dated 4/21/26, indicated the resident will request for kisses by female staff members. The following interventions included, but were not limited to, care in pairs (more than one staff member was to provide care to Resident B).An observation was made of Resident B sitting in his wheelchair in the hallway by a supply room at 6/2/26 at 2:33 p.m. Certified Nursing Assistant (CNA) 1 was observed leaving the supply room with a trash bag and pushed Resident B to his room. She then closed the resident's door. CNA 1 was the only staff member observed in the resident's room.An interview was conducted with CNA 1 on 6/2/26 at 2:40 p.m. She indicated she had taken Resident B to his room, so he could use the restroom. She did not ask for assistance from another staff member. She was suppose to provide care in pairs, but Resident B was always good with her. She had not experienced any of his behaviors that at times he exhibits.The care plan policy was provided by the Director of Nursing (DON) on 6/3/26 at 8:29 a.m. It indicated .Policy: It is the policy of this facility that each resident would have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial well-being. This citation is related to Intake 3020842 410 IAC (Indiana Administrative Code) 3.1-35(b)(1)

Based on observation, interview and record review, the facility failed to ensure staff were utilizing infection control practices with hand hygiene during a dining observation in Mapleton Dining Room. This had potential to affect 16 of 16 residents observed in the dining room. (Resident 43 and Resident 68) Findings include: An observation was conducted of the Mapleton Unit dining room during a lunch meal service on 9/2/25 at 12:06 p.m. Activities Director (AD) was observed passing out silverware at each table for the residents in the dining room. During that time, AD was reaching inside container pulling out silverware and placing it on napkins. Then touching his face and eyeglasses. There was no observation of AD utilizing hand hygiene after touching his face and eyeglasses. After, AD was observed passing out meal trays and assisting residents with beverages. During that time, he was observed pulling up his pants. There was no observation of hand hygiene after he touched and pulled up his pants. During an observation of the Mapleton Unit dining room on 9/2/25 at 12:07 p.m., the following was observed: Certified Nurse Aide (CNA) 7 touched her hair braids with her hands then touched Resident 68's shirt and her cloth napkin, CNA 7 touched her hair with her hands then served a meal tray to Resident 43, placing her dishes on the table, removing the coverings from the dishes, returned the tray to the meal cart, then used hand sanitizer, and CNA 7 sat down with Resident 68, placed her cloth napkin, that the CNA had touched earlier, on her chest like a bib, and proceeded to assist the resident with their meal. There were 16 residents in the dining room. An interview was conducted with the Regional Director of Operations on 9/4/25 at 8:20 a.m. They indicated the staff should be utilizing hand hygiene if he or she touches their hair and/or body prior to continuing the meal service. The current Hand Hygiene Policy, with a revised date of 12/2021, was provided by the Director of Nursing Services on 9/4/25 at 11:58 a.m. The policy indicated, .To provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganisms on the hands of all employees.personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:.After touching a resident or the resident's immediate environment.After touching self or clothing during meal service. 3.1-18(l)

Based on observation and interview, the facility failed to ensure the facility was free of odor, clean and in good repair with linens and walls for 4 of 4 residents reviewed for physical environment. (Residents' D, F, G, and H) Findings include: A. During the initial tour of the facility on 9/2/25 at 9:55 a.m., the main entry smelled strongly of urine. Upon entering the Meridian Hills Unit, the floor in the hallway was sticky, especially around rooms [ROOM NUMBERS]. The floor between the entrance door and the nurse's station had an approximate six-inch black spot. There was a wet floor sign in the dining room beside the spot. During an observation on 9/2/25 at 2:28 p.m., the floor on the Meridian Hills Unit, between the entrance door and the nurse's station, had an approximate six-inch black spot. During a Confidential Interview 20, they indicated the Meridian Unit does have a urine odor. B. Upon entering the Mapleton Unit on 9/2/25 at 9:57 a.m., a strong urine odor was noted. An observation was conducted of the Mapleton Unit on 9/2/25 at 10:59 a.m. The unit smelled strong of urine odor. Upon entering the Mapleton Unit on 9/4/25 at 2:26 p.m., a strong urine odor was noted. C. An observation was conducted of Resident G's room on 9/5/25 at 1:11 p.m. The door frame to the bathroom was observed with chips and scratches. The bed linen had a small hole in the top right corner. During a Confidential Interview 21, they indicated the Meridian Unit recently had a urine odor when you walk in the unit. The floors were dirty, linens were worn with holes, the rooms are not kept tidy with throwing of used gloves, dirty briefs and clothing on the floor. An environmental tour was conducted, on 9/8/25 at 11:00 a.m., with the Maintenance Supervisor (MS) and the Administrator. An observation was made of Resident G's room. The bathroom door frame was observed with chips and scratches on it. A used glove was lying on the floor below the bathroom sink. During that time, the resident's linen on his bed was observed. A small hole was in the linen on the top right corner. The MS reported the top of the door frame was chipped by the door closing and the bottom half was from wheelchairs hitting it. The dirty glove on the floor at that time was removed and discarded. Next, Resident D's room was observed. The chair rail along the wall had scrapes and chips and missing a piece of the chair rail by the bed. After, Resident H's room was observed. The walls were observed with two scrapes and paint missing. An interview was conducted with the Administrator and the MS on 9/8/25 at 11:15 a.m. The Administrator indicated she had been working with the housekeeping department to replace the older linen. She recently had the floors cleaned. An interview was conducted with the MS on 9/8/25 at 11:59 a.m. He indicated the repairs were completed in the resident's room on an as needed basis. The residents' families and the staff fill out work orders that were located at the nurse's station if they observe rooms that need to be repaired. The facility does not have a policy for homelike environment. This citation relates to Intake 1576791. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure a resident had his face washed and shaved for 1 of 3 residents reviewed for activities of daily living (ADL) care. (Resident K) Findings include: The clinical record for Resident K was reviewed on 9/2/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia and acute osteomyelitis. A care plan, last reviewed/revised on 8/21/25 and obtained from the electronic health record on 9/4/25 at 9:19 a.m., indicated Resident K needed assistance with ADL care. The goal was for him to maintain his current functional status. The interventions included, but were not limited to, assisting with bathing as needed, assisting with dressing, grooming and hygiene as needed, and encouraging him to do as much for himself as possible. A care plan, last reviewed/revised on 8/21/25 and obtained from the electronic health record on 9/4/25 at 9:19 a.m., indicated Resident has a DX [Diagnosis] of Vascular Dementia. Resident has impaired daily decision-making skills and poor insight into care. Resident will refuse medications or allow staff to get him out of bed at times. Resident will not allow staff to turn or reposition. Per the family resident has always been very cautious of taking medications and believed that taking vitamins was the way to maintain good health. Resident will also refuse showers at times. resident is continuously putting on his call light stating that his TV is messed up despite staff turning TV back to preferred channel each time. Resident will not have any negative side effects due to medication refusals. On 9/2/25 at 10:55 a.m., Resident K was observed lying in bed. He had a heavy growth of beard on his face with dry flakey skin in his beard. On 9/3/25 at 10:01 a.m., Resident K was observed lying in his bed. He was unshaved and had dry, flakey skin in his beard and food on his face. During an interview on 9/4/25 at 11:28 a.m., Certified Nurse Aide (CNA) 16 indicated she sometimes provided care for Resident K. He required extensive assistance with ADL care. He would sometimes refuse care, but she had not known him to refuse to wash his face or shave. He would refuse to use deodorant. Residents were usually shaved on their shower days. On 9/4/25 at 3:00 p.m., Resident K was observed lying in bed. He was unshaved and had dry skin and food stuck in his beard and on the corners of his mouth. He indicated he used to get shaved. During an interview on 9/4/25 at 3:06 p.m., Registered Nurse 18 indicated Resident K's shower days were on Wednesday and Saturday on evening shift. On 9/5/25 at 11:20 a.m., Resident K was observed sitting in his wheelchair wearing a black t-shirt. He was unshaved and had dry skin in his beard. There were dried skin flakes present by the collar of his shirt, under his chin. The corners of his mouth were red. During an interview on 9/5/25 at 11:26 a.m., Licensed Practical Nurse (LPN) 14 indicated there was dried skin in Resident K's beard and probably flakes of potato chips that he liked to eat. Resident K was picky about things. He had previously lived off the grid. During an observation on 9/5/25 at 2:24 p.m., the Director of Nursing Services (DNS) obtained a warm washcloth and gently washed Resident K's face. This citation relates to Intake 1576791.3.1-38(a)(3)(A)3.1-38(a)(3)(D)

Based on observation, interview, and record review, the facility failed to administer an antibiotic as ordered by the physician, obtain blood sugars and administer insulin as ordered by the physician, and to administer insulin per the manufacturer's guidelines for 2 of 5 residents reviewed for unnecessary medications and 2 of 20 residents reviewed for quality of care. (Resident K, Resident F, Resident 20, and Resident 59)Findings include: 1. The clinical record for Resident F was reviewed on 9/2/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia and acute osteomyelitis (infection of the bone) of the right ankle and foot. A Significant Change of Status Minimum Data Set (MDS) assessment, completed 8/15/25, indicated he was severely cognitively impaired. A care plan, initiated 7/31/25, indicated Resident F had impaired skin integrity with a pressure injury to the sacrum and right heel. The goal was for his wounds to heal without complications. The interventions included, but were not limited to, obtain labs as ordered, provide treatment as ordered by the physician, and notify the physician of changes in wound such as worsening or signs of infection. A wound care progress note, dated 8/27/25 at 11:30 a.m., indicated Resident F's heel was painful and with suspected osteomyelitis (infection of bone). Resident F was to begin Cipro (antibiotic) 500 milligram (mg) every 12 hours for 14 days for osteomyelitis of the right heel starting 8/27/25. The August 2025 Medication Administration Record (MAR) indicated Resident F had received a dose of Cipro on 8/27/25 at 8:00 p.m., and 8/28/25 at 8:00 a.m. The MAR indicated the 8/28/25 8:00 p.m. dose of Cipro was unavailable from the pharmacy. The 8/29/25 and 8/30/25 doses were administered as ordered. The Cipro dose was not signed as being given on 8/31/25 at 8:00 a.m., and the 8/31/25 8:00 p.m. dose was documented as not given due to unavailable from the pharmacy. During an interview on 9/5/25 at 1:43 p.m., the Director of Nursing Services (DNS) indicated the first two doses administered were removed from the emergency drug cabinet. Resident F's supply of Cipro arrived at the facility on 8/29/25 at 5:03 a.m. She was unsure of why the supply of Cipro did not arrive from the pharmacy sooner and was unsure why the 8/31/25 8:00 p.m. dose was not administered because the Cipro was in the building. 2. The clinical record for Resident K was reviewed on 9/2/25 at 12:13 p.m. The diagnoses included, but were not limited to, dementia and diabetes. A physician's order, dated 4/8/25, indicated he was to have blood sugar checks with meals and at bedtime. The physician was to be notified if the blood sugar was below 70 or greater than 350. A physician's order, dated 7/28/25, indicated he was to receive lispro (short-acting) insulin five units subcutaneously (injection in the fat layer below the skin) three times a day. The dose was to be held if blood sugar was below 70. The administration times were listed as 7:00 a.m., 11:00 p.m., and 5:00 p.m. A Quarterly MDS assessment, completed 8/8/25, indicated he had severely impaired cognition and received insulin daily. The August 2025 MAR did not contain documentation that Resident K had received blood sugar checks on the following day(s) and time(s): 8/9/25 at 8:00 p.m., 8/25/25 at 7:00 a.m., and 8/26/25 at 7:00 a.m. The August 2025 MAR did not contain documentation that he had received lispro insulin on the following day(s) and time(s): 8/1/25 at 11:00 p.m., 8/9/25 at 11:00 p.m., 8/15/25 at 11:00 p.m., 8/20/25 at 11:00 p.m., 8/25/25 at 7:00 a.m., 8/26/25 at 7:00 a.m., and 8/27/25 at 11:00 p.m. During an interview on 9/8/25 at 1:05 p.m., the Regional Nurse Consultant (RNC) indicated the staff should have documented the blood sugar results on the MAR. The insulin administration should have been documented when completed. She was unsure why there was a dose of lispro insulin due at 11:00 p.m., instead of 11:00 a.m., and would clarify the lispro order. The Nurses should follow the physician's orders. 3. During an observation on 9/2/25 at 12:06 p.m., Licensed Practical Nurse (LPN) 5 was preparing to administer Humalog insulin to Resident 20. The LPN removed the Humalog insulin pen from the medication drawer, applied a needle, turned the dose knob to 9 units, then pushed the end of the pen indicating he was priming the pen by wasting a unit of insulin. The pen was held sideways, and the cap was still covering the needle, so no insulin was visible coming out of the needle. He then administered 8 units of insulin to Resident 20. 4. During an observation on 9/2/25 at 12:12 p.m., LPN 5 was preparing to administer Humalog insulin to Resident 59. The LPN removed the Humalog pen from the medication drawer, applied a needle, turned the dose knob to 5 units, then pushed the end of the pen indicating he was priming the pen by wasting a unit of insulin. The pen was held sideways, and the cap was still covering the needle, so no insulin was visible coming out of the needle. He then administered 4 units of insulin to Resident 59. During an interview on 9/4/25 at 10:15 a.m., Registered Nurse 2 indicated when administering insulin using a pen, staff should clean the top of the pen before applying the needle. The pen should be primed by holding it up right with the cap off to ensure the insulin came out of the needle tip. On 9/4/25 at 11:49 a.m., the DNS indicated the facility would follow the manufacturer's guidelines related to insulin administration. The Humalog Manufacturer's Instructions were provided by the DNS on 9/4/25 at 11:49 a.m. The instructions indicated, .Wipe the rubber seal with an alcohol swab .Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly .If you do not prime before each injection, you may get too much or too little insulin .To prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming .no more than 4 times . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure care planned fall interventions were implemented appropriately for 1 of 3 residents reviewed for accidents. (Resident 22)Findings include: On 9/3/25 at 9:45 A.M., Resident 22 was observed in her room in her bed. The resident's wheelchair was several feet away from the resident near the other bed in the room but was still visible to the resident from where she was lying. A black recliner with a remote control was in the room a few feet away from the resident to the right of her bed.On 9/3/25 at 12:57 P.M., the resident was observed in her room in her bed. The resident's wheelchair was several feet away from the resident near the foot of the other bed in the room but was still visible to the resident from where she was lying. A black recliner with a remote control was in the room a few feet away from the resident to the right of her bed.On 9/4/25 at 10:01 A.M., the resident was observed in her room in her bed. The resident's wheelchair was a few feet away from the resident in between the two beds in the room but was still visible to the resident from where she was lying. A black recliner with a remote control was in the room a few feet away from the resident to the right of her bed. The resident's clinical record was reviewed at 9/3/25 at 10:04 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia, repeated falls, and depression. The resident used a wheelchair and required staff supervision or touch assistance when walking. The resident had experienced two or more falls without injury, and one fall with an injury that was not a major injury since the last assessment.An Interdisciplinary Team (IDT) Progress Note, dated 6/26/25 at 10:44 A.M., indicated the resident experienced a fall on 6/26/25 at 5:30 A.M. Staff witnessed the resident attempting to self-transfer from her bed to her wheelchair when the resident fell to the floor. The resident was not injured. The immediate/short-term intervention was for nursing staff to assess the resident and then assist her up and into her chair as she requested. The IDT review determined the root cause of the fall was that the resident attempted to self-transfer from her bed to the wheelchair. The resident required hands-on staff assistance for transfers. The resident was impulsive and had poor safety awareness. The intervention put in place to address the root cause of the fall was to keep the resident's wheelchair out of sight while it was not in use. The resident's care plan was updated with the new intervention.An IDT Progress Note, dated 8/11/25 at 4:01 P.M., indicated the resident experienced a witnessed fall on 8/9/25 at 2:33 P.M. The resident had been sitting in her recliner in her room and put the recliner in the upright position so she could adjust her fan. Staff were unable to get to the resident in time and the resident slid to the floor. The resident was not injured. The immediate/short term intervention was for nursing staff to assist the resident back to her chair, place it in a reclining position, and adjust the fan to her liking. The resident's call light was placed within her reach. The IDT review determined the root cause of the fall. The resident stated she was trying to adjust her fan. The intervention put in place to address the root cause of the fall was to ask the resident's family to bring in a recliner that could not be adjusted to the point that the resident could slide out. The resident's care plan was updated with the new intervention.During an interview on 9/4/25 at 10:06 A.M., Registered Nurse (RN) 4 indicated the resident understood her physical decline but had poor safety awareness. Currently, the resident was in her room in bed. RN 4 observed the resident's room and indicated the recliner in her room was the same one she had before she fell, and it had not been moved out of the room. A different recliner had not been brought in by the family at this time. The resident's wheelchair was observed and was not out of the resident's line of sight. RN 4 indicated the resident's wheelchair was usually moved out of her room and placed in the hallway at night. RN 4 moved the wheelchair out of the resident's room and placed it in the hallway. The current facility policy, titled Fall Management Policy, with a most recent revision date of 6/25, was provided by the Director of Nursing Services on 9/4/25 at 11:58 A.M. The policy indicated, .ensure residents residing within the community have adequate assistance to prevent injury related to falls.falls will be discussed by the interdisciplinary team.to determine root cause and other interventions to prevent future falls.3.1-45(a)(2)

Based on interview and record review, the facility failed to accurately document the urinary output for a resident with an indwelling urinary catheter for 1 of 1 resident reviewed for urinary catheter. (Resident 49) Findings include: The clinical record for Resident 49 was reviewed on 9/5/25 9:32 a.m. The diagnoses included, but were not limited to, dementia and retention of urine. A Quarterly Minimum Data Set (MDS) assessment, completed 8/7/25, indicated he was severely cognitively impaired. A physician's order, dated 8/28/25, indicated he should receive catheter care, and the nurse was to record the urinary output every shift. The August and September 2025 Medication Administration Record (MAR) did not include documentation of Resident 49's urinary output each shift.The urinary output documented in the electronic health record (EHR), under vital signs, were as follows:8/29/25- night shift large, day shift large, evening shift medium,8/30/25- day shift large, evening shift 500 milliliters (ml), night shift large,8/31/25- night shift medium, day shift large,9/1/25- night shift large, day shift 300 ml, evening shift 400 ml,9/2/25- night shift 500 ml, day shift 400 ml, evening shift large, 9/3/25- day shift large, evening shift large, night shift large, 9/4/25- day shift large, evening shift large, night shift large,9/5/25- day shift 600 ml, evening shift large,9/6/25- night, day, and evening shift large,9/7/25- night and day shift large, evening shift medium, and 9/8/25- night shift large, day shift 800 ml.During an interview on 9/8/25 at 10:50 a.m., Licensed Practical Nurse (LPN) 12 indicated the nurses should document urinary output from an indwelling urinary catheter in milliliters. The Electronic MAR prompts the nurse to enter the output. She was unsure why the urinary output was not showing on the MAR. On 9/8/25 at 1:10 p.m., the Regional Nurse Consultant provided the Bowel and Bladder Program Policy, last revised May 2019, that indicated .Urinary output from indwelling urinary catheters will be documented .3.1-41(a)(2)

Based on interview and record review, the facility failed to timely develop and implement an individualized plan of care for a resident with dementia who displayed a new behavior of making physical contact with peers for 2 of 3 residents reviewed for abuse (Resident B and Resident C). Findings include: 1a. The clinical record for Resident C was reviewed on 9/2/25 at 11:37 a.m. The diagnoses included, but were not limited to, dementia, anxiety, and insomnia. He was admitted to the facility on [DATE]. 1b. The clinical record for Resident B was reviewed on 9/3/25 at 8:55 a.m. The diagnoses included, but were not limited to, dementia with psychotic disturbances and psychotic disorder with delusions. The resident was admitted to the facility on [DATE]. Resident C had room changes on the following dates: 5/27/25, 7/1/25, 7/16/25, 7/24/25, and 7/25/25.A Social Service Progress Note, dated 7/24/25 at 12:11 p.m., indicated Resident C's daughter gave approval for him to move rooms. A Social Service Progress Note, dated 7/25/25 at 2:57 p.m., indicated Resident C was moved to room [ROOM NUMBER] due to him not being compatible with his peer. A New/Worsening/High Risk Behavior Event, dated 7/28/25 at 3:15 p.m., indicated Resident C was in the dining area. Another resident was banging a toy on the table. Resident C grabbed the other resident by the wrists to get the toy out of their hands. The residents were separated, and Resident C was able to go to his room, away from stimulation. The intervention put into place to prevent another behavior was for Resident C to have his medications evaluated. An Interdisciplinary Team (IDT) note, dated 7/29/25 at 9:46 a.m., indicated Resident C was in the dining area when another resident grabbed an item and banged the item on the table. In an effort to stop the other resident from banging, Resident C made contact with the other resident's wrist. Both residents were immediately separated and placed in their rooms in a less stimulating environment. The assessment of potential correlation to the root cause was overstimulation in the common area. Resident C was to have labs completed and to be seen by the physician and the psychiatric provider. Resident C has had multiple room moves due to incompatible roommate. The root cause of behavioral expression was Resident C has diagnoses of dementia, cognitive impairment, and insomnia. Resident C was still adjusting to community, peers and new environment. Resident C may have been experiencing overstimulation in the dining room. Resident space invaded and peer banging on table. The preventative intervention relating to above root cause was Resident C being redirected to room to decrease overstimulation. Resident C will undergo a medication review and labs. He was added to the physician and psychiatric provider list. Resident C will have increased supervision when the other resident was present. A New/ Worsening/ High Risk Behavior Event, dated 7/29/25 at 6:46 p.m., indicated Resident C was in the dining area when another resident entered Resident C's personal space. The environment was quiet and calm. The event occurred in the common area. Resident C asked the other resident to get out of his personal space. The other resident did not respond and got closer. Resident C then grabbed the other resident in an attempt to move the other resident out of his way. The two residents were separated. The physician and family of Resident C were notified. The intervention put into place to prevent another behavior was for Resident C to be evaluated by the Psychiatric Nurse Practitioner. The clinical record did not contain a care plan addressing Resident C's new behavior of grabbing another resident. A Quarterly Minimum Data Set (MDS) assessment, completed 7/31/25, indicated he was severely cognitively impaired. He had displayed physical behaviors, such as hitting, kicking, pushing, or grabbing others, one to three days during the seven day look back period. He was able to independently perform a sit to stand transfer and independently able to walk 150 feet in the corridor. A Psychiatric Provider Progress Note, dated 7/31/25 at 7:07 a.m., indicated the visit was a New Patient Visit. Nursing staff reported ongoing anxiety and aggression since admission, including incidents of grabbing peers. Resident C has required six room changes due to behavioral disruptions and was currently awaiting a room move into a private room. Staff report no signs of depression, sleep disturbances, appetite changes, or hallucinations. Resident C will be started on lorazepam (anti-anxiety medication) 0.5 milligrams (mg) twice daily to target anxiety and reduce agitation. The clinical record did not contain a care plan addressing Resident C receiving lorazepam. The clinical record did not contain a care plan addressing anxiety and agitation. On 7/31/25, Resident C was moved to a different room without a roommate. A Physician's Progress Note, dated 8/1/25 at 9:35 a.m., indicated the reason for the visit was for medication review, increased agitation, and anxiety. The facility requested Resident C to be seen for medicine review. Resident C had labs received 7/30/25. He was noted with increased agitation and anxiety by facility staff. He was moved to a private room and was started on lorazepam 0.5 mg twice daily, thus resolving his agitation. A care plan, last reviewed 8/4/25, indicated Resident C had cognitive loss/ dementia and was moderately to severely impaired. The goal was for him to continue to participate in daily decisions as able and to remain alert and oriented at current status. The interventions included to encourage participation in daily activities particularly regarding orientation, socialization and stimulation. Give him choices throughout the day regarding decisions. Provide him with prompts and cues as needed. Provide him with simple instructions and repeat them as needed. A Psychiatric Provider Progress Note, dated 8/7/25 at 7:04 a.m., indicated lorazepam was initiated at the last visit to target anxiety and reduce agitation. Nursing staff reported no ongoing anxiety or aggression since lorazepam initiation and no observed side effects. Staff reported no signs of depression, sleep disturbances, appetite changes, or hallucinations. On 8/13/25, Resident B was admitted to the facility and placed with Resident C as his roommate. A Nursing Progress Note, dated 8/14/25 at 1:52 a.m., indicated on 8/14/25 at 1:47 a.m., Resident C was seen pulling Resident B by his shirt to the doorway of the room. Resident B claimed that Resident C had made contact with him. The residents were immediately separated. One-on-one attention was given to each resident. Both residents were assessed and placed on increased supervision. Resident C never appeared upset or angry, just confused. Suggested intervention was a room move. A care plan, dated 8/15/25, indicated Resident C had behavioral symptoms. Resident C had diagnoses of dementia, anxiety, and insomnia. He was at risk for peer incidents due to perceived invasion of personal space and overstimulation in busy environments. Resident C was also at risk for increased confusion or sundowning (confusion in the evening) and may attempt to make contact with peers in an attempt to redirect them. The goal was for staff to prevent triggering situations that provoke or encourage him to attempt to redirect peers through physical contact. The interventions included to build coping skills and non-physical communication methods with resident when he attempts to make contact with peers, give medications as ordered, promote respectful environment and reduce any potential triggers. The clinical record did not contain a care plan addressing Resident C's incompatibility, agitation, or aggression with roommates. A reportable incident to the Indiana Department of Health, dated 8/14/25, indicated [Resident B] claimed to staff that roommate, [Resident C] made contact with him.Immediate Action Taken: Staff immediately separated residents. Staff moved [Resident C] to room [number].Follow up: 8/19/25 Based on investigation, it is unsubstantiated that contact was made by [Resident C] to [Resident B] as described by [Resident B]. Based on investigation, [Resident C] assisted [Resident B] out of the room by resident's shirt. During this assistance, neither resident showed any signs of symptoms of psychosocial distress. According to [Resident B's Representatives] resident has a hx [history] of delusions, as referenced by [Resident B's Representatives] in other settings. In interviews with [Resident B] he has had conversations that are conflicting due to his dx [diagnoses] of dementia with psychotic disturbances, UTI [Urinary Tract Infection] and psychotic disorder with delusions . The reportable incident investigation was provided by the Administrator on 9/3/25 at 9:00 a.m. It included, but was not limited to, the following documents: A statement by Licensed Practical Nurse (LPN) 10, dated 8/17/25, indicated, On the evening of 8/13/25 this writer heard commotion down the hallway of the Meridian unit, noticed resident [C] pulling another resident [B] through the doorway of their shared room, the resident being pulled was on the floor on his back with his shirt up over his head while the other resident has both hands on his shirt pulling him. I got up and yelled for the nurse on the other unit while running to the area where the resident was now on the floor on his back leaning slightly against the wall by this time the other resident had let go of the resident's shirt. The scene was this - small/moderate amount of blood under the resident who had been pulled to the doorway, foley catheter on the floor inside room hooked to bed with the bulb inflated with small amount of urine in the catheter bag. Residents bed was in the lowest position, light in room was on. Resident that was on the floor had a polo type shirt on and a disposable brief along with non-slip socks. When asked resident that was on the floor what happened he said 'I was shot in the back I think,' nurse from other unit suggested this writer contact Administrator and DNS [Director of Nursing Services] immediately. Called facility Administrator explained what happened and she said, 'I am getting clothes on, It will take me about 30 minutes to drive in.' CNA [Certified Nurse Aide] and nurse from other unit assisted patient that was on the floor to his bed his v/s [vital signs] were taken and we assessed his body for any open areas or bruising, two small purple bruises noted on bruise of nose and the sclera [the white outer layer of the eyeball] was red. Went back and talked to the resident after he was in bed and when asked what happened he stated, 'some man got me.' Administrator came in and advised we put him in another room for the night, his bed was moved, staff was sitting in doorway of his room for the shift.An interview was conducted with LPN 10 on 9/3/25 at 10:36 a.m. She indicated, on the night of 8/13/25, she had been sitting at the nurse's station when she had heard a commotion meaning a rustling noise down the hallway. She looked up and saw Resident B was on the floor being pulled out of his room by his roommate, Resident C, by his shirt. She yelled out for LPN 9 to assist her and ran down to Resident B and Resident C's room. The residents were not observed yelling or aggressive toward one another. During that time, she had observed blood on the floor and Resident B's Foley catheter was out and the bulb still inflated. Resident B's nose was bruised, and his eye was red. Resident B had pointed to his roommate and stated, he shot me in the back. Resident C did not respond when he was asked what happened. She had not observed Resident C being aggressive to other residents before. Resident B had fallen a couple hours prior due to getting himself up without assistance to use the bathroom. After she had assessed, he did not have any injuries from the fall. Resident C was moved to another room after the incident. Later, Resident B was sent out to the hospital for an evaluation, because his blood pressure was elevated. During an interview on 9/3/25 at 2:48 p.m., CNA 11 indicated she worked with Resident C previously. She had not been informed that Resident C had a history of putting his hands on other residents. During an interview on 9/3/25 at 2:50 p.m., CNA 13 indicated she worked with Resident C previously. She was not aware that he had a history of putting his hands on other residents. During an interview on 9/3/25 at 2:14 p.m., the Dementia Care Director (DCD) indicated Resident C had several room moves due to not being compatible with roommates. The rooms at the facility were small spaces and it could be challenging to find compatible roommates. Resident C displayed sundowning in the evening with increased confusion. Resident C's behaviors seemed to be a side effect of the confusion. Resident C had worked with troubled youth in his past and was prone to trying to help others. The lorazepam had been started due to increased anxiety. During an interview on 9/4/25 at 10:28 a.m., the Social Services Director (SSD) indicated a care plan had not been initiated when the new behaviors of grabbing other residents were observed on 7/28/25 and 7/29/25. The IDT team had met and reviewed the behaviors. During an interview on 9/4/25 at 11:53 a.m., Nurse Practitioner (NP) 8 indicated she had seen Resident C, on 7/31/25, and had started lorazepam for his anxiety and agitation. NP 8 was aware that Resident C had several room changes since his admission and understood at the time of her, 7/31/25, visit with Resident C, that he was to get a private room as an intervention for his anxiety and agitation. Resident C's behavior toward Resident B, on 8/14/25, was not normal behavior for Resident C. On 9/4/25 at 8:28 a.m., the Administrator provided the Behavior Management Policy, revised August 2022, which indicated .It is the policy of American Senior Communities to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expression.1. Care plans should be initiated for any behavioral expression that is problematic or distressing to the resident, other residents or caregivers. Care plan interventions should be individualized and non pharmacological interventions which address both proactive and responsive interventions. 2. Care plans should be initiated when a resident is receiving a psychotropic medication used to treat either mood or behavior. The care plan should clearly identify the specific mood, thought process or behavioral expression which the prescriber has identified as the indication for use of the psychotropic medication.7. Direct care staff will be educated as to the interventions for residents reviewed by the IDT.This citation relates to Intake 2591193 and Intake 2589663.3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide privacy curtains that extended completely around the bed in a room shared by two residents for 2 of 2 residents randomly observed for privacy. (Resident 16 and Resident 49)Findings include: 1 a. The clinical record for Resident 49 was reviewed on 9/5/25 9:32 a.m. The diagnoses included, but were not limited to, dementia and retention of urine. 1 b. The clinical record for Resident 16 was reviewed on 9/8/25 at 10:20 a.m. The diagnoses included, but were not limited to, dementia. On 9/8/25 at 9:50 a.m., Licensed Practical Nurse (LPN) 12 and the Assistant Director of Nursing (ADON) were observed providing urinary catheter care for Resident 49. Resident 49's privacy curtain was drawn between Resident 49 and Resident 16. The privacy curtain for Resident 49's bed did not go around the entirety of the ceiling track and did not obscure view from the room walkway leading to the bathroom. Resident 16's privacy curtain did not extend the entirety of the track and did provide total visual privacy for his bed. During an interview on 9/8/25 at 10:05 a.m., LPN 12 indicated the wrong size privacy curtains may have been hung in the room. During an interview on 9/8/25 at 10:06 a.m., the ADON indicated the privacy curtains should go all the way around the bed. On 9/8/25 at 10:12 a.m., the Administrator provided the Privacy Curtains Policy, last revised in December 2021, which indicated .Routine daily, weekly and/or monthly visual inspections should be completed to ensure curtains are hung properly .The curtain shall provide adequate privacy to the resident . 3.1-19(l)(7)

Based on observation, interview and record review, the facility failed to ensure the flooring, and the ceiling vents were kept clean in the kitchen and to ensure an ice machine on the Meridian unit was kept clean and sanitary by having a black substance growing on internal components within the ice bin. This had a potential to affect 70 of 70 residents that consume food from the kitchen had the potential to affect 23 of 23 residents who reside on the Meridian unit. (Facility) Findings include: 1. An observation was made of the kitchen with the Culinary Manager on 8/23/24 at 11:23 a.m. The dishwasher area's flooring along the back wall under the dishwasher was observed with a black substance on it. The ceiling vents above the food prep area was observed with a gray substance within the metal plates of the vent. During a kitchen tour with the Culinary Manager on 8/27/24 at 11:30 a.m., the dishwasher area flooring was observed with a black substance along the back wall under the dishwasher. Ceiling vents in the food prep area were observed with a gray substance within the metal plates of the vent. An interview was conducted with the Culinary Manager on 8/27/24 at 11:30 a.m. She indicated she had received a power washer, and it should remove the black substance. The ceiling vents were cleaned by the maintenance department, and she was unsure when the last time the ceiling vents were cleaned. The July 2024 and August 2024 cleaning schedules were provided by the Interim Administrator on 8/28/24 at 10:01 a.m. The cleaning schedules indicated on Saturdays the staff were to clean the wall and baseboard behind the dishwasher. The staff were to clean and mop the dishwasher area daily. An interview was conducted with the Interim Administrator on 8/27/24 at 1:24 p.m. He indicated the maintenance department was looking into the last date the overhead vents in the kitchen were cleaned. The Culinary Manager had completed a kitchen inspection log and had noticed the flooring under the dishwasher needed to be scrubbed prior to the kitchen tour. At the time of exit on 8/29/24, the Interim Administrator had not provided documentation regarding the last time the ceiling vents were cleaned by the maintenance department. A floor care policy was provided by the Interim Administrator on 8/27/24 at 2:53 p.m. It indicated .Policy: Kitchen floors and floor care equipment will be well maintained, clean, and odor free. Procedure. 1. Floors will be swept at a minimum of twice daily and mopped with appropriate floor cleaning solution at least once daily, or more frequently as needed. A desk brush should be used to scrub floors of build-up and debris, as needed . 41129 2. A random observation of the Meridian unit ice machine was conducted on 8/27/24 at 9:52 a.m. The ice machine was observed having a blanket/towel on the floor in front on the ice machine. The ice machine had dust and dried droplets of a reddish substance visible on its outer surfaces. The lid of the ice machine was opened to view the cleanliness of the inside. The inside of the ice machine contained a black substance on the area where the ice drops into the storage bin. An interview and observation with the Interim Administrator were conducted immediately following the observation of the ice machine. He indicated, the maintenance department was responsible for the cleaning and sanitation of the ice machines. An interview with Maintenance Supervisor (MS) was conducted on 8/27/24 at 1:28 p.m. He indicated the last time the Meridian unit ice machine was cleaned was on July 8, 2024. He indicated TELS (a building management system) had the cleaning and sanitation of the ice machines scheduled for every three months or quarterly. He indicated if the machine was not keeping temperature, it can cause mold to grow much quicker. He indicated the towel on the floor in front of the ice machine was there due to the unit having draining issues that he had yet to work on. He indicated the ice machine probably needed to be replaced. A copy of the TELS ice machine maintenance was provided by the Interim Administrator on 8/27/24 at 10:18 a.m. It indicated to check filters (if present), clean coils, sanitize interior and delime as necessary. This was to be conducted every 3 months. The instructions included, but were not limited to, sanitize interior of ice machine per manufacturer's instructions and to clean out and sanitize the ice bin. The manufacturer's instructions were provided by the Interim Administrator on 8/27/24 at 1:15 p.m. They indicated De-scale and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent de-scaling, consult a qualified service company to test the water quality .An Extremely dirty ice machine must be taken apart for de-scaling and sanitizing .Detailed De-scaling and Sanitizing Procedures .Ice machine sanitizer disinfect and removes algae and slime. 3.1-21(i)(1) 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure trash was contained in receptacles for 70 of 70 residents in the facility. Findings include: During a kitchen tour with the Culinary Manager, on 8/27/24 at 11:23 a.m., two outside dumpsters were observed. One of the dumpster's had one sliding side door opened with trash bags inside. The ground around the dumpsters and along the fence line in the parking lot was observed with paper and plastic debris, medication cups and gloves scattered around the dumpsters and grass area. The Culinary Manager indicated the sliding side doors should be shut, and the maintenance department maintains the surrounding area around the dumpsters and the grass area. An observation was made of the dumpster area with the Maintenance Supervisor on 8/27/24 at 11:46 a.m. The dumpster area and grass area along the fence was observed with plastic bottles, paper product debris, medication cups, gloves, plastic silverware, food wrappers and cups. An interview was conducted with the Maintenance Supervisor on 8/27/24 at 11:50 a.m. He indicated the maintenance department was responsible for maintaining the grounds. He does not observe the surrounding area by the dumpsters on a regular basis. 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of flying insects. This had a potential to affect 70 to 70 residents that receive food out of the kitchen. Findings include: An observation was made of the kitchen with the Culinary Manager on 8/23/24 at 11:23 a.m. The dishwasher area and the storage area was observed with flying insects. During a kitchen tour with the Culinary Manager, on 8/27/24 at 11:23 a.m., the dishwasher area and the back door area was observed with flying insects. A red bucket containing soiled rags was observed with flying insects sitting on top of the soiled rags. At that time, the Culinary Manager grabbed a trash bag and removed the soiled rags from the bucket disrupting the flying insects. Several flying insects were observed flying from the bucket. After, the food prep area wall was observed with one flying insect. An interview was conducted with the Culinary Manager on 8/27/24 at 11:30 a.m. She indicated the flying insects had been in the kitchen area for at least two weeks. The rags should have not been left in the bucket. The exterminator service visit, dated 6/4/24, indicated the kitchen area was observed with small flies in the dishwasher area. Please clean in and around drains frequently to help prevent pest breeding sites. The exterminator service visit, dated 8/5/24, indicated no rodent or insect activity. 3.1-19(f)(4)

Based on interview and record review, the facility failed to ensure the medical provider was notified for blood sugars exceeding the parameter as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 8/27/24 at 12:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus and dementia. A care plan, dated 3/15/21, indicated, Resident is at risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus, insulin dependent .medications as ordered . A physician order, dated 5/20/21, indicated the staff was to obtain the resident's blood sugars twice a day. The staff was to notify the medical provider if the resident's blood sugar reading was greater than 300 or less than 70. A physician order, dated 12/19/22, indicated the resident was to receive 28 units of glargine (long acting) insulin daily. The August 2024 Medication Administration Record (MAR) indicated the following days and times the resident's blood sugar reading was greater than 300: 8/1/24 at 4:00 p.m. = blood sugar reading of 345, 8/7/24 at 4:00 p.m. = blood sugar reading of 319, 8/10/24 at 4:00 p.m. = blood sugar reading of 320, and 8/11/24 at 4:00 p.m. = blood sugar reading of 308. The resident's clinical record did not indicate the medical provider was notified of the blood sugar readings that were greater than 300. An interview was conducted with the Director of Nursing on 8/28/24 1:27 p.m. She indicated she was unable to provide documentation the staff notified the medical provider when the resident's blood sugar was greater than 300 on 8/1/24, 8/7/24, 8/10/24 and 8/11/24. 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure orthostatic blood pressures (a measurement of blood pressure while a person is lying, sitting, and standing) were completed as per a physician's order for 1 of 5 residents reviewed for unnecessary medications. (Resident 17) Findings include: The clinical record for Resident 17 was reviewed on 8/26/24 at 2:33 p.m. The diagnoses included, but were not limited to, chronic kidney disease, generalized anxiety disorder, and hypertension. An August 2024 pharmacy consultation report for Resident 17 indicated Resident 17 received doxazosin (a medication used to treat high blood pressure) 6 mg (milligrams) every morning for hypertension. It indicated doxazosin should be avoided in older adults due to the risk for adverse effects (e.g., orthostatic hypotension). The recommendation was to consider discontinuing doxazosin and if needed to control blood pressure, then initiate lisinopril (a medication used to lower blood pressure) 10 mg daily and to titrate as tolerated. The recommendations were accepted on 8/15/24, with the modification to check orthostatic vital signs and to discuss possible discontinuation of doxazosin with the family and to slow [sic, arrow pointing downward] titrate. A progress note, dated 8/19/2024 at 1:35 p.m., indicated new orders were received to check orthostatic blood pressures daily prior to medication administration for 14 days and to notify medical doctor or nurse practitioner if systolic (the pressure in the arteries when you heart beats and pump blood out into the body) was greater than 170 mm Hg (millimeters of mercury) or less than 100 mm Hg. It also indicated to administer 4 mg of doxazosin by mouth every morning and give 10 mg of lisinopril by mouth daily. The August 2024 medication administration record (MAR) for the orthostatic blood pressure readings, which were reviewed on 8/26/24 at 2:33 p.m., indicated only one blood pressure reading each day (August 20, 21, 22, 23, 24, and 25) and did not indicate if the blood pressure reading was conducted while lying, sitting, or standing. A progress note, dated 8/20/2024 at 1:43 p.m., indicated Resident 17's orthostatic blood pressures were: sitting - 128/65 laying [sic, lying]- 134/72 standing - 138/80 A progress note, dated 8/21/2024 at 8:17 a.m., and recorded as a late entry on 8/26/2024 at 4:16 p.m., indicated Resident 17's orthostatic blood pressures were: laying 168/87 [sic] sitting 158/82 standing - 150/78 The clinical record for Resident 17 did not contain orthostatic blood pressure readings on 8/22/24. A progress note, dated 8/23/2024 at11:32 a.m., and recorded as a late entry on 8/26/2024 at 4:17 p.m., indicated Resident 17's orthostatic blood pressures were: l [sic, lying]- 150/74 sitting - 146/82 standing, - 150/88 A progress note, dated 8/26/2024 at 11:58 a.m., indicated Resident 17's orthostatic blood pressures were: sitting - 136/74 standing 140/82 laying[sic] - 134/86 The clinical record for Resident 17 did not contain orthostatic blood pressure readings on 8/24/24 or 8/25/24. An interview with the Director of Nursing (DON) was conducted on 8/27/24 at 10:01 a.m. She indicated if a resident had an order for orthostatic blood pressures, it would be the expectation to perform blood pressure checks while the resident is lying down, then sitting, then standing and the blood pressure readings for each position need to be documented in the medical record as lying, sitting and standing. The DON indicated; the facility did not have a policy on conducting orthostatic blood pressures. 3.1-37(a)

Based on interview and record review, the facility failed to ensure effective services for monitoring, assessment, and care was provided to relieve constipation for a resident who was incontinent of bowel and had a history of constipation, partial bowel obstruction, and ileus for 1 of 6 residents reviewed for constipation. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/26/24 at 3:08 p.m. The diagnoses included, but were not limited to, dementia, history of partial intestinal obstruction, and constipation. A discharge Minimum Data Set (MDS) assessment, dated 3/28/24, indicated always incontinent of bowel and bladder and required maximum assistance of the staff for toileting. A physician's order, dated 11/9/23, indicated Miralax (laxative) 17 grams should be administered daily as needed (PRN) for constipation. The order did not include sufficient information to define as needed or to determine the specific frequency for administration of the PRN medication. A physician's order, dated 12/12/23, indicated a Dulcolax (laxative) suppository 10 milligrams (mg) should be administered rectally daily at bedtime as needed for constipation. The order did not include sufficient information to define as needed or to determine the specific frequency for administration of the PRN medication. The hospital radiology reports and physician progress notes, dated from 12/15/23 through 1/25/24, indicated Resident B had a history of an ileus (an intestinal blockage) and constipation that was effectively relieved with the use of Miralax and Dulcolax suppositories. A care plan, last reviewed on 1/26/24, indicated that Resident B was at risk for constipation due to dementia, with a goal they would have a soft formed bowel movement at least every three days. The approaches included to perform an abdominal assessment if no bowel movement in four days for bowel sounds, abdominal distention, hyper (louder and more frequent) and hypo (less active) bowel sounds, abdominal pain or tenderness. Document the findings and notify the physician (MD) of abnormal findings, administer medications as ordered, document abnormal findings and notify MD, encourage fluids, monitor bowel function, and notify MD if no bowel movement after the third day. The comprehensive plan of care, dated 1/26/24, did not include interventions to evaluate or monitor the resident for signs and symptoms of ileus or partial bowel obstruction. The nursing progress notes, the Medication Administration Records (MAR), the bowel records, dated from 2/2/24 through 3/14/24, indicated Resident B experienced constipation that was effectively relieved with the use of Miralax and Dulcolax suppositories. The bowel record, dated from 3/15/24 through 3/18/24, indicated Resident B did not have a bowel movement. The MAR, dated 3/18/24, indicated Miralax or Dulcolax was not administered when the resident experienced three days of constipation in accordance with the physician orders and the plan of care. The bowel records, dated 3/19/24 at 11:15 p.m., indicated Resident B had a large bowel movement. The bowel records, dated from 3/22/24 through 3/24/24, indicated Resident B Resident B did not have a bowel movement. The MAR, dated 3/24/24, indicated Miralax or Dulcolax was not administered when the resident experienced three days of constipation in accordance with the physician orders and the plan of care. The bowel record, dated 3/25/24, indicated Resident B did not have a bowel movement. The MAR, dated 3/25/24, indicated Miralax or Dulcolax was not administered when the resident experienced four days of constipation. The nursing assessments and progress notes, dated 3/25/24, did not include documentation to determine an abdominal assessment was performed or the physician was notified when the resident experienced four days of constipation. The bowel record, dated 3/26/24, indicated Resident B did not have a bowel movement. The MAR, dated 3/26/24, indicated Miralax or Dulcolax was not administered when the resident experienced five days of constipation. The nursing assessments and progress notes, dated 3/26/24, did not include documentation to determine an abdominal assessment was performed or the physician was notified when the resident experienced five days of constipation. During an interview on 8/29/24 at 11:46 a.m., the Clinical Nurse Consultant (CNC) indicated Resident B had a history of an ileus and an extensive history of constipation. During an interview on 8/28/24 at 2:43 p.m., Licensed Practical Nurse (LPN) 6 indicated that Resident B had issues with constipation since her admission to the facility. When Resident B became constipated an as needed laxative was given. LPN 6 reviewed the Bowel Report each shift she worked, and normally did not count documentation of a small bowel movement when determining if an as needed laxative needed to be given. During an interview on 8/28/24 at 4:11 p.m., the Director of Nursing (DON) indicated that small bowel movements were counted when determining the need for as needed laxatives. The bowel report should be run daily. During an interview on 8/29/24 at 9:27 a.m., LPN 7 indicated Resident B was often on the bowel report. If a resident had no bowel movement for three days, an as needed laxative was given, if no results by the fourth day, then the physician was notified. Resident B should have been closely monitored for bowel movements due to her history of constipation. On 8/27/24 at 11:09 a.m., the DON provided the current Bowel Elimination policy that read .It is the policy to to ensure that each resident maintains a safe and health bowel elimination pattern . 3. Bowel assessment will be completed based upon each resident's specific plan of care and documented in the EMR [Electronic Medical Record]. 4. Bowel movements will be recorded on the facility EMR and/ or record daily by the direct care staff. 5. A resident bowel report will be completed by the assigned charge nurse of resident [s] who have not had a bowel movement for 3 consecutive days. 6. Any resident not having a bowel movement for 3 consecutive days, will be given a laxative or stool softener, as prescribed by the physician, at the end of the 3rd day. 7. Resident [s] no [sic] having results from the laxative or stool softener will be given a [sic] enema, if ordered by the physician. 8. If by the 4th afternoon, the resident [s] has not had results, the nurse will do an abdominal assessment, chart the results of the assessment, and notify the physician for further order . This citation relates to Complaint IN00436961. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident receiving dialysis services was provided the therapeutic diet as ordered. (Resident 31) Findings include: The clinical record for Resident 31 was reviewed on 8/23/24 at 1:30 p.m. The diagnoses included, but were not limited to, dementia and end stage renal disease. A care plan, dated 11/7/18, indicated, Resident presents for nutritional risk r/t [related to] dx [diagnosis] of renal osteodystrophy [abnormal bone growth] and needs for HD [hemodialysis] to fluctuate r/t [related to] changes in fluid volumes .Approach .start date 11/30/23 ice cream with every meal .start date 10/9/22 soft & bite sized diet with no oranges, OJ [orange juice], bananas, spinach, beets, baked or sweet potatoes . A dialysis care plan, dated 11/7/18, indicated the resident was at risk for complications. The resident received dialysis on Tuesdays, Thursdays, and Saturdays. She had a left upper chest port and left arm fistula. The interventions on the care plan included, but were not limited to, the staff was to provide diet as ordered. An observation was conducted of Resident 31 eating breakfast on 8/28/24 at 8:29 a.m. The resident was observed being assisted by Certified Nurse Aide (CNA) 4 with breakfast. The resident was not observed being fed ice cream with her breakfast bowl. A cup with a lid containing an orange liquid was sitting in front of the resident at the table. CNA 4 then removed the breakfast bowl from the table and walked away. At that time, the resident picked up the cup with the lid and drank the orange liquid. CNA 4 then returned to the table. CNA 4 indicated, at that time, the drink sitting in front of the resident was orange juice. She was unaware the resident was on dialysis and was not supposed to receive orange juice. After, CNA 4 removed the resident from the table and took her out of the dining area. During that time, License Practical Nurse (LPN) 3 indicated CNA 4 was new to the unit and was unaware Resident 31 was to receive cranberry juice and not orange juice. The resident was a good eater, and she would eat everything the dietary department brought her. The dietary staff did not bring ice cream for the resident to eat that morning as ordered. If dietary brought the ice cream; she would have eaten it. An interview was conducted with the Culinary Manager on 8/28/24 at 8:56 a.m. She indicated the dietary staff had forgot to send the ice cream down to Resident 31. A diet orders policy was provided by the Director of Nursing on 8/28/24 at 3:00 p.m. It indicated, .Policy: In order to help maintain/improve nutrition and quality of life, liberalized diets will be offered. The Registered Dietitian, or designee, will evaluate the need for more restricted diet therapy according to each resident's individual medical condition, needs, desires, and rights . 3.1-46(a)(2)

Based on interview and record review, the facility failed to complete an admission assessment and monitor a resident's blood pressure, as care planned, for 1 of 2 residents reviewed for hospitalization . (Resident F) Findings include: The clinical record for Resident F was reviewed on 6/1/23 at 11:56 a.m. Her diagnoses included, but were not limited to: hypertension, dementia, type 2 diabetes mellitus, seizures, hyperlipidemia, aortic stenosis, and anxiety disorder. She was admitted to the facility on [DATE]; discharged from the facility to a psychiatric hospital on 5/3/23; readmitted to the facility on [DATE]; and discharged to the hospital on 5/13/23. Resident F's 12/14/22 original admission assessment included an assessment of the following: mental/neurological status, eyes, ears, nose and throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, skin, and pain. There was no 5/11/23 admission/readmission assessment in Resident F's clinical record. The 5/11/23, 2:06 p.m. nurse's note read, MD her [sic] to evaluate resident upon return from [name of psychiatric hospital] stay and resident continues to remain delusional and states she is not [name of Resident F] she is [name of famous singer] and is up pacing the halls and persistent delusions of place. New order to increase Abilify to 5mg q [every] day and to give an extra 4mg x [times] 1. MD and sister, [name of sister], aware of current plan of care. The 5/11/23 physician evaluation was not available in Resident F's clinical record. The 1/5/23, last reviewed/revised 6/1/23, at risk for ineffective tissue perfusion care plan indicated the goal was to maintain adequate tissue perfusion as evidenced by blood pressure within normal limits for resident, no change in mental status, no complaints of dizziness/lightheadedness/syncope, or edema. An approach was to monitor her vital signs, starting 1/5/23. The physician's orders indicated she was taking a carvedilol 25 mg tablet twice a day for hypertension from 3/7/23 through 5/3/23, which was restarted upon her 5/11/23 readmission. She was taking a Norvasc 10 mg tablet once a day for hypertension from 3/9/23 through 5/3/23 and a Losartan 50 mg tablet once day for hypertension starting 5/11/23. The Administration History report from 4/1/23 through 6/2/23 indicated her blood pressure was being taken and documented daily with the administration of her Carvedilol until she discharged from the facility on 5/3/23. There were no documented blood pressures on the report after her 5/11/23 readmission to the facility. An interview was conducted with the ADON (Assistant Director of Nursing) on 6/1/23 at 2:48 p.m. She indicated they completed admission assessments on residents who were newly admitted or readmitted every shift for 72 hours, which included vital signs. Nursing should be documenting the vitals under the vitals section of the electronic health record, including blood pressure. The ADON reviewed Resident F's clinical record at this time and indicated the only documented blood pressure she could find after Resident F's 5/11/23 readmission to the facility was the one from the 5/13/23 nurse's note when she was sent to the hospital. The 5/13/23, 6:50 a.m. nurse's note read, upon nurse assessment, resident showing change in condition, previous accu [blood sugar checks] 72, 79, resident unable to answer questions or commands from staff, unsteady gait, slurred speech, vitals 156/119 [blood pressure.] pr [pulse rate] 131, r [respirations] 14, temp [temperature] 97.9, md notified of change, order given to send to ER [emergency room ] for assessment, sister [name of sister] notified, don [director of nursing] notified, report called to [name of staff member at local hospital,] resident picked up by ambulance at this time, stable upon transfer. The 5/13/23, 1:14 p.m. nurse's note read, resident to be admitted to [name of local hospital] for elevated blood pressure. The every shift for 72-hour nursing assessments referenced by the ADON were documented in the 5/12/23, 12:08 a.m. progress note, the 5/12/23, 11:56 a.m. progress note, and the 5/12/23, 7:54 p.m. progress note. All 3 notes indicated vital signs were assessed and documented in the vital sign section of the EHR (electronic health record) and were within normal limits. The vitals section of the EHR did not include documented blood pressures for the above 3 assessments. An interview was conducted with the DON (Director of Nursing) on 6/2/23 at 11:16 a.m. She reviewed Resident F's clinical record and indicated she was unable to locate an admission assessment for her 5/11/23 readmission to the facility. She expected one to have been completed. The purpose of the admission assessment was to have a current plan of care since readmission. She spoke to nursing about Resident F and was informed the vitals were taken, but not documented. Prior to Resident F discharging from the facility on 5/3/23, her blood pressures were taken and documented with the administration of medication, but upon her 5/11/23 readmission, the EHR was not set up that way. The 5/13/23 hospital notes indicated she presented to the emergency department for altered mental status. The ED note for 5/13/23 at 7:12 a.m. read, Today she has no hypoxia but is still profoundly hypertensive requiring nicardipine drip, admission and will get MRI as an inpatient. Her blood pressures in the emergency department on 5/13/23 were as follows at the following times: 7:16 a.m. @ 134/79, 8:26 a.m. @ 219/92, 8:31 am 226/100, 8:46 a.m. @ 223/102, 9:17 a.m. @ 213/110, 9:32 a.m. @ 202/97, and 9:47 a.m. @ 231/93. The clinical impression was listed as, 1. Encephalopathy 2. History of seizure disorder 3. Hypertensive emergency. The Nursing Admission/Return Admission Policy and Procedure was provided by the DON on 6/2/23 at 10:39 a.m. It read, Resident admission to the nursing unit: .3. Admitting nurse must interview resident and/or family in order to accurately complete the admission assessment (Admission Observation) Nursing assessment/documentation at admission: 1. All residents will be assessed at least every shift for the first 72 hours following admission. Documentation will be related to pertinent health conditions, including vital signs, pain symptoms, orientation to surroundings, and any physical complaints he/she may have Initial nursing assessment: Admission Observation 1. The initial nursing assessment must be completed within the 1st 24 hours of admission (initiated by the admitting nurse .) 3.1-37(a)

Based on interview and record review, the facility failed to assess a resident's pain that included location and intensity of the resident's pain when staff provided an as needed (PRN) pain medication, and ensure nonpharmacological interventions were provided to address a resident's pain for 1 of 1 resident reviewed for pain. (Resident 4) Findings include: The clinical record for Resident 4 was reviewed on 5/31/23 at 12:30 p.m. The diagnosis for Resident 4 included, but was not limited to, chronic pain. The Quarterly MDS (Minimum Data Set) Assessment completed on 5/8/23 indicated Resident 4 was moderately impaired. A pain care plan dated 2/15/23 indicated .Resident is at risk for pain related to: hx [history] of vascular wounds, dementia, BLE [bilateral lower extremities] chronic pain. Resident may refuse to get out of bed at times and yells out for assistance maybe related to pain Approach: reposition resident for comfort as tolerated. Observe for adverse side effects of pain medication including, but not limited to over sedation, constipation, skin rash, nausea/vomiting, loss of appetite, change in mental status, stomach upset. Document abnormal findings and notify MD [medical doctor]. Notify MD if pain is unrelieved and/or worsening. Assist with positioning to comfort. Document effectiveness of prn medications. Administer meds as ordered. 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 . An interview was conducted with Resident 4 on 5/31/23 at 12:24 p.m. He indicated his bottom was in moderate pain all the time. A physician order dated 2/3/23 indicated staff was to monitor effectiveness of routine pain medication every shift. The staff was to mark a yes or a no on electronic medication administration record (MAR). If the resident indicated a no a pain assessment was to be conducted. A physician order dated 2/15/23 indicated Resident 4 was to receive 325 milligrams of Tylenol for mild pain every 6 hours as needed. A physician order dated 2/17/23 indicated the resident was to receive 1/2 tablet of 5-325 milligrams of hydrocodone every 12 hours for chronic pain. A physician order dated 2/17/23 indicated Resident 4 was to receive 5-325 milligrams of hydrocodone every 4 hours as needed. A pain assessment dated [DATE] indicated Resident 4 had experienced frequent mild pain in the last 5 days. The assessment indicated Resident 4 did not indicate his pain was affecting his sleep or daily activities. The May 2023 MAR for Resident 4 indicated the following days Resident 4 had received as needed hydrocodone and did not include a location of the resident's pain, intensity of his pain on all administrations of as needed pain medication administrations nor nonpharmacological interventions attempted: 5/6/23 at 2:12 a.m., = reason given - documented as pain - and medication was effective, 5/15/23 at 12:34 p.m., = reason given - documented as pain - and medication was effective, 5/15/23 at 4:47 p.m., = reason given- documented as buttocks - and medication was effective, & 5/16/23 at 5:56 a.m., and 5:31 p.m., = reason given - documented as pain - and medication was effective. The MAR indicated Resident's routine pain medication was effective on 5/6/23, 5/15/23 and 5/16/23. The residents clinical record did not include nonpharmacological interventions attempted on 5/6/23, 5/15/23, nor 5/16/23 to address the resident's pain. An interview was conducted with the Director of Nursing on 6/2/23 at 8:53 a.m. She indicated she was unable to provide staff assessments of the residents' pain intensity or location of his pain on the following days the resident received as needed hydrocodone: 5/6/23 at 2:12 a.m., 5/15/23 at 12:34 p.m., and 5/16/23 5:56 a.m., and 5:31 p.m. She did not have documentation on 5/15/23 the resident's intensity of his buttock pain. The staff follow the plan of care and do not document nonpharmacological interventions that were attempted to address Resident 4's pain. A pain management policy was provided by the Regional [NAME] President Director of Operations on 5/8/23 at 10:58 a.m. It indicated .Policy: It is the policy of American Senior Communities to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management. 1. Residents are assessed for pain upon admission, weekly, and during medication administration as outlined below. 2. The following will be used when assessing pain. Nursing Admission Observation, Weekly Summary, IDT [Interdisciplinary Team] Pain Interview, Ongoing nursing assessments can also be documented in matrix progress notes or matrix vitals. 3. Interviewable Resident - Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or [NAME]-Baker FACES Scale 7. Residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass. 8. Documentation of administration of ordered PRN pain medication will be documented on the Electronic Medication Administration Record (EMAR). 9. Additional information including, but not limited to reasons for administration, and effectiveness of pain medications will be documented on the Electronic Medication Administration Record (EMAR) . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide residents with an identified diagnosis of dementia and the need for close supervision as to prevent them from wandering into the rooms of other residents for 2 of 4 residents reviewed for abuse. (Resident B and D) Findings include: 1. The clinical record for Resident D was reviewed on 5/31/23 at 11:30 a.m. The diagnoses for Resident D included, but were not limited to, dementia, mood disturbance, anxiety, obsessive-compulsive disorder, restlessness and agitation. A care plan, initiated 4/26/22, indicated Resident D may become upset with redirection as exhibited by using inappropriate language with staff at times. He at times may experience feelings of loss of independence due to skilled nursing facility placement. The goal was for him to have no negative outcomes related to behavioral expressions. The interventions were to encourage him by using phrases that emphasize choices, initiated 4/26/22, and male staff member to redirect as available with therapeutic conversations, initiated 7/20/22. A care plan, initiated 7/25/22, indicated Resident D attempted to take peers' personal care items at times. He may become preoccupied with grooming and cleanliness, such as repetitive tooth brushing, hand washing, and requests for multiple showers. He may utilize multiple tubes of toothpaste and multiple toothbrushes per day. He becomes upset if staff attempt to secure his toothbrush and toothpaste. He becomes upset if staff disturbs his towels, washcloths or any toiletry items. He may enter peers' rooms and attempt to take their toiletry items. He could become disoriented in his environment and becomes anxious when redirected. Resident D had a diagnosis of dementia and obsessive-compulsive disorder. The goal was for him not to take peers' personal items. The approaches included, but were not limited to, when he attempts to take peers' items offer him the opportunity to engage in hygiene tasks such as brushing teeth, showering, brushing his hair with his own items, initiated 7/25/23, room sign to door, 8/31/22, encourage him to keep toiletry items in walker basket during meals, initiated 10/27/22, offer occupational task to redirect such as folding napkins or clothing protectors, initiated 11/6/22, offer showers on Sundays, initiated 11/28/22, psychiatric physician to review as indicated, initiated 1/19/23, Offer walking or physical activities when he begins to wander into peers' rooms, initiated 2/1/23. The Quarterly MDS (Minimum Data Set) Assessment completed on 2/1/23 indicated Resident D was moderately impaired. The resident's functional abilities required supervision, oversite for walking in a room walking in a corridor, locomotion on and off unit with no impairments to upper or lower extremities, and used a walker for ambulation. A physician's order, dated 3/11/23, indicated he was to receive sertraline (anti-depressant medication) 200 mg (milligram) once daily for obsessive- compulsive disorder. A behavior progress note dated 3/18/23 indicated Resident D had been wandering in and out of residents' rooms. A care plan, initiated 3/20/23, indicated that Resident D would make comments to peers that they found offensive, intrusive wandering into peers' rooms and disrobe at times. The intrusive wandering places resident at higher risk for resident-to-resident altercations. He rummages through peers' personal items and taking peers items. He has increased anxiety and will attempt to take peers' drinks at times. He has a diagnosis of dementia and personality disorder. The goal was for him to have no negative outcomes related to his wandering. The interventions, initiated 3/20/23, were to redirect with diversional activity such as painting or sketching, offer snacks and drinks, offer to have him walk off of the cottage, offer one on one conversations, place on 15 minute checks, initiated 3/29/23, created occupational tasks such as assisting with setting up dining room, initiated 4/3/23, administer scheduled anti- anxiety medication, initiated 4/4, have him assist with making beds, initiated 4/26/23, place on 15 minute checks, initiated 5/3/23, and when increased wandering occurs assess for any unmet needs such as hunger, thirst, or toileting, initiated 5/8/23. A behavior progress note dated 3/20/23 indicated Resident D had been intrusive wandering in residents' rooms uninvited on 3/18/23 and 3/19/23. A behavior progress note dated 3/25/23 indicate Resident D was intrusive wandering in resident's rooms. A nursing note dated 3/26/23 indicated the resident was intrusive wandering in a resident's room while the other resident had visitors. A behavior progress note dated 3/28/23 indicated the resident was intrusive wandering in and out of residents' rooms. A physician's order, dated 3/28/23, indicated he was to receive Ativan (anti-anxiety medication) 0.5 mg twice daily, as needed, for 7 days. A behaviors progress note dated 3/29/23 indicated the resident continues to intrusive wander in and out of residents' rooms. A physician's order, dated 3/30/23, indicated his sertraline was to be decreased to 100 mg once daily and he was to receive Paxil (anti-depressant medication) 5 mg daily for depression. A behavior progress note dated 4/1/23 indicated the resident going through roommate's clothes and in roommates' personal space while he was trying to sleep . A physician's order, dated 4/4/23, indicated he was to receive Ativan 0.5 mg twice daily in the morning and evening. A behavior progress note dated 4/6/23 indicated the resident was going into peers' rooms attempting to take peers personal items from rooms and became upset with staff when staff attempted to redirect telling staff they are insane and need to be locked up in a mental hospital .Resident kept insisting on going in peer rooms to read personal books . A progress note date 4/7/23 indicated resident was going to an inpatient psychiatric hospital due to difficulty with redirection and disrobing. On 4/21/23, Resident D returned from the inpatient psychiatric hospital. A physician's order, dated 4/21/23, indicated he was to receive nortriptyline (anti-depressant medication) 25 mg daily for depression. This medication was discontinued on 4/27/23. A behavior progress note dated 4/25/23 dated 7:00 p.m., indicated Resident D was intrusive wandering in other resident's room and room pulling cable cords on wall. The staff had redirected 3 times out of the room. The staff had given medications, offered snacks and drinks, and the interventions were not effective. A nursing progress note dated 4/26/23 at 5:49 a.m., indicated the QMA [Qualified Medication Aide] on night shift reported resident had to have direct supervision because of intrusive wandering into another resident's room. He has been awake all night and needed redirection throughout the night. He had kept the other resident up all night. The other resident had told staff he would use a stick to make contact with Resident D if Resident D kept coming in the other resident's room. A physician's order, dated 4/26/23, indicated he was to receive trazadone (anti-depressant medication) 25 mg daily for generalized anxiety disorder. A physician's order, dated 4/26/23, indicated he was to receive Ativan 0.5 mg twice daily, as needed, for anxiety. A nursing progress note dated 4/27/23 at 5:17 a.m., indicated Resident D was intrusive wandering, but took redirection well. An Interdisciplinary Team note dated 4/27/23 indicated Resident D had behaviors of intrusive wandering and would be transferred to Mapleton Cottage that day. A nursing progress note dated 4/27/23 at 8:09 p.m., indicated Resident D had been very active, walking about the unit, entering all rooms with the stop signs, open and closing doors. He had testing locked doors. Redirections have not been successful for more than a minute or two at a time. Staff has offered snacks and fluids; activities staff took him for a walk off the unit. He was asked if he could sort papers, he refused stating he was too busy. Has stood in the middle of the short hallway, doing standing exercises with his walker. The physician was notified of wandering and exit seeking behaviors. A progress note for Resident D dated 4/28/23 at 9:06 p.m., indicated Resident D continued to intrusively wander in and out of rooms of female peers. He would enter a room and then will turn around and walk out. Has been very focused on past experience of being asked to leave his apartment. Staff has provided reassurance that he does not have to leave here. He was attempting to rearrange the furniture in the dining room. He was offered yarn and asked to roll into a ball, but stated he would do that later, he was busy. He was provided a snack and fluids. He continues to ambulate on unit. A behavior event progress note for Resident D dated 4/28/23 at 9:23 p.m., indicated Resident D had entered a peer's room multiples times and when asked to leave, states he was tired and was going to bed. He tried to lay down on the second bed in the peer's room. The staff provided assistance to his room and reoriented to the location of the bathroom, call light and his bed with each redirection, within minutes he enters the peers room again. During the last entry Resident D began talking of reimbursing the peer for any problems. When redirection was attempted, he grabbed the doorknob holding tight and stated he wasn't leaving he was going to go to bed. Resident D was educated that his room was next door, again directed him back to his room, where he pulled the call lights out of the walls and attempted to pull call box off the wall. A sandwich and fluids were offered in the dining room. Resident D sat in dining room and ate his snack then he went back to his peer's room and opened the door. Peer yelled at Resident D to leave their room and told him to stop coming in because they were trying to sleep. Resident D was redirected back to the dining room, where he straightened a ball of yarn for a few minutes. A nursing progress note for Resident D dated 4/30/23 at 1:38 p.m., indicated Resident D was going in and out of rooms. Resident trying to pull stuff off the wall. Resident redirected several times to his room but will keep coming out. A behavior progress note for Resident D dated 5/1/23 at 1:24 a.m., indicated Resident D continues to intrusively wander in and out residents' rooms waking up other residents. The staff offered activities, snacks and fluids. The interventions were effective but had to be attempted numerous times. A behavior progress note for Resident D dated 5/1/23 indicated, he was exhibiting behaviors of intrusive wandering. He was clogging toilets and smearing feces. He was redirected and provided one on one support. The root cause of the behavior was a change in units and cognitive decline. His medications were reviewed, and he was given as needed medications. A behavior expression note for Resident D dated 5/2/23 indicated .Resident was hit on the head by his peer when he tried entering peer's room. No injury or redness to head .Resident redirected to room with staff closely monitoring . A nursing progress note dated 5/4/23 indicated Resident D continues to enter the rooms of peers, even if doors are closed or he has been asked not to enter. He states he has to get something out of the rooms when staff attempts to redirect him. He remains on 15-minute checks. A behavior expression note dated 5/8/23 indicated Resident D had walked into female peer's room while she was undressing. A physician's order, dated 5/11/23, indicated to give trazadone 75 mg each bedtime for generalized anxiety disorder. A physician's order, dated 5/14/23, indicated he was to receive Ativan 0.25 mg twice daily as needed for generalized anxiety disorder. A behavior note dated 5/15/23 indicated Resident D was intrusive wandering. He was transferred to a new unit. A nursing progress note for Resident D dated 5/16/23 indicated Staff overheard this resident and peer resident raising their voices in peer's room and upon entering the room both CNAs observed this resident standing next to peer's bed with blood on his lower lip and peer resident was in his own bed. One CNA immediately took this resident out of the room to the nurse's station for further assessment and the other CNA stayed with peer resident in his room. It should be noted that this resident was previously in this room as he has had a recent room change. This resident has increased staff supervision . An IDT note for Resident D dated 5/16/23 indicated the resident was placed on one-on-one supervision. A nursing progress note, dated 5/17/23 at 5:54 a.m., indicated Resident D had a restful night and slept in the common area in a recliner. One-on-one monitoring was done throughout the night shift. A physician's order, dated 5/18/23, indicated he was to receive Rexulti (anti-psychotic medication) 0.25 mg twice daily for major depressive disorder. A nursing progress note, dated 5/19/23 at 1:51 p.m., indicate Resident D continued with one-on-one supervision, with no distress. He had no intrusive wandering behaviors. A nursing progress note, dated 5/20/23 at 8:22 a.m., indicated Resident D continued with one-on-one supervision. He was ambulating continuously on the cottage; activities had been encouraged and were effective for a short time. He was focusing on brushing teeth, getting into the sink and cabinets and thinking of various tasks he needed to do. A physician's order, dated 5/21/23, indicated to increase Rexulti to 0.5 mg twice daily. A nursing progress note, dated 5/24/23 at 3:54 p.m., indicated Resident D continued to receive one-on-one care and was in a pleasant mood, with not agitation or behaviors. A physician's order, dated 5/25/23, indicated to increase his Ativan 0.5 mg every 6 hours as needed, for generalized anxiety disorder. The nursing progress notes from 5/25/23 through 6/2/23 indicated continued one-on-one supervision and did not contain any documentation of further intrusive wandering behaviors. During an interview on 6/02/23 at 10:27 a.m., CNA (Certified Nursing Assistant) 6 indicated Resident D frequently wandered into other resident's rooms. During an interview on 6/5/23 at 10:13 a.m., CNA 5 indicated that Resident D did have wandering behaviors and the staff tried to keep him busy. Resident D was currently receiving one-on-one care due to his wandering behaviors. An interview was conducted with Social Services Director 2 on 6/5/23 at 11:13 a.m. She indicated Resident D first resided on the [NAME] unit. He continued to have wandering and disrobing behaviors, so he was sent for a psych stay in early April 2023. After he returned from the psych stay, Resident D did have continued behaviors with intrusively wandering in and out of residents' rooms. Another resident had gotten upset with Resident D's wandering in his room, so it had been decided to transfer Resident D to Mapleton Unit, which is larger and had more space to wander in the common areas. The residents that reside on the Mapleton unit also were less cognitively intact and may not be bothered by Resident D's intrusive wandering. There were some residents that already live on the Mapleton Unit who also had wandering behaviors. One of the residents on Mapleton was upset that Resident D was continuing going in and out of her room. On 5/2/23, he had attempted to go into her room, and she got upset and swatted Resident D in the back of the head after staff redirected Resident D way from the other resident's doorway. It then was decided to transfer Resident D back to the [NAME] Unit. The resident who had previously been upset about Resident D's wandering had been moved off the [NAME] Unit. After Resident D returned to the [NAME] Unit, he did continue to have intrusive wandering behaviors. The staff attempted multiple interventions, but Resident D was very restless. The management staff would assist with taking him off the unit for errands with them or to walk. After the management staff left for the day, the staff on the unit continued to monitor him and provide interventions. On 5/16/23, the CNAs were providing care to another resident and had heard loud voices coming from the room across the hall. The CNAs went into Resident G's room and observed Resident D with a bloody lip while standing at the bedside, and Resident G was in bed. Resident D had wandered into Resident G's room and startled Resident G while he was sleeping. Resident G accidentally hit Resident D on the lip. Resident G was not aggressive, and it was not intentional. Resident D was placed on one-on-one supervision and was currently still receiving one-on-one care. During an interview on 6/5/23 at 2:33 p.m., the Psychiatric Physician indicated that Resident D was a very complex patient. Resident D suffered from 5 mental health issues simultaneously, dementia, depression, obsessive- compulsive disorder, generalized anxiety disorder, and delusions which had started this year. There had been multiple attempts to adjust his medications to an optimal dose and regimen since Resident D had been admitted to the facility. Resident D's behaviors were routine based and predictable. During an interview on 6/5/23 at 2:33 p.m., the DON (Director of Nursing) indicated that when Resident got up from sleeping, he was constantly on the move. Resident D became fixated on certain thing due to his OCD (obsessive - compulsive disorder). 41129 2. The clinical record for Resident B was reviewed on 6/2/23 at 9:48 a.m. Resident B's diagnoses included, but not limited to, anxiety disorder and dementia. Resident B's quarterly MDS (Minimum Data Set) dated 5/17/23 indicated, Resident B was unable to complete the cognitive assessment related to refusal or the resident provided nonsensical answers. Resident B's cognitive pattern was described as fluctuates with inattention and disorganized thinking. Resident B required supervision with set up for locomotion on/off the unit and for walking in the corridors. A nursing note dated 2/1/2023 at 11:51 p.m. indicated, Resident B wandered the unit this evening, entered peers rooms multiple times, wanting to sit/lay down in the beds. Staff redirected to her room and assisted into bed. A nursing note dated 2/3/2023 at 1:33 a.m. indicated, Resident B has been restless this shift, has wandered the unit entering peers rooms multiple times, wanting to sit/lay down in the beds. Staff has redirected to her room and assisted into bed, multiple times. A Behavior Communication Note (recorded as late entry on 2/5/2023 at 6:11 p.m.) dated 2/3/2023 at 6:09 p.m. indicated the following: Date and Time of behavioral expression: 02/03/2023 01:33 AM Location of expression: Mapleton unit Describe the specific behavioral expression: [sic, Resident B's name] has been restless this shift, has wandered the unit entering peers rooms multiple times, wanting to sit/lay down in the beds. Staff has redirected to her room and assisted into bed, multiple times. [sic, Resident B's name] is currently resting in her bed with eyes closed. Interventions attempted: Redirected to her bed Effectiveness of Interventions: somewhat effective Suggestions/Other information: None An IDT (Interdisciplinary Team) note dated 3/15/2023 at 3 p.m. indicated, IDT met for behavior management on this date regarding Resident B and discussed a medication review which was denied related to Resident B remained restless with noted frequent pacing. A nursing note dated 5/28/2023 at 5:31 a.m. indicated, Resident B was found lying on the bed with another female resident in her room at 3.am [sic]. Resident was redirected back to her room. An IDT note dated 5/30/23 at 10:13 a.m. indicated the following: Resident found in bed with another female in the middle of the night. Immediate interventions: Redirected resident back to her room . Potential correlation(s) to root cause: Dementia and anxiety Root cause of behavioral expression: Resident has little stimulation throughout the day. Describe preventative intervention relating to above root cause: Walk client throughout the day Care plan updated and current interventions revised as applicable: Yes The nursing and/or IDT notes did not indicate if Resident B's representative was notified of each occurrence nor the other resident's representatives whose rooms Resident B had entered, sat or whose beds she had lay. Resident B's care plan dated 4/8/22 identified Resident B had a behavior in which they may show increased signs/symptoms of anxiety as evidenced by increased pacing, facial grimacing, dwelling at exits, and repetitive speech. Resident may follow peers around Cottage. Resident has a diagnosis of anxiety. Interventions included, medications per order, offer resident to sit with robotic pet, offer resident a shower to help relieve signs/symptoms of anxiety, and offer books with cats in them or other activities that have cats in them. Resident B's care plan dated 12/8/21 indicated, Resident has a diagnosis of Dementia and was at risk of having altercations with her peers related to: attempts to take food/items that belong to peers, attempts to get in peer's beds at times, and attempts to touch a babydoll that another resident was holding. Interventions added on 6/5/23 included, but not limited to, remove resident from area of peer and redirect to activities of interest i.e., walk, music, watching TV or electronic cat, stuffed bear or baby doll that resident can hold. Resident B's care plan dated 8/31/21 indicated, Resident may intrusively wander at times and look for a place to rest but will also wander in and out of peers' rooms looking for her stuffed cat or laying in their beds. Interventions included, but not limited to, assist resident back to room, assist resident to activity of choice, offer resident snack of choice, offer a shower to help relieve anxiety. An interview with CNA (Certified Nursing Assistant) 7 was conducted on 6/2/23 at 10:03 a.m. CNA 7 indicated, Resident B wanders every night and has been found in other residents' beds. CNA 7 indicated; she was working the night of 5/28/23 when Resident B was found in Resident C's bed. She indicated; she was approached by CNA 8 asking her for assistance with getting Resident B out of Resident C's bed. When she arrived at the room, both residents were sleeping in the same bed, fully clothed. CNA 7 stated, Resident B intrusively wanders into other residents' rooms all the time and seems to have a 'favorite' room which was the first room next to the exit leaving the unit and near the front entrance. She further indicated, Resident B's behaviors of intrusive wandering and lying in peers' beds (occupied and unoccupied) has been getting more frequent. An interview with CNA 8 was conducted on 6/5/23 at 10:05 a.m. CNA 8 indicated; Resident B was an extreme wanderer. She gets into bed with everyone and on 5/28/23 at about 3:30 a.m. she found Resident B in bed with Resident C. She stated both residents were both under the covers and asleep. CNA 8 indicated; she was surprised to see Resident B under the covers because usually she would lay on top of the covers. When she pulled the covers back, she could see both residents were clothed and not touching each other. In fact, they were back-to-back in the bed. She then left the room and got Resident B's aide and the nurse to assist with getting Resident B back to her own room. CNA 8 indicated; Resident B intrusively wanders into everyone's room. She believes Resident B's behaviors are excessive and it was becoming more difficult to get her out of the other residents' beds. CNA 8 indicated she had called the Executive Director (ED) during the night to report the incident because it was strange to me because she was under the covers. An interview with CNA 6 was conducted on 6/2/23 at 10:27 a.m. CNA 6 indicated; she had worked on Mapleton (where Resident B, C, and 10 reside) yesterday. She indicated, there were several residents who wander into other resident's rooms on the unit and Resident B has climbed into bed with other residents. She indicated; Resident B seemed to really like getting into bed with Resident 10. An observation of Resident B was conducted on 6/2/23 at 10:56 a.m. She was observed walking out of Resident 10 and 18's room. Residents 10 and 18's room did not have a stop sign across their door. An interview with DON (Director of Nursing) and ED was conducted on 6/2/23 at 2:15 p.m. DON indicated; they follow the plan of care when it comes to dealing with residents' behaviors. She stated the main goal was to redirect the resident. She indicated when a resident has displayed a behavior, the expectation was for the nurse to place a behavior communication note in the progress notes. When asked how any other staff member such as CNAs would document on behaviors, she indicated, the CNA or other staff member would inform the nurse and the nurse would document the behavior. She indicated; she did not believe residents with dementia who wander into another resident's room was considered intrusive unless an event occurred. When asked how they track the behaviors frequency, the effectiveness of interventions, what interventions were utilized for each resident, she indicated, they review the progress notes daily. The ED indicated, she could see how Resident B's behaviors of wandering into other resident rooms and lying in other residents' beds had been considered her baseline. A Behavior Management policy was provided by ED on 6/2/23 at 11:43 a.m. The policy indicated, to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expressions . 1. Care plans should be initiated for any behavioral expression that is problematic or distressing to the resident, other resident or caregivers. Care plan interventions should .address both proactive and responsive interventions . 3. When a behavioral expression occurs, the staff communicates to the nurse what behavior occurred. The nurse records the behavior in Matrix [sic, their charting system]. 4. If the behavioral expression is new, worsening, or high risk, the nurse will record the behavior using the New/Worsening Behavior Event .New/Worsening behaviors include .b. behaviors that are directed at another resident . c. behaviors that are increasing in either frequency or severity d. Behaviors that have potential for risk to others including sexual advances, intrusive wandering, exit seeking and chronic combativeness with care . 6. Residents with documented behaviors will have a Behavioral Health Monthly Review. This review includes evaluation of behaviors which have occurred that month and that interventions for behavioral expressions are current and effective. This Federal tag relates to Complaint IN00409906. 3.1-37(a)

Based on interview and record review the facility failed to ensure resident to resident sexual abuse did not occur with a resident who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions were not implemented per the plan of care and after a room move post an unusual occurrence involving Resident B and Resident C that later resulted in a resident, (Resident C), having his private parts touched by another resident, (Resident B). The Past Noncompliance Immediate Jeopardy began on 8/26/22. The Facility Administrator, Director of Nursing Service's and the Regional Director of Clinical Service's were notified of the Immediate Jeopardy on September 7, 2022 at 5:04 P.M. The Immediate Jeopardy was removed and corrected on 8/30/22, before entrance into the facility, when the facility completed staff training on abuse and resident identification labels for room changes, following resident-specific behavior care plans, keeping residents separated that are not to be near one another, and ensure staff are acclimated to the unit/assignment they are working if not familiar with the assignment. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: 1a. The clinical record for Resident B was reviewed on 9/7/22 at 1:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 8/1/22, noted Resident B with moderate cognitive impairment. A care plan, dated 5/28/21, was in place for Resident B's history of making sexual comments towards female staff at times. Resident B may also inappropriately touch staff members at times, especially during care interactions. This appeared to exceed during periods of isolation. An approach was to offer to assist resident with calling his wife during the times he was experiencing sexual expressions. A care plan, dated 7/13/21, was in place for Resident B's history of public masturbation at previous facility he resided at. He continued to prefer to masturbate while in his room. A preference care plan, dated 8/30/21, was in place for Resident B's preference to sleep in the nude. A care plan, dated 8/26/22, indicated the following, .Resident may at times attempt to assist roommate when he perceives roommate needing help aeb [as evidenced by] roommate moaning or yelling out. Res [Resident] has contributing dx [diagnosis] of dementia and may forget at times to ask staff for assistance when needed for him or peer. This puts res at risk for peer to peer incidents .Approach .increased supervision as needed .room move occurred to allow res more privacy and less worry about roommate's condition A psychiatric progress note, dated 8/31/22, noted a Mental Status Examination that indicated the following for Resident B, .Alert and oriented x2 .oriented to person and situation .THOUGHTS: Disorganized at times .MEMORY: Immediate memory is poor. Recent memory and remote memory, depending on what you talk about, are normal .IMMEDIATE: He is unable to perform digit recall .INSIGHT/JUDGEMENT: His insight & judgement is obviously poor because he just does not anticipate any consequences whatsoever A progress note, dated 8/23/22 at 2:13 p.m., indicated Resident B was sitting in the doorway with no clothing on and asking staff for sexual favors. A progress note, dated 8/25/22 at 1:38 p.m., indicated Resident B was attempting to touch female activity staff twice. A progress note, dated 8/25/22 at 1:45 p.m., indicated Resident B grabbed a female staff member breast. Resident B apologized and stated he was just kidding. 1b. The clinical record for Resident C was reviewed on 9/7/22 at 1:45 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 8/2/22, noted Resident C with severe cognitive impairment. A physician note, dated 5/3/22, indicated the following, .Physical Exam .Psychiatric .Insight: poor insight .Mental Status: confused, anxious, agitated, and abnormal affect. Orientation: not oriented to time, place, and person. Memory: recent memory abnormal and remote memory abnormal The investigative file was reviewed for an incident involving Resident B and Resident C on 8/26/22 at 12:20 p.m. It indicated Personal Care Assistant (PCA) 10 observed Resident B standing up, naked from his wheelchair, next to Resident C's bed with his arm above Resident C's body, but not touching him. The Interdisciplinary Team (IDT) determined the root cause was Resident B was checking on roommate but was not dressed appropriately. Intervention put in place was for Resident C to move back into his original room since his isolation period was complete, place Resident B on 15-minute checks, signed Resident B for counseling services to create social boundaries, and STAT (right away) lab work to be completed. An interview conducted with PCA 10, on 9/7/22 at 1:13 p.m., indicated she was working day shift on 8/26/22 with Resident B and Resident C. She walked into the room and observed Resident B over Resident C. Resident C's brief was pulled over and looked different from when she observed him previously. She wasn't sure what Resident B was doing and proceeded to call his name and Resident B pulled away from Resident C in his wheelchair. There was no physical contact. Resident B's hand was over Resident C's abdomen/hip area while Resident C was asleep. PCA 10 was told that Resident C was supposed to be put in another room but was still in their wheelchair in the dining room when she completed her shift at 2:00 p.m. The clinical record noted Resident C was moved to another room on 8/26/22 at 5:28 p.m. Another incident reported to the Indiana State Department of Health Survey Report System, dated 8/26/22 at 9:15 p.m., indicated staff entered Resident B's room and observed Resident B making inappropriate contact with Resident C. A written statement, dated 8/26/22 at 9:25 p.m., was written by Certified Nursing Assistant (CNA) 12. The statement indicated the following, .I came out of a patients room after providing care and saw [Resident B's room number] call light on. I went to go get the call light and I saw [name of Resident B] touching [name of Resident C's] penis. I asked [name of Resident B] what was he doing, he replied that he [Resident C] was gurgling and got up to help him. An interview conducted with CNA 12, on 9/7/22 at 1:01 p.m., indicated she went to answer the call light that was on in Resident B's room and observed Resident B physically touching Resident C's private area. CNA 12 asked Resident B what he was doing, and he responded that Resident C was choking, and he wanted to check on him. Resident B then proceeded to masturbate there in the room naked. Resident C was still residing in the room with Resident B at the time of the incident. Resident C went into a room across the hallway after the incident but was in the room with Resident B while she was on shift from 6:00 p.m. until the incident occurred. CNA 12 commented on how she was not usually scheduled to work on the unit where Resident B and Resident C reside, and she wasn't sure what a normal behavior was over on that unit. Resident C was located inside Resident B's room during the time CNA 12 was on shift from 6:00 p.m. until the incident occurred involving Resident B touching Resident C's private area at 9:15 p.m. Resident B neither Resident C had an assessment completed for their capacity to consent to sexual interactions An interview conducted with the Executive Director (ED), on 9/7/22 at 3:25 p.m., indicated there was education conducted on abuse and room moves. The staff moved Resident C back to his original room due to his isolation period being completed for COVID-19. The only item that wasn't done was the nametag off of Resident C's door from when he was in the room with Resident B. The policy titled Abuse Prohibition, Reporting, and Investigation, revised February 2020, was provided by the Executive Director (ED) on 9/7/22 at 12:08 p.m. The policy indicated the following, .to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .Sexual Abuse- Nonconsensual sexual contact of any type. Examples may include but not be limited to fondling, touching, rubbing, exposing, licking, kissing, gestures, sharing pornography, assault, rape, harassment, seduction, coercion, photographing a resident's rectal, genital, or breast areas, and/or exhibitionism .Investigation .Resident to Resident abuse .2. Staff member(s) will maintain the resident initiating the abuse under direct supervision until the initial investigation is complete and resident safety is maintained .c. Room changes may be necessary if residents are roommates The Past Noncompliance Immediate Jeopardy began on 8/26/22. The Immediate Jeopardy was removed and corrected on 8/30/22, before entrance into the facility, when the facility completed staff training on abuse and resident identification labels for room changes, following resident-specific behavior care plans, keeping residents separated that are not to be near one another, and ensure staff are acclimated to the unit/assignment they are working if not familiar with the assignment. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal Tag relates to Complaint IN 336. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse regarding placement of a newly admitted resident with a history of physical aggression into a room with a resident with a history of invading peers' personal space, resulting in emotional distress and an ER (emergency room ) visit with contusion of the occipital region of the scalp for 1 of 2 residents reviewed for abuse. (Resident J) Findings include: 1. The clinical record for Resident J was reviewed on 6/21/22 at 3:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on a secured, all male unit of the facility. The 8/13/21 care plan read, Resident will attempt to leave an environment d/t [due to] over stimulation and invade peers personal space d/t lack of spacial awareness secondary to dementia dx [diagnosis.] Resident may become verbally agitated when peers attempt to ask resident not to do this secondary to cognitive communication deficit. This puts resident at higher risk for resident to resident altercations. The goal was for him to have no negative interactions with peers. The 9/14/20 anxiety care plan, last revised 5/16/22, indicated an approach was to maintain a calm environment. The 1/28/20 behavior care plan, last revised 5/16/22, indicated he would intrusively wander into peers rooms. The 2/18/20 behavior care plan, last revised 5/16/22, indicated he would at times become agitated with staff during attempts to redirect as evidenced by attempting to throw a walker and yelling. 2. The clinical record for Resident H was reviewed on 6/21/22 at 2:58 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the facility on [DATE] at 2:09 p.m. from the behavioral unit of an out of state hospital. He was admitted into a room with Resident J. The 12/28/21 to 1/18/22 hospital behavioral unit records indicated he was brought into the hospital by his daughter with chief complaints of behavioral disturbances. He had been hallucinating, seeing people around the home. There was also a question that he had been a little bit aggressive with his daughter and there was concern for safety. The 12/30/21 Inpatient Consult to Neuropsychology note read, referred by his psychiatry resident [name of psychiatry resident] for a neuropsychological assessment while on the Senior Behavioral Health Unit due to concerns of memory decline, increased falls, and recent onset hallucinations to assist with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per chart review he was brought to the ED [emergency department] on 12/27/2021 via EMS [emergency medical services] with his daughter due to increased confusion and hallucinations. She had reported [name of Resident H] had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She noted changes in his cognition over the past 6 months which is worsened with behaviors in the last 6 weeks. She noted that he had been hallucinating cats and people in their home. She identified that he has been wandering at home She stated that he also recently lunged at her with his cane believing there were 5 men in the house He stated that he is blind in his left eye following a surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . He endorsed consuming a six pack a day; however, his daughter had noted that he may have been drinking 12 beers daily at minimum. He endorsed experiencing 'a little depression' but felt that it was not significant. He denied suicidal ideation. His daughter had noted history of physical aggression as he was verbally abusive to her and his wife. She also identified that he had sexually abused her during childhood. The daily progress notes from the behavioral health unit indicated Resident H was not stable for discharge at this time and continued to meet criteria for inpatient psychiatric admission due to poor impulse control placed him at imminent risk of harm to self or others. The last daily progress note to indicate this was dated 1/18/22. There were no hospital notes between 1/19/22 and 1/27/22 in the clinical record. During an interview with SSD (Social Services Director) 3 on 6/23/22 at 9:44 a.m., he indicated he was uncertain of Resident H's whereabouts between 1/19/22 and 1/27/22, whether he was discharged from the hospital and sent to an ECF (extended care facility,) remained in the hospital, or otherwise. The 1/28/22 to 2/7/22 hospital discharge notes indicated he was being discharged to the facility on [DATE]. Resident H's 2/7/22 baseline care plans indicated he had short and long term memory deficit with impaired decision making ability; was at risk for elopement; resided on a secured memory care unit related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no care plan specifically addressing his behavioral disturbance. Resident H's 2/7/22, 3:23 p.m. nurse's note, written by LPN (Licensed Practical Nurse) 4, indicated he arrived to the facility via stretcher. His daughter was currently at the facility. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was pleasant, alert, and oriented with forgetfulness. Per his daughter, he was blind in his right eye and deaf in his right ear. Resident H's 2/7/22, 3:29 p.m. social services note, written by SSD 3, indicated he was admitted from the hospital where he was receiving mental health treatment related to changes in his mood and behavior in the home. He previously resided in the community with the assistance of family. He had a pending legal guardian. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident H's 2/7/22, 5:15 p.m. nurses note, written by LPN 4, indicated he was found on the floor, sitting on his buttocks. He denied any complaints of pain or discomfort. His neurological checks and vital signs were within normal limits. There were no injuries noted at the time. The physician and daughter were notified. Resident H's 2/7/22, 6:20 p.m. nurses note, written by LPN 4, indicated the CNA (Certified Nursing Assistant) informed her that Resident H and his roommate, Resident J, were on the floor and Resident H was hitting Resident J with his cane several times. The cane was immediately removed by the CNA. Resident H then began punching Resident J. Resident J was immediately separated from Resident H. Resident H was aggressive and refused to be separated. The ED (Executive Director,) DON (Director of Nursing,) physician, and Resident H's daughter were all notified. The physician ordered Resident H to be sent to the ER (emergency room ) for evaluation and treatment. Resident H's 2/7/22, 8:09 p.m. nurses note, written by LPN 2, read, resident told ambulance personnel that other resident was a burglar and was breaking into HIS house. The investigative file into the 2/7/22 incident between Resident H and Resident J was provided by the ED on 6/21/22 at 3:20 p.m. The investigative file included a 2/7/22 written statement from CNA 5. It read, I entered the unit @ 6:20 p.m. on Monday Feb [February] 7, 2022 and witnessed resident hitting the roommate with his [NAME] [sic] several times. I immediately took the cane away and resident started hitting with his fist. I yelled for help and was assisted by staff to remove the injured resident from situation. An interview was conducted with CNA 5 on 6/22/22 at 11:13 a.m. She indicated she was walking down the hallway and could hear Resident J yelling out. She entered the room and observed Resident H hitting Resident J with his cane several times. Both residents were on the floor. Resident J was crying, shaky, and very upset. She was able to take the cane away and the 2 residents were separated. No one at the facility informed her about Resident H's previous physically aggressive behaviors. She would have wanted to know, so she knew how to approach him. She was only informed if a resident was incontinent, could ambulate, stuff like that. She didn't find out about behaviors until an incident happened. She was never told he came from a psyche place. If other staff knew he was physically aggressive, she didn't understand why he was placed in a room with another resident. The investigative file included a 2/7/22 written statement from LPN 2. It read, I was on [name of other unit] nursing station. I heard help. Myself and the nurse on [all male unit where Residents H and J resided] ran down the hall. I saw [name of Resident J] on the floor and [name of Resident H] on the floor. [Name of Resident H] was waiving his fist and a [NAME] [sic] trying to hit [name of Resident J] with the [NAME] [sic.] We separated the 2 men. [Name of Resident J] had injuries to face/head. [Name of Resident J] was placed in dining area. [Name of Resident H] left in room. [Name of Resident H] stated this was 'HIS' room and [Name of Resident J] needed to get out. 911 was called for [name of Resident J] for injuries. An interview was conducted with LPN 2 on 6/22/22 at 11:25 a.m. She indicated she heard staff calling for assistance. When she got to Resident H's and J's room, Resident H and Resident J were both on the floor on their sides. Resident H was waiving his cane, trying to hit Resident J. She did not witness contact, just attempts at contact, but Resident J had a bump on his face, so she could tell there was contact. Resident H was saying he wanted it be only his room and 'this man is in my room.' They got the cane away from Resident H and explained to him that it was Resident J's room too. They did not foresee this incident occurring. Resident J was quiet, passive, and cooperative, in her opinion, but she did not work that particular unit a lot. After the incident, Resident J was very sensitive, cried, and was saying he got beat up. LPN 2 reassured him, and informed him he would be going to the ER. Resident J was bleeding from his head, and she thought he had cuts to his head. As far as new admissions, they just received a resident's standard intake form, their likes and dislikes. She was unaware Resident H had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . All staff anticipated behaviors, as they have a constant eye. She remembered when Resident H arrived at the facility, and he seemed okay. She was uncertain why or how they became roommates, and didn't know the dynamics of admissions. She thought IDT (interdisciplinary team) decided that. Resident J did not mind having roommates in the past. The ER notes for Resident J indicated he arrived on 2/7/22 at 6:59 p.m. and discharged on [DATE] at 2:33 a.m. The notes read, Type of Assault: Physical Assault .Location of Assault: Patient reports the incident occurred in his room at the ECF where he lives, [room, bed, name and address of facility.] Assailant Description: Assailant described as 'my new roommate, who hasn't been there for very long yet. He is about [specific description,] who walks with a cane. Patient reports that he does not know the assailant's name .Patient Narrative: Patient states 'I was standing in my room and was telling this guy to get out of my room. He wouldn't leave. I threatened to beat him if he didn't leave. I thought hw [sic] was going to steal something the way he was acting. I guess he was my new roommate. That is what they told me. I turned my back on him and turned back around when he poked me in the face with the end of his cane. Then he hit me on the back of my head with the long part of the cane. I fell down on my hands and knees to try to crawl away from him. I guess he stopped and left the room when he decided that I was no longer a threat to him. The back of my head hurts now. I just don't want him to be in my room when I get home and want to press charges against him.' .Patient report 8/10 headache, 8/10 'lump' on back of head, and 'seeing spots' since the incident Patient's ECF [name and title of facility nurse] reports that the assailant has been moved to another empty room so patient will have his own room when he returns to the ECF. Per [name of facility nurse] patient has a history of dementia and is often argumentative with other ECF residents and staff members. The 2/7/22 ER After Visit Summary for Resident J indicated the reason for his visit was a headache and assault victim. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/7/22 ER notes for Resident H indicated pt [patient] was just admitted to [name of facility] today. ECF staff found pt on [sic] physical altercation with his new potential roommate. Pt thought he was 'trying to steal from him.' Patient was not hurt during this altercation Facility is refusing to take pt back 2/2 [secondary to] feeling unsafe. An interview was conducted with SSD 3 on 6/22/22 at 1:30 p.m. in regards to how it was determined Resident H and Resident J would be roommates. He indicated they discussed new admissions and roommates during IDT meetings. Resident J was verbalizing he wanted a roommate. They were actively looking for someone to room with him, and Resident H was the next admission to Resident J's unit, so he became his roommate. SSD 3 knew of Resident H's history of physical aggression. He was informed the aggression was at home, prior to his hospitalization , and had been sober for 60 days prior to admitting to the facility. An interview was conducted with SSD 3 on 6/23/22 at 9:44 a.m. He indicated the previous DON (Director of Nursing,) the other facility SSD, the ED, and he all would have known about Resident H's history of physically aggressive behaviors. He was uncertain what information about that was given to nursing staff on the unit. On 6/23/22 at 9:56 a.m., an interview was conducted with DON 8, the facility's previous DON when the 2/7/22 incident occurred. She indicated Resident H just admitted to the facility, and was placed on the all male unit of the facility, because he had issues with his daughter, but was unsure exactly what those issues were. They thought he would be fine residing on that unit. Resident H fell after his family left, and then was in the room with Resident J, who came in a bit later. Resident H thought Resident J was coming in to steal his stuff. She didn't recall if she actually read resident H's referral, or if it was brought up in morning meeting. She only recalled he was physically aggressive with his daughter. She did not communicate that information to nursing staff on the floor. Normally, they would give the nursing staff on the floor a heads up, just in case that specific family member came in to visit. In this case, they thought it was all about the daughter. They didn't know anything about him being aggressive towards anyone else. They didn't get very much information on him before he came. It was a bit more of a surprise that the incident happened. The 2/8/22 IDT note read, Res [Resident] noted to have made contact with peer using his cane and his fists .Res is at risk for psychosocial distress due to change of environment, family participation, change in mental and physical status. Res has dx [diagnosis] of dementia. Res has hx of psychotic symptoms such as VH [visual hallucinations] and delusions. Res new to this facility. admitted on [DATE] -res was in facility approx [approximately] 4.5 hrs [hours.] Res is new to long term care placement. Res was previously living alone in the community. Root cause of behavioral expression: delusions and new to facility. An interview and observation was conducted with Resident J on 6/23/22 at 11:45 a.m. He was lying bed, holding a robotic cat. He did not currently have a roommate. He indicated he did not want a roommate, because they tend to complain about everything. He did not recall the incident with Resident H. The 5/12/22 Annual MDS (Minimum Data Set) Assessment indicated Resident J had a BIMS (brief interview for mental status) score of 3, indicating he was severely cognitively impaired. The Abuse Prohibition, Reporting and Investigation policy was provided by the ED (Executive Director) on 6/22/22 at 9:15 a.m. It read, It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion [Name of facility] will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents, consultants, volunteers, staff or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals Definitions/Examples of Abuse: Willful used in the definition of abuse means the individual must have acted deliberately, not that the individual intended to inflict injury or harm Physical Abuse - A willful act against a resident by another resident, staff member, or other individual (s). Examples may include but not be limited to hitting, beating, slapping, punching, shoving, striking with an object, pulling, twisting, squeezing, pinching, scratching, tripping, biting, burning, rough treatment and use of improper restraints Mental Abuse -Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. This includes any episode of staff to resident; and resident to resident, if it appears to be willfully directed to a specific resident. Examples of mental abuse include but not limited to: Harassing a resident. Mocking, insulting, ridiculing. Yelling or hovering over a resident, with the intent to intimidate . This Federal Tag relates to Complaint IN 427. 3.1-27(a)(1)

Based on observation, interview and record review the facility failed to ensure verbal, physical and sexual abuse resident to resident sexual, physical, and verbal abuse did not occur with a repeated occurrences for 12 of 12 cognitively impaired residents. Interventions were not put into place to prevent occurrences. Using the reasonable person concept, it is likely that this would lead to chronic or recurrent fear and anxiety. (Residents C, E, B, F, D,. G, H, J, L, O, FF, EE). The Immediate Jeopardy began on 7/25/2019 and when Resident [NAME] verbally and physically abused Resident C and repeated occurrences occurred The Executive Director, Director of Nursing Services, Registered Nurse Senior Director of Clinical Services, and Director of Social and Behavioral Wellness were notified of the Immediate Jeopardy on 11/1/2019 at 5:20 p.m. The Immediate Jeopardy was removed on 11/4/2019, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The clinical record for Resident C was reviewed on 10/30/19 at 11:30 a.m. The [DIAGNOSES REDACTED]. Resident C was admitted to the facility on [DATE]. The 8/1/19 Admission Minimum Data Set (MDS) assessment for Resident C indicated a Brief Interview for Mental Status (BIMS) assessment was conducted, and she was severely impaired. A care plan dated 7/27/19 indicated .Resident (C) is a new admission to the facility and requires implementation of services to promote physical, emotional, and psychosocial wellbeing r/t (related to) dementia, adjustment to new facility, intrusive wandering, cancer dx (diagnosis) Approach .start date 7/27/19 Behavior interventions: resident is one on one supervision r/t communal living and intrusive wandering . A care plan dated 7/26/19 indicated Resident (C) has a dx of Dementia .Resident has severe impairment and intrusively wanders into peers room and get into their beds. Resident is at risk of altercation with peers due to wandering. Resident wanders the unit and intrusively roams in/out of peers rooms. Resident walks/paces aimlessly without known purpose and is not necessarily looking for her room or in need of assistance/personal need, although she does have a door identifier with her picture on it to help her identify her room easier if needed. Resident is noted to walk around the unit and pick up items and rearrange them or move them, likes to fidget with things. Resident is non-compliant in participating in 1:1 activities, therapeutic, and structured work activities. Resident is nonsensical and cannot express her thoughts. Resident has delayed response time and thought processes is delayed .Goal .Ensure the safety and wellbeing of resident and her peers .Approach start date 9/11/19 .intrusive wanderer .monitor resident whereabouts .assess for unmet needs: hunger/thirst, toileting needs, over/under stimulation, needing rest, etc .Walk with resident on or off Cottage .start date 9/4/19 Assist resident with dispensing of her food or drink appropriately .start date 9/3/19 Care plan to discuss transitioning resident to appropriate cottage for needs now and then as needed .start date 9/3/19 ST (therapy) to complete Dementia staging now and then per policy .start date 8/2/19 provide resident with a body pillow and utilize while she is in bed .start date 7/31/19 assist resident back to room and put TV on (name of channel) or (name of channel), her fav (favorite) channels per the family .start date 7/26/19 Provide resident with one on one attention . The clinical record for Resident [NAME] was reviewed on 10/30/19 at 10:30 a.m. The [DIAGNOSES REDACTED]. The 9/14/19 Quarterly MDS assessment for Resident [NAME] indicated he was moderately impaired. Resident E's functional status was supervision and no assistance device used for walking. A care plan dated 8/26/19 indicated Resident (E) can be verbally aggressive with peers when they enter into his room uninvited. Resident will curse at peers when he is telling them to leave room. Approach .start date 8/26/19. Allow resident to vent to staff but in a setting without peers being subject to frustration. Encourage resident to use call light to signal for help. Provide resident with reassurance and support. Remove peers from area Stop sign place on door help divert others from entering room uninvited . A care plan dated 12/28/15 was last reviewed on 10/2/19 for Resident E. It indicated Resident (E) displaying signs and symptoms of mood distress as evidenced by finding little interest or pleasure in doing things. has dx of persistent mood disorder. Resident prefers to stay in his room most of the time and does not wish to interact/socialize with others .Approach .start date 12/28/15 Acknowledge to the resident that the current situation must be difficult. Encourage resident to verbalize feelings, concerns, fears, etc. Clarify misconceptions. Establish a trusting, relationship with the resident. Explore with resident past effective and ineffective coping mechanisms. Identify relationships that resident could draw on . A care plan dated 6/30/14 and was last reviewed 10/2/19 indicated Behavioral Symptoms. Resident (E) has a hx (history) of being bothered by wanderers. Resident can become physically aggressive .Goal .Resident will not exhibit agitation towards others when they wander into his room .Approach .start date 8/21/19 stop sign placed across door to divert uninvited guest .start date 7/25/17. staff will close resident?s (sic) door as he tolerates .start date 8/12/14 .Offer time for resident to voice his frustrations; offer support and reassurances . An interview was conducted with Family Member 32 on 10/30/19 at 10:27 a.m. She indicated Resident C had been abused by another resident in the past. Resident C was pushed down by another resident causing a back fracture. Since the incident, she had been moved to another unit. 1.a. An incident report dated 7/25/19 indicated .Brief Description of Incident: Description added -- 7/25/19 .At approximately 9:10 pm (sic) a CNA reported to the Executive Director a resident to resident altercation between (Resident E) and (Resident C). The CNA reported (Resident C) had ambulated into (Resident E)'s room. (Resident E) made contact with (Resident C) in attempt to get out of his room. The CNA immediately separated the residents and re-directed (Resident C) out of (Resident E)'s room .Immediate Action Taken .7/25/19. The residents were immediately separated by nursing staff. The charge nurse completed a head to toe skin assessment on each resident with no injuries noted. (Resident C) was placed on direct supervision and re-directed to an activity .(Resident C) will remain on 1:1 supervision .Follow up: (Resident C) will be re-directed from (Resident E)'s room and provided an activity as needed to prevent further altercation . A statement written by CNA 25 indicated I was in the room (Resident E)'s changing (name of Resident E's roommate) putting him to bed. (Resident C) walked in behind me and I did not know, behind the curtain he (Resident E) instantly got angry & hit her (Resident C) I heard the hit so I know it was not a punch. She (Resident C) hit back & Resident (E) grabbed her then I got in the middle and exited her out of the room . The IDT Review for Resident [NAME] dated 7/26/19 indicated .contribute to the Root Cause or trigger of the behavioral expression .Resident has impaired cognition and decision making skills. Resident (E) is territorial over his space. Root Cause of behavioral expression .Resident (E) was provoked when peer entered room uninvited and did not leave when asked by peer .Interventions. resident (E) has stop sign on door. The IDT Review for Resident C dated 7/26/19 indicated .interventions: At this time resident will remain on a one on one . An IDT review for Resident C dated 8/2/19 indicated .interventions: .setting up care plan to discuss resident being moved to Mapleton due to level of care and cognition. Will also utilize body pillow to see if that provides comfort to resident . Resident C's progress notes indicated 1 on 1 supervision and 15 minute safety checks had stopped on 7/29/19. 1.b. An incident report dated 8/15/19 indicated .Brief Description of Incident: Description added -- At approximately 7:21 p.m., the charge nurse reported to Executive Director a resident to resident altercation between (Resident C) and (Resident E). The charge nurse reported (Resident C) followed a CNA into (Resident E)'s room. Staff were unable to re-direct (Resident C) out of (Resident E)'s before (Resident E) made contact with (Resident C). Nursing immediately separated the residents and re-directed (Resident C) to an activity .Follow up .A stop sign was placed outside (Resident E)'s room to provide a visual identifier . In the file, a Behavior Event form for Resident [NAME] indicated .8/15/19 at 7:00 p.m .CNA was in room providing care to res (Resident E)'s roommate. CNA turned and saw this res (Resident E) choke (Resident C). CNA immediately intervened, separating the 2 res. When asked (Resident E) why he choked res (Resident C), he stated 'She came in my muthaf---in room'. Nursing informed res not to put his hand on other residents. Interventions put in place for Resident [NAME] after the incident was place door closure during all res care. A written statement by CNA 26 indicated I (CNA 26) was giving care to (Resident E's roommate) when the incident happened (sic). (Resident E) chocked a resident because she came into his room. Immediately separated the two for (sic) each other A Behavior Event form for Resident C dated 8/15/19 indicated interventions put in place for Resident C after incident was 15 min checks, 1 to 1 supervision. Resident C's clinical record indicated documented 1 on 1 supervision until 8/15/19 and then placed on 15 minute safety checks until 8/17/19. 1.c. An incident report dated 8/22/19 indicated .Brief Description of Incident: Description added -- At approximately 2:30 p.m. nursing staff overheard a verbal resident to resident altercation involving (Resident E) and (Resident C). Staff reported (Resident E) cursed at (Resident C) for entering his room. The nursing immediately separated the two residents and re-directed them to an activity .Immediate Action .(Resident C) was placed on direct supervision .Follow up The charge nurse completed a head to toe skin assessment on both residents with no injuries noted. (Resident C) was placed on 15 minute safety checks .A stop sign was placed outside (Resident E)'s room to provide a visual reminder for (Resident C) . A Behavior Event form for Resident [NAME] indicated Description: Verbal Aggression .8/22/19 at 3:00 p.m. peer came into resident room and resident became upset and began to yell and curse at peer stating get the h--- out of my room now .removed peer from room .stop sign rehung at residents door . A Behavior Event form for Resident C indicated interventions in place to prevent another behavior continue to redirect resident. A written statement dated 8/22/19 by CNA 27 indicated I (CNA 27) heard someone yell I looked over to see (Resident E) pushing (Resident C) out of his room. (Resident E) pushed her into the double door it happened within seconds. I wasn't fast enough to stop the pushing but I did get (Resident C) safe and tried to calm (Resident E) down . A nursing progress note for Resident [NAME] dated 8/22/19 indicated .This nurse went into ask resident what happened and resident stated 'That woman just ripped that thing down (stop sign) and came in here and I cussed her out and told her to get out', when asked did he push resident out of room resident stated 'No I did not touch her I swear I didn't I just cussed her out and told her to get out that's it . An IDT review for Resident [NAME] dated 8/23/19 indicated .Root cause of behavioral .Resident was provoked by peer (Resident C) entering into room uninvited. Resident curse when peer did not leave when she was asked the first time .Interventions .to ensure stoop (sic) (stop) sign is on door and redirect from room. An IDT review for Resident C dated 8/23/19 indicated .Interventions: .Stop signs have been placed on peers rooms that may provoke agitation. Staff will cont. to ambulate with peer when she is being invasive. Have discussed with (family) resident transitioning to another cottage that wandering would not be intrusive. Due to cognition resident requires redirection . Resident C's clinical record did not include documented 1 on 1 supervision or 15 minute safety checks. 1.d. An incident report dated 8/31/19 indicated .Brief Description of Incident: Description added --8/31/19 (Resident E) had entered his room and (Resident C) entered behind him. (Resident E) turned around and made contact with her causing her to fall backwards .Follow up: 9/5/19 The residents were immediately separated by nursing staff and re-directed to an activity. The charge nurse completed a head to toe assessment on residents with no injuries noted. (Resident C) was placed on direct supervision. (Resident E) was placed on 15 minute checks .A stop sign will remain outside (Resident E)'s room to help with visual reminders. (Resident C) was moved to a different cottage . A Behavior Event form for Resident [NAME] indicated .Description Res (Resident) to Res .progress notes: 9/1/19 Res returned from LOA (leave of absence) with (family member), res was waited by nurse for his medications, after receiving his medication, res decided to return to his room. While res was walking into his room, another res wandered in his room, and this res pushed her out, making her land on the floor. When asked why he pushed the other res, this res stated 'she came in my room' . A skin assessment dated [DATE] for Resident C indicated No bruises bumps c/o (complaints of) back pain A written statement from Certified Nursing Assistant (CNA) 28 dated 8/31/19 indicated I (CNA 28) was coming down the hall to dump trash and I heard a commotion I looked and saw a woman (Resident C) laying down on the floor, and there were a few residents standing around her. I did not see what happened. A written statement from Nurse Aide 29 dated 8/31/19 indicated I didn't see what happened but I heard the two yelling. I did see when she was falling. A written statement from License Practical Nurse (LPN) 30 dated 8/31/19 indicated I did not hear or see anything I was notified by the CNA that Resident (E) had pushed Resident (C) out of his room where she landed on the floor. A progress note documented by LPN 30 dated 8/31/19 indicated .When the writer approached the scene, this resident was lying on the floor. Vitals were taken and were WNL (within normal limits), res was able to move all extremities. No bruising or injuries noted at this time, however res did c/o (complaints of) back pain. PRN (as needed) tylenol given at 8pm (sic). Will cont to monitor. Res was placed on 1:1 from time of incident until 2am, at that time she will be placed on 15 minute safety checks . A Interdisciplinary Team (IDT) fall review dated 9/2/19 indicated .un-witnessed fall on 8/31/19 at 7:45 p.m. Resident (C) was noted sitting on bottom in the hallway .Resident did have complaints of back pain. MD was notified and orders was received for Tylenol and a X-ray of back .X-ray indicated L2 compression deformity, and indicated a MRI for further evaluation .Upon interview with resident she was unable to state how fall occurred. Upon interview with staff they heard commotion and then noted resident was sitting on the floor. Root cause: wandering, Immediate interventions: assessed, and assisted to chair. Resident was placed on direct supervision .Intervention put in place: resident (C) will be moved to a more appropriate unit .Evaluation notes: Res (Resident E) does not like personal space invaded. Interventions in place. A Radiology report for Resident C dated 9/1/19 indicated .Reason: low back pain .Results: there is a mild L2 (lumbar) superior endplate compression deformity. A Magnetic Resonance Imaging (MRI) for Resident C dated 9/6/19 indicated study date 9/6/19 final date - exam: lumbar spine without contrast. Indication: Pain, unspecified pt (patient) pushed down a few days ago at facility with low back pain since. 2. Compression fracture involving the superior endplate of L1 with approximately 25% height loss. There is mild retropulsion of bone fragments in additional to abnormal signal in the ventral [MEDICATION NAME] hematoma which contributes to moderate to severe spinal canal stenosis. The associated bone marrow [MEDICAL CONDITION] is compatible with a relatively recent injury .electronic signed 9/9/19. An interview was conducted with LPN 30 on 11/1/19 at 10:13 a.m. She indicated she had not witnessed Resident [NAME] pushing Resident C and neither did NA 29, but the way she was coming out of that room what else could have happened if he did not push her. Resident C's clinical record did not have documented 1 on 1 supervision or 15 minute safety checks after 8/31/19. Interviews were conducted with Executive Director (ED), Director of Nursing Services (DNS), Nurse Consultant (NC)1, Assisted Director of Nursing (ADNS), Social Services Director (SSD) 1 and SSD 2 on 11/1/19 at 10:13 a.m. ED, DNS and SSD 1 indicated Resident C was moved from Meridian [NAME]s Cottage to Mapleton Cottage due to her intrusive wandering behaviors. Resident C was not appropriate for the Meridian [NAME]s Cottage. The intrusive wandering was daily and was occurring depending on the day, on all shifts. Family had been consulted that Resident C needed to be moved to a more appropriate unit. SSD 1 stated the first discussion with the family was on 8/2/19, and the discussions continued until she moved on 9/5/19 with the family's agreement. The DNS indicated the first incident occurred between the two residents the day Resident C was admitted . A paper stop sign was placed on Resident E's door and medication changes were made for Resident C. Resident C was placed on 1 on 1 supervision until 7/29/19. After 7/29/19, Resident C continued to intrusively wander in and out of peers rooms daily. The interventions that were in place after the 8/15/19 incident for Resident C were chairs placed in the hallway for her to sit, re-direction, transition to another unit was discussed, redirect to an activity, staff was to ambulate with her when noticed intrusive behavior, medication time changes and as of 8/21/19, a stop sign that went across the door frame was placed on Resident E's door. After the incident with Resident [NAME] on 8/22/19, Resident C was placed on 1 on 1 supervision only for that day. Resident E's interventions in place after the incidents were focused on to keep Resident C from entering his room. Resident [NAME] did see psych after the 8/31/19 incident. The ED indicated he had reviewed the video cameras after the 8/31/19 incident. He observed Resident E's hand moving in an up and down motion while Resident C was falling out of his door. SSD 1 indicated Resident [NAME] reported he guided Resident C out of the room. Resident C and Resident E's rooms were close in proximity, but it was not considered to move Resident C to a different room on the unit. The focus was to move her to the appropriate cottage. DNS indicated there was no staff documentation 1 on 1 supervision or 15 minute checks were conducted after the 8/31/19 progress note. The staff should have been documenting if Resident C was on 1 on 1 supervision or 15 minute safety checks on every shift. They had not been doing that. One on one supervision meant a staff person should have been with her at all times. ED indicated if the staff observed Resident C intrusively wandering staff was to provide one on one attention per the plan of care. 2. The investigative file for a 9/5/19 incident regarding Resident B inappropriately sexually touching Resident F was provided by the ED (Executive Director) on 10/31/19 at 1:05 p.m. The clinical record for Resident F was reviewed on 10/31/19 at 1:02 p.m. The [DIAGNOSES REDACTED]. She began receiving hospice services, effective 5/7/19. The 9/19/19 Quarterly MDS assessment indicated Resident F required extensive assistance of one person for ambulation on and off the unit, and had no BIMS score as she was rarely or never understood. Observations of Resident F were made on 11/1/19 at 2:20 p.m. and 11/2/19 at 10:42 a.m. She was lying in bed with her eyes closed, during both observations. The clinical record for Resident B was reviewed on 10/31/19 1:00 p.m. The [DIAGNOSES REDACTED]. He admitted to an all-male unit of the facility on 7/19/18, but was moved to the Chatham Unit of the facility on 6/27/19. The 9/4/19 Quarterly MDS assessment indicated Resident B required extensive assistance of one person for ambulation on and off the unit, and had a BIMS (brief interview for mental status) score of 4 indicating severe cognitive impairment. The behavior care plan, effective 7/19/18, indicated Resident B would sometimes make sexually inappropriate gestures. The goal was for him not to display inappropriate behaviors. The interventions were to redirect him with conversation about his work history, family, and past hobbies. Provide space and approach him at another time. Redirect him to other activities such as spiritual programs. The investigative file included a 9/11/19 follow up reportable. It read, 9/5/19 At approximately 9:30 am (name of Certified Nursing Assistant-CNA 7), CNA observed (name of Resident B) touching the breast and groin area of (name of Resident F) as they were sitting next to each other in the common area. (Name of CNA 7) stated she separated the two residents and reported the altercation (sic) the Charge Nurse. The altercation was then reported to the Executive Director. (Name of Resident B) was placed on direct supervision. (Name of CNA 7). The investigative file included a 9/5/19 written statement from CNA 8. It read, On 8/31/19 I (name of CNA 8) witnessed (name of Resident B) touch (name of Resident F's) private area. I reported it to my charge nurse immediately and removed resident. On 9/5/19 I witnessed (name of Resident B) touching (name of Resident F) again by putting his hands in her shirt and touching her breast. Staff removed residents hand and moved them away from each other and reported to nurse immediately. An interview was conducted with CNA 8 on 11/1/19 at 9:30 a.m. She indicated she witnessed Resident B inappropriately sexually touch Resident F on 2 different occasions. The first time was a Saturday, and they were sitting next to each other in front of the television on the Chatham Unit, about to do activities. CNA 8 looked over and Resident B was groping Resident F between her legs on the outside of her pants. Resident F was asleep at this time. CNA 8 informed LPN (Licensed Practical Nurse) 9 and UM (Unit Manager) 10 of the incident immediately after separating the residents, pushing Resident B's wheel chair so he was not sitting next to anyone. The second time happened a few days later, when she and CNA 7 were lining residents up for activities. We were short staffed. I was running around like a chicken with my head cut off. Residents were lined up in a line, when CNA 7 called CNA 8's name. Resident B had his hand in Resident F's shirt, on the inside, groping her breast. CNA 8 was by the exit door. CNA 7 was by the other door and they were both trying to get to Resident B to stop him. CNA 8 got there first and removed his hand from Resident B's shirt. Resident F was asleep during this time. CNA 8 reported this immediately to LPN 9, UM 10, the DNS (Director of Nursing Services), and the ED (Executive Director.) The second time, when they were lined up next to each other, Resident B was pushed there. I may have pushed him over there. That's on me. The day was crazy. It didn't dawn on me they were by each other. After the first occurrence, CNA 8 wasn't given any new interventions to implement. I definitely tried to keep (name of Resident B) away from female residents. After the first incident, no one questioned CNA 8 about the incident. After the second incident, the ED informed CNA 8 that she should have reported the first incident to him immediately. I didn't know I was supposed to call (name of ED) for resident to resident. I just thought staff to resident. CNA 8 thought AA (Activity Assistant) 11 may have been working when the first incident happened, but was unsure. An interview was conducted with AA 11 on 11/1/19 at 10:46 a.m. She indicated she witnessed Resident B inappropriately sexually touch Resident F on 2 different occasions, neither of which were 8/31/19 or 9/5/19. A couple of months ago in July, 2019, AA 11 witnessed incidents between Resident B and Resident F twice. The first time, AA 11 saw Resident B's hand on Resident F's leg, next to her private area. AA 11 informed Resident B that was not appropriate. Resident B asked why not. AA 11 informed Resident B he couldn't touch Resident F, so Resident B removed his hand and, AA 11 moved Resident F elsewhere. AA 11 stated, His hand was on her lap. The second occurrence was about 3 weeks later. Resident B's hand was inside of Resident F's shirt, rubbing her breast. I did not report the hand under her shirt to the ED. I probably should have. I just reported to the charge nurse. There was no information in Resident B or Resident F's clinical records referencing the 2 incidents witnessed by AA 11 in July, 2019 or the 8/31/19 incident witnessed by CNA 8. The investigative file included a 9/5/19 written statement by CNA 7. It read, On today (MONTH) 5th, 2019 I noticed the resident (name of Resident B) with his hands inappropriately placed on another resident in a sexual manner. I rushed over to stop (name of Resident B) by removing his hands out of her shirt. By then I notified my nurse and unit manager. I separated the two on separate sides of the room. The investigative file included a 9/5/19 written statement by LPN 9. It read, This morning after breakfast staff reported male resident was inappropriately (sic) touching female resident. No other incident had been reported to me before this one, nor have I witnessed resident touching other residents. The investigative file included a 9/5/19 written statement by UM 10. It read, On Thursday 9/5/19 was the first time that it was reported to me that (name of Resident B) had inappropriately touched a female resident. I asked staff is this the first time he has done this and had he tried (sic) to do it to staff and I was told no. I then went to the large conf (conference) room and informed the ED (name of ED) and DNS (name of DNS) about the incident. An interview was conducted with the ED on 10/31/19 at 2:15 p.m. He indicated after investigating the 9/5/19 incident between Resident B and Resident F, he substantiated sexual abuse. Prior to the 9/5/19 incident, he was unaware of any incidents between Resident B and Resident F. 3 a. The clinical record for Resident D was reviewed on 10/31/2019 at 1:59 p.m. The [DIAGNOSES REDACTED]. The clinical record contained a Significant Change on Status MDS Assessment, completed 8/31/2019, which indicated Resident D's cognition was severely impaired. The record for Resident D contained a New/Worsening Behavior Communication Event, dated 7/27/2019 at 6:08 p.m., indicating Resident D was using his wheelchair to ambulate and attempting to get to a certain place in the dining room. Resident G was backing his own wheelchair up when Resident D pushed Resident G's wheelchair. Resident G grabbed at him. Resident D hit Resident G in the back of the head. The clinical record for Resident D contained a care plan, with a start date of 8/5/2019, which indicated he was at risk for increased behaviors due to refusals of his medications, leading to unmanaged [MEDICAL CONDITION]. He would not take medications at times, was combative with care, and involved in resident to resident altercation. The goal was for him to take his medications to control his [MEDICAL CONDITION]. The care plan approaches included to have the M.D review his medications, observe him for increased agitation, encourage him to do independent activities in his room to decrease overstimulation, and when he refused medication to observe for increased agitation. A progress note, written 7/31/2019 at 7:07 p.m. by LCSW (Licensed Clinical Social Worker) 20 indicated Resident D was very agitated, and not easily redirected. He had refused medication, seemed very anxious and did not want to speak to anyone. He was also exit seeking. The staff was contacting the physician for an as needed anti- anxiety medication. A progress note, dated 8/2/2019 at 7:29 a.m., indicated Resident D had removed his personal belongings from the closet and attempted to move into another room. He had kept his roommate up all night with intrusive behaviors. He was displaying paranoia and believed everyone was lying to him. He had received [MEDICATION NAME] (anti-anxiety medication) I.M. (intramuscularly) which was effective. An IDT (Interdisciplinary Team) progress note, dated 8/2/2019, indicated Resident D was noted to have increased agitation, delusions, exit seeking behaviors and refusal of medications. The root cause was believed to be uncontrolled [MEDICAL CONDITION] and the preventative intervention was have his see the facility Psychiatrist for review of current behaviors and a medication review. The clinical record for Resident G was reviewed on 10/31/2019 at 2:30 p.m. The [DIAGNOSES REDACTED]. The clinical record contained an Annual MDS (Minimum Data Set) Assessment, completed 7/3/2019, which indicated Resident G's cognition was moderately impaired. During an interview on 11/1/2019 at 2:17 p.m., the ED (Executive Director) indicated 15 minute checks were initiated after the incident for Resident D and attempts were made by the staff to keep him and Resident G away from each other. 3b. A New/ Worsening Behavior Communication Event, dated 8/4/2019 7:45 p.m., indicated Resident D was in the common area after dinner. Resident H was visiting with his family member and Resident D slapped Resident H in the chest. 2 staff members attempted to remove Resident D from the situation but were unable to remove him. Resident H and his family member were moved to another area. Resident D was placed on 1:1 supervision after the incident. The clinical record for Resident H was reviewed on 11/1/2019 at 8:50 a.m. The [DIAGNOSES REDACTED]. The clinical record contained a Quarterly MDS Assessment, completed 7/30/2019, which indicated Resident H's cognition was moderately impaired. A progress note, dated 8/4/2019 at 11:55 p.m., indicated Resident D was placed on 1:1 supervision beginning at around 8:00 p.m. He had had received a lot of 1:1 attention prior to that time due to needing a lot of redirection during the shift. A progress note, dated 8/5/2019 at 5:21 a.m., indicated Resident D was having increased agitation since his peers were beginning to wake up and come into the

Based on observation, interview and record review, the facility failed to adequately supervise and implement interventions in place for a resident with dementia that wanders in other residents' rooms, who fell resulting in a [MEDICAL CONDITION] for 1 of 4 residents reviewed for falls. (Resident O) Findings include: The clinical record for Resident O was reviewed on 10/29/19 at 1:00 p.m. The [DIAGNOSES REDACTED]. Resident O was admitted to the facility on [DATE]. The 9/10/19 Quarterly MDS assessment for Resident O indicated she was severely impaired. Resident O's functional status was supervision for walking and locomotion with no assistance device. A care plan dated 6/7/19 indicated .Behavior 1: Resident has hx of intrusively wanders in and out of peers rooms, Resident intrusively wanders secondary to dx of [DIAGNOSES REDACTED], resident has a hx wandering into peers room when looking for a place to rest or toileting .assess for unmet needs (toileting, needing rest, hunger/thirst). Walk with resident on or off Cottage. Encourage resident to rest in bed or chair when tired. Resident is easily redirected when offering to hold her hand or asking her to come with you .Monitor resident whereabouts . A care plan dated 6/4/19 indicated .Resident is at risk for falls due to: dementia, [MEDICAL CONDITION], delusional, pain, [MEDICAL CONDITION], resident previously ambulates, medications, advanced age, resident continuously ambulates on cottage, resident looks straight ahead, resident does not use her peripheral vision, fast paced gait, resident will change up her gait when being redirected at times. Resident currently has a right hip fx with surgical repair and is utilizing a high back w/c (wheel chair) .Approach .ensure clear pathway in the common area .When resident appears tired, offer to help to lay down A care plan dated 8/19/19 indicated Resident O was .involved with verbal/physical altercations. At risk for resident to resident altercations due to hx (history) of wandering, resident had a recent decline r/t (related to) right hip fx (fracture) and is nonambulatory A behavior care plan for Resident O dated 7/15/19 indicated .Behavior 1: Resident may display physical aggression toward staff/residents Resident has a hx of wandering on the cottage, hx of ambulates at a fast pace, .Approach 8/5/19 .observe resident whereabouts and assist resident when in crowded spaces . A behavior care plan dated 7/15/19 for Resident O indicated .Resident is currently not a risk for elopement per elopement risk assessment aeb (as evidence by) resident no longer ambulates without assistance and has severe cognitive impairment .Provide 1:1 attention and conversation . A care plan dated 7/8/19 indicated .Res (resident) at times will place self on floor (sit or lay) when tired .Approach .Encourage frequent rest periods when pacing/wandering .Offer and assist resident to chair or bed when tired . The investigation file for Resident O's unwitnessed fall resulted in a fracture was provided by the Executive Director on 11/7/19 at 8:40 a.m. The file contained an incident report for Resident O dated 9/30/19 indicated .Brief Description .9/30/2019 Resident who is independent with ambulation was noted sitting on floor in peer's room. Resident was assessed. Resident had decreased range of motion to right leg, and exhibited signs of pain .Follow up: .10/7/2019 .New order received to obtain x ray in house. Order received to send resident to ED (emergency department) for further evaluation secondary to x ray results. Resident returned to facility following surgical repair of hip . A fall event dated 9/30/19 indicated Resident O had an unwitnessed fall. .Prior to the fall Resident last seen pacing the hallway near the common area . Resident O was found in another resident's room. She was observed to be .sitting on bedroom floor with BLE (bilateral lower extremities) extended in front resident back against room door . On assessment, Resident O had complaints of pain and limited range of motion to her right lower extremity. Another resident present in the room had reported Resident O . slid out of bed onto the floor . The floor had been noted on the fall event as slippery at that time of the fall. A radiology report for Resident O dated 9/30/19 indicated .Reason: Pain .Results: See fracture femoral neck. Superior and lateral displacement. No dislocation. Conclusion. Fracture femoral neck . CT hip right without IV (intravenous) contrast dated 9/30/19 indicated .exam: CT hip right wo (without) contrast. Indication: pain .Findings: There is a subcapital [MEDICAL CONDITION] hip. An IDT (interdisciplinary team) fall review dated 10/1/19 indicated .unwitnessed fall on 9/30/19 at 1:30 p.m. Resident noted sitting in a peer's room on the floor with back against the door. She was ambulating in hall prior to fall. Resident was fully dressed with nonskid socks on. Resident was not incontinent at the time of fall. No recent change in condition., increased her [MEDICATION NAME] r/t (related to) increased agitation. No recent decline in ambulation., transfers or ADL's (Activity of Daily Living) noted. Resident has a fast gait while ambulating .Upon assessment right hip noted to have increased pain and limited movement noted. Skin tear to right elbow noted, first aid applied. STAT (immediate) hip x ray ordered. Peers room had a slippery floor and resident was sliding all over the floor. Resident is not able to state how fall occurred. Peer stated that man sat on my bed and slid and was all over the place. Resident will ambulate the hallway, very rarely does resident enter another peers room, IDT feels that her room is next door to the peers room, IDT feels that resident entered peers room by mistake. Root Cause: slippery floor in peers room. Immediate intervention: resident was assessed and then assisted up into w/c (wheelchair), then to bed, x ray order obtained, sent to ED for further evaluation. Current interventions: nonskid footwear as tolerated, all rolling stools to be removed from dining room, when appears tired offer to lay down, hipsters on except during care, if awake in the early morning offer to take to common area and offer a snack/drink, ensure clear pathway in the common area and offer to lay down after meals, after use place stand up lift in appropriate place. Intervention put in place: bright colored paper on door as a room identifier. A fall event dated 8/29/19 indicated Resident O had wandered in another resident's room and slipped and fell . The fall was witnessed by a CN[NAME] The note indicated .Witnessed fall at 7:40 p.m. Resident was wanding (sic) in another res (resident) room lost balance and was lowered to the floor by CNA landing on buttocks in another res room. Res was ambulating in the hallway prior to fall. Resident was fully dressed adn (sic) had changed her socks, non-skid pu (sic) into place. Resident was not incontinent at the time. No new injuries, res stated she was not in pain with no facial grimacing v/s (vital signs) within normal range and res continued ambulating the unit . An IDT Behavior Review after a unwitnessed resident to resident incident dated 8/14/19 indicated Resident O was intrusive wandering and was found on the floor in another resident's room. IDT had determined the root cause was Resident O had a history of [REDACTED]. Interventions put in place at that time were redirection and stops signs placed on door frames per the request of other residents on the unit. The evaluation note for the event indicated .staff be aware of (Resident O)'s whereabouts . A nursing progress note dated 9/23/19 indicated res continues to be psychically aggressive towards staff, res very combative and swings and kicks when staff tried to perform care, res has been needing 2 staff members to assist with toileting and grooming d/t (due to) behaviors, res continues to wonder about unit in and out of peers rooms, no behaviors with peers at this time . The (MONTH) 2019 Medication and Treatment Administration Record (MAR/TAR) for Resident O indicated .Behavior 1: Resident wanders in and out of peers rooms . The staff twice a day were to document how many episodes of the behavior observed, interventions tried, and if interventions tried were effective. The following were days, times and episodes documented of Resident O wandering in and out of residents' rooms: 9/1/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/2/19 - 7:00 p.m. to 7:00 a.m. = 6 episodes, 9/3/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/3/19 - 7:00 p.m., to 7:00 a.m. = 10 episodes, 9/4/19 - 7:00 p.m. to 7:00 a.m. = 10 episodes, 9/5/19 - 7:00 a.m. to 7:00 a.m. = 10 plus episodes, 9/5/19 - 7:00 p.m. to 7:00 a.m. = 5 episodes, 9/6/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/8/19 - 7:00 a.m. to 7:00 p.m. = 4 episodes, 9/8/19 - 7:00 p.m. to 7:00 a.m. = 3 episodes, 9/9/19 - 7:00 a.m. to 7:00 p.m. = 10 episodes, 9/9/19 - 7:00 p.m. to 7:00 a.m. = 3 episodes, 9/10/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/12/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/12/19 - 7:00 p.m. to 7:00 a.m. = 25 episodes, 9/13/19 - 7:00 a.m. to 7:00 p.m. = 25 episodes, 9/14/19 - 7:00 a.m. to 7:00 p.m., = several episodes, 9/15/19 - 7:00 a.m. to 700 p.m. = 20 plus episodes, 9/17/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/17/19 - 7:00 p.m. to 7:00 a.m. = 20 episodes, 9/18/19 - 7:00 a.m. to 7:00 p.m. = 25 episodes, 9/19/19 - 7:00 a.m. to 7:00 p.m. = 20 episodes, 9/19/19 - 7:00 p.m. to 7:00 a.m. = 15 episodes, 9/20/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/21/19 - 7:00 a.m. to 7:00 p.m. = 12 plus episodes, 9/21/19 - 7:00 p.m. to 7:00 a.m. = 5 plus episodes, 9/22/19 - 7:00 a.m., to 7:00 p.m. = 20 plus episodes, 9/22/19 - 7:00 p.m. to 7:00 a.m. = 10 episodes, 9/23/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/26/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, 9/26/19 - 7:00 p.m. to 7:00 a.m. = 25 episodes, and 9/30/19 - 7:00 a.m. to 7:00 p.m. = 20 plus episodes, An observation was made of Resident O on 10/31/19 at 10:04 a.m. Resident O was sitting in her wheelchair in front of nursing station. An observation was made of Resident O on 11/6/19 at 11:10 a.m. She was sitting in her wheel chair in the dining room for the lunch meal. After the meal, Resident O was pushed by staff person out of dining room and parked in front of the nurse's station. An interview was conducted with Director of Nursing Services (DNS) on 11/7/19 at 11:30 a.m. She indicated prior to the fall on 9/30/19, Resident O walked up and down the halls on the unit, but rarely wandered in other residents' rooms. Resident O had wandered into the resident's room on 9/30/19, by mistaking it for her own room. The resident that lived in the room does use a urinal and spills the contents on the floor. The floor was wet at the time of the fall. This Federal tag relates to complaint IN 824. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident was free from physical, verbal and mental abuse resulting in potential psychosocial harm by Staff Person 3 videotaping a resident (Resident B). This had the potential to affect 105 residents in the facility. The immediate jeopardy began on 5/31/17 when the facility failed to ensure a resident was free from physical, verbal and mental abuse resulting in potential psychosocial harm by Staff Person 3 videotaping a resident (Resident B). The Executive Director (ED) was notified of the immediate jeopardy at 12:21 p.m., on 6/13/17. The immediate jeopardy was removed on 6/15/17, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 6/12/17 at 12:15 p.m., the clinical record was reviewed for Resident B. The [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) Assessment, dated 5/12/17, indicated a BIMS (Brief Interview for Mental Status) score of 1, indicating Resident B had severe cognitive impairment. On 6/12/17 at 3:10 p.m., a document titled Incident was reviewed. The document was the facility's copy of the reportable submitted to Indiana State Department of Health on 6/1/17 at 12:01 p.m. The document indicated the following, .(name of Resident B) .Staff Involved: Staff Person 3 .CNA (certified nursing assistant) 10 .CNA 5 .CNA 6 .Brief Description of Incident .Staff Person 3 made an allegation that a resident was handled roughly by #1 (sic) with in the resident's room. Staff Person 3 alleged CNA 6, CNA 5, CNA 10 (sic) also were involved .Follow up: .Investigation could not rule out abuse by CNA 6 .CNA 5 and Staff Person 3 have been terminated for failure to comply with the Abuse Prohibition and Reporting Policy as signed upon employment An interview was conducted with Family Member 11 on 6/12/17 at 3:25 p.m. He indicated he was made aware of an incident where a staff member grabbed Resident B and shoved her onto the mat that was positioned on the floor next to her bed because that staff member was frustrated with Resident B. An interview was conducted with the Director of Nursing (DON) on 6/12/17 at 3:50 p.m. She indicated, during an interview with Staff Person 3, there was a reference to a video. She believed there were no videos taken of residents. An interview was conducted with the Executive Director (ED) on 6/12/17 at 4:22 p.m. She indicated she observed a video taken by Staff Person 3 on the evening shift of 5/31/17. The video showed CNA 6 getting Resident B ready for bed and CNA 6 was transferring Resident B very roughly. CNA 6 was forcefully putting Resident B onto a mattress positioned on the floor beside the bed. The ED indicated this was physical abuse of CNA 6 towards Resident B. An interview was conducted with Staff Person 3 on 6/13/17 at 10:55 a.m. He indicated he witnessed abuse to Resident B. He came to the facility on [DATE] to provide 1:1 care for Resident B and the resident was fighting with CNA 6. Staff Person 3 indicated CNA 6 grabbed Resident B by the face and banged her head against the wall in the bathroom while CNA 6 was giving a shower to Resident B. Staff Person 3 told CNA 6 to stop hitting Resident B and CNA 6 said get the f**k off of me, you are not a CNA. He indicated he told numerous staff members, including a nurse and CNA 10, about the incident involving abuse towards Resident B. He indicated since no staff member was helping Resident B that he would proceed to record, with his personal cell phone, the abuse occurring towards Resident B. CNA 6 took hot water and utilized a shower head to spray Resident B in the face. Staff Person 3 indicated the ED was not in the facility on 5/31/17 and he attempted to obtain contact information for the ED from a nurse on that unit and CNA 10 but was unable to find any information on how to contact the ED. Staff Person 3 indicated, on 5/31/17 at approximately 8:00 p.m., he also recorded CNA 6 throwing Resident B onto the floor and CNA 6 proceeded to sit on Resident B and hit Resident B with her hand. Staff Person 3 also observed CNA 6 grab Resident B by the arm and told Resident B did I f**king tell you to stop and CNA 6 told Staff Member 3 that Resident B was bleeding from her arm due to CNA 6's nails. He indicated CNA 6 put Resident B to bed around 8:00 p.m. and he said he was going to stay until 10:00 p.m., due to CNA 6 making a comment towards Resident B of the following, .this white woman gets on my nerves. Staff Member 3 also heard CNA 6 make a threat towards Resident B of placing a pillow over Resident B's face. Staff Person 3 indicated he couldn't just sit back and watch the staff abuse Resident B like that. Staff Person 3 came back into the facility around 7:30 a.m., on 6/1/17, and asked a QMA (Qualified Medication Aide) as to where the ED was. He indicated he told the QMA that he witnessed abuse and had a video recording of it. The QMA directed him to the ED. An interview was conducted with the ED on 6/13/17 at 12:30 p.m. She indicated on the video recording in the bedroom that the ED heard a slap noise but didn't see any contact with CNA 6 and Resident B. The ED observed CNA 6 pushing Resident B onto the mattress located on the floor. Resident B was noted on her back with her legs flexed and her arms flailing. CNA 6 was noted on top of Resident B, towards her legs, in a holding motion while CNA 6 was on her knees. She indicated when Resident B doesn't want to do something she will let you know or refuse to have it done. The ED indicated on the video when Resident B was in the shower, CNA 6 was noted spraying Resident B with water from the shower head. The ED stated the water made contact with Resident B's face and the front of her body. A form titled Shower Report, dated 6/1/17, was reviewed for Resident B. The form indicated Resident B had a healed S/T (skin tear) to her left arm and an area marked yellow to her left hip/waist area. There were no other skin issues noted on the Shower Report form. A physician progress notes [REDACTED].Skin: No bruising noted with clothing .Plan: .Head to toe assessment also done by RN and no physical injuries noted other than minor scratch marks on arms An interview was conducted with the ED on 6/13/17 at 9:30 a.m. She indicated there were videos taken of Resident B. The first video was the physical abuse of CNA 6 towards Resident B and the other video was a brief video taken of Resident B in the shower room that revealed Resident B's breasts. A policy titled ABUSE PROHIBITION, REPORTING, AND INVESTIGATION, revised 11/16, was provided by the DON on 6/13/17 at 1:05 p.m. The policy indicated the following, .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain, or mental anguish .Physical Abuse- a willful act against a resident by another resident, staff or other individuals .Examples: hitting, beating, slapping, punching, shoving, spitting, striking with an object, pulling/twisting, squeezing, pinching, scratching, tripping, biting, burning, using overly hot/cold water, and/or improper use of restraints .Verbal Abuse- oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family member again; or scolding and/or speaking to them in harsh voice tones .Mental Abuse .1. Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. Examples: humiliation, harassment, threats of punishment or deprivation, bullying .2. Staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). This would include using any type of equipment (e.g. cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media) The immediate jeopardy that began on 5/31/17 was removed on 6/15/17 when the facility conducted interviews of staff, residents and families regarding abuse prohibition. Completed inservice education to staff as well as behavior training for direct care staff and reviewing policy and procedure for abuse prohibition, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility is completing family education, and quality assurance audits. This federal tag relates to Complaint IN 608. 3.1-27(a)

Based on interview and record review, the facility staff failed to immediately report allegations of staff to resident abuse (Resident B). This had the potential to affect 105 residents in the facility. The immediate jeopardy began on 5/31/17 when the facility staff failed to immediately report allegations of staff to resident abuse (Resident B). The Executive Director (ED) was notified of the immediate jeopardy at 12:21 p.m., on 6/13/17. The immediate jeopardy was removed on 6/15/17, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 6/12/17 at 12:15 p.m., the clinical record was reviewed for Resident B. The [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) Assessment, dated 5/12/17, indicated a BIMS (Brief Interview for Mental Status) score of 1, indicating Resident B had severe cognitive impairment. On 6/12/17 at 3:10 p.m., a document titled Incident was reviewed. The document was the facility's copy of the reportable submitted to the Indiana State Department of Health on 6/1/17 at 12:01 p.m. The document indicated the following, .(name of Resident B) .Staff Involved: Staff Person 3 .CNA (certified nursing assistant) 10 .CNA 5 .CNA 6 .Brief Description of Incident .Staff Person 3 made an allegation that a resident was handled roughly by #1 (sic) with in the resident's room. Staff Person 3 alleged other staff CNA 6, CNA 5, CNA 10 (sic) also were involved .Follow up: .Investigation could not rule out abuse by CNA 6 .CNA 5 and Staff Person 3 have been terminated for failure to comply with the Abuse Prohibition and Reporting Policy as signed upon employment An interview was conducted with Staff Person 3 on 6/13/17 at 10:55 a.m. He indicated he witnessed abuse being done to Resident B. He told numerous staff members, including a nurse and CNA 10, about the incident involving abuse towards Resident B. He indicated since no staff member was helping Resident B then he proceeded to record the abuse, with his personal cell phone, occurring towards Resident B. He indicated he wasn't going to sit back and watch the staff abuse Resident B like that. Staff Person 3 came back to the facility around 7:30 a.m., on 6/1/17, and was able to find a QMA (Qualified Medication Aide) in the facility to report the abuse and he was directed to the ED at that time. Staff Person 3 showed the ED the video he recorded, with his personal cell phone, of Resident B being abused by CNA 6 and the ED indicated Staff Person 3 needed to delete the video from his phone or he would get in trouble. An interview was conducted with the ED on 6/12/17 at 4:22 p.m. She indicated she was interviewing Staff Person 9 in regards to a statement left underneath her door that she found on 6/1/17. The statement by Staff Person 9 addressed a video and when the ED asked Staff Member 9 about the video it was identified as a video taken of a resident. The ED indicated she spoke with Staff Person 3 and was told a video was taken of staff to resident abuse towards Resident B. An interview was conducted with the ED on 6/13/17 at 9:30 a.m. She indicated there were two videos recorded of Resident B by Staff Person 3. The first video was the physical abuse of Resident B by CNA 6 and the other video was a brief video taken of Resident B in the shower room with CNA 6. She indicated Resident B was sitting on the shower chair while CNA 6 was noted spraying Resident B with water towards her face and on the front part of her body. An interview was conducted with the ED on 6/13/17 at 12:30 p.m. She indicated she was on vacation on 5/31/17 but told staff to contact her with any concerns. She indicated she never received a phone call about the alleged abuse towards Resident B. She came into the facility on [DATE] and spoke with Staff Person 3 for a significant amount of time in regards to what occurred on the evening shift of 5/31/17 with Resident B. The ED indicated she expected staff to call her or the Director of Nursing for any allegations of abuse towards a resident. An interview was conducted with the Director of Operations (DO) on 6/13/17 at 2:30 p.m. He indicated he arrived to facility on 6/1/17 at 1:00 p.m. He conducted an interview with Staff Person 3 with the ED and DON present. He indicated he knew there was a video of a resident but he didn't observe the video. A policy titled ABUSE PROHIBITION, REPORTING, AND INVESTIGATION, revised 11/16, was provided by the DON on 6/13/17 at 1:05 p.m. The policy indicated the following, .Mental Abuse .1. Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. Examples: humiliation, harassment, threats of punishment or deprivation, bullying .2. Staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). This would include using any type of equipment (e.g. cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media) .Policy/Procedure .5. All abuse allegations/abuse must be reported to the Executive Director immediately and to the resident's representative within 24 hours of the report. Failure to report will result in disciplinary action, up to and including immediate termination .7. The Executive Director/designee will report all unusual occurrences, which include allegations of abuse, neglect, misappropriation of property and injuries of unknown origin immediately, to the Long Term Care Division of the Indiana State Department of Health .RESIDENT ABUSE .Procedure: If resident abuse is identified or suspected, the following guidelines will be followed: 1. The resident(s) involved in the incident will be protected and/or removed from the situation immediately .2. Any individual who witnesses abuse, or has suspicion of, shall immediately notify the charge nurse of the unit, which the resident resides .3. Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation in completed .4. The Executive Director and/or Director of Nursing will be immediately notified of the report and the initiation of the investigation The immediate jeopardy that began on 5/31/17 was removed on 6/15/17 when the facility conducted interviews of staff, residents and families regarding abuse prohibition. Completed inservice education to staff as well as behavior training for direct care staff and reviewing policy and procedure for abuse prohibition, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility is completing family education, and quality assurance audits. This federal tag relates to Complaint IN 608. 3.1-28(a) 3.1-28(c)