Every finding on record at Hawthorne Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to self-administer his own medication before leaving the resident's medications in his room without staff present for 1 of 3 residents reviewed for pharmaceutical services. (Resident B) Finding includes:On 8/4/26 at 8:46 a.m., observed a small pill cup with four white pills sitting on Resident B's bedside table. At that time, Resident B indicated the staff leave his pills in the room all the time.The clinical record for Resident B was reviewed on 8/4/26 at 10:59 a.m. The diagnoses included, but were not limited to, schizophrenia, mood disorder, and anxiety disorder.Resident B's clinical record lacked a self-administration of medication assessment that indicated Resident B could safely administer his own medications.During an interview on 8/4/26 at 9:04 a.m., Licensed Practical Nurse (LPN) 1 indicated the medications should not be left in Resident B's room.On 8/4/26 at 12:28 p.m., the Regional Director of Nursing provided a copy of a facility policy, titled Storage of Medication, dated 9/2025, and indicated this was the current policy used by the facility. A review of the policy indicated medication were safely administered by staff.This citation relates to Intake 3106608.410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent residents' potential access to the materials for 3 of 5 days of the survey. Findings include:1. On 12/1/25 at 8:20 a.m., the following was observed in a room near the front entrance of the facility: A room close to the front entrance, labeled Conference Room on a sign to the right of the door was ajar approximately 4-6 inches wide and unlocked. Inside the conference room on the table was a mostly white 16 ounce red-capped bottle sitting on the table; the label on the bottle indicated it was an Rx [Prescription] Destroyer drug disposal all-purpose formula. The bottle appeared mostly full with sticky residue noted around the cap and top of bottle. On the far side of the room from the door, on the floor near a plastic waste receptacle in a clear plastic bag, were eight more bottles of the same appearance and labeling, all full. The labels on the bottle also indicated Keep out of reach. and Always store in a secure location. No staff were noted in the immediate area.2. On 12/2/25 at 9:43 a.m., a door on the 600-hallway labeled Electrical Room with a sign to the left of the door labeled Mechanical Room across from a room labeled Social Services and closest to rooms [ROOM NUMBERS] was observed to be unlocked. No staff had a direct line of sight to the unlocked room at the time of the observation and multiple residents were noted to be moving through or near the area. On 12/3/25 at 9:50 a.m., a door on the 600-hallway labeled Electrical Room with a sign to the left of the door labeled Mechanical Room across from a room labeled Social Services and closest to rooms [ROOM NUMBERS] was observed to be unlocked. No staff had a direct line of sight to the unlocked room at the time of the observation and multiple residents were noted to be moving through or near the area.On 12/3/25 at 10:10 a.m., a door on the 600-hallway labeled Electrical Room with a sign to the left of the door labeled Mechanical Room across from a room labeled Social Services and closest to rooms [ROOM NUMBERS] was observed to be unlocked. No staff had a direct line of sight to the unlocked room at the time of the observation and multiple residents were noted to be moving through or near the area. Inside, the following was observed: In the first room area on the left side of the wall were two power supply panels, the top one labeled Power supply for double door leading to [NAME] Lane and the bottom one labeled Power supply for new smoker's door. A small closet-like room with no doors in frames opened into a second back room. In the small closet like room area were numerous exposed electric, internet, and other cables and cords. Above the first doorway entrance to the closet room above the door frame were several bare circular saw blades suspended on the wall. In the back-room area, there were more power control panels. A very large, paneled area on the left wall was labeled with Danger hazardous voltage, will cause severe injury and death' with four smaller levers in a square above a fifth labeled lever. The very back wall of the second larger room area also had an unlocked panel of electrical fuses. During an interview on 12/3/25 at 10:25 a.m., the Director of Plant Operations (DOPO) and Maintenance Tech 1 indicated that the Electrical Room/Mechanical Room should be kept locked at all times. During an interview on 12/4/25 at 1:22 p.m., the Administrator indicated that the drug disposal containers found in the unlocked Conference Room should have been kept in a secured area, and that the Electrical Room/Mechanical Room should be kept locked at all times. On 12/1/25 at 12:50 p.m., the Divisional Director of Clinical Operations (DDCO) provided a copy of an undated policy titled Hazardous Materials Storage and indicated it was the policy currently in use by the facility. A review of the policy indicated, hazardous materials, including but not limited to any chemicals or sharp objects kept out of reach of those who are unfamiliar with the materials or who might inadvertently become exposed or injured. On 12/4/25 at 1:45 p.m., the [NAME] President of Risk Management (VPORM) indicated that the facility did not have a specific policy that spoke directly to electrical type hazards, such as the exposed wires, power panels, and fuses, but that rooms containing such hazards should be kept locked. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents with enteral feedings physician's orders were followed and equipment was dated for 1 of 1 residents reviewed for enteral feedings. (Resident 6)Finding includes:On 12/1/25 at 10:36 a.m., Resident 6 was observed resting in bed. Next to the bed was a pole with an electronic pump device (kangaroo). Hanging from the pole was a 1000 ml (milliliter) plastic bottle of Osmolite (a type of nutritional supplement) 1.5 cal and was connected to the kangaroo pump but was not connected to Resident 6 at that time. The bottle was observed to be three fourths full of a brown colored liquid. The bottle and tubing was undated. During an interview at that time Resident 6 indicated that he did receive Osmolite 1.5 by G-tube.On 12/1/25 at 11:45 a.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, intestinal bypass and anastomosis status (the surgical creation of a connection between two tubular structures, like blood vessels or loops of intestine), and noninfective gastroenteritis and colitis (inflammation of the digestive tract).A physician's order, initiated on 9/4/25, indicated Resident 6 had an order for Osmolite 1.2 cal to administer 355 ml every 6 hours by mouth as needed for supplement. During an interview on 12/2/25 at 10:26 a.m., Resident 6 indicated that he did not get any Osmolite by mouth because he had a feeding tube in place. Resident 6 indicated he did receive Osmolite 1.5 via the feeding tube a few days ago.During an interview on 12/3/25 at 8:12 a.m., the Divisional Director for Clinical Operations (DDCO) indicated that the weekend supervisor was on duty on 12/1/25 and Resident 6 had refused Osmolite 1.2 cal 355 ml by mouth, the weekend supervisor called and received an order to administer Osmolite 1.5 cal via G-tube but forgot to document the order or to put it in the electronic health record.On 12/2/25 at 1:20 p.m., the RN Consultant provided an undated copy of Policies and Standard Procedure, Subject: Physician Orders, and indicated it was the current policy in use by the facility. The policy indicated a provider may give a medical order over the telephone, and the nurse would transcribe the order into the electronic health record. On 12/3/25 at 2:42 p.m., the [NAME] President of Risk Management RN provided an undated copy of Policies and Standard Procedures, Subject, Enteral General Nutritional (tube feeding) Guidelines, and indicated it was the current policy in use by the facility. A review of the policy indicated to change syringes, tubing or bottles used for feeding daily, label and date items, verify the practitioner's order, including the prescribed route and prescribed formula, and label the administration set with the date and time of administration including the licensed nurse initials.3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent a cognitively impaired resident who resided on the secured memory care unit from exiting the facility property without staff knowledge. The resident was found approximately 1.5 miles from the facility. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/13/25 at approximately 1:00 a.m., when the facility failed to provide supervision to a cognitively impaired resident, that resided on the memory care unit, to prevent an elopement. The Administrator, Director of Nursing, and Regional Director of Nursing were notified of the Immediate Jeopardy on 4/22/25 at 12:35 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, 4/14/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: On 4/22/25 at 8:48 a.m., the Administrator provided a copy of a facility reportable incident, dated 4/13/25 at 4:45 a.m. A review of the reportable incident indicated Resident B walked out of the facility through an emergency exit door. Resident B was located and returned to the facility by the police. On 4/22/25 at 9:00 a.m., the Administrator provided a copy of the following staff witness statements: - CNA 1, dated 4/13/25, indicated CNA 1 left the secured memory care unit to go outside to her car. On CNA 1's walk back into the facility she was made aware that Resident B exited the facility. CNA 1 was told Resident B tried to exit the secured memory care unit using the front entrance to the unit but when staff heard Resident B knocking on that door they redirected him to his room. Then the alarm on the emergency exit door located at the back of the unit had begun to sound. - CNA 2, undated, indicated CNA 2 heard a door alarm sounding, so CNA 2 went to the secured memory care unit and the emergency exit door at that back of the unit was open. The clinical record for Resident B was reviewed on 4/22/25 at 9:08 a.m. The diagnoses included, but were not limited to, Alzheimer's disease and dementia. An order appointing guardian over ward, dated 7/18/23, indicated Resident B was an incapacitated person and was appointed a guardian over person and estate. A Nursing Admission Evaluation, dated 4/9/25 at 4:59 p.m., indicated Resident B had not shown exit seeking behavior since admission, but had a history of wandering, exit seeking behaviors, elopement, and told the nurse he wanted to go home. A Brief Interview for Mental Status (BIMS) assessment, dated 4/10/25, indicated Resident B was severely cognitively impaired. A care plan, dated 4/9/25, indicated Resident B was at risk for an elopement. The interventions included, but were not limited to, provide diversionary activities as needed (initiated 4/9/25), redirect Resident B when appropriate and assess for hunger, thirst, ambulation, and toileting needs (initiated 4/9/25). A care plan, dated 4/10/25, indicated Resident B required a secured unit. The interventions included, but were not limited to, educate Resident B and Resident B's representative of the need for a secured unit to maintain Resident B's safety (initiated 4/10/25) and provide diversionary activities as needed (initiated 4/10/25). A progress note, dated 4/9/25 at 6:33 p.m., indicated Resident B's family had come to visit and stated that Resident B was exit seeking and that when Resident B realized that he could not get out of the facility, he would start screaming. Writer assured family that Resident B was in a safe, secure environment. Resident B's son stated that Resident B exited their home and was picked up wandering the streets. A progress note, dated 4/10/25 at 11:04 p.m., indicated Resident B had been exit seeking multiple times throughout shift. Staff continued re-directing resident which was somewhat effective. A progress note, dated 4/12/25 at 11:40 a.m., indicated Resident B was confused and wandering that morning and asked about leaving. A progress note, dated 4/13/25 at 5:23 a.m., indicated Resident B had exited the facility and was returned to the facility by police escort. During an interview on 4/22/25 at 10:43 a.m., the Administrator indicated, on 4/13/25 at approximately 1:15 a.m., he was notified that staff were unable to locate Resident B. Resident B was located approximately 1.5 miles north on a main road. The CNA that was working on the secured memory care unit that night had a personal emergency and had to leave the secured memory care unit to go outside to her car. There were no staff members on the secured memory care unit when Resident B exited the facility through the emergency exit door on the secured memory care unit. On 4/22/25 at 11:00 a.m., the path Resident B walked when he exited the facility was observed. From the facility Resident B walked north on the main road. There was a concrete sidewalk and parking lots that lined the road for the entire distance. The area that the Administrator reported Resident B was located by the police was near a busy intersection approximately 1.5 miles from the facility. On 4/23/25 at 10:30 a.m., the Administrator provided the as worked clinical schedule, dated 4/12/25. A review of the schedule indicated CNA 1 was the only CNA schedule for the 500 hall (secured memory care unit). On 4/22/25 at 9:00 a.m., the Administrator provided a copy of an undated facility policy, titled Elopement Prevention and Management Overview, and indicated this was the current policy used by the facility. A review of the policy indicated an elopement is defined as a resident that leaves the premises or a safe area without authorization or any necessary supervision and places the resident at risk for harm. The past noncompliance Immediate Jeopardy began on 4/13/25. The Immediate Jeopardy was removed and the deficient practice corrected by 4/14/25 after the facility implemented a systemic plan that included the following actions: audits of elopement evaluations and care plans, inservicing staff on elopement procedures, and ongoing monitoring. This citation relates to Complaint IN00457472. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 3 of 4 kitchen observations. Staff hair was not covered while in the kitchen. (Dietary [NAME] 2) Findings include: On 11/6/24 from 11:20 a.m. to 11:23 a.m., Dietary [NAME] 2 was observed walking near the steam table area, located next to the grill and steamer, where the noon foods were being held. Dietary [NAME] 2 was observed to have facial hair, approximately one-half inch in length, above and below the lips. The facial hair was observed to not be covered. During a follow-up kitchen observation on 11/6/24 from 11:35 a.m. to 11:40 a.m., Dietary [NAME] 2 was observed at the steam table area taking the noon meal starting temperatures and plating the noon meal. Dietary [NAME] 2 was observed to have facial hair, approximately one-half inch in length, above and below the lips. The facial hair was observed to not be covered. On 11/6/24 from 12:12 p.m. to 12:20 p.m., Dietary [NAME] 2 was observed at the steam table plating the noon meal. Dietary [NAME] 2 was then observed taking the noon meal ending temperatures. Dietary [NAME] 2 was observed to have facial hair, approximately one-half inch in length, above and below the lips. The facial hair was observed to not be covered. During an interview at that time, the Regional Dietary Consultant indicated that staff hair, including facial hair, was to be kept covered while in the kitchen. On 11/6/24 at 12:45 p.m., the Administrator provided a copy of the Staff Attire policy, dated September 2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all staff members will have their hair .confined in a hair net .and facial hair properly restrained . On 11/6/24 at 3:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets, beard restraints .that are designed and worn to wear effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for 1 of 2 residents reviewed for catheter care. (Resident 3) Finding includes: On 11/6/24 at 11:20 a.m., Resident 3 was observed resting in bed using his laptop computer. A covered urinary catheter bag was observed hanging on the bed frame. On 11/7/24 at 9:21 a.m., Resident 3 was observed resting in bed using his laptop computer. A covered urinary catheter bag was observed hanging on the bed frame. During an interview at that time, Resident 3 indicated he had the indwelling urinary catheter for about a month. On 11/8/24 at 10:00 a.m., Resident 3's clinical record was reviewed. The diagnosis included, but was not limited to, neuromuscular dysfunction of bladder (a condition that causes bladder control issues due to damage to the nervous system). The Quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident 3 was cognitively intact. Physician's orders included, but were not limited to, indwelling urinary catheter, start date of 10/1/24, and with no end date noted. Resident 3's clinical record lacked a comprehensive person-centered care plan related to the indwelling urinary catheter. During an interview on 11/8/24 at 11:34 a.m., the Corporate Clinical Nurse Consultant indicated Resident 3 had an indwelling urinary catheter since 10/1/24. No indwelling urinary catheter care plan had been developed for Resident 3. A care plan should have been developed. On 11/13/24 at 8:25 a.m., the Corporate Clinical Nurse Consultant provided a copy of Plan of Care Overview policy, dated 2017, and indicated it was the current policy in use by the facility. A review of the document indicated, .written treatment provided for a resident that is resident-focused and provides for optimal personalized care . 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure the ground next to the kitchen's rear door was free from rubbish and failed to ensure the dumpster sliding side panel door was kept closed when not in use for 2 of 3 observations. Findings include: 1. During the initial facility tour with the Dietary Manager on 11/6/24 at 9:35 a.m., the following was observed: - On the ground just outside the kitchen's rear door was a large cardboard box that had unidentifiable debris inside the uncovered box. On the ground near the box, the following was observed: used cups, rags, and other various unidentifiable debris. - The dumpster container area, located approximately 100 yards from the kitchen's rear door was observed. The dumpster area had 2 large dumpster containers. The east dumpster container had 2 sliding side panel doors. The sliding side panel door on the left side of the dumpster container was observed to not be closed. No staff were visible in the area at that time. 2. During a follow up observation on 11/7/24 at 4:50 p.m., the dumpster area was observed. The dumpster area had 2 large dumpster containers. The east dumpster container had 2 sliding side panel doors. The sliding side panel door on the left side of the dumpster container was observed to not be closed. No staff were visible in the area at that time. During an interview on 11/8/24 at 2:54 p.m., the Dietary Manager indicated the dumpster container lids and sliding side panel doors were to be kept closed when not in use. All debris should be placed into the dumpster containers. On 11/6/24 at 12:45 p.m., the Administrator provided a copy of the Environment policy, dated September 2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris . On 11/6/24 at 3:15 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(5)

Based on interview and record review, the facility failed to notify a resident's guardian prior to a transfer for 1 of 3 residents reviewed for transfers requirements. (Resident D) Finding includes: The clinical record for Resident D was reviewed on 8/19/24 at 1:16 p.m. The diagnoses included, but were not limited to, epilepsy, alcohol dependence, and vascular dementia. An Order Appointing Guardian Over Incapacitated Person, dated 2/22/23, indicated a guardian was appointed on 2/22/23. A progress note, dated 7/18/24 at 9:34 a.m., indicated Resident D discharged to another facility. All Resident D's belongings were sent with Resident D. The clinical record lacked documentation the guardian was notified prior to Resident D's discharge. During an interview on 8/20/24 at 10:00 a.m., Corporate Nurse 1 indicated there was no additional documentation regarding Resident D's discharge. During an interview on 8/20/24 at 10:45 a.m., LPN 1 indicated Resident D's guardian should have been notified before he was transferred. On 8/20/24 at 10:27 a.m., Corporate Nurse 1 provided a copy of an undated policy, titled Admission, Discharge, and Transfer, and indicated this was the current policy used by the facility. A review of the policy indicated notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Record the reasons for the transfer or discharge in the medical record. This citation relates to Complaint IN00441243. 3.1-5(a)(4)

Based on interview and record review, the facility failed to provide a written Notice of Transfer/Discharge to the resident's representative prior to a discharge for 1 of 3 residents reviewed for transfer and discharge requirements. (Resident D) Finding includes: The clinical record for Resident D was reviewed on 8/19/24 at 1:16 p.m. The diagnoses included, but were not limited to, epilepsy, alcohol dependence, and vascular dementia. An Order Appointing Guardian Over Incapacitated Person, dated 2/22/23, indicated a guardian was appointed, on 2/22/23. A progress note, dated 7/18/24 at 9:34 a.m., indicated Resident D discharged to another facility. All Resident D's belongings were sent with Resident D. The clinical record lacked documentation the written Notice of Transfer/Discharge was provided to the resident's representative prior to the discharge. During an interview on 8/20/24 at 10:00 a.m., Corporate Nurse 1 indicated there was no additional documentation regarding Resident D's discharge. On 8/20/24 at 10:27 a.m., Corporate Nurse 1 provided a copy of an undated policy, titled Admission, Discharge, and Transfer, and indicated this was the current policy used by the facility. A review of the policy indicated record the reasons for the transfer or discharge in the medical record. This citation relates to Complaint IN00441243. 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure resident's records were complete and accurate for 2 of 3 residents reviewed. Medications were not documented when administered. (Resident B, Resident C) Finding includes: 1. The clinical record for Resident B was reviewed on 8/19/24 at 10:42 a.m. The diagnoses included, but were not limited to, gastroesophageal reflux disease and dystonia. The physician's orders included, but were not limited to: - Carbidopa-Levodopa (medication used to treat central nervous system disorders) 25/250 mg (milligrams) tablet, give one tablet by mouth every three hours, started on 1/19/24. - Hydrocodone/Acetaminophen (narcotic pain reliever) 5/325 mg tablet, give one tablet by mouth every 6 hours for pain, started on 7/22/24. - Omeprazole (medication used for acid reflux) 20 mg delayed release capsule, give one capsule by mouth in the morning, started on 1/19/24. The August 2024 MAR (Medication Administration Record), dated from 8/17/24 at 12:00 a.m., through 8/17/24 at 9:00 p.m., indicated Resident B did not receive the following medications in accordance with the physician's orders: - Carbidopa-Levodopa 25/250 mg at 12:00 a.m., 3:00 a.m., and 6:00 a.m. - Hydrocodone/Acetaminophen 5/325 mg at 12:00 a.m. and 8:00 a.m. - Omeprazole 20 mg at 8:00 a.m. During an interview on 8/20/24 at 8:35 a.m., Corporate Nurse 1 indicated Resident B's medications were administered. The staff should have documented the medication administration when they were administered. 2. The clinical record for Resident C was reviewed on 8/20/24 at 8:46 a.m. The diagnoses included, but were not limited to, diabetes, morbid obesity, and depression. The physician's orders included, but were not limited to: - Furosemide (medication used to remove excess fluid) 40 mg tablet, give one tablet by mouth one time a day, started on 8/14/24. - Amlodipine (medication used to lower blood pressure) 10 mg tablet, give one tablet by mouth one time a day, started 8/14/24. - Doxepin (medication used to treat depression) 100 mg capsule, give one capsule by mouth at bedtime, started on 8/13/24, - Clonazepam (medication used to treat anxiety) 1 mg tablet, give one tablet by mouth one time a day, started on 8/14/24. - Insulin glargine (long acting insulin used to treat diabetes) 100 units/ml (units/milliliter), inject 10 units subcutaneously (under the skin into the fat) at bedtime, started on 8/13/24. - Trulicity (medication used to treat diabetes) 3 mg/0.5 ml, inject 3 mg subcutaneously in the morning every Friday, started on 8/16/24. - Insulin lispro (fast acting insulin used to treat diabetes) 100 units/ml, inject subcutaneously three times daily per sliding scale, started on 8/13/24. - Oxycodone/Acetaminophen (narcotic pain medication) 5/325 mg tablet, give one tablet by mouth three times daily, started on 8/14/24. The August 2024 MAR (Medication Administration Record), dated from 8/15/24 at 8:00 a.m., through 8/18/24 at 8:00 p.m., indicated Resident C did not receive the following medications in accordance with the physician's orders: - Furosemide 40 mg tablet on 8/15/24 at 8:00 a.m. - Amlodipine 10 mg tablet on 8/15/24 at 8:00 a.m. - Doxepin 100 mg capsule on 8/16/24 at 8:00 p.m., 8/17/24 at 8:00 p.m., and 8/18/24 at 8:00 p.m. - Clonazepam 1 mg tablet on 8/15/24 at 8:00 a.m. - Insulin glargine 100 units/ml on 8/16/24 at 8:00 p.m., 8/17/24 at 8:00 p.m., and 8/18/24 at 8:00 p.m. - Trulicity 3 mg/0.5ml on 8/16/24 at 8:00 a.m. - Insulin lispro 100 units/ml on 8/15/24 at 8:00 a.m. and 12:00 p.m., 8/16/24 at 8:00 a.m., 12:00 p.m., and 5:00 p.m., 8/17/24 at 5:00 p.m., and 8/18/24 at 5:00 p.m. - Oxycodone/Acetaminophen 5/325mg tablet, on 8/15/24 at 8:00 a.m., and 12:00 p.m. During an interview on 8/20/24 at 8:35 a.m., Corporate Nurse 1 indicated Resident C's medications were administered. The staff should have documented the medication administration when they were administered. The Corporate Nurse provided a copy of an undated facility policy, titled Medication Administration, and indicated this was the current policy used by the facility. A review of the policy indicated administer medications as prescribed by the provider and medications will be charted when given. This citation relates to Complaint IN00441229. 3.1-50(a)

Based on record review and interview, the facility failed to ensure resident rights were maintained related to being able to go outside in the facility courtyard unsupervised during non-smoking times for 5 of 5 residents reviewed for resident rights. (Residents F, Resident G, Resident H, Resident J, Resident K) Findings Include: 1. During an interview with Resident K on 8/1/24 at 1:00 p.m., he indicated could only go outside in the courtyard during smoking times. He indicated this changed after there was a fight in the gazebo and the Executive Director would not let anyone go out without supervision. Those residents who got in the fight aren't here anymore so residents should be able to go outside. He stated I don't want to be inside all the time with TV. He wanted to go outside and enjoy the beautiful weather. He indicated if you signed out you could go off the property to smoke. 2. During an interview with Resident F on 8/1/24 at 1:14 p.m., he indicated he had been informed by facility staff he was not allowed to go outside to the courtyard to get fresh air at any time unless he was supervised. He stated the heat helps my arthritis pain. The record for Resident F was reviewed on 8/1/24 at 1:43 p.m. A Quarterly Minimum Data Set (MDS) Assessment, dated 7/11/24, indicated the resident was cognitively intact and felt it was very important to go outside and get fresh air when the weather was good. A care plan, dated 7/23/24, indicated the resident had a concern of psychosocial well-being with a goal that the resident would report decreased feelings of social isolation by next review. Interventions included, but not limited to, observe resident for signs and symptoms of new onset of psychosocial issues and initiate resident specific interventions. 3. During an interview on 8/1/24 at 1:08 p.m., Resident G indicated she could not go outside except during smoking times without supervision. Facility staff had informed her of this a few weeks ago. She stated it's just not right. The record for Resident G was reviewed on 8/1/24 at 1:49 p.m. A Quarterly MDS assessment, dated 5/10/24, indicated the resident was cognitively intact. An MDS assessment, dated 4/10/24, indicated the resident felt it was very important to go outside to get fresh air when the weather was good. A care plan, dated 7/30/24, indicated the resident had a problem of at risk for impaired psychosocial well-being related to negative interactions with peers with a goal the resident will report maintained/improved psychosocial well-being. 4. During an interview with Resident H on 8/1/24 at 1:15 p.m., he indicated he was not allowed to go outside unless it was smoking time or his wife was with him. He was newly admitted and was informed this on admission. The record for Resident H was reviewed on 8/1/24 at 1:52 p.m. An Admission MDS assessment, dated 7/24/24, indicated the resident was cognitively intact and it was very important to go outside to get fresh air when the weather was good. A care plan, dated 7/22/24, indicated at risk for psychosocial well being with a goal the resident would report decreased feelings of social isolation. 5. During an interview with Resident J on 8/1/24 at 1:33 p.m., he indicated he cannot go outside in the courtyard unless it is supervised smoking times. The rules had changed so often it was hard to keep up. The record for Resident J was reviewed on 8/1/24 at 1:58 p.m. An MDS assessment, dated 7/24/24, indicated the resident was cognitively intact and felt it was very important to go outside to get fresh air when the weather was nice. During an interview with CNA 6 on 8/1/24 at 1:33 p.m., she indicated residents cannot go outside in the courtyard at any time unless they are supervised. During an interview with the Executive Director on 8/1/24 at 2:25 p.m., he indicated the residents had designated smoking times and could be outside during those times. Residents were not allowed in the courtyard unless they were supervised, even if they were cognitively intact. There had been a resident to resident altercation out there so their could not be large groups outside without supervision. 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to notify the state health department of an injury of unknown origin for 1 of 3 residents reviewed for abuse. Staff observed a scrape with swelling and bruising to the nose and left eye but did not know how the injury occurred. (Resident M) Finding included: The clinical record for Resident M was reviewed on 8/1/24 at 1:30 p.m. The diagnoses included, but were not limited to, autistic disorder, intellectual disability, and epilepsy. A Quarterly MDS (Minimum Data Set) assessment, dated 7/13/24, indicated Resident M was severely cognitively impaired. A physician's telephone order, dated 7/24/24, indicated x-ray of nose. The order was discontinued. A physician's verbal order, dated 7/25/24 at approximately 3:00 a.m., indicated x-ray of nose due to swelling, mass, lump. An x-ray result, dated 7/25/24 at 9:45 a.m., indicated exam of nasal bones for nasal pain. There was no fracture, dislocation, nor bony destructive lesion noted. Paranasal air cells demonstrate no specific abnormality. No acute traumatic osseous abnormality. A progress note, dated 7/25/24 at 1:17 p.m., indicated the DON observed Resident M bump into a wall while ambulating. The Nurse Practitioner was notified and gave a new physician's order for an x-ray. The progress note was entered into the electronic medical record on 8/1/24 at 1:18 p.m. (7 days after the x-ray was ordered) A weekly skin assessment, dated 7/29/24 at 11:27 a.m., indicated Resident M did not refuse a skin assessment. Resident M did not have any skin alterations noted. The weekly skin assessment was completed by the DON. During an interview on 8/1/24 at 1:43 p.m., the Activity Director indicated Resident M looked like he had a broken nose because his nose was swollen, cut, and bruised. The Activity Director couldn't remember the exact date she first saw the injury but was sure it was before Resident M moved to the 600 hall on 7/24/24. During an interview on 8/1/24 at 2:17 p.m., the Administrator indicated, during the morning clinical meeting, on 7/25/24, he was made aware of a scratch and some discoloration on Resident M's nose. The nurse got a physician's order for an x-ray of Resident M's nose to make sure there was no further injury. The Administrator needed to speak with the DON to find out if the DON found anyone that knew what happened. This would have been considered an injury of unknown origin. During an interview on 8/1/24 at 2:34 p.m., the DON indicated on the morning of 7/25/24, she was going outside to take a break when she watched Resident M bump into a wall. It was possible that Resident M's nose had swelling, a cut, and bruising before the DON saw Resident M bump into the wall. The DON may not have been notified of any injury prior to that. The DON should have documented the injury and entered a progress note the morning she watched Resident M bump into the wall, so the medical record was accurate. During an interview on 8/1/24 at 2:54 p.m., CNA 10 indicated on 7/24/24 at approximately 3:00 p.m., Resident M's left eye was black, his nose was swollen, cut, and bruised. Resident M's nose looked crooked like it was broken. CNA 10 reported this to RN 9 but didn't feel like the injury was taken seriously. During an observation on 8/2/24 at 7:30 a.m., Resident M was sitting in his room. Observed a small scratch and discoloration along the bridge and to the left side of Resident M's nose. On 8/2/24 at 11:15 a.m., the Corporate Nurse provided a copy of an undated facility policy, titled Indiana Abuse and Neglect and Misappropriation of Property, and indicated this was the current policy used by the facility. A review of the policy indicated all allegations involving injuries of unknown injury will be reported to the state. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin when a resident was observed to have a scrape on his nose with swelling and bruising on his nose and left eye for 1 of 3 residents reviewed for abuse. (Resident M) Finding includes: The clinical record for Resident M was reviewed, on 8/1/24 1:30 p.m. The diagnoses included, but were not limited to, autistic disorder, intellectual disability, and epilepsy. A quarterly MDS (Minimum Data Set) assessment, dated 7/13/24, indicated Resident M was rarely/never understood. A physician's phone order, dated 7/24/24, indicated x-ray of the nose. A physician's verbal order, dated 7/25/24, indicated x-ray of nose due to swelling, mass, lump. An x-ray result, dated 7/25/24 at 9:45 a.m., indicated exam of nasal bones for nasal pain. There was no fracture, dislocation, nor bony destructive lesion noted. Paranasal air cells demonstrate no specific abnormality. No acute traumatic osseous abnormality. A progress note, dated 7/25/24 at 1:17 p.m., indicated the DON (Director of Nursing) observed Resident M bump into a wall while ambulating. The Nurse Practitioner was notified and gave a new physician's order for an x-ray. This progress note was entered into the electronic medical record on 8/1/24 at 1:18 p.m. (7 days after the x-ray was ordered) During an interview on 8/1/24 at 2:17 p.m., the Administrator indicated, during the morning clinical meeting, on 7/25/24, he was made aware of a scratch and some discoloration on Resident M's nose. The nurse got a physician's order for an x-ray of Resident M's nose to make sure there was no further injury. The Administrator needed to speak with the DON (Director of Nursing) to find out if the DON found anyone that knew how the scrape, swelling, and bruising to Resident M's nose happened. This would have been considered an injury of unknown origin. During an interview on 8/1/24 at 2:34 p.m., the DON indicated, on the morning of 7/25/24, she was going outside to take a break when she watched Resident M bump into a wall. The DON may not have been made aware of the scrape with swelling and bruising to Resident M's nose and eye prior to Resident M bumping the wall. The DON should have documented the injury and entered a progress note the morning she watched Resident M bump into the wall, so the medical record was accurate. During an interview on 8/1/24 at 2:54 p.m. CNA 10 (Certified Nursing Aide) indicated, on 7/24/24 at approximately 3:00 p.m. Resident M's left eye was black, his nose was swollen, cut, and bruised. Resident M's nose looked crooked like it was broken. CNA 10 reported this to RN 9 but didn't feel like the injury was taken seriously. During an observation on 8/2/24 at 7:30 a.m., Resident M was sitting in his room. Observed a small scratch and discoloration along the bridge and to the left side of Resident M's nose. On 8/2/24 at 11:15 a.m., the Corporate Nurse provided a copy of an undated facility policy, titled Indiana Abuse and Neglect and Misappropriation of Property, and indicated this was the current policy used by the facility. A review of the policy indicated all allegations involving injuries of unknown origin will be investigated. On 8/2/24 at 11:35 a.m., the facility had not identified the source of the cut, swelling, and bruising to Resident M's nose and left eye by survey exit. 3.1-28(d)

Based on interview and record review, the facility failed to provide the written bed hold policy prior to leaving the facility or at any time after for 2 of 3 residents reviewed for transfers and discharges. (Resident D, Resident E) Finding included: 1. The clinical record for Resident D was reviewed on 7/31/24 at 11:40 a.m. The diagnoses included, but were not limited to, end stage renal disease, fistula of intestine, and dysphagia. A quarterly MDS (Minimum Data Set) assessment, dated 4/24/24, indicated Resident D was moderately cognitively impaired. A progress note, dated 7/27/24 at 9:40 p.m., indicated Resident D called 911 and asked to be sent to the hospital. Resident D complained of nausea and vomiting and pain at his port site. The clinical record lacked documentation that the written bed hold policy was provided to the resident at the time of transfer or anytime after. During an interview on 7/31/24 at 3:24 p.m., the DON (Director of Nursing) indicated when Resident D called 911 so he could go to the hospital, the staff should have provided a bed hold policy to Resident D before he left the facility. If the nurse sent the bed hold policy, the nurse should have documented a progress note that indicated the document was sent. 21662 2. The record for Resident E was reviewed on 7/31/24 at 2:02 p.m. The diagnosis included, but was not limited to, wounds on bilateral thumbs. A progress note, dated 7/27/24 at 7:20 p.m., indicated Resident E was to sent to the hospital per his request. He complained of bilateral hand pain, inflammation, and redness at the site. The record lacked documentation the resident was given the written bed-hold policy information at time of transfer or at any time after. The resident was his own responsible party. On 7/31/24 at 2:20 p.m., the Administrator provided a copy of an undated facility policy, titled Transfer and Discharge Policy, and indicated this was the current policy used by the facility. A review of the policy indicated when an acute transfer occurs, present the acute transfer letter to the resident prior to the transfer. Discuss the transfer and transfer letter with the resident or responsible party if the resident is incapable of understanding or the transfer is an emergency. The resident's bed will be held while the facility representative contacts the resident or responsible party to discuss bed hold. This Federal tag relates to Complaint IN00439096. 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure medications were secured and labeled for 1 of 1 medication rooms and 1 of 1 random observations. Controlled substances were not double locked and TPN was not labeled and dated. (Resident P, Resident D) Finding included: 1. During an observation on 8/1/24 at 1:38 p.m., an unlocked medication refrigerator was inside the South Medication Room. Inside the refrigerator, observed a clear plastic bag sitting in a pink bin with other medications. The label on the bag, dated 7/30/24, indicated Resident P with a prescription number, Ativan (a controlled anti-anxiety/anti-seizure medication) 2 mg/ml (milligrams/milliliter), inject 0.5 ml (1 mg) intramuscularly (into the muscle) as needed for seizures. The bag contained 5 capped 1 ml vials of liquid. At that time, QMA 1 indicated the Ativan injections should be locked in the lock box in the refrigerator not laying in the pink bin with the other medications. On 8/1/24 at 9:11 a.m., the Administrator provided a copy of a policy, dated 9/2018, titled Storage of Medications, and indicated this was the current policy used by the facility. A review of the policy indicated controlled substances that require refrigeration are stored within a locked box attached to the inside of the refrigerator. 2. During an observation on 7/31/24 at 9:09 a.m., a clear plastic bag that contained 1400 ml of yellowish liquid was hanging on a pole in Resident D's room. The bag was labeled Resident D with a prescription number, TPN (total parental nutrition) 2:1, total bag volume 1660 ml, volume to be infused 1560 ml, and instructions to infuse 1560 ml over 24 hours. The bag of TPN was not labeled with any initials nor the date it was hung. During an interview on 7/31/24 at 9:25 a.m., the DON (Director of Nursing) indicated Resident D's TPN should have been labeled with the nurses initials and dated for the date it was administered. The TPN should have been taken down when Resident D went out to the hospital, on 7/27/24. (4 days before the observation and interview) On 8/2/24 at 11:35 a.m., the facility was unable to provide a policy regarding labeling medications. 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to notify the physician when staff found a large knife in the drawer of a resident with a history of suicidal ideations and suicidal attempts for 1 of 3 residents reviewed. (Resident B) Finding includes: During an interview 7/17/24 at 8:19 a.m., CNA 1 indicated, on 7/2/24 at approximately 12:15 a.m., Resident B asked CNA 1 to count some money that she kept in a drawer. When CNA 1 opened the drawer CNA 1 saw a large butcher knife. CNA 1 removed the knife and notified LPN 1 and the DON (Director of Nursing). The DON told CNA 1 to put the knife in the medication room and the DON would take care of it. CNA 1 put the knife in the medication room next to a pink plastic wash basin. On 7/17/24 at 8:32 a.m., during an observation of the medication room a pink plastic wash basin was sitting in a cabinet above the sink. Under the pink basin, observed a large metal knife with a dark handle. The blade on the knife was approximately 10 inches long and approximately 2 inches tall. The clinical record for Resident B was reviewed on 7/17/24 at 11:00 a.m. The diagnoses included, but were not limited to, major depressive disorder with psychotic symptoms, panic disorder, assaultive behavior, suicidal ideation, and post-traumatic stress disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 5/11/24, indicated Resident B was cognitively intact with moderate depression. A History and Physical, dated 12/27/23, indicated Resident B presented from an outside hospital after presenting to them after an attempted suicide by overdose at a hotel. A Psychiatric Progress Note, dated 1/28/24, indicated Resident B was seen for reevaluation of history of suicide attempts, suicidal ideation, agitation, and physical aggression. Resident B overdosed on an antidepressant on 12/22/23. Resident B overdosed on a handful of antidepressant per Resident B's report because she wanted to sleep and not wake up again after having an argument with her daughter. Resident B reported a history of four suicide attempts and a history of multiple psychiatric hospitalization s in the past. A Hospital History and Physical, dated 2/16/24, indicated Resident B was having thoughts of self-harm. She was very impulsive, and Resident B had insomnia. A facility progress note, dated 2/14/24 at 10:56 a.m., indicated Resident B stated she was not happy with the medication regimen for depression and anxiety. Resident B wanted an antidepressant three times daily. Educated Resident B that was not the ordered dose. Resident B stated she had been on it for years and knew how to take it. Resident B previously had a psychiatric visit for attempting to overdose on the antidepressant. The clinical record for Resident B lacked documentation of physician notification when a large knife was found in her drawer on 7/2/24. During an interview on 7/17/24 at 12:38 p.m., the DON indicated the physician should have been notified when the knife was found in Resident B's room. On 7/16/24 at 11:20 a.m., the Administrator provided a copy of an undated facility policy, titled Behavior Management General, and indicated this was the current policy used by the facility. A review of the policy indicated it is the policy of the facility to identify and safely manage resident who may present a danger to themselves or others. Contact the physician for new onset or unusual behaviors. This citation relates to Complaint IN00438670. 3.1-5(a)(2)

Based on interview and record review, the facility failed to report an allegation of abuse to the state health department for 1 of 3 allegations reviewed. A resident with a history of IV (intravenous) drug use made an allegation that a nurse supplied heroin to the resident. (Resident C) Finding includes: During an interview on [DATE] at 5:22 a.m., Resident C indicated she remembered being sent to the emergency department at night on [DATE]. Resident C was told she required CPR (cardiopulmonary resuscitation) and Narcan (medication used to reverse opioid overdose). Resident C snorted heroin (an opioid schedule 1 controlled substance). Resident C got the heroin from someone at the facility but would not say who she got it from because she already told the Administrator and DON (Director of Nursing). During an interview on [DATE] at 6:27 a.m., the Administrator indicated Resident C required CPR in early July and was sent to the emergency department. The facility believed she had taken illegal drugs that night. Initially, Resident C would not tell the facility where she got the drugs. Then on [DATE] Resident C told him she got the drugs from LPN 1. LPN 1 was suspended and the Administrator started an investigation. The clinical record for Resident C was reviewed on [DATE] at 11:21 a.m. An Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident C was moderately cognitively impaired. During an interview on [DATE] at 12:42 p.m., the Administrator indicated he did not think the allegation made by Resident C against LPN 1 needed to be reported to the state health department. The investigation into the allegation was ongoing. On [DATE] at 11:05 a.m., the Administrator provided a copy of an undated facility policy, titled Occurrence Incident Reporting, and indicated this was the current policy used by the facility. A review of the policy indicated a level 2 incident is considered more serious or an incident that resulted in harm and should be reported as applicable to state authorities. This citation relates to Complaint IN00438670. 3XXX,d+[DATE](c)

Based on observation, interview, and record review, the facility failed to implement a care plans with person-centered interventions for a resident diagnosed with suicidal ideations and a history of trauma and suicide attempts for suicidal ideations and suicide attempts for 1 of 3 residents reviewed. Staff found a large knife in the resident's drawer during care. (Resident B) Finding included: During an interview 7/17/24 at 8:19 a.m., CNA 1 indicated on 7/2/24 at approximately 12:15 a.m., Resident B asked CNA 1 to count some money that she kept in a drawer. When CNA 1 opened the drawer CNA 1 saw a large butcher knife. CNA 1 removed the knife and notified LPN 1 and the DON (Director of Nursing). The DON told CNA 1 to put the knife in the medication room and the DON would take care of it. CNA 1 put the knife in the medication room next to a pink plastic wash basin. On 7/17/24 at 8:32 a.m., during an observation of the medication room a pink plastic wash basin was sitting in a cabinet above the sink. Under the pink basin, observed a large metal knife with a dark handle. The blade on the knife was approximately 10 inches long and approximately 2 inches tall. The clinical record for Resident B was reviewed on 7/17/24 at 11:00 a.m. The diagnoses included, but were not limited to, major depressive disorder with psychotic symptoms, panic disorder, assaultive behavior, suicidal ideation, and post-traumatic stress disorder. A quarterly MDS (Minimum Data Set) assessment, dated 5/11/24, indicated Resident B was cognitively intact with moderate depression. A History and Physical, dated 12/27/23, indicated Resident B presented from an outside hospital after presenting to them after an attempted suicide by overdose at a hotel. A Psychiatric Progress Note, dated 1/28/24, indicated Resident B was seen for reevaluation of history of suicide attempts, suicidal ideation, agitation, and physical aggression. Resident B overdosed on an antidepressant on 12/22/23. Resident B overdosed on a handful of antidepressant per Resident B's report because she wanted to sleep and not wake up again after having an argument with her daughter. Resident B reported a history of four suicide attempts and a history of multiple psychiatric hospitalization s in the past. A Hospital History and Physical, dated 2/16/24, indicated Resident B was having thoughts of self-harm. She was very impulsive and Resident B had insomnia. A facility progress note, dated 2/14/24 at 10:56 a.m., indicated Resident B stated she was not happy with the medication regimen for depression and anxiety. Resident B wanted an antidepressant three times daily. Educated Resident B that was not the ordered dose. Resident B stated she had been on it for years and knew how to take it. Resident B previously had a psychiatric visit for attempting to overdose on the antidepressant. The clinical record for Resident B lacked a care plan with person-centered interventions for suicidal ideations. The clinical record for Resident B lacked a care plan with person-centered interventions for suicide attempts. During an interview on 7/17/24 at 12:38 p.m., the DON indicated Resident B should have had care plans with person-centered interventions for suicidal ideations and suicide attempts. On 7/17/24 at 11:20 a.m., the Administrator provided a copy of an undated policy, titled Behavior Management General, and indicated this was the current policy used by the facility. A review of the policy indicated complete a care plan, update with changes and or new behaviors. Include specific interventions. This citation relates to Complaint IN00438670. 3.1-43(a)(1)

Based on interview and record review, the facility administration failed to maintain the mental and physical wellbeing of residents for 1 of 3 residents reviewed. An allegation of abuse was made against a nurse but was not reported to the state health department and the nurse was not reported to the police. (Resident C) Finding included: During an interview, on [DATE] at 5:22 a.m. Resident C indicated she remembered being sent to the emergency department at night on [DATE]. Resident C was told she required CPR (cardiopulmonary resuscitation) and Narcan (medication used to reverse opioid overdose). Resident C snorted heroin (an opioid schedule 1 controlled substance). Resident C got the heroin from someone at the facility but would not say who she got it from because she already told the Administrator and DON (Director of Nursing). During an interview on [DATE] at 6:27 a.m., the Administrator indicated Resident C required CPR in early July and was sent to the emergency department. The facility believed she had taken illegal drugs that night. Initially, Resident C would not tell the facility where she got the drugs. Then on [DATE], Resident C told him she got the drugs from LPN 1 (Licensed Practical Nurse). LPN 1 was suspended, and I started an investigation. On [DATE] at 11:05 a.m., the Administrator provided a copy of an Indianapolis Metro Police Department Southeast District Information Card, dated [DATE], and indicated this was the police report regarding the allegation made by Resident C against LPN 1. A review of the document indicated incident type: property disposal. On [DATE] at 11:05 a.m., the Administrator provided a copy of an undated facility policy, titled Occurrence Incident Reporting, and indicated this was the current policy used by the facility. A review of the policy indicated a level 2 incident is considered more serious or an incident that resulted in harm and should be reported as applicable to state authorities. This citation relates to Complaint IN00438670. 3XXX,d+[DATE](q)

Based on interview and record review, the facility failed to provide behavioral health services to maintain residents highest practicable well-being for 2 of 3 residents reviewed. Residents with a known history of resident to resident altercations lacked interventions to prevent aggressive behaviors and a resident with a history of drinking alcohol in the facility did not have a plan for treatment and prevention for a substance use disorder. (Resident B, Resident C) Finding included: 1. During an interview on 7/3/24 at 11:53 a.m., the Activity Director indicated Resident B was outside in the courtyard on his way to smoke. Resident C walked up behind Resident B and threatened Resident B. Resident C said if Resident B didn't get out of Resident C's way he would . and then Resident B stood up. At that time, Resident C lunged at Resident B and they both went down to the ground. Neither resident hit the other. They were separated immediately. The Activity Director was not aware of another time when either resident was aggressive with another resident. During an interview on 7/3/24 at 11:59 a.m., QMA 1 (Qualified Medication Aide) indicated she heard someone yell a resident had fallen outside. QMA 1 looked and saw Resident C on top of Resident B on the ground holding on to each other but not hitting each other. The Activity Director was separating Resident B and Resident C and QMA 1 immediately went to assist. During an interview on 7/3/24 at 12:36 p.m., the Administrator indicated he witnessed an incident approximately a year ago when another resident told Resident B to get out of the way and Resident B stood up in a defensive stance and was verbally defensive. During an interview on 7/5/24 at 9:22 a.m., the Social Service Director indicated she went to speak with Resident B almost immediately after the incident with Resident C. Resident B was agitated and upset and said he wasn't going to let anyone push him around. Resident B was not able to recall the details of what happened with Resident C. Then, the Social Service Director went to speak to Resident C. Resident C's hair was disheveled from the tussle. Resident C told the Social Service Director that Resident B pushed him, Resident C wasn't going to take that, and Resident C would kill Resident B. The Social Service Director went back to speak with Resident B and Resident C a little while later and neither resident could recall the incident. The clinical record for Resident B was reviewed on 7/3/24 at 12:08 p.m. The diagnoses included, but were not limited to, dementia, Wernicke's encephalopathy, and anxiety disorder. A quarterly MDS (Minimum Data Set) assessment, dated 6/18/24, indicated Resident B was moderately cognitively impaired. A progress note, dated 4/13/24 at 1:00 p.m., indicated Resident B had a verbal disagreement with another resident. The residents were immediately separated. Law enforcement notified. Guardian gave permission for resident to be moved to another room. A progress note, dated 7/3/24 at 8:30 a.m., indicated Resident B was outside for a smoke break when Resident C said if Resident B didn't move. Then, Resident B stood up and made physical contact with Resident C. Both residents ended up on the ground before supervising staff were able to reach the residents. The residents were immediately separated. Resident B's clinical record lacked interventions for a history of resident to resident aggression. The clinical record for Resident C was reviewed on 7/3/24 at 12:15 p.m. The diagnoses included, but were not limited to, dementia and traumatic brain injury. A quarterly MDS assessment, dated 5/15/24, indicated Resident C was moderately cognitively impaired. A progress note, dated 3/3/24 at 11:40 a.m., indicated Resident C was observed being verbally aggressive in a common area. Resident C was educated on importance of being respectful to peers while in common areas. The DON was notified. Resident C's clinical record lacked interventions for a history of resident to resident aggression. 2. During an interview on 7/5/24 at 9:22 a.m., the Social Service Director indicated she was aware of one time when Resident B was intoxicated. Resident B hid a bottle of alcohol in the toilet tank. The Activity Director caught him with the alcohol in May. Resident B was also sent out to the hospital and diagnosed with alcohol intoxication in April. During an interview 7/5/24 on 9:42 a.m., the Activity Director indicated she found a glass bottle of liquor in the back of Resident B's toilet. Resident B smelled like alcohol and was trying to wash vomit off of his clothes. Resident B was intoxicated. The Activity Director reported to the Administrator and the Director of Nursing. The clinical record for Resident B was reviewed on 7/3/24 at 12:08 p.m. The diagnoses included, but were not limited to, alcohol dependence with alcohol induced persistent dementia and Wernicke's encephalopathy. A quarterly MDS assessment, dated 6/18/24, indicated Resident B was moderately cognitively impaired. A progress note, dated 4/16/24 at 4:24 p.m., indicated Resident B was sent to the emergency room this morning for a fall. Resident B was brought back to the facility during this shift with a diagnosis of alcohol intoxication. Resident B drank mouthwash overnight to the point of intoxication. A progress note, dated 5/3/24 at 2:51 p.m., indicated on 5/1/24, staff reported to writer there was a smell of smoke coming from Resident B's room. Upon entering the room, Resident B was in the bathroom with the tank lid removed and Resident B had vomited and was trying to wash out his clothes. Staff reported Resident B was intoxicated. A post fall evaluation, dated 4/14/24, indicated Resident B was drunk. A hospital discharge summary, dated 4/16/24, indicated a diagnosis of acute alcohol intoxication. An alcohol, serum plasma laboratory result, dated 4/16/24 at 10:02 a.m., indicated Resident B's blood alcohol level was 262.0 mg/dl (milligrams per decaliter). The normal range was less than 10.0 mg/dl. The clinical record lacked a plan for prevention and treatment of Resident B's substance use disorder. During an interview on 7/5/24 at 1:27 p.m., the Director of Nursing indicated Resident B should have had a care plan for hiding the liquor in the back of his toilet and smelling like alcohol. On 7/5/24 at 2:32 p.m., the Director of Nursing provided a copy of an undated facility policy, titled Behavior Management, and indicated this was the current policy used by the facility. A review of the policy indicated update the care plan with changes and or new behaviors. Include resident specific interventions. 3.1-37(a)

Based on observation, interview and record review, the facility failed to prevent significant medication errors when a resident diagnosed with C. diff (Clostridium difficile is a germ that causes inflammation of the colon and can be life threatening.) only received 8 of 39 doses of vancomycin (antibiotic used to treat intestinal infections). (Resident B) Finding included: During an interview, on 6/12/24 at 9:24 a.m. Resident B indicated Resident B had an infection but wasn't sure if he received all of his medications. The clinical record for Resident B was reviewed on 6/13/24 at 10:15 a.m. The diagnoses included, but were not limited to, fracture of right humerus, diabetes, and atrial fibrillation. An Admission MDS (Minimum Data Set) assessment, dated 6/3/24, indicated Resident B was cognitively intact and frequently incontinent of bowel. A hospital discharge summary, dated 5/29/24, indicated Resident B's primary diagnoses included, but were not limited to, diarrhea secondary to C. diff. Resident B was to continue oral vancomycin capsule (antibiotic used to treat intestinal infections) 125 mg (milligrams) orally 4 times daily for 12 days. An Inter-Facility Infection Control Transfer Form, dated 5/29/24, indicated Resident B had an active C. diff. infection and was in contact precautions at the hospital. Current Physician's orders included, but were not limited to: Vancomycin capsule 125 mg, give 1 capsule by mouth 4 times daily for infection for 12 days, initiated on 5/29/24. The June 2024 Medication Administration Record indicated Vancomycin 125 mg capsule orally 4 times daily: 6/1/24 at 9:00 a.m., not documented 6/1/24 at 12:00 p.m., not documented 6/1/24 at 5:00 p.m., awaiting pharmacy 6/1/24 at 9:00 p.m., awaiting pharmacy 6/2/24 at 9:00 a.m., awaiting pharmacy 6/2/24 at 12:00 p.m., awaiting pharmacy 6/2/24 at 5:00 p.m., not documented 6/2/24 at 9:00 p.m., not documented 6/3/24 at 9:00 a.m., administered 6/3/24 at 12:00 p.m., administered 6/3/24 at 5:00 p.m., on order 6/3/24 at 9:00 p.m., on order 6/4/24 at 9:00 a.m., not documented 6/4/24 at 12:00 p.m., not documented 6/4/24 at 5:00 p.m., not documented 6/4/24 at 9:00 p.m., not documented 6/5/24 at 9:00 a.m., not documented 6/5/24 at 12:00 p.m., not documented 6/5/24 at 5:00 p.m., not documented 6/5/24 at 9:00 p.m., not documented 6/6/24 at 9:00 a.m., not documented 6/6/24 at 12:00 p.m., not documented 6/6/24 at 5:00 p.m., administered 6/6/24 at 9:00 p.m., administered 6/7/24 at 9:00 a.m., on order 6/7/24 at 12:00 p.m., on order 6/7/24 at 5:00 p.m., on order 6/7/24 at 9:00 p.m., not documented 6/8/24 at 9:00 a.m., medication not available 6/8/24 at 12:00 p.m., medication not available 6/8/24 at 5:00 p.m., medication not available 6/8/24 at 9:00 p.m., medication not available 6/9/24 at 9:00 a.m., administered 6/9/24 at 12:00 p.m., administered 6/9/24 at 5:00 p.m., administered 6/9/24 at 9:00 p.m., administered 6/10/24 at 9:00 a.m., not documented 6/10/24 at 12:00 p.m., not documented 6/10/24 at 5:00 p.m., on order A pharmacy proof of delivery form indicated: Prescription number 5648946 was for Resident B's vancomycin 25mg/ml (milliliter) oral solution and 150ml bottle was delivered, on 6/1/24 at 5:23 a.m. (2 days after the physicians order was initiation) Prescription number 5666204 was for Resident B's vancomycin 25mg/ml oral solution and 150ml bottle was delivered, on 6/7/24 at 3:00 a.m. Prescription number 5676012 was for Resident B's vancomycin 25mg/ml oral solution and 150ml bottle was delivered, on 6/11/24 at 2:43 a.m. (approximately 8 hours after the physicians order was completed) On 6/13/24 at 1:34 p.m., inside the medication room refrigerator observed: A white plastic 150 ml (milliliter) bottle with a label that indicated prescription number 5648946, Resident B, Vancomycin 25 mg/ml oral solution give 5 ml (125 mg) orally 4 times daily for 12 days for infection. The bottle had not been opened. A white plastic 150 ml bottle with a label that indicated prescription number 5666204, Resident B, Vancomycin 25 mg/ml oral solution give 5 ml (125mg) orally 4 times daily for 12 days for infection. The bottle had not been opened. A white plastic 150 ml bottle with a label that indicated prescription number 5676012, Resident B, Vancomycin 25 mg/ml oral solution give 5 ml (125mg) orally 4 times daily for 12 days for infection. The bottle had been opened and contained approximately 140 ml fluid. During an interview on 6/17/24 at 8:34 a.m., the Director of Nursing indicated the pharmacy delivered vancomycin solution for Resident B instead of capsules because the pharmacy did not carry vancomycin capsules. The physician should have been notified. During an interview on 6/17/24 at 8:57 a.m., the Assistant Director of Nursing indicated she was also the Infection Preventionist. Staff should have clarified the physicians order for Vancomycin with the physician and pharmacy since oral solution was sent instead of capsules and the physicians order should have been updated in the medical record and the medication administration record. The Infection Preventionist or another nurse should have clarified what infection the antibiotic was treating. On 6/13/24 at 9:48 a.m., the Administrator in Training provided a copy of an undated facility policy, titled Medication Administration. A review of the policy indicated documentation of medications will follow accepted standards of nursing practice. This Federal tag relates to Complaint IN00433061. 3.1-48(c)(2)

A. Based on interview and record review, the facility failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Two days later the resident was found unresponsive for 1 of 3 residents reviewed for hospital transfers. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 1/11/22 at approximately 2:32 p.m., when the facility failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Two days later the resident was found unresponsive. The Administrator, Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on 3/11/22 at 5:00 p.m. The Immediate Jeopardy was removed on 3/16/22 at 4:05 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. B. Based on interview and record review, the facility failed to ensure medication for reversal of low blood sugar was available and given per nursing measures to treat an acute episode of [CONDITION(S)] resulting in hospitalization for 1 of 3 residents reviewed for diabetic care. (Resident C) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 2/22/22 at approximately 8:50 a.m., when the facility failed to provided [MEDICATION(S)] as a nursing measure to treat a hypoglycemic episode. The resident was sent emergently to the emergency room . The Administrator, Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on 3/11/22 at 5:00 p.m. The Immediate Jeopardy was removed on 3/16/22 at 4:05 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. C. Based on observation, interview, and record review, the facility failed to ensure care was provided to maintain the highest practicable well being for 4 of 21 residents reviewed. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: A. The clinical record for Resident B was reviewed on 3/9/22 at 11:22 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 1/1/22, indicated Resident B was cognitively intact. A Nurse Practitioner Note, dated 1/11/22 at 2:32 p.m., indicated Resident B was seen for increased confusion and fever. The Physical Therapist reported Resident B had increased confusion and agitation. The resident requested to go to the hospital. An order to send the resident to the emergency room for evaluation was written. A Nurse's progress note, dated 1/13/22 at 3:49 p.m., indicated Resident B was found unresponsive. Resident B's blood pressure was 80/39 mm/Hg (millimeters/Mercury), temperature 101.2 degrees Fahrenheit, pulse 139 beats per minutes, and the blood sugar was 154. Emergency services were called to transport the resident to the emergency room for evaluation. During an interview on 3/9/22 at 3:13 p.m., the Director of Nursing indicated there was no order written to send Resident B to the hospital nor was an order entered into the electronic medical record. The Nurse Practitioner note, dated 1/11/22 at 2:32 p.m., was not actually signed until 1/14/22 at 10:22 a.m., so the staff wouldn't have been aware Resident B needed to be sent to the hospital. During an interview on 3/11/22 at 11:01 a.m., the Nurse Practitioner indicated she had written an order to send Resident B to the Emergency Department and had not reported that to a nurse because it wasn't emergent at that time. The Nurse Practitioner put the order in a mailbox outside the Assistant Director of Nursing's (ADNS) office which was the standard practice used when the Nurse Practitioner wrote new orders for any residents. When the Nurse Practitioner saw him on 1/13/22, she was going to follow up on labs because he was never sent to the hospital as per the 1/11/22 written order. She does not remember Resident B reporting he had refused to go to the Emergency Department nor the staff reporting that Resident B refused to go to the Emergency Department. Resident B should have been sent to the Emergency Department on 1/11/22. During an interview on 3/11/22 at 2:47 p.m., RN (Registered Nurse) 1 indicated she had been working at the facility for several weeks. The Assistant Director of Nursing (ADNS) had been entering the new orders into the electronic medical record and would give a verbal report to the staff to notify them of the new orders. The Nurse Practitioners sometimes entered the orders for themselves, but most of the time it had been the ADNS. During an interview on 3/11/22 at 3:07 p.m., the ADNS indicated she had been entering the new orders for the Nurse Practitioners during the month of January. The Nurse Practitioner's would put the new orders in a mailbox outside her office and then she, the DON, or the Infection Preventionist would enter them into the electronic medical record. They did this because the Nurse Practitioner was not able to sign into the electronic medical record to enter the new orders. She was not aware of an order to send Resident B to the hospital. On 3/11/22 at 2:30 P.M., a Hospital Progress Note, dated 1/13/22, indicated Resident B was admitted with [CONDITION(S)], [CONDITION(S)], an acute urinary tract infection. On 3/11/22 at 2:30 P.M., a Hospital Discharge Summary, dated 2/8/22, indicated on 1/28/22 Resident B was comfort measures only. Resident B's respirations had ceased. On 3/11/22 at 4:21 p.m., the Administrator provided a copy of a facility policy, titled Physician Orders, dated 8/2010, and indicated this was the current policy used by the facility. A review of the policy indicated .The provider may write the order in the medical record . place orders in electronic medical record . print copy for Physician to sign and place in paper chart unless they are being signed electronically . the nurse that takes the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . contact .outside venders as required to execute the medical order . notify internal staff of changes/updates as appropriate. document contacts in the medical record. B. The clinical record for Resident C was reviewed on 3/11/22 at 12:50 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) assessment, dated 12/24/21, indicated Resident C was cognitively intact and had received insulin every day. A Nurse's progress note, dated 2/22/22 at 1:52 p.m. indicated I was informed by the QMA (Qualified Medication Aide) on 700-hallway that [Resident C] was having [CONDITION(S)] activities at 0850. I immediately rushed to the room knowing that a QMA was on that hallway. When I got to the room [Resident C] was sitting up in the wheelchair dressed. Both QMA and CNA (Certified Nursing Aide) were in the room. [Resident C] was lethargic but could respond to voices . While observing [Resident C] for [CONDITION(S)] activity, I did not see any activity going on. Then I asked the QMA what [Resident C's] blood sugar was. QMA reported that [Resident C's] blood sugar was 70 this morning . when she rechecked the blood sugar, it reads 64. [Resident C's] unresponsiveness continues to worsen. The QMA brought orange juice but [Resident C] was not able to drink. Then I rushed to get [MEDICATION(S)] [a prescription medication to treat [CONDITION(S)]] to administer and there is none on the cart or EDK [Emergency Drug Kit] on both sides. Then I called 911. When the ambulance arrived, I reported to them what the situation was and asked for [MEDICATION(S)]. During their assessment, [Resident C's] blood sugar went down to 36. [Resident C] was transported to the hospital. The February 2022 MAR (Medication Administration Record) indicated Resident C's blood sugar reading, on 2/22/22 at 7:30 a.m., was 70. During an interview on 3/11/22 at 3:15 p.m., RN (Registered Nurse) 1 indicated she was unable to locate the [MEDICATION(S)] for when a resident becomes hypoglycemic. She was unsure where to find the EDK. During an interview on 3/11/22 at 3:30 p.m., LPN (Licensed Practical Nurse) 1 indicated nurses ask each other where to find the [MEDICATION(S)] for when a resident's blood sugar declines. LPN 1 was observed to search through the east and west wing medication room refrigerators and was unable to find the [MEDICATION(S)] in either refrigerator. During an interview on 3/12/22 at 10:25 a.m., the Director of Nursing indicated the facility did not have standing orders for an emergency reversal medication for [CONDITION(S)] (low blood sugar). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/13/22 at 10:00 a.m., UM 1 indicated that if a resident was admitted with insulin orders she would call the physician to see if they would like to add an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/13/22 at 1:54 p.m., the Medical Director indicated that if a nurse would have called and asked for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/11/22 at 3:00 p.m., the Director of Nursing provided a copy of a facility policy, titled Blood Glucose Point of Care Testing, dated 12/2014, and indicated this was the current policy used by the facility. A review of the policy indicated It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .Extremely low blood glucose levels ([CONDITION(S)]) may result in confusion, unusual behaviors, coma, and even death if left untreated. C1. During an interview on 3/14/22 at 10:08 A.M., Resident J indicated his surgical wound treatment to his left ankle had not been completed as ordered by the physician when he initially admitted to the facility. The clinical record for Resident J was reviewed on 3/10/22 at 9:40 A.M. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 10/30/21, indicated Resident J was cognitively intact, did have surgical wounds, but did not require surgical wound care. An Initial Admission Evaluation, dated 10/23/21, indicated Skilled services/reason for admission: wound care . skin intact, resident will remain free of skin breakdown .nurse completing this section [the wound nurse]. A hospital discharge summary, dated 10/23/21, indicated [MEDICATION(S)] ointment (a prescription ointment used to debride wounds) apply 1 application topically 2 times a day. A Wound Nurse Practitioner Note, dated 10/25/21 at 9:06 A.M., indicated location - left medial ankle .follow surgeon's orders and scheduled follow up appointments-wet to dry dressings daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The November 2021 TAR (treatment administration record) indicated on 11/17/21 Resident J started receiving the wet to dry dressing to the left foot and ankle that was ordered on 10/25/21. On 3/18/21 at 2:00 P.M., the Activity Director provided a document, titled Resident Council Minutes, dated December 2022. A review of the document indicated concerns with wound care and medication administration were discussed. Residents in attendance for that meeting included, but were not limited to, Resident J, Resident C and Resident F as indicated by the document. During an interview on 3/21/22 at 9:25 A.M., the Wound Nurse indicated she could not explain why the treatment order from 10/25/21 was not entered into the electronic medical record until 11/17/21 because she didn't work for the facility at that time. However, the Initial Admission Evaluation, dated 10/23/21, indicated she completed the skin section of the evaluation. She was able to recall Resident J admitted with an infection in his wounds. On 3/11/22 at 4:21 P.M. The Administrator provided a copy of a facility policy, titled Physician Orders, dated 8/3/2010, and indicated this was the current policy used by the facility. A review of the policy indicated Medical Orders Transcription .the provider may write the order in the medical record .a provider may give a medical order over the phone .verbal orders are accepted but will be input into [the electronic medical record] by the nurse as soon as practicable. The practitioner will need to sign off on these orders . C2. During a random observation on 3/13/22 at 10:00 a.m., Resident D was observed in his room. The resident was lying in his bed. A soiled, undated dressing was noted on his mid-abdomen. The resident was observed to expose the wound. The wound had a moderate amount of thick, dark red, and whitish drainage. During an interview the resident indicated his dressing did not get changed every day. On 3/14/22 at 9:30 a.m., Resident D was observed in his room. An undated dressing was noted on his mid-abdomen. During a wound care observation on 3/15/22 at 10:00 a.m., the Wound Nurse was observed at the resident's bedside. The Wound Nurse removed an undated dressing. During an interview, at that time the Wound Nurse indicated the dressing should be dated at the time the dressing was changed. On 3/15/22 at 10:30 a.m., the clinical record of Resident D was reviewed. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 2/21/22, indicated Resident D was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 4/30/21 and current through 3/28/22, indicated Resident D was at risk for altered skin integrity related to impaired mobility. The resident had a surgical wound. The interventions included but were not limited to administer treatments as ordered by a medical provider. A Nurse Practitioner note, dated 3/7/22, indicated to encourage nursing staff to change dressings as ordered. A wound evaluation, dated 3/14/22, indicated to change the dressing daily. C3. During an interview on 3/18/22 at 2:30 p.m., Resident E indicated his dressings did not get changed every day as ordered by the physician. On 3/21/22 at 8:30 a.m., the clinical record of Resident E was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS assessment, dated 12/17/21, indicated Resident E was cognitively intact. The physician orders, dated 3/17/22, indicated Right plantar/heel eschar: Cleanse area with wound cleanser or normal saline. Paint the areas with [MEDICATION(S)] daily, secure with dry gauze/kerlix daily. During a wound care observation on 3/17/22 at 2:33 p.m., the Wound Nurse was observed completing Resident E's dressing change. The dressing on Resident E's right foot was undated. During an interview at that time, the Wound Nurse indicated the dressing should have been dated. On 3/18/21 at 2:00 P.M., the Activity Director provided a document, titled Resident Council Minutes, dated December 2022. A review of the document indicated concerns with wound care and medication administration were discussed. Residents in attendance for that meeting included, but were not limited to, Resident J, Resident C and Resident F as indicated by the document. C4. During an interview on 3/13/22 at 11:30 a.m., Resident F indicated the areas on his legs were getting worse and sometimes the dressings on this legs do not get changed for days. On 3/15/22 at 2:33 p.m., the clinical record of Resident F was reviewed. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS assessment, dated 3/12/22, indicated Resident F was cognitively intact. A Physicians Order, with a start date of 12/27/21, indicated to wrap the bilateral lower extremities with kerlix and ace wraps from toes to knees every day for [CONDITION(S)]. A care plan, undated, indicated Resident F was at risk for further skin breakdown. The interventions included, but were not limited to: evaluate existing wound daily. During a wound care observation on 3/18/22 at 2:00 p.m., the ADON was observed providing wound care. The ADON removed the undated dressing. During an interview at that time, the ADON indicated the dressing should have been dated indicating the date of the previous dressing change. A wound evaluation, dated 3/14/22, indicated to change the dressing daily. On 3/18/22 at 2:15 p.m., a policy/procedure was requested from the ADON for dating the dressing at the time it was changed. On 3/18/21 at 2:00 P.M., the Activity Director provided a document, titled Resident Council Minutes, dated December 2022. A review of the document indicated concerns with wound care and medication administration were discussed. Residents in attendance for that meeting included, but were not limited to, Resident J, Resident C and Resident F as indicated by the document. On 3/21/22 at 4:00 p.m., a policy/procedure for dating dressings was not provided from the facility by the end of the exit date. The Immediate Jeopardy, that began on 1/11/22 and 2/22/22, was removed on 3/16/22 when the facility inserviced the facility staff on following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal tag is related to Complaint IN 538. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure sufficient and competent nursing staff was provided. Treatment orders were not in place, appropriate care for a gtube was not provided, dressings were not dated, PICC line dressings were not changed, catheter care was not provided, medications were left in resident rooms, and antibiotics were given longer than prescribed. (Resident B, Resident Y, Resident E, Resident X, Resident M, Resident F, Resident D, Resident K, Resident J, Resident N) Finding includes: 1. During the survey dates of 3/9/22 through 3/21/22 the following interviews were completed. a. The facility does not have enough staff on evenings and weekends. b. The facility does not have enough staff. It takes an hour for call lights to be answered. 2. During an interview on 3/14/22 at 9:10 a.m. the Director of Nursing indicated the facility does not use competencies, instead the facility uses staff in-services for education. 3. On 3/18/21 at 2:00 P.M., the Activity Director provided a documents, titled Resident Council Minutes. A review of the documents indicated long call light times were discussed at the Resident Council Meetings on 1/31/22 and 2/28/22. During Resident Council Meeting on 3/18/22 at 2:15 p.m., the residents indicated the facility does not have enough staff on third shift. 4. The Facility Assessment Tool, dated 10/1/21, indicated: .average daily census 72 . staffing needs .for direct care needs: 3 or 4 Licensed Practical Nurses (LPN) or Registered Nurses (RN) on day shift, 3 or 4 LPN or RN on evening shift, and 2 LPN or RN on night shift. 5. The as worked nursing schedule, dated 2/23/22 to 3/9/22, indicated: a. On 2/23/22, the facility had 1 Licensed Practical Nurse (LPN) that worked day shift, 1 LPN that worked evening shift, and 1 Registered Nurse (RN) that worked night shift. b. On 2/24/22, the facility had 1 LPN that worked day shift, 2 LPN's that worked evening shift, and 1 LPN that worked night shift. c. On 2/25/22, the facility had 1 LPN that worked day shift, 1 RN that worked evening shift, and 1 RN that worked night shift. d. On 2/26/22, the facility had 1 LPN that worked day shift, 1 LPN that worked evening shift, and 1 LPN that worked night shift. e. On 2/27/22, the facility had 1 LPN that worked day shift, 1 LPN that worked evening shift, and 1 LPN that worked night shift. f. On 2/28/22, the facility had 1 LPN that worked day shift, 2 LPN's that worked evening shift, and 1 RN that worked night shift. g. On 3/1/22, the facility had 2 LPN's that worked day shift, 1 LPN that worked evening shift, and 1 LPN that worked night shift. h. On 3/2/22, the facility had 1 LPN that worked day shift, 1 LPN that worked evening shift, and 1 LPN that worked night shift. i. On 3/3/22, the facility had 1 LPN that worked day shift, 1 LPN and 1 RN that worked evening shift, and 1 RN that worked night shift. j. On 3/4/22, the facility had 2 LPN's that worked day shift, 2 LPN's that worked evening shift, and 1 LPN that worked night shift. k. On 3/5/22, the facility had 1 LPN that worked day shift, 1 LPN and 1 RN that worked evening and night shift. l. On 3/6/22, the facility had 2 LPN's that worked day shift, 1 LPN and 1 RN that worked evening and night shift. m. On 3/7/22, the facility had 1 LPN that worked day shift, 1 LPN and 1 RN that worked evening shift, and 1 RN that worked night shift. n. On 3/8/22, the facility had 1 LPN that worked day shift, 1 LPN that worked evening shift, and 1 LPN that worked night shift. o. On 3/9/22, the facility had 1 LPN that worked day shift, 1 LPN that worked evening shift, and 1 LPN that worked night shift. 6. The lack of sufficient nursing staff resulted surgical dressing changes not being completed. Cross reference F684. 7. The lack of sufficient nursing staff resulted care not being provided for a feeding tube. Cross reference F693. 8. The lack of sufficient nursing staff resulted PICC line dressings not being changed. Cross reference F694. 9. The lack of sufficient nursing staff resulted nutritional supplements not being provided. Cross reference F692. 10. The lack of sufficient nursing staff resulted medications being left in a resident room. Cross reference F689. 11. The lack of sufficient nursing staff resulted a resident receiving unnecessary medications. Cross reference F757. 12. The lack of sufficient nursing staff resulted a lack of urinary catheter care. Cross reference F690. This Federal tag relates to Complaint IN 538. 3.1-17(a)

Based on interview and record review, the facility failed to ensure urinary catheter care was provided for 1 of 2 residents reviewed for catheter care. This resulted in a resident being diagnosed with [CONDITION(S)] and a urinary tract infection. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 3/9/22 at 11:22 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 1/1/22, indicated Resident B was cognitively intact and did not have an indwelling urinary catheter. An Initial Admission Evaluation, dated 12/27/21 at 6:26 p.m., indicated Resident B had a 14f (size) indwelling Foley catheter that was draining clear urine. A Nurse Practitioner Progress Note, dated 1/11/22 at 2:32 p.m., indicated Resident B was seen for increased confusion and fever. The Physical Therapist reported Resident B had increased confusion and agitation. The resident requested to go to the hospital. An order to send the resident to the emergency room for evaluation was written. A Nurse Practitioner Progress Note, dated 1/13/22 at 2:08 P.M., indicated .Resident B had an indwelling Foley catheter and the catheter had been removed three days prior due to irritation. A Nurse's progress note, dated 1/13/22 at 3:49 p.m., indicated Resident B was found unresponsive. Resident B's blood pressure was 80/39 mm/Hg (millimeters/Mercury), temperature 101.2 degrees Fahrenheit, pulse 139 beats per minutes, and the blood sugar was 154. Emergency services were called to transport the resident to the emergency room for evaluation. The clinical record lacked physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked a care plan for the indwelling urinary catheter. The clinical record lacked documentation that urinary catheter care had been provided. During an interview on 3/11/22 at 9:45 a.m., the DON indicated Resident B should have had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/11/22 at 2:30 p.m., a Hospital Progress Note, dated 1/13/22, indicated Resident B was admitted with [CONDITION(S)], [CONDITION(S)], an acute urinary tract infection. On 3/11/22 at 2:30 p.m., a Hospital Discharge Summary, dated 2/8/22, indicated on 1/28/22 Resident B was comfort measures only. Resident B's respirations had ceased. On 3/14/22 at 10:00 a.m., a urinalysis result, dated 1/17/22, indicated the urinalysis that had been collected on 1/13/22 had greater than 100,000 CFU/ML (colony-forming unit per milliliter) of Proteus vulgaris (bacteria) in the urine. On 3/14/22 at 10:30 a.m., the DON provided a copy of a facility policy, titled Catheter Care, dated 10/13/13, and indicated this was the current policy used by the facility. A review of the policy indicated catheter care is performed at least twice daily on residents that have indwelling catheters, for as long as the catheter is in place .the risk of bacteremia (bacteria in the blood) is 3 to 36 times more likely than residents without an indwelling catheter. This Federal tag relates to Complaint IN 538. 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure nutritional supplements recommended by a dietician were implemented for 1 of 2 residents reviewed for nutrition. (Resident X) Resident X experienced a significant weight loss before intervention was recommended. Finding includes: On 3/11/22 at 10:49 A.M., Resident X's medical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) assessment, dated 2/15/22, indicated Resident X had moderate cognitive impairment and required set up assistance and supervision for eating. The care plan indicated goals and interventions were in place for increased nutritional risks and that Resident X had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The weights included, but were not limited to: 3/1/22-108.2 pounds 2/15/22- 105.2 pounds The 2/15/22 weight struck out in the medical record on 2/26/22 as incorrect documentation. 1/2/22-148 pounds 1/1/22-147 pounds The clinical record lacked any other weight documentation from February 2022 through March 2022. A Progress Note, dated 3/4/22, indicated a weight change was recorded. The note included, but was not limited to, a recommendation from the Registered Dietician for Ensure (a nutritional supplement) TID (three times daily) at this time to promote weight maintenance. A review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/22 at 9:30 A.M., an interview with LPN 7 indicated on 2/8/22 Resident X had readmitted after a fall with a fracture. No weight was recorded for resident's readmitted . LPN 7 indicated she would get a current weight on Resident X and also check on nutritional supplement orders. On 3/17/22 at 11:01 A.M., the DON indicated Resident X was reweighed at 110.2 pounds; this was a loss of 37.8 pounds since the 1/2/22 weight, or a 25.5% weight loss. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On 3/17/22 at 1:35 P.M., a Resident Height and Weight policy, dated 5/19/16, was provided by the DON who indicated this was the policy currently being used. The policy indicated that reweight parameters included a plus or minus of 5 pounds of weight in one week and that this would result in a reweight within 24 hours, validation with nurse for an accurate weight, and the notification of the IDT (interdisciplinary) team, doctor, and family if indicated. On 3/21/22 at 8:47 A.M., an interview with the DON indicated that Resident X should have been reweighed and had orders for Ensure or other nutritional supplements prior to 3/17/22. 3.1-46(a)(2)

A. Based on observation, interview and record review, the facility failed to prevent sexual and physical (death) abuse resulting in a female resident being physically and sexually abused by a male resident for 2 of 4 residents reviewed for abuse. (Residents C, Resident B) B. Based on interview and record review, the facility failed to prevent verbal abuse resulting in 2 female residents being threatened with physical and sexual abuse by a male resident that was not Immediate Jeopardy for 3 of 4 residents reviewed for abuse. (Residents D, Resident B, Resident E) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 2/2/22 at approximately 5:00 a.m., when the facility failed to prevent physical (death) and sexual abuse. The Administrator, Administrator in Training, Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on 2/7/22 at 5:00 p.m. The Immediate Jeopardy was removed on 2/10/22 at 2:40 p.m., but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A. During the initial tour of the facility, on 2/2/22 from 11:40 a.m. to 12:15 p.m., Resident C was in her room with Police Officers standing guard at the door. Resident C could not be observed from the hallway. Resident B was in his room, located on a different unit in the facility, with a Police Officer standing guard at the door to the room. Resident B was observed sitting up in his electric wheelchair staring at the hallway with a flat affect (showing no emotion on his face). The clinical record for Resident B was reviewed on 2/2/22 at 12:30 p.m The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 1/12/22, indicated Resident B was cognitively intact, required extensive assistance of one staff member for bed mobility and transfers, and had moderate depression. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident C was reviewed on 2/2/22 at 12:15 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Initial Evaluation, dated 1/28/22 at 3:15 p.m., indicated Resident C was nonverbal, bedfast (confined to bed), and mobility was very limited (she made occasional slight changes in body or extremity position but unable to make frequent or significant changes independently). During an interview on 2/3/22 at 5:10 p.m., QMA (Qualified Medication Aide) 1 indicated she entered Resident C's room and Resident B was lying on top of Resident C, in bed, with his pants down. Resident C's face was covered with Resident B's hand. Resident B jumped off of Resident C and left the room. QMA 1 removed a pillow from Resident C's face. Resident C was without clothing, had a small scratch to her left leg, and her incontinence brief was pulled to the side. During an interview on 2/7/22 at 10:20 a.m., LPN (Licensed Practical Nurse) 2 indicated on 2/2/22 at approximately 5:00 a.m., he was at the nurse's station for the 100 and 200 Hall. QMA 1 had come to the nurse's station and was unable to verbalize what she saw. QMA 1 grabbed his hand and said, come on, come on. When he entered Resident C's room, he saw Resident B standing approximately a foot away from Resident C's bed with his pants down to his ankles. The resident's electric wheelchair was inside the room, approximately a foot behind him. Resident B was trying to sit in the wheelchair but was unsteady and confused when trying to speak to the nurse. The nurse smelled alcohol when Resident B was trying to speak. There was a large bottle of dry [NAME] on the floor. Resident B was escorted out of Resident C's room and immediately placed on one-on-one supervision with another staff member. Resident C was lying in bed, on her back, with legs spread apart and her face looking at the ceiling. Resident C did not have a pulse, but her body was warm to touch. During an interview on 2/3/22 at 5:24 p.m., CNA (Certified Nursing Assistant) 1 indicated, on 2/2/22, when she entered Resident C's room the resident's brief was pulled to the side. During an interview on 2/7/22 at 8:53 a.m., QMA 2 indicated Resident B seemed depressed over the past few weeks because his roommate moved out. On 2/2/22 at 2:06 p.m., Resident B was observed to be handcuffed and assisted into the back of the police van. He required minimal assistance from the police officer. Resident B stepped up into the back of the van. B.1. During an interview on 2/7/22 at 9:00 a.m., QMA 3 indicated on 1/28/22 Resident B had been drinking out of a cup that smelled like alcohol. The resident could be verbally aggressive when he had been drinking alcohol. Resident B threatened to rape Resident D several times on 2/1/22. The QMA had overheard other staff discussing this at the nurse's station. The QMA was not sure if this had been reported but indicated the threats should have been reported to the supervisor. The QMA was unable to remember which staff members she heard discussing this at the nurse's station. During an interview on 2/7/22 at 9:20 a.m., Resident D indicated on 2/1/22 at approximately 2:00 p.m., Resident B began making inappropriate sexual comments toward her. Resident B indicated to Resident D that he was going to eat between my legs and made comments about Resident D's breasts. Resident B laughed and said, just wait until tonight, just wait until tonight. Resident B continued to make these comments several times throughout that day. Resident D reported this to QMA 4 around 11:00 p.m. on 2/1/22. At that time, QMA 4 indicated to her (Resident D) not to worry because she would watch the hall. The clinical record for Resident D was reviewed on 2/7/22 at 11:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 12/11/21, indicated Resident D was cognitively intact. B.2. During an interview on 2/7/22 at 9:50 a.m., Resident E indicated Resident B told her she was beautiful and offered to buy her jewelry. She said no. When he (Resident B) got drunk, he would get violent. There was a day, the week before last, Resident B got out of his wheelchair and in her face and said, you f**king b*tch, I'll knock you out of that wheelchair. Resident E told a member of the resident council and he said he would take care of it. During an interview on 2/7/22 at 10:00 a.m., the resident council member indicated Resident B had been vulgar to female residents that didn't like him. About a week and a half ago, Resident E was afraid of Resident B because of vulgar comments he had made to her. The resident council member had reported this to staff. He was unable to remember which staff member he reported this to. The clinical record for Resident E was reviewed on 2/7/22 at 11:40 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 11/11/21, indicated Resident E was cognitively intact. On 2/7/22 at 11:00 a.m., the Director of Nursing provided a copy of a facility policy, dated 9/1/17, titled Indiana Abuse and Neglect and Misappropriation of Property, and indicated this was the current policy used by the facility. A review of the policy indicated, It is the intent of this facility to prevent the abuse, mistreatment or neglect of residents. The Immediate Jeopardy, that began on 2/2/22, was removed on 2/10/22 when the facility inserviced the facility staff on abuse policies and behaviors, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaints IN 277 and IN 425. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to report allegations of sexual abuse for 3 of 4 residents reviewed for abuse (Residents B, Resident D, Resident E) this resulted in a female resident being physically (death) and sexually abused by a male resident. (Resident C, Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, [DATE] at approximately 2:00 p.m., when the facility failed to report prior sexual actions of a resident which resulted in a female resident being sexually and physically (death) assaulted. The Administrator, Administrator in Training, Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 5:00 p.m. The Immediate Jeopardy was removed on [DATE] at 2:40 p.m., but noncompliance remained at a lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview on [DATE] at 9:00 a.m., QMA 3 indicated Resident B threatened to rape Resident D several times on [DATE]. The QMA had overheard other staff discussing this at the nurse's station on [DATE]. The QMA was not sure if this had been reported but indicated the threats should have been reported to the supervisor. The QMA was unable to remember which staff members she heard discussing this at the nurse's station. During an interview on [DATE] at 9:20 a.m., Resident D indicated on [DATE] at approximately 2:00 p.m., Resident B began making inappropriate sexual comments toward her. Resident B indicated to Resident D that he was going to eat between my legs and made comments about Resident D's breasts. Resident B laughed and said, just wait until tonight, just wait until tonight. Resident B continued to make these comments several times throughout that day. Resident D reported this to QMA 4 around 11:00 p.m. on [DATE]. At that time, QMA 4 had indicated to her (Resident D) not to worry because she would watch the hall. The clinical record for Resident D was reviewed on [DATE] at 11:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident D was cognitively intact. 2. During an interview on [DATE] at 9:50 a.m., Resident E indicated there was a day, the week before last, Resident B got out of his wheelchair and in her face and said, you f**king b*tch, I'll knock you out of that wheelchair. She didn't think staff saw this happen and had not reported this to staff. Resident E told a member of the resident council about the incident with Resident B, and he said he would take care of it. During an interview on [DATE] at 10:00 a.m., the resident council member indicated Resident B had been vulgar to female residents that didn't like him. About a week and a half ago, Resident E was afraid of Resident B because of vulgar comments he had made to her. The resident council member had reported this to staff. He was unable to remember which staff member he reported this to. The clinical record for Resident E was reviewed on [DATE] at 11:40 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated [DATE], indicated Resident E was cognitively intact. 3. During the initial tour of the facility, on [DATE] from 11:40 a.m. to 12:15 p.m., Resident C was in her room with Police Officers standing guard at the door. Resident C could not be observed from the hallway. Resident B was in his room, located on a different unit in the facility, with a Police Officer standing guard at the door to the room. During an interview on [DATE] at 5:10 p.m., QMA (Qualified Medication Aide) 1 indicated, on [DATE] at approximately 5:00 a.m., she entered Resident C's room and Resident B was on top of Resident C, in bed, with his pants down. Resident C's face was covered with Resident B's hand. Resident B jumped off of Resident C and left the room. Resident C was naked, had a small scratch to her left leg, and her incontinence brief was pulled to the side. Resident C's pupils were dilated and she was found to be deceased . On [DATE] at 11:00 a.m., the Director of Nursing provided a copy of a facility policy, dated [DATE], titled Indiana Abuse and Neglect and Misappropriation of Property, and indicated this was the current policy used by the facility. A review of the policy indicated, Each occurrence . of alleged abuse . will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director of the incident or allegation immediately The Immediate Jeopardy, that began on [DATE], was removed on [DATE] when the facility inserviced the staff on reporting abuse, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaints IN 277 and IN 425. 3.,d+[DATE](c)

Based on interview and record review, the facility failed to investigate allegations of verbal abuse for 2 of 4 residents reviewed for abuse. (Residents D and E). This resulted in a female resident being physically (death) and sexually assaulted. (Resident C, Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, [DATE] at approximately 2:00 p.m., when the facility failed to investigate reported allegations of sexual and verbal abuse. The Administrator, Administrator in Training, Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 5:00 p.m. The Immediate Jeopardy was removed on [DATE] at 2:40 p.m., but noncompliance remained at a lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview on [DATE] at 9:20 a.m., Resident D indicated on [DATE] at approximately 2:00 p.m., Resident B began making inappropriate sexual comments toward her. She had reported to QMA 4 around 11:00 p.m. on [DATE] that Resident B had made inappropriate sexual comments towards her. The QMA had indicated to her not to worry because she would watch the hall. The clinical record for Resident D was reviewed on [DATE] at 11:00 a.m. The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident D was cognitively intact. During an interview on [DATE] at 9:00 a.m., QMA 3 indicated she had overheard other staff discussing that Resident B threatened to rape Resident D several times on [DATE]. The QMA was not sure if this had been reported but indicated the threats should have been reported to the supervisor. QMA 3 was unable to remember which staff members she heard discussing this at the nurse's station. 2. During an interview on [DATE] at 10:00 a.m., the resident council member indicated Resident E came to him and was afraid of Resident B. Resident B had made vulgar comments to her about a week and a half ago. The resident council member indicated he had told Resident B that he could not behave in that manner. He had reported this information to a staff member after Resident E spoke to him. During an interview on [DATE] at 9:50 a.m., Resident E indicated Resident B was making inappropriate comments and was verbally aggressive towards her. The resident reported Resident B's behaviors to a resident council member and he indicated he would take care of it. The clinical record for Resident E was reviewed on [DATE] at 11:40 a.m. The Quarterly MDS assessment, dated [DATE], indicated Resident E was cognitively intact. On [DATE] at 1:30 p.m., the police officer indicated that at approximately 5:00 a.m. on [DATE], police were dispatched to the facility following a sexual assault resulting in Resident C being found deceased . On [DATE] at 2:00 p.m., the Administrator in Training, DON, and Regional Nurse Consultant indicated they were unaware of Residents D's or E's allegations of verbal abuse. On [DATE] at 9:15 a.m., the DON indicated that the allegations should have been reported and investigated. On [DATE] at 11:00 a.m., The Director of Nursing provided a copy of a facility policy, dated [DATE], titled Indiana Abuse and Neglect and Misappropriation of Property, and indicated this was the current policy used by the facility. A review of the policy indicated, Each occurrence . of alleged abuse . will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director of the incident or allegation immediately. The Immediate Jeopardy, that began on [DATE], was removed on [DATE] when the facility inserviced staff on abuse policies and procedures, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaints IN 277 and IN 425. 3.,d+[DATE](d)

Based on observation, interview, and record review, the facility failed to monitor a male resident for verbal and physically aggressive behaviors, towards female residents, and alcohol consumption for 1 of 1 residents reviewed for behaviors. This resulted in resulted in 2 female residents being verbally abused and 1 female resident being physically (death) and sexually abused. (Resident B, Resident C, Resident D, Resident E) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 1/28/22 at approximately 12:00 p.m., when the facility failed to implement behavior monitoring and appropriate interventions to manage the behaviors for a male resident that became aggressive toward female residents and consuming alcohol. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/10/22 at 2:40 p.m. The Immediate Jeopardy was removed on 2/11/22 at 1:15 p.m., but noncompliance remained at a lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record of Resident B was reviewed on 2/2/22 at 12:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 1/12/22, indicated Resident B was cognitively intact. The clinical record for Resident B lacked a person-centered care plan with appropriate interventions to address major depressive disorder, alcohol abuse, and behaviors related to consuming alcohol. The hospital discharge summary, dated 9/16/21 at 2:19 a.m., indicated Resident B had been consuming alcohol 3 to 5 times per week, consumed more alcohol than intended, and was homeless because his family member had made him leave home due to alcohol consumption. During an interview on 2/7/22 at 8:53 a.m., QMA 2 indicated Resident B seemed depressed over the past few weeks because his roommate moved out. During the initial tour of the facility, on 2/2/22 from 11:40 a.m. to 12:15 p.m., Resident C was in her room with Police Officers standing guard at the door. Resident C could not be observed from the hallway. Resident B was in his room, located on a different unit in the facility, with a Police Officer standing guard at the door to the room. Resident B was observed sitting up in his electric wheelchair staring at the hallway with a flat affect (showing no emotion on face). During an interview on 2/3/22 at 5:10 p.m., QMA (Qualified Medication Aide) 1 indicated, she entered Resident C's room and Resident B was on top of Resident C, in bed, with his pants down. Resident C's face was covered with Resident B's hand. Resident B jumped off of Resident C and left the room. Resident C was naked, had a small scratch to her left leg, and her incontinence brief was pulled to the side. During an interview on 2/7/22 at 10:20 a.m., LPN (Licensed Practical Nurse) 2 indicated on 2/2/22 at approximately 5:00 a.m., he was at the nurse's station for the 100 and 200 Hall. QMA 1 had come to the nurse's station and was unable to verbalize what she saw. QMA 1 grabbed his hand and said, come on, come on. When he entered Resident C's room, he saw Resident B standing approximately a foot away from Resident C's bed with his pants down to his ankles. Resident C's electric wheelchair was inside the room, approximately a foot behind him. Resident B was trying to sit in the wheelchair but was unsteady and confused when trying to speak to the nurse. The nurse smelled alcohol when Resident B was trying to speak. There was a large bottle of dry [NAME] on the floor. Resident B was escorted out of Resident C's room and immediately placed on one-on-one supervision with another staff member. Resident C was lying in bed, on her back, with legs spread apart and her face looking at the ceiling. Resident C did not have a pulse, but her body was warm to touch. During an interview on 2/7/22 at 9:00 a.m., QMA 3 indicated on 1/28/22 Resident B had been drinking out of a cup that smelled like alcohol. Resident B could be verbally aggressive when he had been drinking alcohol. Resident B threatened to rape Resident D several times on 2/1/22. QMA 3 overheard other staff discussing this at the nurse's station Resident D hadn't reported this to QMA 3. The QMA was not sure if this had been reported but indicated the threats should have been reported to the supervisor. The QMA was unable to remember which staff members she had heard discussing this at the nurse's station. During an interview on 2/7/22 at 9:20 a.m., Resident D indicated on 2/1/22 at approximately 2:00 p.m., Resident B began making inappropriate sexual comments toward her. Resident B indicated to Resident D that he was going to eat between my legs and made comments about Resident D's breasts. Resident B laughed and said, just wait until tonight, just wait until tonight. Resident B continued to make these comments several times throughout that day. Resident D reported this to QMA 4 around 11:00 p.m. on 2/1/22. The QMA had indicated to Resident D not to worry because she would watch the hall. During an interview on 2/7/22 at 9:50 a.m., Resident E indicated Resident B told her she was beautiful and offered to buy her jewelry. She said no. When he (Resident B) got drunk, he would get violent. There was a day, the week before last, Resident B got out of his wheelchair and in her face and said, you f**king b*tch, I'll knock you out of that wheelchair. Resident E told a member of the resident council about the incident with Resident B, and he said he would take care of it. During an interview on 2/7/22 at 10:00 a.m., the resident council member indicated Resident B had been vulgar to female residents that he didn't think liked him. About a week and a half ago, Resident E was afraid of Resident B because of vulgar comments he had made to her. The resident council member had reported this to staff. He was unable to remember which staff member he reported this to. During an interview on 2/10/22 at 1:03 p.m., the Social Service Director indicated she was not aware of Resident B's alcohol use prior to admission but if a resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident was currently consuming alcohol, first she would have attempted to send the resident to a recovery center. If a recovery center was not available or could not care for that resident, she would have had the resident sign a behavior contract. The contract should have included if the resident consumed alcohol, they would have received a 30-day notice for discharge. If psychiatric services would have recommended behavior monitoring, we would have had it in place. During an interview on 2/10/22 at 1:12 p.m., the Admission Coordinator indicated she could not remember the admission for Resident B but if a resident was referred for admission with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/10/22 at 1:20 p.m., the Director of Nursing indicated she had a concern regarding Resident B's admission because he had left other facilities against medical advice and a criminal background check showed he had previous drug and alcohol problems. Resident B originally was admitted for rehabilitation to home, but when the discharge process was started Resident B indicated to social services he was homeless. During an interview on 2/11/22 at 8:30 a.m., the Director of Nursing indicated the alcohol consumption and behaviors caused by consuming alcohol should have been monitored. There should have been appropriate interventions in place to address Resident B's behaviors. On 2/11/22 at 8:30 a.m., the Director of Nursing provided a copy of a facility policy titled, Behavior Management General, dated 4/8/16, and indicated this was the current policy used by the facility. A review of the policy indicated It is the policy of this facility to identify and safely manage residents who are exhibiting behaviors related to [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy, that began on 1/28/22, was removed on 2/11/22 when the facility inserviced staff on reporting behaviors, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 277. 3.1-43(a)(1)

Based on observation, record review, and interview, the facility failed to ensure an Intravenous (IV) Peripherally Inserted Central Catheter (PICC) site was assessed, maintained, and cared for; which resulted in hospitalization , [DIAGNOSES REDACTED]. In addition to the resident in immediate jeopardy, the facility failed to ensure a resident's Peripherally Inserted Central Catheter (PICC Line) site was monitored and recorded in the clinical record resulting the potential for more than minimal harm that is not immediate jeopardy for 1 of 3 residents reviewed for IV line care (Resident L). The immediate jeopardy began on 1/08/2021 when Resident B had a PICC line inserted and the facility failed to ensure PICC line care and monitoring were completed for 8 days, when the resident was found non-responsive on 1/16/2021, and sent to the hospital where the resident was diagnosed with [REDACTED]. The Executive Director and Director of Nursing were notified of the immediate jeopardy at 4:06 p.m. on 2/18/2021. The immediate jeopardy was removed on 2/19/2021, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with the potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's closed clinical record was reviewed on 2/18/2021 at 10:04 a.m., [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 12/24/2020, indicated Resident B's cognitive status was moderately impaired. Resident B required extensive assist of one for bed mobility and transfers. Supervision was required for ambulation, eating, dressing, and personal hygiene. Laboratory data results dated, 1/7/2021 indicated, [MEDICAL CONDITION] (low blood sodium). Resident B's physician indicated due to [MEDICAL CONDITION]/dehydration and acute kidney injury with required fluid restrictions, a central IV catheter will be implemented with an order for [REDACTED]. Medication Administration Records, dated 1/1/2021 through 1/31/2021, indicated an order dated 1/7/2021, for Normal saline solution 0.9%, use 2 liter intravenously one time only for abnormal labs for 1 day. Run wide open times 2 liters. A progress note, dated 1/7/2021 at 9:08 p.m., indicated Resident B had a PICC line inserted, as ordered by the Physician and saline was to be administered, due to dehydration. Reportedly he had not eaten or drank anything for 10 days. A progress note, dated 1/8/2021 4:03 p.m., indicated Midline (PICC) intact to the Lt (left) upper arm with N/S (normal saline) infusing as ordered, transparent dressing intact no s/s (signs/symptoms) of infection at the site. Resident is alert/orient to self and others, appetite is poor, incontinent of urine and bm (bowel movement). v/s wnL (vital signs within normal limits). The clinical record lacked other progress notes regarding the assessment, care, and/or maintenance of the PICC line. The clinical record lacked a care plan to provide goals and interventions to care for the PICC line. The clinical record lacked physician's orders [REDACTED]. The January 2021, Medication Administration Records and Treatment Administration Records lacked documentation of assessment, care, and/or maintenance of the PICC line. A Progress note, dated 1/16/2021 at 8:39 a.m., indicated Resident B was found to be non-responsive and was sent to the emergency room . emergency room notes, dated 1/16/2021 (no time), indicated .[MEDICAL CONDITION]/septic shock (life-threatening physical response to an infection) source included line related, due to the PICC line that reportedly was infected with purulent drainage (discharging pus) .emergency room Registered Nurse, reports patient arrived with left upper extremity midline IV access with heavily soiled dressing, unable to flush and purulent drainage. Hospital Notes, dated 1/17/2021 (no time), indicated .blood cultures positive for staph aureus (bacterial infection) confirming the suspicion for (PICC) [MEDICAL CONDITION]. Hospital Notes, dated 2/1/2021 (no time), indicated Resident B was critically sick. Due to septic shock related to PICC line infection. Resident's Mother was updated about patient's condition and told he would probably not survive. Prognosis Poor, unlikely to survive hospitalization . Patient is in the process of dying. Patient made Do Not Resuscitate (DNR) at family request. Hospital notes, dated 2/2/21, indicated Time of death 2/2/21 at 9:40 a.m. During interview, on 2/18/2020 at 12:10 p.m., Licensed Practical Nurse (LPN) 2, indicated she recalled Resident B having had a PICC line. LPN 2 did not recall having documented any care for the resident's PICC Line. The documentation of assessments of the PICC line should have been on the, Medication Administration Record. During interview, on 2/18/2020 at 12:10 p.m., LPN 3, indicated she took care of Resident B during the time he had a PICC line. She did not recall any treatments on the Medication Administration Record regarding the PICC line. LPN 3 did not recall having documented any assessment regarding Resident B's PICC line. During interview, on 2/18/2020 at 11:30 a.m., the Director of Nursing (DON), indicated all care, treatments, assessments of the PICC line should have been documented on the Medication Administration Record. The DON indicated the facility had no additional documentation and/or care plan for the assessment, care, and/or maintenance of Resident B's PICC line. On 2/18/2021 at 11:24 a.m., the Director of Nursing provided a policy titled Central Venous Access, dated February 2009, and indicated it was the current policy being used by the facility. A review of the policy indicated, 1. Site Care .8. Observe the insertion site for a. [DIAGNOSES REDACTED], b. purulent drainage c. [MEDICAL CONDITION]. (infection) .15. Document the procedure, site appearance, and patient's tolerance of the procedure in nurse's notes. III. Flushing .3. Flush catheter . 2. Resident L's clinical record was reviewed on 2/18/21 at 2:00 p.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 2/2/21, indicated Resident L was cognitively intact and required assistance of one staff member for toileting, personal hygiene, and bathing. The physician's orders [REDACTED].Mid/Central (PICC) (Peripherally Inserted Central Catheter) Line .monitor site .every shift . Resident L's care plan, initiated on 2/11/21 and current through 5/3/21, indicated .is at risk for infection due to midline/PICC .observe midline/PICC site for signs and symptoms of infection as ordered . The Treatment Administration Record (TAR), dated February 1 through 28, 2021, indicated .Mid/Central (PICC) Line .monitor site .every shift . The February 2021 TAR record indicated 17 of 52 shifts lacked signatures which indicated the PICC Line site was monitored and the results recorded in the clinical record for the following dates and shifts: On 2/2/21 - night shift On 2/5/21 - evening shift On 2/6/21 - night shift On 2/7/21 - evening shift On 2/7/21 - night shift On 2/8/21 - day shift On 2/11/21 - evening shift On 2/11/21 - night shift On 2/12/21 - day shift On 2/12/21 - evening shift On 2/13/21 - day shift On 2/13/21 - night shift On 2/14/21 - evening shift On 2/15/21 - day shift On 2/15/21 - evening shift On 2/15/21 - night shift On 2/16/21 - evening shift During interview, on 2/18/21 at 3:00 p.m., RN (Registered Nurse) 4 indicated Resident L's PICC Line site was to be monitored on each shift as indicated by the physician's orders [REDACTED]. On 2/18/21 at 4:00 p.m., the Director of Nursing provided a copy of the facility's Clinical Documentation Standards, dated 5/29/2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .a complete record contains an accurate and functional representation of actual experience of the resident and must contain enough information to show that the status of the individual resident is known .Basic Nursing Standards of Documentation: the primary purpose of the medical record is to provide continuity of care .clinical evidence of care and treatment records as evidence of care .document entries during the work shift and complete all entries before leaving the facility for that tour/shift .chart in real time when an event is occurring or shortly thereafter . The immediate jeopardy, that began on 1/8/21 was removed on 2/19/21, when the facility identified and assessed all residents with Intravenous Access devices for signs and symptoms of infection and documented as indicated by facility policy. An audit had been conducted on all residents with Intravenous Access devices to validate orders were in place for assessment, maintenance, and care. All licensed nurses had been educated on the facility's Central Venous Access and Peripheral Venous Access policies with emphasis on assessment, maintenance, and care. Skills validation had been completed with return demonstration on all licensed nurses for: care of central venous catheter, administration of medication via an IV, and Administration of IV fluids. All licensed nurses had been educated on following physician orders [REDACTED]. Noncompliance remained at the lower scope and severity of isolated, no harm, with potential for more than minimal harm that is not immediate jeopardy; because of the need for continued monitoring. This Federal tag relates to Complaint IN 721. 3.1-47(a)(2)

Based on record review and interview, the facility failed to ensure a resident received skin assessments and timely pressure ulcer treatments for 3 pressure ulcers, as ordered by the physician, which resulted in increased size and advanced stages of all pressure ulcers for 1 of 2 residents reviewed for pressure ulcers in a sample of 3 (Resident B). Findings include: The record for Resident B was reviewed on 4/15/19 at 12:16 p.m. [DIAGNOSES REDACTED]. The medical record lacked documentation of weekly skin assessments after 2/15/19. Resident B was admitted to the hospital emergency department (ED) on 3/6/19 at 6:01 p.m., and discharged back to the nursing home on 3/6/19 at 10:01 p.m. A hospital ED discharge note, dated 3/6/19, indicated Resident B had scattered stage 2 decubitus ulcers (partial-thickness loss of skin) on her sacrum (area at the base of the spine) and complained of pain to that area. A facility progress note, dated 3/7/19 at 2:20 a.m., indicated the resident returned from the hospital ED, but lacked documentation of an assessment of the sacrum area or the stage 2 pressure ulcers (identified by the hospital). A facility progress note, dated 3/9/19 at 2:01 p.m., (2 days after returning from hospital ED), indicated Resident B's family was notified of a suspected deep tissue injury (a pressure-related injury to tissue under intact skin and having the appearance of a bruise) to the coccyx/sacrum. The NP (nurse practitioner) had been notified and a treatment was obtained. The family indicated they had been informed by the hospital physician the resident had open areas. The clinical record lacked documentation of NP orders for wound treatment. A facility Pressure Ulcer Wound Sheet 2, dated 3/14/19 (7 days after returning from the hospital ED), indicated the resident had an unstageable-deep tissue injury that measured 4.0 cm (centimeters) length by 5.0 cm in width. The wound treatment orders, dated 3/15/19, indicated the wound was to be cleansed with a wound cleaner and pat dry, then apply Santyl (Ointment used to help the healing of skin ulcers. The ointment breaks up and removes dead skin and tissue.) and cover with a foam dressing every day and as needed. A facility Weekly Wound Evaluation Flow Record, dated 3/21/19, indicated the wound was unstageable with slough and/or eschar (necrotic/dead tissue) and measured 9.0 cm X 8.4 cm. treatment for [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A facility Weekly Wound Evaluation Flow Record, dated 3/21/19, indicated Resident B had a stage 3 pressure area (full thickness skin loss of tissue that presents as a deep crater) to the left inner leg that measured 2.2 cm X 0.7 cm. The clinical record lacked documentation of physician orders [REDACTED]. treatment for [REDACTED]. Review of the MAR (Medication Administration Record) for (MONTH) 2019, lacked documentation of implementation of wound treatment orders from 3/21/19 to 3/24/19. A facility Weekly Wound Evaluation Flow Record, dated 3/21/19, indicated Resident B had an unstageable deep tissue injury (a pressure-related injury to tissue under intact skin and having the appearance of a bruise) to the left heel that measured 1.6 cm x 2.1 cm and to the right heel that measured 2.4 cm x 3.5 cm. The clinical record lacked documentation of physician orders [REDACTED]. Treatment orders, dated 3/22/19, indicated to apply [MEDICATION NAME] gauze (wound care product to kill germs that cause wound infections) to the heels and cover with ABD (abdomen) pads and wrap with Kerlix daily and as needed. The MAR (Medication Administration Record) for (MONTH) 2019, lacked documentation of implementation of physician orders [REDACTED]. During an interview with LPN 1, on 4/16/19 at 2:20 p.m., she indicated she was not Resident B's nurse but documented the progress note (3/9/19 at 2:01 p.m.) to assist another facility nurse. LPN 1 had called the resident's family and recorded in the progress notes the information another nurse had provided. During an interview with the Administrator, on 4/16/19 at 3:45 p.m., she indicated no further documentation could be found for wounds or wound treatments for Resident B. This Federal tag relates to Complaint IN 645. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure implementation of care plan interventions to prevent the development of a stage II pressure ulcer and worsening of the pressure ulcer to a stage III for 1 of 3 residents reviewed for pressure ulcers (Resident 23). Findings: Resident 23's clinical record was reviewed on 3/1/18 at 2:20 p.m. [DIAGNOSES REDACTED]. A Skin Risk Assessment, dated 6/2/17, indicated Resident 23 was at moderate risk for developing a pressure ulcer. Risks included slightly limited sensory perception, occasionally moist skin, bedfast, very limited mobility, and difficulties with friction and shearing during movement. The Skin assessment dated [DATE], indicated redness on the resident's coccyx (area at the base of the spinal column). A Progress note, dated 6/15/17, indicated Resident 23 acquired an in-house stage II pressure ulcer to the coccyx. A pressure ulcer is defined as injury to the skin and underlying tissue resulting from prolonged pressure on an area. Stage II pressure ulcer is defined as a partial-thickness loss of skin with exposed dermis (tissue just below the skin). A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had a mild cognitive deficit. The resident did not have delusions, hallucinations, or behaviors during the observed period of time. The skin assessment included identification of a stage III pressure ulcer. A stage III pressure ulcer is defined as a full-thickness loss of skin. The resident was an extensive assist for all ADL's (activities for daily living) and mobility. A Physician order [REDACTED]. During an interview with the DON, on 3/7/18 at 3:00 p.m., the DON indicated they were unable to locate any skin assessments between the dates of 5/1/17 through 6/20/17. The Pressure Ulcer Wound Sheets identified the pressure ulcer as stage II on 6/19/17, and the pressure ulcer having converted to stage III on 6/26/17. A Care Plan, current through 3/24/18, indicated Resident 23 had a stage III pressure ulcer to the coccyx. The care plan was initiated on 6/19/17, with a revision on 2/26/18. Interventions included, but were not limited to: monitor area weekly, repositioning while up in wheelchair, and turn and reposition ever two hours and as needed. A Care Plan current through 3/24/18, initiated on 1/12/17, with a revision on 2/26/18, indicated the resident had contractures and was at risk for skin breakdown. Interventions included, but were not limited to: assist with repositioning every two hours and as needed, and observe for complications of immobility. There was no care plan with interventions for the resident's refusal of care. During an observation, on 6/1/18 at 2:15 p.m., Resident 23 was observed sitting in a Broda chair. Positioned on his buttocks with his legs elevated, and upper torso leaning back. Residents weight being placed on the wound on his coccyx. During an observation, on 3/5/18 at 2:50 p.m., Resident 23 was sitting up in his Broda chair. He was positioned on his buttocks with his legs just slightly elevated. During an observation, on 3/6/18 at 8:45 a.m., Resident 23 was lying in bed position on his back with the head of the bed elevated just slightly. During an observation, on 3/6/18 at 11:44 a.m., Resident was in his bed. He was positioned on his back with his head just slightly elevated on two pillows. During an interview, on 3/6/18 at 11:44 a.m., Resident 23 indicated his pressure ulcer had healed. The Resident was difficult to understand, as speech was garbled and slow. Resident 23 loudly said no while nodding his head up and down, that he did not have a pressure ulcer on his bottom. He was unable to verbalize the care needed. During an observation, on 3/6/18 at 1:45 p.m., Resident 23 was in his room, positioned on his back with the head of the bed slightly elevated. During an interview, on 3/6/18 at 12:50 p.m., Licensed Practical Nurse (LPN 3) indicated Resident 23 had a stage III pressure ulcer to his coccyx. During a interview, on 3/7/18 at 12:25 p.m., LPN 3 indicated that Resident 23 could be resistive to care. The resident did not like to reposition and sometimes he will not let staff reposition him. LPN was unable to provide information, in regard, to what the staff could do to assist Resident 23 to reposition. During a dressing change for Resident 23, on 3/7/18 at 12:05 p.m., observed two staff members to enter his room and reposition him onto his left side without difficulty. The wound was observed to be a stage III pressure ulcer that measured 1.5 by .5 cm (centimeters). No drainage, on signs of infection, and no odor. The resident was not resistive to changing position for the dressing change. After the dressing change, the resident was positioned by staff onto his back with his head slightly elevated. On 3/7/18 at 3:00 p.m., the DON provided a policy titled: Prevention of Pressure Ulcers, dated 10/2010 and indicated it was the current policy being used by the facility. Review of the policy indicated, General Preventative Measures: .2. For a person in bed: a. Change position at least every two hours .3. For a person in a chair: .a. Change position at least every hour .9.Residents identified to be at risk for pressure ulcer development should have a skin assessment completed at least weekly. This policy continued on, to provide Interventions and Preventative Measures: Residents with Risk factors .Additional Factors that Indicate Residents at Risk 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident who was admitted to the facility without a pressure ulcer, received waffle boots, off loading heels, and Skin Prep to prevent the development of an unstageable pressure ulcer for 1 of 1 resident who met the criteria for review of pressure ulcers. (Resident #78) Findings include: The clinical record of Resident #78 was reviewed on 2/24/17 at 11:39 a.m. [DIAGNOSES REDACTED]. Resident #78 was readmitted to the facility on [DATE], after surgery for [REDACTED]. A significant change Minimum Data Set assessment, dated 9/14/16, indicated the resident was moderately impaired in her ability to make decisions, and needed extensive assistance from 2+ staff persons for bed mobility, transferring, and toileting. A Pressure Ulcer Risk Assessment, dated 9/6/16, indicated Resident #78 was a high risk to develop a pressure ulcer. A nursing admission assessment, dated 9/6/16, indicated Resident #78's right heel was red with 2 scabbed areas. A pressure reducing mattress was on the resident's bed. Hospital discharge orders, dated 9/6/16, indicated the resident, Needs weight offloading of feet w/ (with) foam boots. (Offloading with foam boots reduces the pressure on areas of concern) This order was not transcribed to the facility Order Recap Report until 9/14/16 (8 days after the resident was admitted to the facility). A physician's orders [REDACTED].#78's heel every shift. Skin Prep is a liquid, which when applied, forms a skin protectant to help prevent irritation to intact or damaged skin. This order was not transcribed to the facility Order Recap Report. An Interim care plan, created 9/6/16, indicated a problem of Resident #78 being at risk for, Break in Skin Integrity .scab. Interventions included, but were not limited to, Elevate heels off bed surface and 'float' heels-no pressure on heels, Skin treatment: Skin Prep, weekly skin check, Assess .boots .heel protectors, offloading bil(ateral) feet (with) foam boots. No further assessments of Resident #78's right heel were found in her record, until 9/14/16 (8 days later). On that date, a Pressure Ulcer Wound Sheet indicated the resident now had an unstageable deep tissue injury pressure ulcer on her right heel. An unstageable pressure is a full thickness tissue loss, where the wound bed is covered by slough or eschar, making it impossible to fully assess the stage of the pressure ulcer. Review of a Treatment Administration for September, 2016, did not indicate the facility implemented waffle boots, offloading of feet, floating heels, or Skin Prep application, to help prevent further skin breakdown to the resident's right heel, between her readmission on 9/6/16, when the scabs on her right heel were first observed, through 9/14/16, 8 days after her admission to the facility, when the unstageable pressure ulcer to the right heel was identified. On 2/27/17 at 3:58 p.m., the Director of Nursing (DON) indicated Resident #78's right foot was wrapped with a figure 8 dressing to protect the toe amputation areas, but the right heel would have been visible in order for the nurses to assess it for further breakdown. She indicated the resident's record did not indicate the nurses applied Skin Prep or the waffle boot for offloading, between 9/6/17 and 9/14/17, when the unstageable pressure ulcer was identified. On 3/1/17 at 8:45 a.m., Resident #78's unstageable right heel ulcer dressing change was observed with Licensed Practical Nurse #12. At that time, the resident indicated the pain from her pressure was not as bad as it used to be, but it still hurt, especially when the dressing was changed. On 3/1/17 at 11:30 a.m., the DON provided a policy dated 10/2010, titled, Prevention of Pressure Ulcers, and indicated it was the policy currently used by the facility. The policy indicated, .Routinely assess and document the condition of the resident's skin. Residents identified to be at risk for pressure ulcer development should have a skin assessment completed at least weekly .The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. 3.1-40(a)(1)

Based on record review and interview, the facility failed to ensure a resident was protected from abuse according to the facility policy which resulted in the resident sustaining a bloody lip, for 1 of 1 resident reviewed for abuse in a sample of 6 (Resident #F). Findings include: The clinical record for Resident #F was reviewed on 5/6/15 at 10:50 a.m. [DIAGNOSES REDACTED]. The resident was admitted on [DATE], and discharged on [DATE] (unable to observe). A care plan conference meeting held 2/5/15, with Resident #F's son indicated he was concerned about the resident not eating enough and requested an appetite stimulant. At this time the facility spoke to the son regarding his approach and how uncomfortable it makes his mother and staff feel. A care plan dated 3/2/15, indicated Resident #F's son (POA) has episodes of socially inappropriate behavior as evidenced by, force feeding his mother and yelling at her to eat and take her meds. A reportable incident dated 4/1/15, indicated another resident reported she thought she overheard her roommate's son, slap her roommate, Resident #F (no date). A reportable incident dated 4/2/15, indicated Resident #F's son returned the next day and was visibly upset regarding his mother's refusal to eat and then squeezed her mouth open, causing it to bleed. Staff asked resident's son to leave and the Administrator and Director of Nursing (DON) were notified immediately. A nurses note written by LPN #4 and dated 4/2/15 at 9:45 p.m., indicated the resident refused to take her medications and the son was informed. He indicated to the nurse she should provide him the medications and he would get Resident #F to take the meds. He yelled at her and attempted to squeeze open her mouth, which caused the left side to bleed. LPN #4 told the son to stop, because this was abuse. During an interview on 5/6/15 at 12:30 p.m., with the DON, Social Services and LPN #4, they indicated, the resident's son yelled at his mother in the dining room several times for refusing to eat and drink as he wanted her to. The son was then notified his visitation with his mother would be supervised after the event on 4/2/15. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure two staff persons assisted with a Hoyer (mechanical) lift transfer which resulted in a resident falling from the lift sustaining a head injury requiring transfer to the hospital for treatment for 1 of 3 residents reviewed for falls and accidents in a sample of 3. (Resident #B) Findings include: Initial tour of the facility was conducted on 06/14/2011 at 3:05 p.m., with the Director of Nursing (DoN) and RN #1 and RN #2. RN #2 indicated Resident #B was not interviewable, was transferred via Hoyer lift, and used a reclining wheelchair. Observation of Resident #B was made on 06/15/2011 at 1:35 p.m., for a Hoyer lift transfer from bed to reclining wheelchair. Resident #B was observed to be awake, short in statue, and a little lady. Resident #B indicated she did not want to get up at this time and refused to be transferred. The resident's wishes were granted. Resident #B's clinical record was reviewed on 06/15/2011 at 12:10 p.m., and indicated an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The record indicated the resident was 62 inches tall and weighed 115 pounds. Interdisciplinary team notes, dated 05/27/11, indicated the resident sustained [REDACTED]. The resident sustained [REDACTED]. The resident was sent to the emergency room and received 1 stitch to a 1 cm. laceration. Neurochecks were to continue for 72 hours and staff were to monitor for pain. The resident remained in a low bed and was to continue to use her wheelchair during the day. The Hoyer lift was to continue to be used with monitoring and training with resident and staff. Nurse's notes, dated 05/26/2011 at 7:45 p.m., indicated, "CNA called writer to Res. (Resident) room. Res. on floor with blood noted to head on floor parallel to bed with head near foot of bed et (and) feet facing Hoyer - ice applied. MD notified - orders noted to send res. to hosp. (hospital). 911 initiated - family notified - EMT transferred res.... Res. alert/verbalizes pain to head area - no s/s (signs/symptoms) of resp. (respiratory) distress noted." Resident #B's care plan for "Risk for falls related to total assist mobility - cognitive deficits - incont (incontinent) bowel & bladder" with original date of 03/24/2011 and most recent update of 06/09/2011 indicated approaches which included, but were not limited to, "Mech. (Mechanical lift c (with) assist of ii (two)...." Interview with the DoN on 06/15/2011 at 10:55 a.m., indicated she received a call from the facility in regards to the incident and suspended the CNA immediately. The DoN indicated the resident was sent to the hospital and had received a 1 cm. laceration to the back of her head which required 1 stitch. The resident returned to the facility the same night. The DoN indicated she talked to the CNA and indicated she had asked for help one time and then transferred the resident by herself and dropped the resident. The DoN indicated she sternly talked to the CNA and gave her a final warning. The DoN indicated she re-educated her before letting her back on the floor and is in the process of re-educating all the aides in regards to the lifts and doing skills check-offs. The DoN indicated the CNA was very remorseful and tearful. Interview with CNA #1 on 06/15/2011 at 1:50 p.m., indicated she took Resident #B to her room and hooked her up to the Hoyer lift to transfer the resident from her chair to her bed. CNA #1 indicated she looked for someone to assist her and couldn't find anybody as everyone was in rooms assisting other residents. CNA #1 indicated she thought it would be okay if she transferred the resident by herself. CNA #1 indicated the resident was almost all the way up in the air, was out of the wheelchair, and she slipped out of the sling onto the floor with her head hitting the floor first. CNA #1 indicated the resident fell between the Hoyer and the bed. CNA #1 indicated this was the first time she had transferred anyone with a Hoyer lift by herself and the last time. CNA #1 indicated she was re-educated on the Hoyer lift. The facility's undated policy for Transfer From Wheelchair lacked documentation of two persons to assist with the Hoyer lift. The undated manufacturer's owner's manual lacked documentation on how many persons were to assist when using the Hoyer lift. The inservice narrative, dated 04/19/2011, indicated two assist with all lifts and CNA #1 had her signature on the sign in sheet which indicated she attended. This federal finding is related to Complaint IN 327. 3.1-45(a)(2)