Every finding on record at Hickory Creek at Huntington

Based on observation and interview, the facility failed to ensure food was served in a sanitary manner during a kitchen observation of the preparation of pureed food. This deficient practice had the potential to effect 5 of 5 residents who received pureed diets from the facility kitchen.Findings include:During a pureed food observation, on 2/25/26 at 11:13 a.m., the following was observed:Dietary Aide 6 lacked a cover over his long facial hair. Dietary Aide 6 cut up chicken patties in the food processor and blended them together with some hot water. He then scraped the mixture down off the sides and blended it again while adding some hot water to the mixture. He performed a thickness test of the mixture. He added more water and blended the mixture again. He performed another spoon test. He added more water and blended the mixture. He performed another spoon test. During an interview, on 2/25/26 at 11:27 a.m., Dietary Aide 6 indicated he should have worn a beard net.During an interview, on 2/25/26 at 11:27 a.m., the Dietary Manager indicated Dietary Aide 6 had just returned from break. She did not notice he wasn't wearing a beard cover and acknowledged he should have worn one.On 2/25/26 at 11:34 a.m., a posted sign on the kitchen door indicated the following: Notice: Hair net and beard cover required beyond this pointDuring an interview, on 2/26/26 at 9:29 a.m., the Administrator indicated he would expect staff to wear hair net coverings, including beard nets, when entering the kitchen area.16.2-3.1-21(i)(2)16.2-3.1-21(i) (3)

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 resident-to resident altercations reviewed for abuse (Residents 4 and 17). Finding includes:Resident 4's clinical record was reviewed on 2/25/26 at 3:05 p.m. Diagnoses included Alzheimer's disease, dementia, severe, with behavioral disturbance, restlessness/agitation, major depressive disorder, mood disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, indicated the resident was severely cognitively impaired. He used a walker. He required supervision/touching staff assistance with walking. He required substantial/maximal staff assistance with toileting hygiene and toilet transfers. A care plan, initiated 7/10/25 and last revised 1/13/26, indicated the resident exhibited verbal aggression, agitation, and demanding behaviors. He had threatened physical aggression and struck staff. The resident became aggressive and confused regarding the location of his personal belongings (e.g., his coat). Interventions included educating staff on identifying early behavioral cues prior to escalation (10/29/25), reassuring the resident of the location of his coat (10/29/25), redirecting the resident to a quiet area to promote calming (7/10/25), and engaging the resident in conversation about his car trophies when he becomes agitated or aggressive. A care plan, initiated 7/10/25 and last revised 1/13/26, indicated the resident had a diagnosis of unspecified mood disorder and was prescribed an antipsychotic medication for the management of this condition. His symptoms were agitation, pacing, demanding behaviors, and episodes of aggression. Interventions included offering the resident a snack, specifically a banana if available (1/13/26), talking with the resident about his past and his life story (1/13/26), and talking with the resident about his car trophies if he was becoming agitated (7/10/25). A care plan, initiated 11/7/25 and last revised 1/13/26, indicated the resident had exhibited physically aggressive behaviors toward staff and peers. Behaviors included attempting to strike others, swinging his walker at individuals, punching, and making threats with utensils. Interventions included ensuring the safety of other residents and staff and attempting redirection (11/7/25) and transferring the resident to a geriatric psychiatric hospital per nurse practitioner (NP) order to ensure the safety of the resident and others. A care plan, initiated 7/10/25 and last revised 1/13/26, indicated the resident had a diagnosis of unspecified mood disorder and was prescribed an antipsychotic medication for the management of this condition. His symptoms were agitation, pacing, demanding behaviors, and episodes of aggression. Interventions included offering the resident a snack, specifically a banana if available (1/13/26), talking with the resident about his past and his life story (1/13/26), and talking with the resident about his car trophies if he was becoming agitated (7/10/25). A care plan, initiated 1/16/26, indicated the resident, at times, entered other residents' rooms and took items. The resident could become verbally aggressive and threaten physical aggression. The resident was confused and had poor judgement and impulse control. Interventions included redirecting the resident with snacks/drinks or an activity (1/16/26) and talking to the resident in a calm voice and listening understandingly to the resident. A progress note, dated 11/6/25 at 8:35 a.m., indicated the resident became violent and punched his roommate in the face. He attempted to attack his roommate with his silverware. Staff separated the residents to ensure the roommate's safety. The resident continued to have aggressive behaviors and attempted to collect silverware from other residents' trays. When the staff attempted to redirect the resident, he clinched his fist and moved towards them. The medical NP, psychiatric NP, and POA were notified. A progress note, dated 11/6/25 at 2:12 p.m., indicated the staff were unable to redirect the resident, and he continued to be a danger to himself and others. The psychiatric NP was notified and gave orders to transfer the resident to a geriatric psychiatric hospital. The hospital was contacted, the resident's paperwork was sent, and the hospital approved the resident for admission. A progress note, dated 11/6/25 at 5:02 p.m., indicated the resident was very aggressive toward staff and other residents. The staff attempted to deescalate the aggressive behaviors by leaving the resident alone, giving snacks, engaging in conversation, providing music and activities. The resident denied having any pain and yelled at staff with the redirection attempts. The resident's representative was called. She indicated the resident had been dangerous in the past, attempting to hurt neighbors and other people. She was unable to suggest any methods to assist in calming the resident. A progress note, dated 11/6/25 at 5:20 p.m., indicated the resident was transported to the geriatric psychiatric hospital. A progress note, dated 11/7/25 at 10:14 a.m., indicated the resident had demonstrated verbal and physical aggression toward staff and his peers, specifically cursing, throwing things, using his walker as a weapon, and attacking his roommate. The immediate interventions utilized were redirection with conversation, offering of snacks, provision of activities, and assist resident to his room for calming. The assessment of the potential correlation to the root cause was identified as Alzheimer's disease. The root cause of the behavioral expression was identified as the resident was verbally and physically aggressive. He was a danger to himself and others. He attacked his roommate and was not redirectable. Attempts with redirection escalated the resident's behaviors. The situation quickly became unsafe and unstable for the resident and others. The resident was given a one-time injection of haloperidol (antipsychotic medication) and sent to a geriatric psychiatric hospital. A geriatric psychiatric hospital progress note, dated 11/8/25, indicated in the history of present illness section (HPI), the facility reported the resident had been displaying physical aggression over the past 72 hours. On 11/6/25 the resident had a physical altercation with his roommate. The resident punched the roommate in the face and attempted to stab the roommate with a fork. The roommate obtained a small laceration to his cheek. The resident balled up his fists and swatted staff away with staff redirection attempts. Resident 17's clinical record was reviewed on 2/25/26 at 3:34 p.m. Diagnoses included anoxic brain damage, bipolar disorder, unspecified psychosis not due to a substance or known physiological condition, generalized anxiety disorder, and major depressive disorder, recurrent, moderate. A quarterly MDS assessment, dated 8/27/25, indicated the resident was severely cognitively impaired. He required supervision/touching staff assistance with walking and toilet transfers. A care plan, initiated 1/27/23 and revised 2/19/26, indicated, at times, the resident became impatient and moved a resident and wheelchair from where the resident was trying to go such as the bathroom. He was demanding and aggressive with staff wanting a soda when he had none available. Interventions included staff speaking with the resident to understand why he is so upset (2/27/24), educating the resident that staff are here to provide assistance (1/27/23), redirecting the resident to another area such as another bathroom (1/27/23), and resident will ask staff for assistance prior to moving a peer's wheelchair (1/27/23). A progress note, dated 11/6/25 at 10:00 a.m., indicated the NP saw the resident. She indicated the resident was involved in a resident-to-resident altercation where he was not the aggressor. The resident had notable facial injuries from the prior altercation and did not appear to be suffering psychological distress from the altercation. A progress note, dated 11/6/25 at 12:19 p.m., indicated the resident declined to move to another room so that he was no longer with his current roommate. He indicated he was fine and did not want to move. The resident's representative was notified of the resident-to-resident altercation and the resident's wishes to remain in the same room. She was agreeable to the resident's wishes. A progress note, dated 11/6/25 at 1:34 p.m., indicated the resident was safe with no agitation noted. A progress note, dated 11/12/25 at 11:49 a.m., indicated the resident exhibited no distress from the previous argument with his roommate. He was eating and sleeping well. He was performing his usual daily routines. During an interview, on 2/26/26 at 1:10 p.m., the Administrator indicated he would look for the investigation for the resident-to resident altercation between Resident 4 and Resident 17 on 11/6/25. He did not have a state report, because the incident was not a state reportable. During an interview, on 2/26/26 at 1:21 p.m., the Administrator indicated he and the DON had heard a noisy ruckus with lots of yelling on the hall and had gone down to the area to see what was happening. He and the DON did not see anything happen. The residents were yelling. He believed the altercation happened in the bathroom. Resident 4 mentioned that he hit Resident 17. The residents were separated. Resident 17 did not say anything. Resident 4 became increasingly agitated as the day progressed. Someone stayed with him throughout the day. During an interview, at the same time, the DON indicated. Resident 4 said I punched that guy. Resident 4 said a lot of things like that. During an interview, on 2/26/26 at 1:41 p.m., the ADON indicated Resident 4 said he punched Resident 17 in the face. Resident 17 said no. She documented that Resident 4 punched Resident 17 just to cover it. Both residents were severely cognitively impaired. What happened that day was she heard the residents talking very loudly, and she went towards the noise. Resident 4 went to the bathroom, then went back to his room. She saw Resident 4 holding his fork and heading toward Resident 17. She removed all the silverware from their room. Resident 4 had an appointment that day and left the facility for several hours. When he returned, his behaviors escalated. Someone stayed with him throughout the time he came back, they got the order to send him to the geriatric psychiatric hospital, and when he was transported to the geriatric psychiatric hospital. Resident 17 did not have any marks on his face, but she wanted to make sure she charted everything in case a bruise popped up later. During an interview, on 2/26/26 at 1:59 p.m., the Administrator indicated he was unable to provide camera footage as the cameras only went back a week. He had been told the incident happened just outside the bathroom. Resident 4 said he hit Resident 17. But, Resident 17 said no. Taking the silverware was more of a precautionary thing, as Resident 4 would put silverware in his socks. During an interview, on 2/26/26 at 2:17 p.m., CNA 9 (worked 6 a.m. to 6 p.m. on day of the altercation) indicated Resident 4 and Resident 17 were in the bathroom. She watched them walk out of the bathroom. They walked out calmly, no yelling. Then, Resident 4 said he hit Resident 17. She didn't see anything. She tried to find out what happened. She thought Resident 4 stabbed Resident 17 on the side of the neck with something, because his neck was bleeding. The QMA bandaged him. She thought the incident happened around lunch time. Then, later they packed up Resident 4's clothing because he was transferred to a hospital. She indicated Resident 4 could escalate and deescalate within minutes. He went back and forth. Resident 4 said he hit Resident 17 because Resident 17 kept talking. During an interview, on 2/26/26 at 2:28 p.m., QMA 7 indicated Resident 4 and Resident 17 came barreling out of the bathroom together. Resident 4 said he had hit Resident 17. She separated them and got them all checked out. She believed LPN 10 was working that day. She did not see a mark on either of the residents. Resident 4 did try to hide silverware, but she had never seen him be aggressive with it. During an interview, on 2/26/26 at 2:42 p.m., LPN 10 indicated that she heard yelling from the back of the facility and saw Resident 4 and Resident 17 yelling at each other. They were separated. Resident 4 kept yelling and threatening the staff. The NP gave an order because he would not calm down. Resident 4 kept repeating he hit Resident 17. Resident 17 did not say a lot, but he was not scared. Resident 17 did not have a mark on him. During an interview, on 2/26/26 at 3:05 p.m., NP 12 indicated she had spoken to Resident 17 and assessed him before speaking to the nurses that day. She had seen a few marks on his face, but she did not know what had happened. He did not seem upset or talk about anything that happened. She had assumed the marks on his cheeks were from the altercation. She thought the altercation was in the morning that day, but was not certain. During an interview, on 2/26/26 at 3:09 p.m., CNA 11 indicated she heard arguing that day. They separated Resident 4 and Resident 17. The residents were both trying to get into the bathroom and did not want to wait for their turn. The residents were in the doorway of the bathroom. There were no marks on Resident 17. She thought it happened at midday. During an interview, on 3/2/26 at 3:37 p.m., the Administrator indicated he heard the commotion and went to see what was happening. He made sure both residents were okay. He tried to deescalate Resident 4. Then, Resident 4 went to an appointment. As the day progressed Resident 4 became increasingly agitated and aggressive. The order was received to send him to the geriatric psychiatric hospital. During an interview, on 3/3/26 at 11:54 a.m., CNA 9 indicated when a resident made an allegation of abuse, staff were to make sure the resident was safe and then report it immediately to the nurse. During an interview, on 3/3/26 at 11:59 a.m., LPN 10 indicated whenever a resident made an allegation of abuse or a resident-to-resident altercation, she would remove them from danger and immediately report to the Administrator. During an interview, on 3/3/26 at 1:39 p.m., RN 8 indicated she was in the facility on the day Resident 4 and Resident 17 had the altercation. She did not participate in taking care of those residents that day. If she came across the situation where a resident said they hit someone, she would try to get all the story, then report it to the DON. If a resident said they hit someone, she considered that it would be an allegation of abuse, no matter the resident's cognitive status. During an interview, on 3/3/26 at 1:52 p.m., the DON indicated if a resident said they had been hit, then she would consider it an allegation of abuse. She would separate the resident, make sure everyone is safe, ask the staff what was witnessed. Resident 4 and Resident 17 were yelling. Resident 4 was always yelling. She reported allegations to the Administrator. If she had written anything down about the investigation, she would not have kept it, because she did not think it was abuse. During an interview, on 3/3/26 at 2:27 p.m., the Administrator indicated he knew the resident-to-resident altercation happened because he heard the ruckus. Resident 4 was severely cognitively impaired. He did not see anything on Resident 17. He had the nurses check out the residents to be on the safe side. He felt Resident 4 made an outburst statement. During an interview, on 3/3/26 at 2:58 p.m., the Administrator indicated he had found his investigation on the computer. He had forgotten that Resident 4 had said he was going to punch someone - not that he had punched someone. A current facility policy, last revised 2/2020, titled Abuse Prohibition, Reporting and Investigation, provided by the Administrator during entrance conference on 2/24/26, indicated the following: .The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed.Resident to Resident Abuse:.It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the ISDH gateway system. 410 IAC 16.2-3.1-28(e)

Based on record review and interview, the facility failed to ensure the resident and/or resident's representative was notified in writing of the transfer/ discharge appeal rights and bed hold policy for 1 of 3 residents reviewed for discharge. (Resident 37).Findings include:Resident 37's clinical record was reviewed on 2/26/26 at 8:39 a.m. Diagnoses include encephalopathy (change in brain function), aphasia (, major depressive disorder, and history of a stroke.A progress note, dated 1/29/26 at 10:20 a.m., indicated Resident 37 was discharged home. Discharge summary, medications, follow-up appointments and other paperwork were discussed with Resident 37 and representative.The clinical record lacked indication that the resident and the resident's representative were notified of the transfer/discharge appeal rights and bed hold policy in writing for Resident 37's discharge.During an interview, on 2/26/26 at 9:38 a.m., the DON indicated they discussed resident appeal rights, ombudsman notification and transfer/discharge information during admission and during resident council meetings. The Business Office Manager (BOM) was responsible for discussing appeal rights and bed hold policy.During an interview, on 2/26/26 at 12:29 p.m., the BOM indicated she completed resident discharge paperwork. She tried to get those completed 48 hours before the resident discharges. She did not have the resident and/ or representative sign the paperwork or put in a progress note stating the resident or their representative was notified of appeal rights or bed hold policy.During an interview, on 2/26/26 at 1:41 p.m., the ADON indicated resident medications and follow up appointments were discussed during discharge. Any contact information for the ombudsman, facility, the resident's primary care physician and the bed hold policy would also be discussed. She would have the resident and/or their representative sign the discharge summary, which did not include the bed hold or appeal rights. She did not put in a progress note indicating the residents appeal rights or the bed hold policy was discussed during discharge.A current facility policy, dated 11/2017 and revised 1/2019, titled Bed Hold Policy, provided by the Administrator, on 3/2/26 at 4:08 p.m., indicated the following: .3. The Resident's Representative will be informed of the bed hold policy at the time of notification of transfer. The Resident Representative will be provided a copy of the bed hold policy. 4. The facility staff will document the notification to the resident and the resident representative of the bed hold policy on the Emergency Resident Transfer Form.16.2-3.1-12(a)(6)(A)(i)16.2-3.1-12(a)(6)(A)(ii)16.2-3.1-12(a)(6)(A)(iii)

Based on record review and interview, the facility failed to obtain ordered labs for 1 of 5 residents reviewed for unnecessary medications (Resident 17). Finding includes:Resident 17's clinical record was reviewed on 2/25/26 at 3:34 p.m. Diagnoses included epilepsy, unspecified, intractable, without status epilepticus, other cystic kidney disease, hepatic encephalopathy, and alcoholic cirrhosis of liver without ascites Current orders included levetiracetam (seizure medication) 750 mg twice a day (2/11/26), divalproex (seizure medication) 125 mg three times a day (10/22/25), lactulose (laxative) 10 grams/ 15 mL - 15 mL three times a day (12/23/25), rifaximin (antibiotic) 550 mg twice a day (9/24/20), and ammonia, divalproex, and levetiracetam laboratory levels every second Monday of February, May, August, and November (1/19/22). A care plan, initiated 3/13/18 and revised 2/12/26, indicated the resident was at risk for functional decline due to toxic encephalopathy. The goal, with a target date of 5/15/26, indicated the resident will continue treatment for high ammonia levels. Interventions included obtain lab draws as ordered and send to the physician for review (3/13/18). A progress note, dated 7/7/25 at 4:26 p.m., indicated the resident had returned from an appointment with the neurologist with an unclear note to discontinue medications that the NP had wanted to continue upon return from the hospital. The psychiatric NP was to evaluate the medications. A call was placed to the neurology office, and a message was left to clarify orders. An ammonia level and liver profile were to be scheduled with the next blood draw day. A progress note, dated 7/9/25 at 10:00 a.m., indicated NP 13 had received a call from the resident's neurologist concerning the continued use of divalproex due to chronically elevated ammonia levels. The neurologist suggested discontinuing divalproex as it was not being used for seizure control as the resident was taking levetiracetam for seizures. The NP indicated consider decreasing divalproex and consult with the psychiatric NP regarding the decrease. An ammonia level order was sent to the laboratory for the 7/10/25 lab draw. A review of the 7/10/25 lab draw lacked an ammonia level. A progress note, dated 7/10/25 at 2:04 p.m., indicated NP 12 saw the resident for an acute visit for a psychotropic medication review and management, and continue evaluation of moods and behaviors. She had been notified of the neurologist's request to decrease divalproex due to ammonia levels. She had been told labs had been drawn in the morning (7/10/25). She decreased the resident's divalproex [250 mg] from three times a day to two times a day. A progress note, dated 7/15/25 at 6:41 a.m., indicated NP 12 visited the resident for behavior management meeting, recent medication changes, psychotropic medication review and management, and continued evaluation of moods and behaviors. She ordered an ammonia level to be drawn in two weeks. A progress note, dated 7/16/25 at 10:00 a.m., indicated NP 13 visited the resident for interpretation of labs. He reviewed the labs drawn on 7/10/25. He ordered an ammonia level for the next week. The clinical record lacked documentation of an ammonia level from 7/7/25 through 8/10/25. A progress note, dated 8/11/25 at 6:09 a.m., indicated a blood draw was performed for labs. A progress note, dated 8/13/25 at 11:00 a.m., indicated NP 13 visited the resident for interpretation of labs. He indicated the ammonia level was very low and considered very good from the recent lab draw. During an interview, on 3/3/26 at 8:56 a.m., the DON indicated she would look for the ammonia lab results for 2025. During an interview, on 3/3/26 at 1:13 p.m., NP 12 indicated she gave orders verbally to the nurses. She did not enter orders in her documentation that had not already been discussed with the nursing staff. During an interview, on 3/3/26 at 2:00 p.m., NP 13 indicated Resident 17 had difficulties with his ammonia levels being high. Neurology had wanted to decrease the resident's divalproex in July. He referred Neurology's concerns to NP 12 (the psychiatric provider). He had ordered an ammonia level on 7/16/25. The facility had ordered the lab. He had tried looking for the lab on his lab access site. He was unable to locate the ammonia level lab. He wrote the residents' new orders himself for the staff unless it was an order that he gave over the phone. He noted the ammonia level was completed on 8/11/25. He usually put a reminder on his phone if he had something to follow up on. During an interview, on 3/3/26 at 2:20 p.m., the DON indicated the lab said they did not draw the ammonia lab on 7/10/25. The requisition had been turned in on MatrixCare, the lab had missed it. The facility had not put in orders for the ammonia labs ordered on 7/15/26 and 7/16/26. The ADON was responsible for following up on lab draws and putting in orders for labs. The nurses also put in lab orders. She followed up on labs even if the NP ordered the labs. The DON and nurses could put in labs if the ADON was not available. The ammonia level was completed on 8/11/25. A current facility policy, revised 4/2024, titled Guidelines for Lab and Radiology Tracking, provided by the Administrator on 3/3/26 at 3:21 p.m., indicated the following: .All lab and/or radiology orders will be entered into MatrixCare Physician Orders upon receipt of order. Daily order checks by medical records or designee will ensure all orders have been entered in MatrixCare and are accurate. 410 IAC 16.2-3.1-49(a)

Based on observation and interview, the facility failed to prevent contamination of clean resident clothing while distributing resident laundry during a random observation. Findings include:During an observation, on 2/24/26 at 12:23 p.m., the following was observed:A laundry staff member delivered clothing to residents. She pulled clothing out of a covered laundry cart. The resident's clean laundry was pressed up against the front of her body while she knocked on the resident's door and proceeded into the residents room. She opened the closet door and hung the clean laundry up. She performed hand hygiene upon exiting the resident's room.She pushed the covered cart down the hallway. She stopped in front of another resident's room where she pulled their clean laundry out of the cart. The clean laundry was placed against the front of her body as she entered the resident's room. She proceeded to hang clothing in the resident's closet. Hand hygiene was performed while exiting the resident's room.She removed another resident's laundry from the covered cart. The clothing touched the front of her body when she knocked on the resident's door before proceeding into the resident's room. She opened the closet door before putting the clothing away. Hand hygiene was performed upon exiting the room.She pulled another resident's laundry from the covered cart. As she turned to enter the resident's room, the laundry touched the front of her body. Hand hygiene was performed upon exiting the resident's roomDuring an interview, on 2/24/26 at 12:33 p.m., Laundry Aide 5 indicated when delivering clean clothing it should not touch one's body.During an interview, on 3/3/26 at 1:46 p.m., the DON indicated staff should keep laundered clothing or linens away from their body to prevent cross contamination.A current facility policy, dated 8/2017 and revised 12/2021, titled Laundry Policy, provided by the Administrator, on 3/2/26 at 4:41 p.m., indicated the following: .Personnel shall handle, store, process and transport personal clothing and linen in a manner that prevents the spread of infection as follows: 1. Clean linen should be carried away from the body to prevent cross contamination 410 IAC (Indiana Administrative Code) 16.2-3.1-19(g)

Based on observation, record review, and interview, the facility failed to ensure a qualified medication aide obtained authorization from a licensed nurse to administer an as needed (PRN) medication prior to the medication's administration for 2 of 10 residents observed during medication administration (Resident 3 and 29). Findings include: 1. During a medication administration observation, on 2/25/26 at 12:24 p.m., Resident 3 asked for pain medication. She had a 10 on a 1 to 10 scale of back pain. QMA 7 returned to the medication cart, removed a morphine tablet from the narcotics drawer, signed out the morphine, returned to the resident's room with the morphine, and gave the resident the morphine along with her nitrofurantoin and protein supplement. She did not ask a nurse for permission to administer the PRN medication or mention to the nurses at the nurses' station while she pulled the medication from the cart that the resident had requested the pain medication. The ADON, DON, and RN 8 sat at the nurses' station. Resident 3's clinical record was reviewed on 2/26/25 at 10:01 a.m. Diagnoses included chronic kidney disease, generalized anxiety disorder, dysphagia, intervertebral disc degeneration of the lumbar region, pressure area to the sacrum, peripheral vascular disease, obesity, impaired mobility, gastroesophageal reflux disease, and osteomyelitis of the vertebrae sacral region. Current orders included morphine immediate release 15 mg every four hours PRN for moderate to severe pain (2/16/26). A quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A care plan, initiated 5/10/19, indicated the resident was at risk for pain related to intervertebral disc degeneration of the lumbar region, pressure area to the sacrum, peripheral vascular disease, obesity, impaired mobility, gastroesophageal reflux disease, and osteomyelitis of the vertebrae sacral region. An intervention, initiated 3/12/21, indicated to administer oral and topical medication per order and notify the physician if they are not effective. 2. During a medication administration observation, on 2/25/26 at 12:41 p.m., Resident 29 requested pain medication as he walked by the QMA. He indicated his pain was 5 on a 1/10 pain scale. QMA 8 retrieved a 600 mg ibuprofen tablet from the medication cart. She did not ask for permission to administer the medication. The ADON and DON sat at the nurses' station and did not appear to hear the resident's request as they made no comments about the resident's request for pain medication. QMA 8 administered the ibuprofen to the resident in his room. Resident 29's clinical record was reviewed on 2/26/26 at 10:25 a.m. Diagnoses included traumatic brain injury, pain in left hip, and gastroesophageal reflux disease. Current orders include ibuprofen 600 mg every four hours PRN (12/16/25). A quarterly MDS, dated [DATE], indicated the resident was cognitively intact. A care plan, initiated 4/28/25, indicated the resident was at risk for pain related to traumatic brain injury, pain in left hip, and gastroesophageal reflux disease. Interventions included administer medications as ordered (4/28/25). During an interview, on 2/25/26 at 12:53 p.m., QMA 8 indicated she was supposed to ask a nurse prior to giving a PRN medication to a resident. She had been nervous and messed up two times, once with Resident 3 and then with Resident 29. During an interview, on 2/25/26 at 12:54 p.m., the ADON indicated QMAs are supposed to ask for permission prior to the administration of a PRN medication. During an interview, on 3/3/26 at 11:49 a.m., the DON indicated a QMA needed to ask permission prior to giving a PRN medication. According to the Qualified Medication Aide Scope of Practice (for Indiana), accessed 2/25/26 at 1:00 p.m. at https://www.in.gov/health/files/QMAScopeofPractice.pdf, The following tasks are within the scope of practice for the QMA unless prohibited by facility policy: .Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. A current facility procedure, revised 4/2025, titled Medication Administration, provided by the Administrator on 3/3/26 at 12:47 p.m., indicated .Procedure Steps: PRN Medications 31. Licensed nurse assessed resident to determine the need for the PRN medication. 410 IAC 16.2-3.1-35(g)(1)

Based on observation and interview, the facility failed to dispose of unlabeled and unused medications for 2 of 4 medication carts reviewed for medication storage and labeling. (Medication Cart B and Medication Cart C) Findings include: During a medication storage observation of Medication Cart B, accompanied by QMA 3 on 3/5/25 at 11:17 a.m., a loose pill was found on the bottom of the second drawer, towards the back of the cart. An additional loose pill was found at the bottom of the second drawer. QMA 3 indicated the pills should be disposed of. The medication carts were cleaned out once a week. Any loose pills would be discarded using the drug buster solution. During a medication storage observation of Medication Cart C, accompanied by QMA 3 on 3/5/25 at 11:22 a.m., a loose pill was found on the bottom of the second drawer, towards the middle of the drawer. QMA 3 indicated the pill should be disposed of. During an interview with the Corporate Nurse, during the medication cart observation, she indicated loose pills should be disposed of using the drug buster solution. A current facility policy, titled Medication Storage and Expiration, provided by the Administrator on 3/6/25 at 3:35 p.m., indicated the following: .Facility should destroy and reorder medications with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions 3.1-25(j)

Based on record review and interview, the facility failed to ensure narcotic medication was handled and accounted for according to facility policy for 1 of 6 residents reviewed for pharmaceutical services. (Resident B) Findings include: A review of Resident B's clinical record was completed on 7/20/23 at 11:04 a.m. Diagnoses included cerebral atherosclerosis, spastic quadriplegic cerebral palsy, and generalized anxiety disorder. A physician's order, dated 6/7/23 and discontinued on 6/20/23, indicated lorazepam (to treat anxiety) 0.5 mg (milligram) administer 1 mg every four hours for generalized anxiety disorder. During an interview on 7/20/23 at 11:45 a.m., the ADON indicated the medication count on 6/14/23 had been over for lorazepam 0.5 mg during the narcotic count the morning of 6/14/23. The night shift nurse (LPN 6) had administered baclofen (a muscle relaxer) instead of lorazepam. The baclofen medication card had been placed in the narcotic box in error. When LPN 6 arrived the next morning, QMA 3 told her something was off with the count. At that time, it was determined the baclofen had been given instead of lorazepam. The ADON contacted the NP regarding the error. The four Lorazepam tablets were destroyed by the ADON with QMA 3 as a witness. The ADON notified the DON and the Administrator and was counseled for destroying the medication instead of documenting the medication error. During an interview on 7/20/23 at 12:01 p.m., the DON indicated the facility paid for the four destroyed tablets to be replaced. She immediately educated the ADON on the appropriate way to handle a miscount of medications. LPN 6 would not confirm if she gave the baclofen or just skipped the lorazepam doses. During an interview on 7/20/23 at 12:07 p.m., the Administrator indicated he was made aware of the medication error and the inappropriate correction of the lorazepam count. The ADON was educated immediately regarding the policy for disposal of medications and medication errors. Review of a narcotic count sheet for June 2023, provided by the ADON on 7/20/23 at 12:28 p.m. indicated a handwritten notation of count corrected, initialed by the ADON on 6/14/23. A Medication/Treatment Error Report dated 6/14/23 at 9:00 a.m., received from the ADON 7/23/23 at 12:00 p.m., indicated lorazepam 1 mg (two 0.5 mg tablets) not given at 12:00 a.m. and 4:00 a.m. The NP was notified on 6/14/23 at 8 a.m. and Resident B's family was notified on 6/14/23 at 8:30 a.m. The DON was notified by the ADON on 6/14/23 at 9:00 a.m. Measures taken to prevent recurrence included .education and med pass observation. LPN 6, who made the error, refused to sign the Medication/Treatment Error Report and quit her job. The document was signed by the DON on 6/15/23. A document titled Drug Disposition Form dated 6/14/23 at 8:30 a.m. and received from ADON on 7/20/23 at 12:00 p.m. indicated RX # 604434560, drug Lorazepam (Ativan) 0.5 mg, quantity 4, reason for destruction code 5 (dropped/ruined), and method of destruction code D (other - drug buster), was signed by the ADON and QMA 3. A document titled Record of Facility Inservice dated 6/14/23 and received from DON on 7/20/23 at 12:28 p.m. indicated the in-service focused on counting narcotics at shift change and included a summary indicating Nurses and QMA's need to count prior to handing off cart keys to anyone. Every shift, every time. The DON provided a Quality Assurance Tool on 7/24/23 at 2:51 p.m The document was undated. During an interview on 7/24/23 at 2:51 p.m., the DON indicated the date should have been recorded as 6/30/23. The assessment tool was completed by the Regional Director of Clinical Services (RDCS).The document indicated the suspected drug diversion was immediately reported to the DON and/or Administrator, an investigation of the diversion was started immediately and an interview of all staff involved was completed. Human Resources was notified of the drug diversion with potential recommendations followed. The narcotic count sheets were reviewed for the entire facility for discrepancies or unusual activity and indicated no other discrepancies were observed. Individual controlled records were reviewed for each resident for discrepancies and no other discrepancies were observed. The facility cameras were reviewed as needed or available. All narcotics were counted and accuracy was verified for the entire building including the Emergency Drug Kits. The shred boxes were investigated for potential missing card/sheets. A soft file was kept with Administrator/DON regarding investigation with summary of findings typed up. Narcotic storage and destruction was occurring per policy. Staff education was provided for any areas of opportunity. A current Medication Errors policy with a revision date of 11/2018, was provided by the DON on 7/21/23 at 3:01 p.m., and indicated the following: .Policy - It is the policy of this provider to ensure residents residing in the facility are free of medication errors and the facility maintains a medication error rate of less than 5%. Procedure - When a suspected medication error is identified, the nurse will immediately assess the condition of the affected resident and notify the physician of the event. The responsible party/family will be notified of the error. The DON will be notified of the error, resident condition. The charge nurse will correct findings contributing to the error (i.e. destroy/return discontinued meds, correcting transcription errors, etc.) to prevent further errors. The charge nurse will complete a medication error report, including a brief summary of findings. Documentation in the medical record will include physicians/family notification, type of error, and assessment of resident. The licensed nurse/QMA responsible for the error will be required to meet with the DON/designee to review the medication error report. Education/Disciplinary actions are determined based on the medication error and the individual staff member's past performance errors. Medication errors resulting in outcomes that require medical treatment beyond an ER/Physician evaluation or monitoring of vital signs will be reported to IDOH and reviewed as needed in facility QAPI meetings The deficient practice was corrected by 7/3/23, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, audits, and education related to the facility's Medication Errors protocol. This Federal tag relates to complaint IN00412174. 3.1-25(n)

Based on observation, record review, and interview, the facility failed to ensure oxygen was not titrated without a physician's order for 1 of 2 residents reviewed for respiratory care (Resident 29). Findings include: During an observation on 7/18/23 at 10:41 a.m., Resident 29 rested quietly in bed with her eyes closed. She received oxygen at 3 lpm (liters per minute) per nasal cannula. On 7/19/23 at 9:51 a.m., the resident rested in bed with her eyes closed and received oxygen at 3 lpm per nasal cannula. On 7/20/23 at 9:49 a.m., the resident rested in bed with her eyes closed. Her respirations were noisy and congested. She received oxygen at 3 lpm per nasal cannula. The resident's clinical record was reviewed on 7/19/23 at 2:54 p.m. Her diagnoses included chronic obstructive pulmonary disease, pulmonary fibrosis, heart failure, peripheral vascular disease, hypotension, and atherosclerotic heart disease of the native coronary artery without angina pectoris. Current physician's orders included morphine (opioid pain medication) concentrate solution 100 mg/5 ml: 0.25 ml every four hours (7/19/23) and admit to hospice (5/31/23). The facility clinical record lacked physician orders for oxygen therapy. A current care plan, dated 5/30/23, revised on 6/19/23, indicated the resident had the potential for impaired gas exchange related to COPD (chronic obstructive pulmonary disease). The goal, with a target date of 9/5/23, was the resident would have adequate respiratory functions as evidenced by decreased or absence of dyspnea, improved breath sounds, decreased or absence of shortness of breath, and improved oximetry results. The interventions included administer oxygen as ordered (5/31/23). A current care plan, dated 5/30/23, revised on 6/19/23, indicated the resident was at risk for ineffective tissue perfusion related to heart failure, atherosclerotic heart disease of the native coronary artery without angina pectoris, peripheral vascular disease, and hypotension. The interventions included administer oxygen as ordered (5/31/23). A Progress Note, dated 5/31/23 at 2:40 p.m., indicated the resident was admitted to the facility with an oxygen saturation of 81% on room air. Oxygen was applied at 2 lpm. A Progress Note, dated 6/8/23 at 4:28 p.m., indicated the resident received oxygen per nasal cannula at 3 lpm. A Progress Note, dated 7/9/23 at 1:48 p.m., indicated the resident's oxygen saturation was 96% with oxygen on at 3 lpm. During an interview, on 7/20/23 at 10:09 a.m., LPN 51 indicated the resident's oxygen delivery was kept around 3 lpm. They titrated the oxygen according to the oxygen saturation levels. Oxygen therapy needed to be ordered by a medical provider. She was unable to locate orders for oxygen for the resident in the facility's clinical record system. During an interview, on 7/20/23 at 10:13 a.m., LPN 52 indicated the resident should have an oxygen order. Many of the resident's medications had been discontinued recently. She was unable locate previous or current orders for the oxygen in the facility clinical record system. On 7/20/23 at 10:32 a.m., the Director of Nursing (DON) indicated the resident did not have an order for oxygen, but should have. Review of the resident's visit note report from the hospice binder, provided by the DON on 7/20/23 at 10:34 a.m., indicated the resident received oxygen at 3 lpm on 7/5/23. Review of the resident's client medication report from the hospice binder, provided by the DON on 7/20/23 at 10:34 a.m., indicated the resident had a hospice order for continuous oxygen at 2-4 lpm. The order lacked parameters for adjustment of oxygen liter flow. The hospice contract agreement with the facility, provided by the administrator during the entrance conference on 7/18/23, was reviewed, on 7/21/23 at 2:01 p.m., and indicated .Responsibilities of the Facility .Maintain an accurate medical record that includes all services and events provided. During an interview, on 7/24/23 at 3:07 p.m., the Administrator indicated the facility used a quality assurance tool for oxygen use. The tool was used to ensure oxygen use protocols were followed. The tool was completed in 1/2023 and 5/2023 and was due again 9/2023. The tool included checking for an order for oxygen. The tool completed for 5/2023 had been completed just prior to the admission of the resident. He indicated the resident had a hospice order for oxygen. This order had not been placed in the facility's orders for the resident. A current, undated facility policy, provided by the Administrator on 7/24/23 at 3:08 p.m., indicated, .Initiation of Oxygen 1) Verify physician order .4) Obtain the appropriate oxygen delivery device .7) Apply device to the patient with appropriate liter flow 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to prevent a cognitively impaired, dependent resident from falling from a mechanical lift during a staff-assisted transfer for 1 of 2 residents reviewed for falls with injury (Resident 1). This deficient practice resulted in the resident sustaining a right arm fracture. Finding include: On 5/17/22 at 9:37 a.m., Resident 1 was in bed asleep. On 5/17/22 at 11:22 a.m., she was seated in her high-backed reclining wheelchair in the hallway. The skin around her left eye was reddened and her right arm was covered with an elastic bandage. On 5/18/22 at 11:38 a.m., CNA 30 left her room with a mechanical lift. The resident was seated in her wheelchair. Resident 1's clinical record was reviewed on 5/17/22 at 1:15 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], unspecified intellectual disabilities, spastic quadriplegic [CONDITION(S)], displaced transverse fracture of shaft of humerus of right arm, and [CONDITION(S)]. A 2/10/22, quarterly, Minimum Data Set (MDS) Assessment indicated she was rarely/never understood and rarely/never understood others. She required extensive assistance with bed mobility and transfers and was dependent for locomotion. She had a current, 6/11/16, care plan problem, revised 5/6/22, of requiring total staff assistance with completing daily care/needs such as bed mobility, eating, transfers and toileting. She had a current care plan problem, developed 5/6/22, of thrusting herself forward at times while in the mechanical lift. Review of an event note, dated 5/3/22 at 6:45 p.m., indicated Resident 1 had been in a mechanical lift in her room, near her bed, and then had landed on her right side. She hit her head and had right arm pain; a laceration to the right side of her forehead, near her eyebrow, measured 2.5 centimeters (cm) long x 0.3 cm width. CNA staff stated she had leaned forward out of the mechanical lift quickly. A progress note, dated 5/3/22, indicated the nurse had been summoned to the resident's room at 6:45 p.m. The resident was noted to be lying near her bed, on her right side. She had a laceration to the right side of her forehead and her right upper extremity was more limp than normal. She was transferred to the emergency department for evaluation. A 5/4/22 interdisciplinary team review indicated Resident 1 had leaned forward quickly during a transfer and had a fall. She had sustained a laceration above her right eye and a right arm fracture. She had been transferred in the mechanical lift by two staff. A 5/6/22 assessment note indicated she had sutures in place to the laceration on her forehead. Review of a fall investigation report, provided by the DON on 5/19/22 at 1:45 p.m., indicated she had a witnessed fall on 5/3/22. She had been in the mechanical lift prior to the fall, then had been noted on the ground on her back. During an interview, on 5/19/22 at 2:36 p.m., CNA 32 confirmed she had been present during the resident's fall on 5/3/22. She indicated she and QMA 39 had been transferring the resident from her high-backed reclining wheelchair to the bed with a mechanical lift. She was operating the lift and QMA 39 was standing near the resident. The resident had already had a lift pad under her and she left it against my better judgement. It was a different lift pad than usual, it did not have the straps to go between her legs and looked like a sling, and CNA 32 proceeded to operate the lift. She could not recall details of the fall, but she remembered the resident going forward, head over feet, and landing on the ground. The resident hit her head on the leg of the lift and landed with her arm behind her. She thought maybe the resident had grabbed the lift pad, causing her to flip forward, but she wasn't sure. She had never had an issue while being transferred before this. Review of written witness statements, provided by the Administrator on 5/19/22 at 2:42 p.m., indicated the following: CNA 32's statement indicated on 5/3/22 at 6:45 p.m., she had QMA 39 assist her with transferring Resident 1 to bed. She was on the thin straight lift pad and as they were transferring her, she suddenly leaned forward and fell so fast out of the lift. It happened so fast they could not catch her. LPN 34's statement indicated she was summoned to the resident's room and found her laying on her right side with a laceration to the right side of her forehead and her right arm more limp than usual. CNA staff indicated she had jumped out of the lift. QMA 39's statement indicated she and CNA 32 had lifted the resident onto the lift pad; she then leaned forward and slipped out onto the floor. They couldn't catch her. Review of an emergency department visit summary, dated 5/3/22, indicated a diagnosis of a broken arm, a fall, and a cut on her forehead. Her sutures were to be removed in 10 days and she was to follow up with orthopedics about her right arm fracture. During an interview, on 5/19/22 at 3:10 p.m., the ADON indicated the lift pad used to transfer the resident was gone. The DON indicated all of the lift pads were the same, nothing had changed. An observation of lift pads in the clean linen room indicated two shower slings and bariatric lift pads. Review of a 5/4/22 in-service document, provided by the DON on 5/20/22 at 9:10 a.m., indicated a criss-cross lift pad was to be used for the resident's transfers. A skills validation checklist indicated one staff member should guide the resident as the other staff member operated the lift. During a phone interview, on 5/23/22 at 10:37 a.m., QMA 39 confirmed she had been present during the resident's fall on 5/3/22. She indicated she had been standing in front of the resident, and then to the side of her due to the lift legs being out front, when the resident somehow leaned forward and fell , striking her head and cutting her face above her eye. She had been on a lift sling that went around her, but not between her legs. QMA 39 indicated she was not sure if the facility still had the lift pad and was not sure where it had come from, it had been in with the other lift pads. The resident had a tendency to lean one way or another, that's why she was standing to the side of her, but she somehow went forward. Review of the document User Instruction Manual Hoyer® HPL700, dated 2016 and retrieved from www.joerns.com indicated the following: .DO NOT use a sling unless it is recommended for use with the lift. ALWAYS check the sling is suitable for the particular patient and is of the correct size and capacity Review of the Indiana State Department of Health Nurse Aide Curriculum, revised 11/19/15, and obtained from www.in.gov, indicated the following: .Using mechanical lifts .5. Resident's arms across chest. Stabilize resident's head and neck. 6. Raise sling/resident. 7. Co-worker support resident's legs 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to report allegations of abuse for 1 of 2 residents reviewed for abuse (Resident 13). Findings include: During an interview with Resident 13, on 5/17/22 at 1:37 p.m., he indicated during an evening shift, two girls came in to change him and he was turning over in bed, he was not fast enough and they turned him over and he hit his head on the wall, and he reported it to the ADON. An observation of the wall during the interview there was a white nickel sized area, a white square of paint/spackle was over top of the area as if being repaired. Resident 13's clinical record was reviewed on 5/17/22 at 3:02 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, (Minimum Data Set) dated 3/17/22, indicated he was severely cognitively impaired. He required extensive assistance of two staff members for bed mobility, transfers, toileting and dressing. He had a revised care plan, dated 2/23/22, that indicated at times he made false allegations, i.e.) staff haven't done something that they had. His goal was he would refrain from making false allegations through next review. Interventions dated 1/12/21 included assess for wants and needs, assure resident that he is safe and cared for, listen to resident and report any concerns to charge nurse and administrator and switch staff members if necessary. Review of the investigation provided by the DON, on 5/17/22 at 4:00 p.m., indicated Resident 13 said he did not like how staff did bed mobility during care. Staff was interviewed and indicated the following: CNA 1 never seen him hit his head during care. CNA 2 stated she and CNA 3 provided care and it never happened. CNA 3 had the same story as CNA 2. CNA 4 did not provide care on him. CNA 5 it never happened on his shift or did he ever notice any wounds. The Administrator indicated it was his conclusion that Resident 13 may had seen the dent and assumed it happened. Staff was to be educated on his care strategies and the investigation was signed by the Administrator and dated 4/25/22. Education was provided to staff on 4/25/22 and the summary of the meeting was roll the resident with consideration and patience. Que resident through his care. Resident's refusal of care needs to be re-approached. During an interview with the Administrator, on 5/17/22 at 3:31 p.m., he indicated it had been reported to him and investigated. The SSD visited the resident weekly because he had frequent complaints. He did not report it to IDOH. They interviewed and educated staff about careful consideration when he was being rolled over. He was resistant to care and pushed against staff when they provided care, no staff member had indicated anything had happened (he had not hit his head or hand). During an interview with the SSD (Social Service Director), on 5/19/22 at 1:52 p.m., she indicated he had a false allegation and it was proven to be wrong. There were times he would have a substantial allegation and then say that he was just kidding. He had said he was unhappy about how they did care on him and he did not like how they turned him, he was unable to specify anyone or what shift it had happened. A grievance was completed in April. After the interview with the SSD, she provided a Resident/Family Concern form, dated 4/11/22, that indicated he filed a concern and he was unhappy with his care. The plan for resolution was staff was educated on proper care of resident. They were reminded to have careful consideration with all residents and to give the resident thorough care. He stated he may have hit his hand on the wall with care but was not sure. There was no injury noted. He had stated it may had been when he attempted to turn himself in bed without staff present. His wife stated he always hit his hands on his wheelchair. The plan was reviewed with Resident/Family on 4/11/22. There was a staff member's and the Administrator's signature dated 4/12/22. A current facility policy, titled, Abuse Prohibition, Reporting, and Investigation, provided at entrance to the facility on [DATE], indicated the following: .Reporting/Response .2. The Executive Director will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Long Term Care Division of the Indiana State Department of Health via the Gateway Portal .7. The Executive Director will follow the reporting guidance delineated through the Indiana Department of Health, Division of Long Term Care Incident Reporting Policy. A current policy, titled, Indiana Department of Health, Division of Long Term Care, Incident Reporting Policy, provided by the Administrator on 5/23/22 at 10:00 a.m., indicated the following: .1. Federal Regulations a. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse .are reported immediately to .other officials in accordance with State law through established procedures (including to the State Survey and Certification Agency) 3.1-28(c)

Based on observation, interview and record review, the facility failed to follow a recipe for pureed diets for 1 of 1 follow up observations of the kitchen. Findings include: During a follow up kitchen observation, on 5/19/22 at 11:11 a.m., Dietary Aide 21 indicated she was pureeing vegetable soup. She poured the drained vegetable soup in the Robot Coupe blender, put the lid on the blender and blended the soup. She added an unmeasured amount of water from a pitcher and indicated she did not always add thickener to the food because it made it clumpy. She placed the pureed vegetable soup back in the pan and covered it with aluminum foil and indicated she placed it back in the oven until it was time to serve. She did not follow a recipe. She indicated the recipe binder was on the shelf. The other dietary aide retrieved the binder from the shelf and placed it on the counter. Dietary Aide 21 looked through the binder and was unable to locate the recipe for pureed vegetable soup. There were eight residents who had a pureed diet. On 5/19/22 at 11:34 a.m. Dietary Aide 21 provided the recipe for Pureed Springtime Vegetable Soup and indicated the Administrator had the recipe. The recipe for Pureed Springtime Vegetable Soup ingredients were Springtime Vegetable Soup, Saltines and Food Thickener. The recipe indicated the following: .add soup ingredients and crackers to food processor; process to fine consistency .6. Add Thicken Up and reserved liquid; process until smooth A current policy, titled General Food Preparation and Handling, provided by the Administrator, on 5/23/22 at 10:00 a.m., indicated the following: .Procedure .20. All recipes in use will be standardized and maintained in a book accessible to the cooks 3.1-20(1)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during ice pass and the handling of linens while sorting laundry. Findings include: 1. During a random observation, on 5/18/22 at 3:18 p.m., CNA 35 was passing ice water with CNA 37. CNA 37 left room [ROOM NUMBER] and filled a water cup with ice. She placed the ice scoop back into the ice in the cooler and closed the lid, leaving the scoop inside. CNA 35 entered room [ROOM NUMBER] and obtained a water cup. She removed the ice scoop from the cooler, held the cup over the cooler, and filled the cup with ice, with the scoop touching the inside of the cup. She replaced the scoop into the ice, closed the cooler lid, and took the cup into room [ROOM NUMBER]. During an interview, at the time of the observation, CNA 35 indicated they had stored the scoop in the ice because there was no other place to store the scoop. She indicated there was a scoop storage area, which was facing the opposite direction of the ice cooler, and was smaller than the scoop. Review of a document titled Passing Fresh Ice Water, dated 10/2020 and provided by the DON on 5/23/22 at 11:33 a.m., indicated the following: .NOTE: Do not touch the pitcher with the ice scoop and do not fill the pitcher over the ice chest with an open lid .Replace the scoop in covered scoop container, clean towel, or plastic bag between rooms to prevent contamination 2. During an interview with Housekeeper 26, on 5/19/22 at 2:45 p.m., she indicated one of the laundry aides was putting BM (Bowel Movement) soiled laundry in the utility sink that was used for handwashing and an eye wash station in the laundry room. She had reported it to the Administrator, the ADON and the BOM (Business Office Manager) and they had not done anything about it. During an interview with Laundry Aide 24, on 5/20/22 at 8:25 a.m., she indicated she had thrown soiled linens into the utility sink but not linens with BM on them. This week they had had a lot of linens come through the laundry and she placed laundry in the utility sink as she sorted the laundry. A current facility policy titled, Resident's Personal Laundry, provided by the Administrator, on 5/23/22 at 10:10 a.m., indicated the following: .Procedure: Once laundry is gathered, it should be contained to not cross contaminate other items 3.1-18(l)

Based on interview and record review, the facility failed to provide care to ensure resident dignity related to a staff member not appropriately shielding herself after removing her clothing to drain a walk-in tub of water that failed to drain during a bath for 1 of 3 residents reviewed for dignity. (Resident B) Findings include: During an interview on 8/31/21 at 4:59 a.m., LPN 1 indicated she had no choice but to get into the bathtub to drain the water. She brought the resident in a bath bomb and asked the resident if she wanted to take a bath and she said yes. When the resident was in the bathtub, she was unable to drain the tub because the plug broke and was flush with the bottom of the tub. The other staff also attempted to drain the tub but could not reach the plug. They could not get the resident out of the tub without draining the water. She removed her scrub pants and sports bra and was wearing her scrub top and underwear then got into the tub. She used a butter knife to unplug the drain and then put her top in the dryer and worked only in her sports bra until her top was dry. She did not have an extra set of scrubs to change into and had several hours left on her shift. The incident occurred about one month ago. During an interview on 8/31/21 at 5:25 a.m., Resident B indicated when she was in the bathtub, staff could not get the water to drain. Everyone was in there and the nurse had to get into the tub to drain the water. She indicated the nurse did not have any clothing on and she was not bothered by it. The clinical record for Resident B was reviewed on 8/31/21 at 7:16 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], major depressive disorder, anxiety disorder, diabetes mellitus and acute kidney failure. An Annual Minimum Data Set (MDS) assessment, dated 1/28/21, indicated the resident was cognitively intact. A health care plan, dated 1/29/20, indicated the resident met the Preadmission Screening and Resident Review (PASRR) criteria of mental health related to intellectual disability and [CONDITION(S)] (genetic abnormality). An internal investigation report was provided by the Administrator on 8//31/21 at 8:44 a.m. and included the following: a. A typed statement by the Director of Nursing (DON), dated 8/5/21, indicated she received report from LPN 1 when LPN 1 indicated she had given Resident B a bath. She attempted to pull the plug to let the water drain out, but the water could not be drained. Several staff attempted to drain the water and it was cooling off. The resident was agreeable for LPN 1 to climb into the tub with her. LPN 1 explained she was covered with a towel and had shorts and a shirt on and faced away from the resident when she entered the tub. The resident was interviewed and was glad the nurse was able to help. She denied it caused her any concern or felt weird. b. A typed statement provided by Unit Manager 2, dated 8/5/21, indicated she spoke to CNA 3 and CNA 4 regarding the incident last night. They indicated LPN 1 got into the bathtub with Resident B to let the water out because the plug was accidentally put in upside down. LPN 1 took off her scrubs and covered herself with her hands and faced away from the resident. LPN 1 indicated she took off her clothes because she had to work the rest of the night. c. A statement by the Social Service Director (SSD), dated 8/5/21, indicated she met with Resident B related to the incident in the bathtub. The resident laughed and joked about how comical it must have looked and then stated she was thankful the nurse got her out. She had no signs of mental anguish. On 8/31/21 at 9:16 a.m., the Administrator was interviewed to clarify the different versions of what LPN 1 was wearing at the time she entered the bathtub. He indicated there was a 3rd CNA present and he did not have any written statements from CNA 3 or CNA 4, only their verbal statement. The nurse could not go home and change her clothes and it was a little unorthodox which is why it was not reported, it was not considered abuse. During a telephone interview on 8/31/21 at 9:36 a.m., CNA 6 indicated she arrived to work shortly before 10:00 p.m. The resident was naked in the tub and LPN 1 removed her scrub top, bottom and bra then climbed over the wall with only her underwear on. The plug was stuck and there was no rope attached to the plug. She attempted to hold a towel between LPN 1 and the resident. LPN 1 had to put her head under water to remove the plug and they had made several attempts prior to remove but could not. During a telephone interview on 8/31/21 at 10:56 a.m., CNA 3 indicated she came in later to the situation. She was not sure what she walked into, but LPN 1 only had on her bra and she was already in the tub so she was not sure what else she had on. Another aide was holding a towel up and the resident did not seem bothered. During a telephone interview on 8/31/21 at 10:31 a.m., CNA 4 indicated LPN 1 had given Resident B a bath in the whirlpool with a bath bomb. The plug was stuck and they tried to use a grabber tool but it did not work. LPN 1 took off her shirt and pants and got into the tub and tried to reach with her toes, but could not. She then removed her bra and went under the water. They did have towels up and she was not sure what the resident was able to see. The resident did not seem bothered and if she was, she would say so. A call was received on 8/31/21 at 2:51 p.m. by LPN 1 who indicated she was nervous earlier during the first interview. She indicated she knew she had to get into the tub and took off her scrub top and bottom and climbed into the tub. When she realized she had to go under the water to unplug the drain, she then removed her sports bra. Another aide put a towel between her and the resident and when she came up from the water, the aide wrapped the towel around her. She did keep her underwear on and does not believe the resident saw any part of her. Review of a policy, dated 11/16, titled Resident Rights, provided by the DON on 8/31/21 at 3:00 p.m., indicated the following: POLICY .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care. This Federal Tag relates to Complaint IN 398. 3.1-3(t)

Based on interview and record review, the facility failed to report to the state agency an occurrence that directly threaten the welfare of a resident for 1 of 3 residents reviewed for dignity. (Resident B) Findings include: During an interview on 8/31/21 at 4:59 a.m., LPN 1 indicated she had no choice but to get into the bathtub to drain the water. She brought the resident in a bath bomb and asked the resident if she wanted to take a bath and she said yes. When the resident was in the bathtub, she was unable to drain the tub because the plug broke and was flush with the bottom of the tub. The other staff also attempted to drain the tub but could not reach the plug. They could not get the resident out of the tub without draining the water. She removed her scrub pants and sports bra and was wearing her scrub top and underwear then got into the tub. She used a butter knife to unplug the drain and then put her top in the dryer and worked only in her sports bra until her top was dry. She did not have an extra set of scrubs to change into and had several hours left on her shift. The incident occurred about 1 month ago. During an interview on 8/31/21 at 5:25 a.m., Resident B indicated when she was in the bathtub, staff could not get the water to drain. Everyone was in there and the nurse had to get into the tub to drain the water. She indicated the nurse did not have any clothing on and she was not bothered by it. The clinical record for Resident B was reviewed on 8/31/21 at 7:16 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) assessment, dated 1/28/21, indicated the resident was cognitively intact. A health care plan, dated 1/29/20, indicated the resident met the Preadmission Screening and Resident Review (PASRR) criteria of mental health related to intellectual disability and [CONDITION(S)] (genetic abnormality). An internal investigation report was provided by the Administrator on 8//31/21 at 8:44 a.m. and included the following: a. A typed statement by the Director of Nursing (DON), dated 8/5/21, indicated she received report from LPN 1 when LPN 1 indicated she had given Resident B a bath. She attempted to pull the plug to let the water drain out, but the water could not be drained. Several staff attempted to drain the water and it was cooling off. The resident was agreeable for LPN 1 to climb into the tub with her. LPN 1 explained she was covered with a towel and had shorts and a shirt on and faced away from the resident when she entered the tub. The resident was interviewed and was glad the nurse was able to help. She denied it caused her any concern or felt weird. b. A typed statement provided by Unit Manager 2, dated 8/5/21, indicated she spoke to CNA 3 and CNA 4 regarding the incident last night. They indicated LPN 1 got into the bathtub with Resident B to let the water out because the plug was accidentally put in upside down. LPN 1 took off her scrubs and covered herself with her hands and faced away from the resident. LPN 1 indicated she took off her clothes because she had to work the rest of the night. c. A statement by the Social Service Director (SSD), dated 8/5/21, indicated she met with Resident B related to the incident in the bathtub. The resident laughed and joked about how comical it must have looked and then stated she was thankful the nurse got her out. She had no signs of mental anguish. On 8/31/21 at 9:16 a.m., the Administrator was interviewed to clarify the different versions of what LPN 1 was wearing at the time she entered the bathtub. He indicated there was a 3rd CNA present and he did not have any written statements from CNA 3 or CNA 4, only their verbal statement. The nurse could not go home and change her clothes and it was a little unorthodox which is why it was not reported, it was not considered abuse. During a telephone interview on 8/31/21 at 9:36 a.m., CNA 6 indicated she arrived to work shortly before 10:00 p.m. The resident was naked in the tub and LPN 1 removed her scrub top, bottom and bra then climbed over the wall with only her underwear on. The plug was stuck and there was no rope attached to the plug. She attempted to hold a towel between LPN 1 and the resident. LPN 1 had to put her head under water to remove the plug and they had made several attempts prior to remove but could not. During a telephone interview on 8/31/21 at 10:56 a.m., CNA 3 indicated she came in later to the situation. She was not sure what she walked into, but LPN 1 only had on her bra and she was already in the tub so she was not sure what else she had on. Another aide was holding a towel up and the resident did not seem bothered. During a telephone interview on 8/31/21 at 10:31 a.m., CNA 4 indicated LPN 1 had given Resident B a bath in the whirlpool with a bath bomb. The plug was stuck and they tried to use a grabber tool but it did not work. LPN 1 took off her shirt and pants and got into the tub and tried to reach with her toes, but could not. She then removed her bra and went under the water. They did have towels up and she was not sure what the resident was able to see. The resident did not seem bothered and if she was, she would say so. A call was received on 8/31/21 at 2:51 p.m. by LPN 1 who indicated she was nervous earlier during the first interview. She indicated she knew she had to get into the tub and took off her scrub top and bottom and climbed into the tub. When she realized she had to go under the water to unplug the drain, she them removed her sports bra. Another aide put a towel between her and the resident and when she came up from the water, the aide wrapped the towel around her. She did keep her underwear on and does not believe the resident saw any part of her. Review of a policy, dated 2/20, titled Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 8/31/21 at 7:34 a.m., indicated the following: Policy: .Reporting/Response: .7. The Executive Director will follow the reporting guideline delineated through the Indiana State Department of Health, Division of Long Term Care Incident Reporting Policy. This Federal Tag relates to Complaint IN 398.

Based on observation, record review, and interview, the facility failed to ensure residents did not receive [CONDITION(S)] medications without indication for 2 of 6 residents reviewed for unnecessary [CONDITION(S)] medications (Residents 26 and 21). Findings include: 1. On 7/28/21 at 9:13 a.m., Resident 26 was sitting on a sofa in the hallway across from his room. On 7/28/21 at 2:36 p.m., he was sitting on a wheeled, seated walker in the hallway across from the nurse's station. On 7/29/21 at 9:24 a.m., he was sitting on a sofa in the hallway across from his room, his head was down, and his eyes were closed. On 7/29/21 at 1:41 p.m., he was sitting on a sofa in the hallway across from his room drinking coffee. The resident's clinical record was reviewed on 7/28/21 at 2:37 p.m. Diagnoses included, but were not limited to, [CONDITION(S)] with behavioral disturbance, generalized anxiety disorder, post-traumatic stress disorder, unspecified, psychotic disorder with delusions due to known physiological condition, alcohol dependence with alcohol-induced persisting dementia, and major depressive disorder. Current physician orders included, but were not limited to, [MEDICATION(S)] (antipsychotic) 0.25 mg twice daily for psychotic disorder with delusions due to known physiological condition, order date 5/8/20, and [MEDICATION(S)] (antidepressant) 30 mg (milligram) every bedtime for major depressive disorder, order date 6/16/20. A 6/17/21 annual MDS (Minimum Data Set) assessment indicated he had moderate cognitive impairment. The resident had no behaviors and had received an antipsychotic and antidepressant every day during the assessment period. Antipsychotic was received on a routine basis, last attempt at GDR (Gradual Dose Reduction) of the antipsychotic was 11/19/19. A current care plan, dated 7/25/19, indicated he had a diagnosis of psychotic disorder with delusions due to a known physiological condition that he took [MEDICATION(S)] for, his symptoms included demanding behaviors, delusional comments (thinking he was going to gas chamber), and verbal aggression (yelling and cursing). The goal, with a target date of 6/30/21, was to have three or less episodes per month of exhibiting demanding behaviors, delusional comments, and verbal aggression and he would have no adverse affects from taking [MEDICATION(S)]. Interventions included, but were not limited to, GDR of [MEDICATION(S)] per regulations. A current care plan, dated 7/25/19, indicated he had a diagnosis of major depressive disorder that he took [MEDICATION(S)] for, his symptoms included verbal and physical aggression (yelling and cursing), demanding behaviors (demanding to smoke outside of smoking times), long periods of staying isolated in his room, and hitting at staff or peers if angered. The goal, with a target date of 6/30/21, was to have less than two episodes of verbal aggression a month, make no demanding behaviors, come out of my room on a daily basis, and have no adverse effects from taking [MEDICATION(S)]. Interventions included, but were not limited to, GDR per regulations. A progress note, dated 6/24/21 at 4:15 p.m., indicated the resident had been sitting in the hall in his chair, another resident went by in a merry walker and bumped the side table, spilling the resident's coffee. The resident extended his arm out and open handedly smacked the other resident across the face, this was witnessed by staff, and residents were immediately separated. A Behavior Symptom Monthly Summary Form, with a completed date of 6/15/21, indicated no behaviors. A Behavior Symptom Monthly Summary Form, with a completed date of 7/20/21, indicated no behaviors. A Rounding Providers Psychiatric Progress Note, dated 7/20/21 at 1:12 p.m., indicated during behavior management meeting reviewed [CONDITION(S)] medications and any recent behaviors with interdisciplinary team, staff had reported no new mood or behavioral concerns over current review period, recent event with peer noted and appeared to have been isolated, otherwise, moods and behaviors overall appear to be near baseline. Review of Behavior Logs, provided by the SSD (Social Service Director) on 7/29/21 at 3:43 p.m., indicated no behaviors in April, May, June or July, 2021. During an interview, on 7/30/21 at 8:49 a.m., C.N.A. 5 indicated she was not aware of the resident having behaviors and he asked frequently about smoking. During an interview, on 7/30/21 at 9:15 a.m., QMA 9 indicated the resident didn't really have any behaviors, had some in the past with roommates and they watch for that, if he has his coffee he's usually pretty happy. During an interview, on 7/30/21 at 10:18 a.m., SSD indicated she would be bring the clinically contraindicated letters for a GDR from the physician for review. No additional information provided by the facility prior to exit from the facility. 2. On 7/26/21 at 10:56 a.m., Resident 21 was propelling his wheelchair backward with his leg and talking with garbled speech. On 7/27/21 at 1:23 p.m., he was in bed with the T.V. on. On 7/29/21 at 8:09 a.m., he was in the dining room for breakfast. Resident 21's clinical record was reviewed on 7/26/21 at 11:20 a.m. Diagnoses included, but were not limited to, paranoid personality disorder, restlessness and agitation, [CONDITION(S)] with behavioral disturbance, psychotic disorder, and [CONDITION(S)]. He had current medication orders for, but not limited to, [MEDICATION(S)] (for dementia) 10 mg daily, [MEDICATION(S)] (antipsychotic) 1.5 mg in a.m., 1 mg in p.m. (prescribed 11/6/19), and [MEDICATION(S)] ER (antidepressant) 150 mg every morning. He had a current care plan problem, dated December 2017 and revised June 2021, of [CONDITION(S)] with behavioral disturbance. His symptoms included short term memory loss, forgetting what I was going to say or do, or what I just said and did, not remembering things that just happened or things just said by me or to me. He had a current care plan problem, dated December 2020 and revised July 2021, of major depressive disorder with psychotic symptoms . His symptoms included irritability and agitation at others, cursing and yelling at others, throwing things like of mug a coffee and plates, delusions/paranoia, thinking someone had his things when they did not, and false allegations and poor impulse control. He had a current care plan problem, dated 2016, and revised June 2021 of false accusations or beliefs that others were stealing from him or that he had missing items. A diagnosis of paranoid personality disorder may have caused his inappropriate behaviors and actions. A 10/20/20 contraindication letter indicated a reduction in [MEDICATION(S)] may negatively impact him. Review of a 5/18/21 behavior meeting note indicated his behaviors and medications were reviewed. A GDR of venlaxafine was contraindicated due to a previous failed attempt. A 6/3/21 contraindication letter indicated a reduction of the venlaxafine may be harmful. There were no other details included to specify why it would harmful. Review of a 6/8/21 behavior symptom monthly summary indicated he had not experienced any behaviors. Review of a 6/15/21 psychiatric Nurse Practitioner note indicated due to the complex nature of his psychiatric condition, duplicate therapy with [MEDICATION(S)] and venlaxafine was indicated for his depression with [CONDITION(S)]. Review of a 7/20/21 psychiatric Nurse Practitioner note indicated his target symptoms for which [CONDITION(S)] medications were prescribed overall appeared to be near baseline and his medications should be continued. Review of a 7/20/21 behavior symptom monthly summary indicated he had one episode of verbal aggression, with yelling and throwing things. The last GDR attempt of his antipsychotic was 10/24/19 and the antidepressant was 2/28/19. Review of his Behavior Monitoring Record indicated his behaviors were he may choose to self transfer, sexually inappropriate conversations, false accusations such as others stealing from him, missing items, etc., pouring urine down the sink, yelling out and cursing, propelling self backward in wheelchair, physical aggression such as throwing things, at times could be irritable and/or agitated, could be down or withdrawn at times, and delusional and paranoid that someone was wearing his clothes or hat. He had a behavior of not wanting a shower documented in June 2021. He had no behaviors documented in July, as of 7/29/21. During an interview, on 7/30/21 at 8:45 a.m., CNA 72 indicated the resident would sometimes look blankly into space, could get upset about his drink, and he didn't like to shower. Any behaviors observed would be documented in the behavior log, and reported to the nurse. During an interview, on 7/30/21 at 9:37 a.m., CNA 24 indicated behaviors were documented in the behavior log. Resident 21 would at times, get angry over things. He had no hallucinations. During an interview, on 7/30/21 at 9:39 a.m., the Nurse Manager indicated the resident would get aggravated or angry when he was looking for something couldn't find it. Sometimes he thought the laundry aide had stolen it, but would be okay after the item was found. He had no delusions or hallucinations, but could be irritable. During an interview, on 7/30/21 at 10:04 a.m., the Social Services Director indicated the resident could be verbally aggressive, would throw things, and could be physical as in throwing his mug across the room, and would make false allegations such as so and so has my hat. He could have flashbacks from his past a lot about trauma experienced when he was younger and was easily agitated. His last failed GDR caused behaviors like throwing soup on someone, wheeling himself backward purposely, and being angry where they were not able to calm him down. Review of a current facility policy, titled Medications-Unnecessary, dated June 2021 and provided by the SSD on 7/30/21 at 2:03 p.m., indicated the following: .Each resident's drug regimen will be free from unnecessary drugs. An unnecessary drug is any drug when used .For excessive duration .Without adequate indication for use .The facility will evaluate the resident .Whether the signs and symptoms, or related causes are persistent or clinically significant enough to warrant the initiation or continuation of medication therapy .Whether non-pharmacological interventions are considered 3.1-48(b)(2) 3.1-48(b)(4)

Based on observation, record review, and interview, the facility failed to provide individualized activities programming for 4 of 4 residents reviewed for activities (Residents 26, 9, 21, and 16). Findings include: 1. During a random observation on 7/28/21 at 9:13 a.m., Resident 26 was sitting on a sofa in the the hall across from his room. On 7/28/21 at 1:36 p.m., the resident was sitting by himself on a sofa in the hall across from his room. The activity calendar indicated a movie and popcorn at 1:30 p.m. On 7/29/21 at 9:24 a.m., he was sitting by himself on a sofa in the hall across from his room, his head was down and his eyes were closed. The activity calendar had indicated coffee and reminisce was to have been the activity at 9:00 a.m., this activity was not observed to had occurred. His clinical record was reviewed on 7/28/21 at 2:37 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 6/17/21 annual MDS (Minimum Data Set) assessment indicated he had moderate cognitive impairment. It was very important for him to keep up with the news, do things with groups of people, and to do his favorite activities. A current activity care plan, dated 7/26/19, indicated he was independent in what he wished to do, he liked to exercise, participate in cooking club, and go outside for fresh air. The intervention included, but was not limited to, staff would invite him to activities to allow him to have chosen what he wanted to attend. The resident's activity participation forms, provided by the DON on 7/30/21 at 12:18 p.m., indicated the resident's participation in July included, but was not limited to, fitness program 11 times, cooking club once, and going outside for fresh air once. 2. During a random observation on 7/28/21 at 9:15 a.m., Resident 9 was lying in bed facing the wall. On 7/28/21 at 2:30 p.m., she walked in the hallway by herself. On 7/29/21 at 9:43 p.m., she walked in the hallway and indicated she didn't have anything to do. Her clinical record was reviewed on 7/29/21 at 2:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/13/21 quarterly MDS assessment indicated she had severe cognitive impairment. A current activity care plan, dated 2/16/21, indicated she would like to participate in facility activities. The interventions included, she enjoyed art activities, enjoyed attending facility socials, enjoyed exercise, and liked bingo. The resident's activity participation forms, provided by the DON on 7/30/21 at 12:18 p.m., indicated the resident's participation in July included, but was not limited to, art activity twice, one luncheon, fitness program 11 times, and bingo activity twice. 3. On 7/26/21 at 12:04 p.m. Resident 16 was seated in a chair in the hallway with another resident, with a tray table in front of him, as lunch was being served. On 7/29/21 at 9:55 a.m., he was in bed with the room darkened. Resident 16's clinical record was completed on 7/26/21 at 12:07 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His clinical record lacked an activities care plan. Review of a 5/28/21 activities assessment indicated he enjoyed exercise, bingo, cooking club, and social events. He attended most all activities. Review of an activities calendar for July 2021 indicated a fitness activity was scheduled for 7/26/21 at 10:30 a.m., a sensory activity for 11:30 a.m., a resident lunch in at 12:00 p.m., talk time at 1:00 p.m., and book club at 1:30 p.m. These activities were not observed to occur. The activities calendar indicated on 7/27/21 coffee and reminisce was scheduled for 9:00 a.m., exercise at 10:00 a.m., talk time at 1:00 p.m., Men's workshop at 1:30 p.m., and an ice cream sundae cart at 2:30 p.m. These activities were not observed to occur. Review of the resident's activities programming documentation indicated he attended the 7/26/21 exercise activity, book club, and bingo. On 7/30/21 at 2:03 p.m., the Social Service Director provided an activities care plan, dated 4/13/17 and revised on 7/22/19, with a goal date of 1/1/20, from the facility's former electronic health record system. The care plan indicated he would enjoy Bible study and cooking club. 4. On 7/26/21 at 10:56 a.m., Resident 21 was propelling his wheelchair backward with his leg and talking with garbled speech. On 7/27/21 at 1:23 p.m., he was in bed with the T.V. on. On 7/29/21 at 8:09 a.m., he was in the dining room for breakfast. Resident 21's clinical record was reviewed on 7/26/21 at 11:20 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He ha a current care plan, dated 3/30/16 and revised 6/28/21, of enjoying bingo, resident's luncheons, cooking club, and exercises, although sometimes I would rather stay in my room , listen to my radio, or watch T.V. He also enjoyed talking to staff. Review of a 6/10/21 activities assessment indicated he participated in most all activities weekly and enjoyed exercise, cooking club, outings, arts and crafts, and social gatherings. Review of a 6/14/21 psychiatric therapist note indicated they discussed how engagement in activities outside his room affected his mood and encouraged him to continue staying up more than being in bed all day. Review of an activities calendar for July 2021 indicated a fitness activity was scheduled for 7/26/21 at 10:30 a.m., a sensory activity for 11:30 a.m., a resident lunch in at 12:00 p.m., talk time at 1:00 p.m., and book club at 1:30 p.m. These activities were not observed to occur. The activities calendar indicated on 7/27/21 coffee and reminisce was scheduled for 9:00 a.m., exercise at 10:00 a.m., talk time at 1:00 p.m., Men's workshop at 1:30 p.m., and an ice cream sundae cart at 2:30 p.m. These activities were not observed to occur. Review of the resident's activities programming documentation indicated he attended the 7/26/21 exercise activity, book club, and bingo. During an interview, on 7/27/21 at 2:04 p.m., the Resident Council members indicated the activities programming was lacking and scheduled activities did not usually occur. During an interview, on 7/30/21 at 10:37 a.m., the Activities Assistant indicated she only worked weekends and occasionally on Tuesdays, so she was not aware of what activities took place during the week. Review of a current facility policy, titled Activities, dated 1/2006 and provided by the SSD on 7/30/21 at 2:03 p.m., indicated the following: .It is the policy of this facility to provide for an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident 3.1-33(a) 3.1-33(c)

Based on observation, interview, and record review, the facility failed to ensure resident furniture was clean and in good repair during random observations of the facility. Findings include: During an initial tour of the facility, on 7/26/21 at 8:50 a.m., the following was observed: a. A fabric chair outside of room 5 had dark stains on it and dark grime to the arms of the chair. b. Two fabric chairs outside of room 13 had dark stains on them and dark grime to the arms of the chairs. c. A chair outside of room 15 had dark stains on it and dark grime to the arms of the chair. The chair legs had deep gashes, exposing the wood beneath it. d. Twelve chairs in the small dining/therapy room had dark grime to the arms and debris in the seams. On 7/27/21 at 8:45 a.m., a fabric chair near room 13 had a large, irregular, wet spot on the seat of it. On 7/30/21 at 9:20 a.m., the chairs in the hallway remained with grime on the arms. During an interview, on 7/30/21 at 12:55 p.m., the Business Office Manager/Housekeeping Supervisor indicated the daily housekeeping checklist included cleaning the common area furniture. During an interview, on 7/30/21 at 1:00 p.m., Housekeeper 59 indicated the chairs in the hallways were cleaned daily and as needed when soiled. The small dining room was cleaned on a rotating deep cleaning schedule, which usually equaled a monthly cleaning. Review of the daily housekeeping checklist for July 5-30, 2021, provided by the Housekeeping Supervisor on 7/30/21 at 12:50 p.m., indicated the common area chairs had been cleaned daily. Review of the deep cleaning schedule for July 2021 indicated the small dining room had been deep cleaned on July 18, 2021. 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure mail was consistently delivered for 6 of 6 residents interviewed about mail service (Residents 2, 24, 5, 16, 1, and 27). Findings include: During an interview with the Resident Council, on 7/27/21 at 2:04 p.m., Residents 2 and 24 indicated they had a hard time getting their mail timely and the facility didn't seem to check it daily. The post marks were really old on the mail when it was delivered and had resulted in missed or late birthday cards and holiday cards. Residents 5, 16, 1 and 27 who were present in in the interview confirmed mail was not delivered regularly. During an interview, on 7/30/21 at 10:18 a.m., the Social Service Director indicated the Activity Director was responsible for passing out the resident's mail. The Activity Director was not available for interview during the survey. During an interview, on 7/30/21 at 10:37 a.m., the Activities Assistant indicated she would pass mail out when she saw it, but only worked weekends and occasionally on Tuesdays. Review of a current facility policy titled Mail, dated 10/2011 and provided by the DON on 7/30/21 at 1:04 p.m., indicated the following: .The activity department will facilitate the delivery of resident mail .Mail will be delivered to the resident within 24 hours of being received by the postal service. Mail will be delivered six days weekly, excluding holidays 3.1-3(s)(1)

Based on record review and interview, the facility failed to ensure a cognitively impaired resident had a guardian who made decisions about code status for 2 of 3 residents reviewed for advanced directives (Residents 30 and 9). Findings include: 1. The clinical record for Resident 30 was reviewed on [DATE] at 11:22 a.m., and indicated the resident code status was Do Not Resuscitate (DNR). The Annual MDS , dated [DATE], indicated the resident was severely cognitively impaired and had moderate depression. The CODE STATUS DETERMINATION form was provided by the SSD on [DATE] at 10:18 a.m., and indicated the resident was a NO CODE (no CPR was to be done in the event that his heart stopped). The residents name was printed on the bottom and there was an illegible scribble on the resident signature line. The physician signed the form on [DATE]. During an interview on [DATE] at 1:43 p.m., the SSD (Social Service Director) indicated the resident used to be a full code, during care plan meetings he started talking about death and dying. She indicated they explained to him what it meant to be a full code was and what it meant to be a no code and he chose to be a DNR, she indicated he did not have a POA or guardian and no family, he was his own person. The SSD indicated he had a brother in another state, but he didn't want anything to do with him. The facility tried to get a guardian, but because he has a criminal history, the company they use would not accept him. She indicated he made his own decisions for everything. During a follow up interview on [DATE] at 11:34 a.m., the SSD indicated she did not have documentation of the facility trying to get guardianship for the resident due to they had tried other residents who had criminal records and were not able to get them guardianship. 2. The clinical record for Resident 9 was reviewed on [DATE] at 2:30 p.m., and indicated the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated [DATE], indicated she was severely cognitively impaired and had Alzheimer's disease. The CODE STATUS DETERMINATION form was provided by the SSD (Social Service Director) on ,d+[DATE] at 3:00 p.m., with the resident's printed name and an illegible signature on the resident signature line, dated [DATE], and indicated the resident was a NO CODE (no CPR was to be done in the event that her heart stopped). The physician signature line included a physician signature and was dated [DATE]. During an interview, on [DATE] at 8:57 a.m., C.N.A. 7 indicated she was the resident's daughter, believed her mother was capable of making the decision for no code status, she had not tried to obtain guardianship or power of attorney for her mother, and she has two other children and a husband. The SSD was present during the interview and indicated the resident was capable of making decisions and was her own person. Review of a current facility policy, titled Advance Directives, with a revision date ,d+[DATE] and provided by the DON on [DATE] at 3:49 p.m., indicated . Definitions: .Advance directive - a written instruction, such as a living will or durable power of attorney for health care, recognized under State law .relating to the provision of health care when the individual is capacitated .Healthcare Consent Hierarchy - Indiana Only If an adult incapable of consenting has not appointed a health care representative/power of attorney for healthcare or the healthcare care representative/POA is not available or declines to act, consent for health care may be given in the following order of priority: 1. Court appointed guardian 2. A spouse 3. An adult child (or majority of adult children*) .*If there are multiple members at the same priority level, then the majority of available individuals controls 3.,d+[DATE](f)(7)

Based on record review and interview, the facility failed to ensure timely medical treatment was provided and the physician was notified following a critical low blood glucose level and an unresponsive episode, which resulted in hospitalization for 1 of 10 reviewed for quality of care (Resident E). Findings include: The clinical record for Resident E was reviewed on 8/24/20 at 10:59 a.m. [DIAGNOSES REDACTED]. A health care plan, dated 2/15/19, indicated I have diabetes and am at risk for hypo/hyperglycemic episodes Interventions included, but were not limited to, blood sugar checks as ordered and notify physician of result. An order, dated 3/3/20 at 4:11 p.m., indicated .new order given for (sic) monitor to alarm when BS (blood sugar) gets to 60 and to notify NP (nurse practitioner) Resident E had an order, dated 1/29/20, which indicated to administer [MEDICATION NAME] (to treat severe hypoglycemic) 1 mg intramuscularly as needed for a hypoglycemic reaction. The order indicated to recheck blood sugar after 15 minutes. No specific blood glucose level was specified. A progress note, dated 3/13/20 at 11:05 a.m., indicated At approx (approximately) 1105, CNA came to this nurse and reported that resident was not responding to her and his BG (blood glucose) monitor was reading low got Accucheck supplies and went to residents room to check BS (blood sugar) manually. Accucheck read low. This nurse asked nurse down the hall for help and went to get a [MEDICATION NAME] (to treat severe low blood sugar). Injection was given at 1110. BS read 24 after a couple of minutes .rubbed glucose gel on residents gums and under tongue. BS went up to 51. At that time other nurse told this nurse that she and CNA would stay with resident while this nurse went on to get the rest of the buildings blood sugars before lunchtime. A progress note, dated 3/13/20 at 11:30 a.m., indicated .called into room by CNA and Floor (sic) nurse for assistance, when writer entered room res (resident) was non-responsive and nurse stated blood sugar monitor read LOW, writer instructed floor nurse to get [MEDICATION NAME] injection and gave it .CNA and writer stayed with resident .writer and CNA remained with res to monitor blood sugar was rechecked about 5 minutes after injection and monitor read 25, res was still unresponsive. sugar (sic) paste was placed in res cheek while waiting for injection to get into res system, about 11:45am blood sugar was rechecked and read 51. CNA and writer continued to attempt to get res to respond and res showed some eye movements performed sternal rub and res had slight reaction blood sugar rechecked at 11:55am and read 82 stayed with res allowing blood sugar to come up more and res remained unresponsive but showing signs of slight responsiveness slight mouth movements and attempting to drink, small amounts of orange juice placed in res cheek and res swallowed it rechecked at 12:10 pm and read 137, and again at 12:15 and read 153. Vitals obtained HR: 125, Temp 96.0, BP 131/66, warm wash clothes (sic) placed on res head and armpits to help with temp still remains unresponsive and 911 was notified. 12:25 blood sugar reading 167. ambulance (sic) arrived to facility about 12:30 pm. res (sic) was transferred to gurney and taken to hospital. A progress note, dated 3/13/20 at 12:18 p.m., indicated the Assistant Director of Nursing (ADON) was notified of Resident E's condition, vital signs and blood, glucose level. The ADON notified the Nurse Practitioner (NP) of the blood glucose levels and indicated the resident had received [MEDICATION NAME] and was still not responding to verbal stimuli. The NP gave an order to send the resident to the hospital. On 3/13/20 at 12:37 p.m., Resident E was transported to the local hospital. He returned to the facility on [DATE]. Review of a transfer form, dated 3/13/20 at 12: 47 p.m., indicated Resident E was not alert. On 3/13/20 at 8:00 a.m., the Medication Administration Record [REDACTED]. Review of the MAR, [MEDICATION NAME] (treat very low blood sugar) 1 mg was given at 11:10 a.m. by RN 1. During an interview on 8/25/20 at 9:29 a.m., LPN 2 indicated RN 1 went in to check the resident's blood sugar or an aide told her he was out of it. She thought RN 1 had given the injection and the sugar gel was already in the room. LPN 2 thought she was checking his blood glucose levels but she was not sure and RN 1 was getting his vital signs. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) had gone to assess someone and when they came back they sent him out. She indicated she did not call the physician, but thought his blood glucose parameters were set at 40 for low and 400 for high, but it could be 50 or 60. She just kept thinking his blood sugar level would come up. During an interview on 8/25/20 at 9:30 a.m., RN 1 indicated they had just passed drinks for lunch and they left a drink on his bedside table. When she came around to do his blood sugars he was very diaphoretic. She was at his room and he did not respond to her. LPN 2 came to help her, got the [MEDICATION NAME] and stayed in the room with him. They did give him the sugar gel and they were able to get some orange juice down his throat. LPN 2 indicated his blood sugar had low before and have let the blood sugars come up. Even after his blood sugars came up he was still not coming around. The DON and ADON had went somewhere and then came back and said that he needed to go out. They were waiting to see if his blood sugars came up and always notified the NP, but was not sure why she did not document it. She did go ahead and finish her afternoon blood sugars. On 8/25/20 at 11:26 a.m., the ADON indicated when they came back, the resident was not responding or answering questions. When they walked into the building, the aides grabbed them and said to go to his room. When she saw the resident, she knew immediately and had the DON call 911. She was unsure of why they did not send the resident to the hospital. During an interview on 8/26/20 at 1:08 p.m., the DON indicated her and the ADON had left the building to find hand sanitizer. When they got back to the facility, a CNA came to them and said something was wrong with Resident E. They had gotten food for the staff and as she put it in the break room, she could see into his room. The ADON was already in the room then left to call 911. The resident can have very low blood sugars and still carry on a conversation. She was very upset with the incident and provided a teaching moment for both nurses'. Review of a facility policy, dated 6/04 and revised 2/19, titled Diabetic Testing, provided by the DON on 8/24/20 at 2:10 p.m., indicated the following: POLICY: .DOCUMENTATION: .Blood glucose level in mg/dl, including time and date of test. Physician notification in blood glucose level is above or below normal range, as indicated by the parameters set by physician's orders [REDACTED].>Review of a facility policy, dated 6/04 and revised 12/18, titled Change in Resident Status - Notification, provided by the DON on 8/26/20 at 7:58 a.m., indicated the following: POLICY: The facility will immediately inform the resident; consult with the resident's physician; and notify, consistent .when there is: An accident . A significant change in the resident's physical, mental, or psychosocial status, such as a .life-threatening conditions or clinical complications This Federal Tag relates to complaints IN 520, IN 463, IN 039, IN 980, and IN 411. 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide supervision for a resident with a history of falls for 1 of 3 residents reviewed for falls (Resident 29). This deficient practice resulted in the resident falling and sustaining a fracture to her right femur and requiring surgical intervention. Findings include: During an observation of Resident 29's room on 1/14/19 at 4:16 p.m., nonskid strips were not present on the floor beside the resident's bed. During an observation on 1/16/19 at 8:22 a.m., the resident was observed in bed, a floor mat was next to the residents bed and a bed alarm was attached to the bed rail on the resident's left side and within reach of the resident. On 1/16/19 at 1:12 p.m., the resident was observed in bed, a fall mat was folded near the sink in her room, the bed alarm was attached to the bedrail on the resident's left side and within reach of the resident. The clinical record for Resident 29 was reviewed on 1/14/19 at 3:42 p.m. [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set), dated 10/4/18, indicated the resident was cognitively intact, she had an impairment to her upper and lower extremity on one side, she transferred with supervision of one staff member, she used a walker for ambulation in her room and the corridor with supervision of one staff member, she was occasionally incontinent of bladder and she was a limited assist of one staff member for toileting and had a [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], indicated the resident was cognitively intact, she had an impairment to her upper and lower extremity on one side, she transferred with extensive assist of two staff members, she used a walker for ambulation in her room and the corridor with extensive assist of two staff members, she was frequently incontinent of bladder and needed extensive assist of one staff member for toileting, she used a chair and bed alarm and a [DIAGNOSES REDACTED]. A revised care plan, dated 3/17/17, indicated resident was at risk for falls and injuries related to dementia, [MEDICAL CONDITION], medications and previous stroke that had left her weak. Interventions, dated 11/6/18, included, but were not limited to, she needed to be close to the nurses station and needed a bed alarm on her bed. An intervention, dated 1/11/19, indicated nursing was to check function of her alarms every hour until she was stable enough to walk without assistance. An intervention, dated 1/16/19, indicated she needed a mat by her bed and her bed was to be in the lowest position. A health status note, dated 11/6/18 at 2:55 a.m., indicated resident was lying on the floor and assessed with [REDACTED]. Resident indicated she had needed to go to the bathroom. The resident was assisted to her feet and sat on her bed. Resident complained of a sore neck from sleeping on it. A health status note, dated 11/6/18 at 7:20 a.m., indicated resident had bruising to the right side of her face at the corner of her eye and to her right shoulder. Resident reported right hip and pelvic pain. ROM (range of motion) was attempted, resident complained of pain to right shoulder and hip. Her right shoulder had swelling and discoloration. New orders were obtained from physician for x-rays to right hip/pelvis and right shoulder. A health status note, dated 11/6/18 at 9:38 a.m., indicated x-ray results were received and indicated minimal AC (Acromioclavicular) joint separation, suspicious findings for a non-displaced distal clavicular fracture. IDT met and physician agreed to send the resident to ER (emergency room ) for further evaluation. A health status note, dated 11/6/18 at 12:49 p.m., indicated the nurse from the ER notified the facility, the resident had a large acute brain bleed of right cerebral hemisphere and was being transferred to a different hospital. A health status note, dated 11/7/18 at 9:52 a.m., indicated the IDT met and determined the root cause of fall was due to the resident had attempted to self-ambulate to the bathroom and fell getting out of bed. The resident was independent with gait and mobility with a walker. New intervention was added to the residents care plan to include a bed alarm to alert staff when the resident arises. A health status note, dated 11/12/18 at 3:17 p.m., indicated resident had returned to facility after hospital stay at 1:20 p.m. A health status noted, dated 1/9/19 at 11:35 a.m., indicated resident was found positioned on her right side at the doorway of the bathroom with her walker upright at the doorway, she was yelling out for help. The resident's right lower extremity was slightly rotated outward and the resident was complaining of right hip and leg pain. The resident was sent to the emergency room for evaluation. A health status note, dated 1/9/19 at 5:00 p.m., indicated the facility was updated by the ER nurse that the resident had a comminuted fracture of right femur proximal to prosthesis. A health status note, dated 1/11/19 at 2:57 p.m., indicated resident was in operating room for internal fixation of right femur. A health status note, dated 1/11/19 at 4:18 p.m., indicated the IDT met, they determined the root cause of the fall was the resident attempted to go to the restroom using her walker without assistance and fell between her room and the common restroom across from her room. Residents bed alarm did not sound and when alarm was checked it was off. Staff indicated the resident turned off her alarm. Interventions were updated in the care plan for nursing to check function every hour when resident returns from hospital until therapy indicates resident is stable enough to not have assistance. A health status note, date 1/15/19 at 8:11 p.m., indicated the resident returned to facility at 6:07 p.m. During an interview with the DON and Administrator, on 1/15/19 at 9:17 a.m., the DON indicated the resident normally used her call light. After the resident returned to the facility from the hospital stay in (MONTH) the resident was moved to a room closer to the nurses station and before the fall the resident was one assist of staff for ADLs (Activity for Daily Living) and was independent with ambulation, when the resident returned from the hospital on [DATE] she used a wheelchair and she worked with therapy and then was able to use her walker with staff assist. The Administrator indicated the resident did not normally turn off her alarm prior to the fall on 1/9/18. The DON indicated the CNAs did not use assignment sheets at the facility, they had care sheets hanging on the inside of the residents closet door and she would provide a copy of it. On 1/15/19 at 9:30 a.m., during an observation of the inside of the residents closet door , accompanied by LPN 15, a care sheet was present with another residents name on it. LPN 15 indicated the care sheet belonged to a resident who was no longer at the facility and they would normally have the right care sheet in the closet, she thought the closets might have been changed around. On 1/15/19 at 10:14 a.m., the DON provided a care sheet for the resident and indicated she updated it that day, but it was not in their policy to have the care sheets in the closets. On 1/16/19 at 10:47 a.m., Employee 12 indicated, the residents room was deep cleaned which pulled the previous non skid strips up off the floor and he put new skid strips on the residents floor on 1/15/19 when he was told the resident was returning to the facility. On 1/16/19 at 1:49 p.m., during an observation of the resident lying in bed, accompanied by the DON, a floor mat was not present on the floor next to residents bed and the floor mat was folded up near the sink at the entrance to the residents room. The DON indicated she was not sure if the resident was to have a fall mat next to her bed, and she picked it up and placed it next to the bed, the residents alarm was within reach of the resident and the DON attached the bed alarm lower on the bed rail. The DON removed the care sheet that belonged to the resident that no longer resided at the facility from inside the closet door and she indicated the care sheet did not have to be in the closets because the CNAs used the Kardex. On 1/16/19 at 1:54 p.m., the DON indicated the floor mat was on the physicians orders, but not on the care plan but she had 24 hours to put it on the care plan and the CNAs would know of new interventions because they are update in the communication binder. On 1/16/19 at 1:56 p.m., during a review of the communication binder, with the DON, the binder did not include the floor mat for a new intervention. On 1/17/19 at 11:27 a.m., during a review of the Hourly Alarm Check Sheet, with LPN 15, the alarm check sheet was not completed from 6 a.m. to 11: 27 a.m., LPN 15 indicated she would normally sign it off as she checks on the resident, but just hasn't signed it off yet, she had been busy with the treatments and glucometers, but she had checked on the resident. A current policy provided by the DON, on 1/16/19 at 3:17 p.m., titled Fall Prevention Program, indicated the care plan was to be updated to show the resident's risk of falls and all interventions put into place to prevent falls, including the identifying marker that the facility uses. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and injury for 1 of 4 residents reviewed for accidents (Resident 35). Findings include: On 2/20/17 at 10:20 a.m., Resident 35 was in his padded Broda chair (a high-back reclining wheelchair) in the hallway. Thigh straps were secured in place. On 2/21/17 at 8:45 a.m., he was ambulating in the hallway with the assistance of two staff members and a gait belt. On 2/22/17 at 10:48 a.m., he was ambulated to the bathroom with the assistance of CNA 32 and CNA 33, and then assisted to ambulate two laps around the facility. CNA 33 indicated, He doesn't listen, to like, sit down. He was seated in his Broda chair, with the thigh straps secured, outside of the Administrators office, facing the Activities' closet. On 2/22/17 at 11:22 a.m., he remained seated in the same place. LPN 34 stopped and asked how he was doing and asked if was he hungry. He remained seated in the hallway, unsupervised, as she walked away. On 2/22/17 at 3:18 p.m., he was in bed asleep. On 2/23/17 at 8:37 a.m., he was in his Broda chair in the hallway, asleep. On 2/23/17 at 12:52 p.m., he was in his Broda chair in the hallway outside of the nurse's station. Review of the clinical record began on 2/22/17 at 10:39 a.m. [DIAGNOSES REDACTED]. A 1/30/17 admission Minimum Data Set assessment (MDS), indicated he rarely or never understood others, his daily decision skills were severely impaired, and he required extensive assistance of two people for mobility and ADLs. The assessment indicated his ambulation was not steady, and he needed staff assistance for balance. A physician's orders [REDACTED]. A physician's orders [REDACTED]. He had a current care plan problem of risk for falls with injury related to impaired mobility, history of falls, and Huntington's disease. Interventions included, but were not limited to, keeping a clear pathway, staff assistance with transfers, and a censor cushion to his bed. He had a current care plan problem of an actual fall, revised on 2/13/17, due to an unsteady gait and poor safety awareness. Interventions included, but were not limited to, a Broda chair while up, staff to check on him every 30 minutes, and to release thigh straps and ambulate every two hours. An updated intervention on 2/14/17, to ensure thigh straps are maintained with two finger widths between his thigh and the straps. A Progress Note, dated 1/25/17, indicated he was unable to ambulate on his own, but continued to try to do so. A Progress Note, dated 1/26/17 at 3:39 p.m., indicated therapy working with resident. The note indicated he was ambulating in the hallway and dining room without assistance, went to sit down in a dining chair and leaned to the right, causing the chair to tip and he fell . A Progress Note, dated 1/26/17 at 10:01 p.m., indicated he was sitting in a dining chair, stood up and attempted to ambulate, before falling on the floor. The note indicated he .got up again and fell again stood up again and fell again assisted to feet and ambulated to room per assist of 2 An examination indicated he had received a skin tear to his right forearm. A Progress Note, dated 1/27/17, indicated an Interdisciplinary Team (IDT) review recommended staff was to investigate appropriate seating for him to maintain safety, and to keep chairs against the wall if he was going to sit in them. A Progress Note, dated 1/27/17, indicated when Resident 35 was admitted , both the hospital and his family stated he did not ambulate and was off balance when he did ambulate. The note indicated he had a history of [REDACTED]. It was recommended he would benefit from a Broda chair and to ambulate every two hours when awake. A Progress Note, dated 1/29/17 at 4 a.m., indicated he had a fall from a wheelchair while he was sitting in front of the nurse's station. It indicated he was wide awake and attempting to stand repeatedly, falling before staff could get to him. A Progress Note, dated 2/13/17 at 9:31 p.m., indicated he was in the dining room, got out of his wheelchair, stood up, and fell . He hit his head on the dining room table, resulting in a laceration to his mid-forehead, measuring 1.8 centimeters (cm) x 0.2 cm x 0.1 cm. A Progress Note, dated 2/14/17, indicated an IDT review revealed therapy recommended to loosen his thigh straps, causing him to be able to get his legs out, attributing to the fall from his chair. The note indicated staff was to ensure there were two finger-widths between the straps and his thighs. During an interview, on 2/21/17 at 9:15 a.m., LPN 35 indicated the resident had fallen on 1/26/17, 1/29/17, 1/31/17, and 2/13/17, with the last fall resulting in a laceration to his head. During an interview, on 2/24/17 at 9:21 a.m., LPN 36 indicated Resident 35 had fallen from his Broda chair on 2/13/17 during supper. She indicated his thigh straps had been released while staff was serving drinks, and he had stood and fallen, striking his head on the dining table in front of him. She indicated his thigh straps were to be removed at meals. On 2/24/17 at 10:03 a.m., the DON indicated investigation revealed his fall was due to his thigh straps being loosened per therapy recommendations. She indicated she was not sure why they had made the recommendation, but the investigation led to the indication that his straps were loose and he got his legs out and fell . She reported the investigation indicated the fall occurred on 2/13/17 at 8:38 p.m. in the dining room. On 2/24/17 at 10:07 a.m., LPN 36 indicated the straps may have been in place and loose, but she was not sure, due to the CNA reporting to her that he fell , as she was on the other side of the room, assisting with supper. She indicated she was not sure why therapy would have recommended to loosen straps, unless they were not applied correctly. The DON indicated all restraints should be applied with two fingers-width breadth. The DON also indicated staff was trained on the use of his Broda chair when it was delivered (on 1/30/17). 3.1-45(a)(1) 3.1-45(a)(2)