Every finding on record at Hooverwood

Based on interview and record review, the facility failed to ensure Minimum Date Set (MDS) assessments were accurately coded for 5 of 7 residents reviewed for resident assessments. (Resident 6, 8, 22, 46, and 105)Findings include:1. The clinical record for Resident 6 was reviewed on 4/20/26 at 9:00 a.m. The diagnoses included, but were not limited to muscle weakness, abnormalities of gait and mobility, and falls.A nursing progress note, dated 3/27/26, indicated Resident 6 had a fall in her room, sustained a hematoma to her forehead, and was sent to the emergency room for evaluation.A MDS assessment, dated 3/29/26, indicated Resident 6 had no falls with an injury since admission.During an interview, on 4/17/26 at 3:04 p.m., the MDS coordinator indicated Resident 6's MDS assessment was on 3/29/26 and should have been marked for a fall with injury.2. The clinical record for Resident 8 was reviewed on 4/17/26 at 3:33 p.m. The diagnoses included, but were not limited to, partial intestinal obstruction, congestive heart failure, and hypoglycemia.A MDS assessment, dated 3/25/26, indicated the resident had a tracheostomy.The clinical record did not indicate Resident 8 had a tracheostomy or any physician's orders or care plans for a tracheostomy.During an interview, on 4/17/26 at 3:04 p.m., the MDS coordinator indicated Resident 8 was marked as having a tracheostomy on the 3/25/26 assessment and should not have been marked as having a tracheostomy.3. The clinical record for Resident 22 was reviewed on 4/20/26 at 1:10 p.m. The diagnoses included, but were not limited to, history of falling, hearing loss, and anemia.A nursing progress note, dated 2/24/26, indicated Resident 22 had a fall, a head laceration, and was assessed in the emergency room. She returned with 12 staples to the head.A MDS assessment, dated 3/12/26, indicated Resident 22 did not have any falls with major injuries.During an interview, on 4/17/26 at 3:04 p.m., the MDS coordinator indicated Resident 22 had a fall with injury and it should have been marked on the MDS assessment in completed in March.4. The clinical record for Resident 46 was reviewed on 4/17/26 at 12:00 p.m. The diagnoses included, but were not limited to, fracture of part of the neck of the right femur, unsteadiness on feet, and muscle weakness.A nursing progress note, dated 3/18/26, indicated Resident 46 was recently hospitalized , on 3/14/26, due to a fall which resulted in a right femoral neck fracture.A MDS assessment, dated 3/23/26, indicated Resident 46 had no falls with major injury since admission.A MDS assessment, dated 4/16/26, indicated Resident 46 had no falls with major injury since admission.During an interview, on 4/17/26 at 3:04 p.m., the MDS coordinator indicated Resident 46's fall with injury should have been on the March MDS assessment.5. The clinical record for Resident 105 was reviewed on 4/20/26 at 11:00 a.m. The diagnoses included, but were not limited to, multiple fractures of the ribs, unsteadiness, and lack of coordination.A nursing progress note, dated 1/9/26, indicated Resident 105 had a fall on 1/9/26, a left hip hematoma, and was sent to the emergency room.A MDS assessment, dated 1/28/26, indicated Resident 105 did not have any falls with injuries.During an interview, on 4/17/26 at 3:04 p.m., the MDS coordinator indicated the last MDS assessment for Resident 105 was 1/28/26 and was not marked for any falls. The facility followed the Resident Assessment Instrument (RAI) manual as their policy.During an interview, on 4/20/26 at 11:28 a.m., the MDS coordinator indicated Resident 8's assessment was modified today. She modified and fixed the MDS assessments for the other residents also, but the original MDS completion date remained the same. A RAI manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025, indicated .nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)

Based on interview and record review, the facility failed to ensure physician's orders were followed, medications were administered according to the ordered parameters, and a daily weight was obtained for 4 of 4 residents reviewed for quality of care. (Resident 130, 16, 108 and 14)Findings Include: 1. The clinical record for Resident 130 was reviewed on 4/15/26 at 3:04 p.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), acute osteomyelitis (a serious bone infection) of the right ankle and foot, cognitive communication deficit, hypertension, and malignant neoplasm of the prostate. A care plan, dated 1/21/26, indicated Resident 130 had a diagnosis of congestive heart failure. Interventions included, but were not limited to, monitoring the resident's weight daily. A physician's order, dated 4/10/26, indicated to obtain a daily weight and to notify the physician if the weight was greater than 3 pounds in 24 hours or greater than 5 pounds in 1 week. The Medication Administration Record (MAR) indicated a daily weight for Resident 130 was not obtained on 2/14/26 and 3/17/26. During an interview, on 4/20/26 at 11:21 a.m., the Director of Nursing (DON) indicated if the resident had an order for daily weights, the nurses were expected to obtain the weight and document the weight in the MAR. 2. The clinical record for Resident 16 was reviewed on 4/15/26 at 9:56 a.m. The diagnoses included, but were not limited to, congestive heart failure (CHF), diabetes mellitus, chronic kidney disease, cognitive communication, and hypertension. A care plan, dated 1/21/26, indicated Resident 16 had CHF. The interventions included, but were not limited to, obtaining a daily weight. A physician's order, dated 1/21/26, indicated to obtain a daily weight and to notify the physician if the weight was greater than 3 pounds in 24 hours or greater than 5 pounds in 1 week. The MAR, dated 2/1/26 through 2/28/26, indicated Resident 16 had a 6.2-pound weight increase on 2/28/26. The MAR, dated 3/1/26 through 3/31/26, indicated Resident 16 had an 11.2-pound weight increase on 3/7/26. There was no documentation the physician was notified of Resident 16's weight gain on 2/26/26 and 3/7/26. 3. The clinical record for Resident 108 was reviewed on 4/20/26 at 12:50 p.m. The diagnoses included, but were not limited to, syncope, stroke, high blood pressure, dizziness, and Alzheimer's disease. A care plan, dated 3/12/26, indicated Resident 108 had syncope and to administer medications as ordered. A care plan, dated 3/18/26, indicated Resident 108 had hypertension and to administer antihypertensive medications as ordered. A physician's order, dated 3/5/26, indicated to administer midodrine (a medication used to increase blood pressure) 2.5 milligrams (mg) as needed three times daily for a systolic blood pressure less than 130 related to syncope. A physician's order, dated 3/16/26, indicated to administer amlodipine (a medication used to decrease blood pressure) 2.5 mg every 24 hours as needed for systolic blood pressure greater than 160 related to hypertension. A physician's order, dated 3/10/26, indicated to check Resident 108's blood pressure before meals, and to administer the as needed midodrine 2.5 mg if the systolic blood pressure was less than 130 or administer the as needed amlodipine 2.5 mg if the systolic blood pressure was greater than 160, and do not administer after 6 p.m. The MAR, dated 4/1/26 to 4/19/26, indicated the following systolic blood pressures were less than 130 and midodrine was not administered: a. The 7:30 a.m., systolic blood pressure, on 4/4/26 was 126, on 4/9/26 was 129, on 4/11/26 was 129, and on 4/18/26 was 127. b. The 11:00 a.m., systolic blood pressure, on 4/6/26 was 113, on 4/9/26 was 119, on 4/11/26 was 129, and on 4/18/26 was 123. c. The 4:00 p.m., systolic blood pressure, on 4/6/26 was 113 and on 4/11/26 was 128. The MAR, dated 4/1/26 to 4/19/26, indicated the following systolic blood pressures were greater than 160 and amlodipine was not administered: a. The 7:30 a.m. systolic blood pressure check, on 4/2/26 was 188, on 4/5/26 was 163, and on 4/16/26 was 163. b. The 11:00 a.m. systolic blood pressure check, on 4/2/26 was 174 and on 4/4/26 was 175. c. The 4:00 p.m., systolic blood pressure on 4/16/26 was 165. The MAR, dated March 2026, indicated there were 13 times the systolic blood pressure was less than 130 and midodrine was not administered and two (2) times the systolic blood pressure was greater than 160 and amlodipine was not administered. 4. The clinical record for Resident 14 was reviewed on 4/16/26 at 1:34 p.m. The diagnoses included, but were not limited to, hypotension, hypertension, and congestive heart failure. A care plan, dated 5/22/24, indicated Resident 14 had hypertension (high blood pressure) and to obtain blood pressure readings as ordered. A care plan, dated 8/19/24, indicated Resident 14 had congestive heart failure and to administer medications as ordered. A physician's order, dated 1/7/26, indicated to administer metoprolol (a blood pressure medication), two times a day and to hold the medication for a systolic blood pressure less than 100, a diastolic blood pressure less than 60, and a heartrate less than 60. The MAR, dated 4/1/26 to 4/16/26, indicated metoprolol was administered with the blood pressure readings outside of the physician's hold parameter of a diastolic blood pressure less than 60: a. On 4/3/26, the AM dose was administered with a diastolic blood pressure of 41 and the PM dose was administered with a diastolic blood pressure of 46. b. On 4/6/26, the PM dose was administered with a diastolic blood pressure of 36. c. On 4/8/26, the PM dose was administered with a diastolic blood pressure of 39. d. On 4/10/26, the AM dose was administered with a diastolic blood pressure of 52 and the PM dose was administered with a diastolic blood pressure of 53. e. On 4/13/26, the AM dose was administered with a diastolic blood pressure of 42. f. On 4/16/26, the AM dose was administered with a diastolic blood pressure of 58. The MAR also indicated metoprolol was administered seven (7) times with the diastolic blood pressure outside of the hold parameters in the month of February, and four (4) times with the diastolic blood pressure outside of the hold parameters in the month of March. During an interview, on 4/17/26 at 10:36 a.m., the Director of Nursing (DON) indicated when a physician's order included hold parameters, the nurse would record the vital signs prior to administration and hold the medication according to the order. During an interview, on 4/17/26 at 11:15 a.m., LPN 2 indicated a check mark on the MAR indicated the medication was administered. Medications should not be administered if any vital signs were outside of the ordered hold parameters. During an interview, on 4/20/26 at 12:54 p.m., RN 5 indicated if a physician's order included hold parameters, vital signs would be obtained first. If the vital signs were within the parameters, the medication would be administered. If the vital signs were not within the hold parameters, the medication would be held, and the vital signs would be documented. A note would be attached to the initials of the nurse who administered or held the medication on the medication administration record. A current facility policy, titled Physician Orders, dated 3/2022 and received from the DON on 4/17/26 at 3:00 p.m., indicated .All activities that effect the resident shall be ordered by the physician/designee.Nursing shall follow all orders as written. A current facility policy, titled Weights, dated 10/2023 and received from the Risk Management Director on 4/20/26 at 12:47 p.m., indicated .CHF Diagnosis: Weights for these residents are often performed on a daily basis as ordered by the physician. A current facility policy, titled Medication Administration, dated 8/2022 and received from the DON on 4/17/26 at 3:00 p.m., indicated .The facility will administer medications and treatments in a safe manner.Check order for parameters for withholding medications. If parameters are set in order take blood pressure and/or heart rate prior to administering medication. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a call light was in reach for 1 of 1 resident reviewed for accommodation of needs. (Resident 11) Findings include:During an observation, on 4/15/26 at 9:45 a.m., Resident 11 was sitting in his room in a Broda chair. His call light was coiled up on his night stand out of the resident's reach.During an observation, on 4/17/26, the resident was lying in his bed with the call light on the ground under the bed.The clinical record for Resident 11 was reviewed on 4/17/26 at 3:21 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dislocation of the T3/T4 thoracic vertebra, and history of falling.A care plan, dated 7/8/24, indicated Resident 11 was at risk of falls. Interventions included, but were not limited to, be sure the resident's call light was within reach, and the resident needed a safe environment with a reachable call light.During an interview, on 4/17/26 at 3:21 p.m., CAN 10 indicated the call light was under the resident's bed and it should not be out of reach.During an interview, on 4/20/26 at 11:06 a.m., the Director of Nursing (DON) indicated the call light should be in the resident's reach.During an interview, on 4/20/26 at 12:53 p.m., CNA 9 indicated if a resident was taken to their room or laid down in bed, their call light need to be in reach.A current facility policy, titled Call Lights, dated as last revised/reviewed on 3/2022 and provided by the Director of Risk Management on 4/20/26 at 9:33 a.m., indicated .When the resident is in bed or in a chair be sure the call light is within easy reach.410 IAC (Indiana Administrative Code) 3.1-3(v)(1)

Based on observation, interview and record review, the facility failed to ensure medication was labeled with an open date in 3 of 5 medication carts reviewed for medication storage. (1B [NAME] Medication Cart, 2B East Medication Cart and 1A East Medication Cart)Findings include:1. During an observation, on 4/17/26 at 3:03 p.m. with Licensed Practical Nurse (LPN) 3, the 1B [NAME] medication cart had the following:a. One opened bottle of loperamide hydrochloride (a medication used to treat loose stools) 2 milligrams (mg) was not labeled with an open date and had another resident's name label on the bottle.b. One opened bottle of alendronate (a medication used to treat osteoporosis) 70 mg was not labeled with an open date.During an interview, on 4/17/26 at 3:09 p.m., LPN 3 indicated the other resident's label should not have been on the medication and medication should have been labeled with an open date.2. During an observation, on 4/20/26 at 8:34 a.m. with LPN 4, the 2B East medication cart had the following:a. One opened bottle of liquid morphine (a narcotic medication used to treat pain) 20mg/ml (milliliter) was not labeled with an open date.During an interview, on 4/20/26 at 8:39 a.m., LPN 4 indicated the morphine should have had an open date.3. During an observation, on 4/20/26 at 10:16 a.m. with Registered Nurse (RN) 5, the 1A East medication cart had the following:a. One opened bottle of probiotic (Lactobacillus) was not labeled with an open date.During an interview, on 4/20/26 at 12:54 p.m., RN 5 indicated if a new bottle of medication was opened, the nurse should label it with the date and time it was opened.During an interview, on 4/20/2026 at 11:06 a.m., the DON indicated medications should be labeled with an open date at the time they are opened.A current facility policy, titled Medication Labeling, dated 5/2022 and provided by the Director of Risk Management on 4/20/26 at 9:33 a.m., indicated .To assure all medications are labeled in compliance with State and Federal laws governing prescription dispensing.The facility shall maintain accurately labeled medications to assure safe and effective medication administration to the residents. 410 IAC (Indiana Administrative Code)3.1-25(j)

Based on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of dementia who resided on a secured locked unit and at risk of elopement did not exit the facility unsupervised for 1 of 3 residents reviewed for accidents. (Resident B) Resident B wandered approximately 0.4 miles away from the facility and had crossed a two-lane road.The immediate jeopardy began, on 12/23/25, when Resident B exited the facility unsupervised and without the staff's knowledge while wearing a wanderguard device (a wearable device used to alert staff when a resident approached restrictive areas/doors). The resident exited the secured locked unit through an unlocked stairway door, went down the stairwell to the first floor, and exited the facility through an unlocked but alarmed door. Facility staff reset the door alarm without being able to determine the cause of the alarm. Resident B was found walking down the road in the grass by Certified Nursing Assistant (CNA) 2. The Director of Nursing (DON) was notified of the immediate jeopardy on 12/29/25 at 2:27p.m. Findings include:During an interview, on 12/29/25 at 9:22 a.m., the DON indicated the stairway door on the secured locked unit was supposed to be locked. It required a key to engage the door lock. The door should be checked every morning by the Maintenance Director to ensure it was locked, and it was not checked the morning of the incident. Resident B had ambulated with her walker into the stairwell, left her walker in the stairwell, and walked down the stairs. The resident then exited the stairwell into the first-floor hallway and out an exit door. The exit door did sound an alarm however the door was not locked and it should have been. After the incident, the facility had a company check the function of all the doors and found the door Resident B went out had been tampered with which caused the door to not lock when it was closed. A plastic white wristband had been folded up and placed in a location which altered the door and resulted in the door not working properly.During an observation and interview, on 12/29/25 at 12:20 p.m., the DON played a video of the facility camera footage from the day of the incident. The video started at 1:18 p.m., on 12/23/25. The camera faced down the hallway. Resident B could be seen walking down the hallway away from the camera and towards the stairwell around 1:20 p.m. At 1:24 p.m., she was observed on another camera exiting the stairwell into the first-floor hallway and exiting the building to the parking lot. At 1:26 p.m., LPN 7 and LPN 8 responded to the alarm sounding from the door Resident B had used to exit to the parking lot and at 1:27 p.m., turned off the alarm. The two staff members were observed to look out the window. They were not observed to open the door or step outside to look around. At 1:33 p.m., the staff on the resident's secured locked unit were observed to begin searching for the resident. The recorded footage clip ended around 1:33 p.m. The DON indicated she was not aware the staff members had reset the door alarm and did not open the door or step outside to assess the surrounding area.A typed facility document, dated 12/23/25, indicated at 1:41 p.m., a missing resident code was called. At 1:48 p.m., the police were notified of a missing resident. At 1:52 p.m., the facility staff found Resident B. Resident B was assessed and found to be without injury.The clinical record for Resident B was reviewed on 12/29/25 at 10:22 a.m. The diagnoses included, but were not limited to, dementia, hypertension, congestive heart failure, depression, and glaucoma.A physician's order, dated 6/23/24, indicated Resident B had a wanderguard device.An elopement assessment, dated 10/14/25, indicated Resident B was at risk for elopement.A quarterly Minimum Data Set (MDS) assessment, dated 12/12/25 at 4:40 p.m., indicated Resident B was severely cognitively impaired, had wandering behaviors, and wandering and elopement alarms were utilized daily.A care plan, dated 6/25/24, indicated Resident B was at risk for elopement. The interventions included, but were not limited to, distracting the resident from wandering or exit seeking by offering pleasant diversions, calling daughter on the phone or have daughter come in person to the facility, redirect attention, and place a wanderguard on the right wrist.A behavior note, dated 11/6/25 at 12:35 p.m., indicated Resident B was noted to be going out the west end door, staff were able to catch up with Resident B as she reached the curve of the sidewalk. Staff tried to convince Resident B to come back inside, however she refused. Resident B started toward the front entrance, a nurse and CNA were walking with her, when Resident B almost fell trying to get back up on the sidewalk. The nurse was able to catch her. Staff continued to try to get her into the building and tried calling her daughter. The Social worker came and sat with Resident B for a while and then brought her back to the unit. The Social worker called Resident B's daughter and was able to get the resident moved up to the secured unit. Resident B was administered an as needed Ativan (antianxiety medication) before she went upstairs because she was really agitated.A social service note, dated 11/6/25 at 1:15 a.m., indicated 1:1 was provided to Resident B outside as she was not ready to come inside. After 5 minutes, Resident B indicated she was ready to come in as it was getting cool outside. During the visit, Resident B's daughter was called regarding moving Resident B to a closed unit. The last updated care plan intervention for the care plan, dated 6/25/24, which indicated Resident B was at risk for elopement was 10/7/25. There were no updated interventions documented after Resident B had exited the facility on 11/6/25 and was moved to a locked secured unit.A social service note, dated 12/18/25 at 1:33 p.m., indicated the psychiatric physician, Nurse Practitioner, and Resident B's daughter were aware of the resident's ongoing wandering into other rooms, exit seeking, walking without her rollator walker, and becoming aggressive when staff attempted to redirect her. Labs were ordered and the resident refused. The staff would continue to gently redirect her when she wandered and was exit seeking and would call her daughter to speak with her. A physician's note, dated 12/18/25 at 2:54 p.m., indicated Resident B was seen for a follow-up on increased confusion and had wandered into other residents' rooms earlier this week. A behavior note, dated 12/21/25 at 2:34 p.m., indicated Resident B wandered into other residents' rooms repeatedly, was redirected several times, and stated to the CNA, It's sunny out and I want to go see outside.An incident note, dated 12/23/25 at 2:15 p.m., indicated the nurse was alerted by a CNA Resident B could not be found. A search of the unit began. Resident B had a history of wandering. The nurse also looked off unit to see if she was at an activity or in therapy. When Resident B could not be found, the receptionist was told to call a code purple. As the search continued, the stairwell entry was opened with no alarm sounding and the resident's walker was in the stairwell. Staff members went down the stairway. Once staff were down onto the first floor, no alarms were heard sounding. Staff pushed the exit door to see if the alarm would sound and it did. The search continued. Once Resident B was found, a skin assessment and vital signs were completed. Resident B did have a smear of mud on the back of her pants. The resident stated, the grass was slippery, I kept sliding. Resident B had no bruises, scratches, or open areas on her body.During an interview, on 12/29/25 at 10:51 a.m., CNA 2 indicated she found Resident B walking down the road. She was down the road, across the street from the facility, and walking in the grass. The side of the road the resident was walking down did not have a sidewalk. During an interview, on 12/29/25 at 2:41 p.m., the DON indicated the facility elopement policy did not include how staff were to respond when a door alarm was activated. During an interview, on 12/29/25 at 2:58 p.m., Resident B's daughter indicated, on 12/23/25 around 2:30 p.m., she was notified her mom had gotten out of the building and was located down the road. The resident had also gotten out in November when she resided on the first floor, so she was moved upstairs to the locked unit for safety. Whenever her mom was having exit seeking episodes, the facility would call her so she could talk to Resident B and help calm her down. When she exited in November, the facility called her and she was able to talk Resident B to returning inside the facility. Resident B had now been moved to another locked unit in the facility. During an interview, on 12/29/25 at 3:14 p.m., LPN 7 indicated, on 12/23/25 sometime after lunch, she was by the nurse's station when she heard an alarm going off. She was unsure what the alarm was. Her and another nurse followed the sound to the west door at the end of the hallway. They looked out the door through the window and didn't see anyone. She then reset the alarm. They counted the residents on their unit (which was on the first floor), and they were all accounted for. She did not know about the elopement until later when the facility called a code purple.A facility document from an electronics company, dated 12/24/25, indicated the company was asked to test all door locking systems that exit the property. Each door locking system was checked and all systems were working properly.A current facility policy, titled Elopement Prevention and Response Program, dated 1/22 and provided from the Director of Nursing on 12/29/25 at 9:45 a.m., indicated .provide a safe and secure environment for the residents and in the event of a missing resident, ensuring appropriate action is taken.This citation relates to Intake 2700433.3.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a dependent resident was free from neglect and was provided incontinence care during an eight-hour shift for 1 of 3 residents reviewed for neglect. (Resident E) The deficient practice was corrected on 6/26/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 12/19/25 at 2:06 p.m., Resident E's daughter indicated she went to visit her mother on 6/2/25 at approximately 6:00 p.m. Upon entering Resident E's room, Resident E was sitting in her recliner covered with a blanket. She noted a strong odor of stale urine and feces and requested CNA 3 take her mother to the restroom. She asked CNA 3 why her mother had not been changed and provided incontinence care. CNA 3 indicated during shift report CNA 2 indicated she had just changed and provided incontinence care to Resident E. Resident E's daughter indicated when CNA 3 and another staff member stood Resident E up with the stand-up lift, Resident E's pants as well as her recliner was completely saturated with urine and feces. Her mother's incontinence brief was so saturated the brief fell to Resident E's knees. She took pictures of her mother's soiled pants and recliner and sent the photos to the Director of Nursing (DON).In a signed facility statement, dated 6/2/25, CNA 3 indicated when taking Resident E to the bathroom, CNA 3 and another staff member stood Resident E up using the stand-up lift. Resident E's pants and recliner were soiled and saturated with urine and poop.The clinical record for Resident E was reviewed on 12/19/25 at 12:33 p.m. The diagnoses included, but were not limited to, cerebral infarction (stroke), dementia, and type 2 diabetes mellitus.A care plan, dated 7/10/24, indicated Resident E had frequent bladder incontinence. Interventions included, but were not limited to, ensure peri-care with each incontinence episode was completed.A care plan, dated 7/10/24, indicated Resident E had a self-care deficit, required a stand lift with the assistance of 2 staff members for toileting, and was totally dependent on staff for toileting hygiene.A care plan, dated 7/10/24, indicated Resident E required long-term care placement due to the need for 24-hour 7 day a week care, with a goal to meet Resident E's needs daily.A Minimum Data Set (MDS) assessment, dated 3/19/25, indicated Resident E was always incontinent of bladder and was frequently incontinent of bowels.The facility's point of care report (where CNAs document the completion of their shift duties), dated 6/2/25, indicated CNA 2 did not document the completion of toilet use which included, but were not limited to, how Resident E used the toilet, transferred on/off the toilet, cleansed her-self after elimination, and how Resident E changed her pad (brief) during CNA 2's entire eight-hour shift.During an interview, on 12/19/25 at 11:40 a.m., the DON indicated Resident E's daughter had reported neglect of care by CNA 2 during the CNAs shift on 6/2/25. Resident E's daughter sent pictures of Resident E wearing saturated pants and a saturated recliner. CNA 2 had messaged her (DON) and admitted to neglecting her CNA duties during the shift on 6/2/25.A facility CNA job description, dated 9/11/23 and signed by CNA 2, indicated the responsibilities of a CNA included, but were not limited to, adhering to all resident right policies and procedures, visually checking each assigned resident at least every two hours or more frequently if their condition required, performing all nursing procedures in accordance with facility policy and as recommended by state-approved training and competency programs. The procedures/tasks included, but were not limited to, preparing residents for meals including toileting, assisting the residents in toileting and incontinent needs, observing and correctly recording resident care provided, assuring both the residents and resident's clothing were kept clean throughout the shift, and correctly completing required documentation prior to clocking out.A current facility policy, titled Resident Rights, dated as last revised on 10/2018 and received from the DON on 12/22/25 12:26 p.m., indicated .The facility shall use Resident's Rights [(as identified by the Federal and State Guidelines)] as the basis for their services to residents.A current facility policy, titled Resident Rights Know your Rights under Federal Nursing Home Regulations, dated as last updated 3/15/17 and received from the DON on 12/22/25 at 12:26 p.m., indicated .You have the right to a dignified existence.You have the right to be informed, and participate in, your treatment. This includes the right to.Receive the services and/or items included in the plan of care.You have the right to be free from abuse, neglect.The right to reside and receive services in the facility with reasonable accommodation of your needs.The deficient practice was corrected by 6/26/25, after the facility completed audits, interviews, staff were re-educated, and CNA 2 was terminated.This citation relates to Intake 1765422.3.1-27(a)(3)

Based on interview and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 1 of 3 residents reviewed for misappropriation of property. (Resident C) The deficient practice was corrected on 12/17/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:In a signed facility statement, dated 11/22/25, LPN 1 indicated about 2 weeks ago, Resident C had requested a Norco. According to the narcotic count sheet, it was too early for her to have one. The previous nurse (RN 6) had signed out Norco for Resident C twice that day and it had not been 6 hours since the last dose. Resident C indicated she had not received any Norco that day or any other day. She had only taken narcotic pain medications in the evening before bed to help her rest. RN 6 consistently signed out Norco one tablet at around 8:00 a.m., and 1:00 p.m. LPN 1 called the evening supervisor and let her know everything.In a signed facility statement, dated 11/22/25, LPN 4 indicated LPN 1 reported a discrepancy between Resident C's narcotic count sheet, her order, and her MAR. Norco one (1) tablet had been signed out on the narcotic count sheet at 8:00 a.m., and another one (1) tablet around 1:00 p.m. The order was for two (2) tablets every six (6) hours as needed. Resident C indicated she was upset because she had never received Norco during the day, only at bedtime to help her sleep. Resident C could identify her Norco tablets by sight, and she had looked at her pills before she took them. Resident C knew what medications she took each time and knew she had not taken Norco during the daytime hours. The clinical record for Resident C was reviewed on 12/19/25 at 10:46 a.m. The diagnoses included, but were not limited to, thrombosis of the left popliteal vein, uropathy, diastolic congestive heart failure, type 2 diabetes mellitus, and pain.A physician's order, dated 12/5/23 and discontinued on 12/1/25, indicated to administer Norco (a narcotic pain medication) 5-325 milligrams (mg) two (2) tablets every 6 hours as needed for pain.1. The Medication Administration Record (MAR), dated September 2025, indicated RN 6 administered Resident C Norco on 9/10/25 at 10:32 a.m., and 9/16/25 at 10:15 a.m.The narcotic count sheet for Resident C, dated 8/29/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 9/2/25 at 10:00 a.m. On 9/3/25 at 11:00 a.m.On 9/6/25 at 9:00 a.m.On 9/7/25 at 10:00 a.m.The narcotic count sheet for Resident C, dated 9/21/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 9/24/25 at 10:30 a.m.On 9/25/25 at 11:00 a.m.2. The MAR, dated October 2025, indicated RN 6 administered Resident C Norco on 10/10/25 at 12:00 p.m., and 10/13/25 at 11:00 a.m.The narcotic count sheet for Resident C, dated 10/11/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 10/13/25 at 1:14 p.m.On 10/14/25 at 12:00 p.m.On 10/15/25 at 11:30 a.m.On 10/16/25 at 11:30 a.m.On 10/17/25 at 11:30 a.m.On 10/19/25 at 11:45 a.m.The narcotic count sheet for Resident C, dated 10/20/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 10/22/25 at 11:30 a.m.On 10/23/25 at 8:30 a.m. and 11:00 a.m.On 10/24/25 at 1:00 p.m.On 10/27/25 at 8:30 a.m. and 1:00 p.m.On 10/28/25 at 8:45 a.m. and 1:30 p.m.On 10/29/25 at 8:00 a.m. and 1:00 p.m.On 10/31/25 at 8:30 a.m. and 1:00 p.m.3. The MAR, dated November 2025, indicated Resident C had not received any doses of Norco during the dayshift hours.The narcotic count sheet for Resident C, dated 10/31/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 11/5/25 at 8:00 a.m. and 1:00 p.m.On 11/6/25 at 9:00 a.m. and 1:00 p.m.On 11/7/25 at 9:00 a.m. and 1:00 p.m.On 11/10/25 at 8:30 a.m. and 1:15 p.m.On 11/11/25 at 8:30 a.m.The narcotic count sheet for Resident C, dated 11/10/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 11/10/25 at 1:00 pm.On 11/12/25 at 8:00 a.m. and 1:00 p.m.On 11/14/25 at 8:20 a.m. and 1:30 p.m.On 11/15/25 at 8:40 a.m. and 1:00 p.m.On 11/16/25 at 8:30 a.m. and 1:00 p.m.On 11/19/25 at 8:00 a.m. and 1:45 p.m.On 11/20/25 at 8:00 a.m.The narcotic count sheet for Resident C, dated 11/21/25, indicated RN 6 had administered the Norco medication to Resident C on the following dates and times:On 11/20/25 at 8:20 a.m. and 1:00 p.m.On 11/24/25 2 tablets at 8:00 a.m. A progress note, dated 11/14/25 at 12:34 p.m., indicated Resident C was cognitively intact. During an interview, on 12/19/25 at 10:35 a.m., the Director of Nursing (DON) indicated Resident C was a good historian, completely alert and oriented, and a retired registered nurse. Resident C indicated she had not received any narcotics for pain during the day shift and only took the medication at night to help her rest. Resident C had identified RN 6 as the nurse assigned to her on the diversion dates. When a nurse removed a narcotic, it must be signed out on the narcotic sheet and documented as administered to the resident on the electronic medication administration record. If it was not documented on the MAR, then it was not administered. RN 6 had signed out pain medication Resident C on multiple dates, usually one (1) tablet at a time around 8:00 a.m. and again after lunch, but not documented the narcotics as administered on the MAR. The facility terminated RN 6.During an interview, on 12/19/25 at 11:15 a.m., the unit manager indicated Resident C was alert and oriented with a good memory and cognitive function.During an interview, on 12/22/25 at 9:30 a.m., Resident C indicated she had never received narcotic pain medications during the day. She requested her narcotic medication at night to decrease the pain enough to rest. Resident C indicated she was to receive two (2) Norco tablets when she did take them. She had never taken one (1) Norco at a time.During an interview, on 12/22/25 at 9:45 a.m., RN 5 indicated a medication should always be documented in the electronic medical record when administered, especially narcotics. It should be signed out on the narcotic sheet and documented it in the MAR. If it was not documented in the MAR, then it was not administered. If the resident did not take the medication, then it should be charted as refused. She would not sign out an as needed narcotic medication unless a resident requested it.A current facility policy, titled Medication Administration, dated 8/2022 and provided by the DON on 12/22/25 at 12:26 p.m., indicated .Documentation of all medications given to the resident shall be documented by the person administering the medicine after the medication has been administered.IF YOU ARE GIVING A PRN NARCOTIC MEDICATION, YOU MUST DOCUMENT IN THE E-MAR AND ON THE NARCOTIC SHEET. A current facility policy, titled Narcotic Count, dated 5/2022 and provided by the DON on 12/19/25 at 10:45 a.m., indicated .The facility shall require a narcotic count to ensure safe and accurate accounting of narcotics.A staff nurse from the off-going shift and one from the on-coming shift shall count all narcotics before the end of the shift. This count must be documented by each nurse signing the narcotics count sheet for every shift.A current facility policy, titled Resident Rights Know your Rights under Federal Nursing Home Regulations, last updated 3/15/17 and received from the DON on 12/22/25 at 12:26 p.m., indicated .You have the right to be free from .misappropriation of your property.The deficient practice was corrected by 12/17/25, after the facility audited all the narcotic sheets, interviewed residents, RN 6 was terminated, all nurses were re-educated, and the pharmacy completed a house wide audit of narcotic medications.This citation relates to Intake 2678069. 3.1-28(a)

5. The clinical record for Resident 138 was reviewed on 3/24/25 at 11:47 a.m. The diagnoses included, but were not limited to stage 5 kidney disease, heart failure, and end stage renal disease. A progress note, dated 2/18/25 at 4:28 p.m., indicated the spouse wanted the resident to be sent out to the hospital due to continual decline and complaints of back pain. The resident was sent to the emergency room. A notice of transfer or discharge form was reviewed and observed to be not filled out. There was no documentation in the clinical record to indicate Resident 138 or Resident 138's representative was provided with notice of the facility bed hold policy at the time of transfer, or in cases of emergency transfer, within 24 hours. During an interview, on 3/26/25 at 4:43 p.m., the Director of Nursing indicated the facility staff did not document in the clinical record the bed hold policy had been provided to the resident or resident's representative. The facility did not provide a policy and procedure related to sending and documenting a notice of bed hold policy to the resident or resident's representative for transfers and discharges. 3.1-12(a)(25)(A) 3.1-12(a)(25)(B) 3.1-12(a)(26) 2. The clinical record for Resident 9 was reviewed on 3/24/25 at 10:01 a.m. The diagnoses included, but were not limited to, osteomyelitis, bacteremia, and fracture of the left fibula. The clinical record indicated Resident 9 experienced a fall, on 6/14/24, and she was transferred out of the facility by emergency services to the hospital and was expected to return to the facility. Resident 9 was discharged from the facility 6/14/24 through 6/17/24. A skilled nursing facility to hospital transfer form, a notice of transfer or discharge, an appeal rights, a notice of transfer or discharge request for hearing, and a bed hold policy, dated 6/14/24, were reviewed. The clinical record did not include documentation to indicate the above documents were given to Resident 9 or Resident 9's family representative at the time of transfer, or in cases of emergency transfer, within 24 hours. 3. The clinical record for Resident 66 was reviewed on 3/24/25 at 3:51 p.m. The diagnoses included, but were not limited to, gastrostomy status, interstitial pulmonary disease, and cerebral infarction. The clinical record indicated Resident 66 was transferred to the hospital after the resident's gastrostomy tube (a tube inserted into the stomach to provide nutrition) had become dislodged, on 1/2/25. A progress note, dated 1/2/25, indicated the nurse contacted Resident 66's POA (Power of Attorney) about the dislodged gastrostomy tube. The POA requested Resident 66 be sent to the hospital. A skilled nursing facility to hospital transfer form, a notice of transfer or discharge, an appeal rights, a notice of transfer or discharge request for hearing, and a bed hold policy, dated 1/2/25, were reviewed. The clinical record did not include documentation to indicate the above documents were given to Resident 66 or Resident 66's family representative at the time of transfer, or in case of emergency transfer, within 24 hours. During an interview, on 3/21/25 at 11:49 a.m., Resident 66's POA indicated the facility contacted him about the dislodged G-tube. The facility did not provide him with a notice of the facility bed hold policy when Resident 66 was transferred to the hospital. He was unaware the facility was supposed to provide him with a notice of the facility bed hold policy. 4. The clinical record for Resident 108 was reviewed on 3/24/25 at 12:10 p.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia, retention of urine, and congestive heart failure. a. The clinical record indicated Resident 108 was transferred to the hospital due to issues which arose while staff attempted to re-insert his urinary catheter, on 11/20/24. A progress note, dated 11/20/24, indicated Resident 108's wife was present at the time and requested the resident be sent to the hospital. A skilled nursing facility to hospital transfer form, a notice of transfer or discharge, an appeal rights, a notice of transfer or discharge request for hearing, and a bed hold policy, dated 11/20/24, were reviewed. The clinical record did not include documentation to indicate the above documents were given to Resident 108 or Resident 108's wife at the time of transfer. b. The clinical record indicated Resident 108 was transferred to the hospital again for hypertension (high blood pressure) and low oxygen saturation, on 11/26/24. A skilled nursing facility to hospital transfer form, a notice of transfer or discharge, an appeal rights, and a notice of transfer or discharge request for hearing, dated 11/26/24, were reviewed. A bed hold policy was not included. The clinical record did not include documentation to indicate the above documents were given to Resident 108 or Resident 108's wife at the time of transfer, or in cases of emergency transfer, within 24 hours. During an interview, on 3/25/25 at 9:58 a.m., the Director of Nursing (DON) indicated the facility could not find the bed hold policy provided for the hospital transfer, dated 11/26/24. Based on interview and record review, the facility failed to ensure residents and/or residents' representatives were provided a notice of the facility bed hold policy at the time of transfer, or in cases of emergency transfer, within 24 hours for 5 of 6 residents reviewed for transfer and discharge. (Resident 80, 9, 66, 108 and 138) Findings include: 1. The clinical record for Resident 80 was reviewed on 3/24/25 at 10:52 a.m. The diagnoses included, but were not limited to, diabetes, bipolar disorder, anxiety, borderline personality disorder, seizures, transient ischemic attack, and cerebrovascular accident. A nursing progress note, dated 8/14/24 at 11:00 a.m., indicated the resident was sent to the hospital for a psychiatric evaluation. A social service progress note, dated 8/14/24 at 1:23 p.m., indicated Resident 80 had an active plan to harm himself. The crisis center was contacted, and the resident was willing to go for a psychiatric stay. There was no documentation in the clinical record to indicate the resident or resident's representative was provided with notice of the facility bed hold policy at the time of transfer, or in cases of emergency transfer, within 24 hours.

Based on observation, interview and record review, the facility failed to ensure residents had self-medication administration assessments completed by the interdisciplinary team for 2 of 2 residents reviewed for self-medication administration. (Resident 73 and 77) Findings include: 1. During an observation, on 3/20/25 at 12:21 p.m., Resident 73 had Afrin nasal spray (a decongestant) on her bedside table. The clinical record for Resident 73 was reviewed on 3/20/25 at 12:47 p.m. The diagnoses included, but were not limited to, unspecified edema, bilateral cataract, and hypertension. The clinical record did not contain a self-administration evaluation completed by the interdisciplinary team for the resident to self-administer medications or keep them in her room. 2. During an observation, on 3/20/25 at 12:34 p.m., Resident 77 had lubricant eye drops and diclofenac/lidocaine cream (anti-inflammatory cream) on her bedside table. During an observation, on 3/24/25 at 10:22 a.m., Resident 77 had lubricant eye drops on her bedside table. The clinical record for Resident 77 was reviewed on 3/24/25 at 9:15 a.m. The diagnoses included, but were not limited to, type 2 diabetes, unspecified pain, and low back pain. The clinical record did not contain a self-administration evaluation completed by the interdisciplinary team for the resident to self-administer medications or keep them in her room. During an interview, on 3/24/25 at 10:29 a.m., Licensed Practical Nurse (LPN) 6 indicated she did not see a self-administer medication evaluation for Resident 73 or 77 in their records and they should have one if they had medications in their room. During an interview, on 3/24/25 at 10:43 a.m., Unit Manager (UM) 7 indicated the residents should have had self-administration evaluations if they had medications in their rooms. A current facility policy, titled Medication Administration-Self Administration Evaluation, dated as last revised in May 2022 and received from the Director of Nursing (DON) on 3/26/25 at 1:05 p.m., indicated .If the resident wishes to administer their own medications, they will be assessed by the nursing staff as to their capability. The IDT and physician will review the assessment and decide if the resident will be allowed to administer their medications. 2. If it is the decision not to allow the resident to administer their medications, then all medications shall be removed from the resident's room and kept in the nursing station 3.1-11(a)

Based on interview and record review, the facility failed to ensure the ombudsman and resident, or resident's representative was notified in writing of the reason for the resident's transfer and discharge to the hospital for 2 of 6 residents reviewed for transfer and discharge. (Resident 80 and 9) Findings include: 1. The clinical record for Resident 80 was reviewed on 3/24/25 at 10:52 a.m. The diagnoses included, but were not limited to, diabetes, bipolar disorder, anxiety, borderline personality disorder, seizures, transient ischemic attack, and cerebrovascular accident. A nursing progress note, dated 8/14/24 at 11:00 a.m., indicated the resident was sent to the hospital for a psychiatric evaluation. A social service progress note, dated 8/14/24 at 1:23 p.m., indicated Resident 80 had an active plan to harm himself. The crisis center was contacted, and the resident was willing to go for a psychiatric stay. There was no documentation found in the resident's clinical record to indicate the resident and resident's representative were given information in writing regarding the reason for the resident's transfer to the hospital. There was no documentation found in the resident's clinical record to indicate the ombudsman was notified of the resident's hospitalization. 2. The clinical record for Resident 9 was reviewed on 3/24/25 at 10:01 a.m. The diagnoses included, but were not limited to, osteomyelitis, muscle weakness, and fracture of the left fibula. The clinical record indicated Resident 9 experienced a fall, on 6/14/24, and she was transferred out of the facility by emergency services to the hospital and was expected to return to the facility. Resident 9 was discharged from the facility 6/14/24 through 6/17/24. There was no documentation found in the resident's clinical record to indicate the ombudsman was notified of the resident's hospitalization. During an interview, on 3/25/25 at 9:31 a.m., the Social Service Director indicated the facility did not notify the ombudsman and was under the impression if residents were expected to return to the facility, they did not need to send notification of the transfer or discharge to the ombudsman. A policy the facility was currently using, titled Ombudsman Notification, last updated 3/2023 and received from the Director of Nursing on 3/26/25 at 1:05 p.m., indicated .The facility will notify the Ombudsman office on a monthly basis all residents who are sent out to the Hospital who the facility does not anticipate a return A document, titled Family of Social Service Administration, last updated October 2024, indicated .Dear Nursing Home Administrator: As you know, CMS requires nursing facilities to notify the Long-Term Care (LTC) Ombudsman of the majority of residents' transfers and discharges .When a resident is transferred on an emergency basis to an acute care facility and expected to return, the SLTCO must be notified. Information from facilities regarding emergency transfers should be provided in a monthly list to the SLTCO, which should include residents' names, dates of transfer, facilities to which residents were transferred, and reasons for the transfers. Please make sure your facility's name is included on the monthly list 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) 3.1-12(a)(6)(A)(iv)

Based on observation, interview and record review, the facility failed to ensure staff dressed a resident in a manner to avoid allowing her breast to be exposed and to provide incontinence care in a timely manner for 1 of 1 dependent resident reviewed for activities of daily living (ADL) care. (Resident 28) Findings include: The clinical record for Resident 28 was reviewed on 3/24/25 at 11:29 p.m. The diagnoses included, but were not limited to, dementia and depression. A care plan, dated as revised on 6/20/24, indicated Resident 28 was dependent on staff for activities of daily living. Interventions included, but were not limited to, assistance by 1 staff for personal hygiene and dressing, and assistance by 2 staff for toileting. A quarterly Minimum Data Set (MDS) assessment, dated 2/10/25, indicated Resident 28 was severely cognitively impaired. 1. During an observation, on 3/20/25 at 2:25 p.m., Resident 28 was sitting in the lounge across from the nurse's station with another resident. Resident 28's shirt was pulled up and her left breast was exposed. The Director of Nursing (DON) entered the room, noticed the resident's breast, and pulled her shirt down. During an observation, on 3/25/25 at 9:47 a.m., Resident 28 was sitting in the lounge with two residents. Resident 28's shirt was pulled up exposing half of her left breast. The Assistant Director of Nursing (ADON) entered the room, approached the resident, noticed the resident's exposed breast, and pulled her shirt down. During an interview, on 3/25/25 at 10:09 a.m., the ADON indicated she was not aware the resident's shirt was pulled up and they needed to make sure she was covered. During an interview, on 3/25/25 at 11:29 a.m., the DON indicated the ADON had told her the resident's breast was exposed again and the resident needed to be watched closely. 2. During an observation, on 3/20/25 at 10:30 a.m., Resident 28 was sitting in the lounge across from the nurse's station with bath blankets wrapped around the resident. During an observation, on 3/20/25 at 12:10 p.m., Resident 28 continued to sit in the lounge across from the nurse's station. A strong bowel movement and urine odor came from the resident. The resident was leaning to the right side trying to get off her buttock. The Unit Manager walked by the resident and was informed of the resident condition. The resident was taken to her room for care. During an observation, on 3/20/25 at 12:30 p.m., the Unit Manager told Certified Nursing Assistant (CNA) 9 she would help her change the resident's brief. CNA 9 gathered her supplies and unfastened the resident's brief. The brief was soaked with urine and a large loose bowel movement. A Certified Nursing Assistant job description, dated as revised 8/2007, indicated to visually check each assigned resident at least every two hours, or more frequently if their condition is required, to assist in identifying care needs. During an interview, on 3/20/25 at 12:37 p.m., the Unit Manager indicated the resident's brief was soaked with urine and bowel movement and the resident needed to be checked more often. During an interview, on 3/26/25 at 3:38 p.m., CNA 8 indicated residents needed to be checked and changed every 2 hours or when needed. A current facility policy, titled Incontinence, dated 2021 and received from the Regional Director of Clinical Operations on 4/25/22 at 1:31 p.m., indicated .Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible A current facility policy, titled Resident Care-Perineal Care, dated as revised 7/18 and received from the DON on 3/24/25 at 1:59 p.m., indicated .To provide cleanliness and comfort, prevent infection and skin irritation, and to observe the skin condition of the resident .Perineal cleansing and care is performed as a part of the daily hygiene routine as well as after episodes of incontinence A current facility policy, titled Resident Right Know Your Rights under Federal Nursing Home Regulations, dated 3/15/17 and received from the DON on 3/24/25 at 1:59 p.m., indicated .You have the right to a dignified existence, self-determination, and communication with and access to the persons and services inside and outside the facility .You have the right to be treated with respect and dignity 3.1-38(a)(2)(A) 3.1-38(a)(2)(C)

Based on observation, interview and record review, the facility failed to ensure a dependent resident was evaluated prior to being transferred with a sit-to-stand mechanical lift to ensure a safe transfer for 1 of 3 residents reviewed for accidents hazards. (Resident 28) Findings include: During an observation, on 3/20/25 at 12:10 p.m., Resident 28 was sitting in the lounge across from the nurse's station. A strong bowel movement and urine odor came from the resident. Unit Manager 10 walked by the resident and was informed of the resident condition. The resident was taken to her room for care. During an observation, on 3/20/25 at 12:30 p.m., Unit Manager 10 informed CNA 8 she would help transfer the resident into bed. CNA 8 left the room and returned with a sit-to-stand mechanical lift. Unit Manager 10 put the sling strap for the sit-to-stand lift behind the resident's back and attached it to the lift. CNA 8 instructed Resident 28 to hold on to the handlebars on the top of the lift. The resident was yelling at the staff and refused to hold onto the handlebars. Unit Manager 10 instructed CNA 8 to lift the resident while she guided the resident to bed. The resident was not holding onto the handlebars when CNA 8 started using the lift. While the resident was being lifted, the strap slipped under the resident's armpits and the resident was not using her legs to stand. Unit Manager 10 took the resident by the waist and assisted her to the bed. The clinical record for Resident 28 was reviewed on 3/24/25 at 11:29 p.m. The diagnoses included, but were not limited to, hypertension, dementia, and depression. A quarterly Minimum Data Set (MDS) assessment, dated 2/10/25, indicated the resident was severely cognitively impaired. A care plan, dated 5/31/23, indicated Resident 28 had a self-care deficit related to dementia and blindness. Interventions included, but were not limited to, Resident 28 required total dependence and assistance by 2 staff members to transfer between surfaces. The care plan did not indicate Resident 28 should be transferred with a sit-to-stand lift. The clinical record did not indicate a sit-to-stand mechanical lift evaluation had been completed for safety prior to the resident being transferred using the lift. During an interview, on 3/20/25 at 12:40 p.m., Unit Manager 10 indicated the sit-to-stand mechanical lift was probably not a safe way to transfer the resident. During an interview, on 3/20/25 at 12:43 p.m., CNA 8 indicated the resident had not always held on to the handlebars when the sit-to-stand lift was used. During an interview, on 3/24/25 at 11:11 a.m., Unit Manager 7 indicated when a resident was admitted , they had an evaluation for transfers. If a resident was a 2 person assist and a gait belt (a transfer belt placed around the waist to aid in safe movement during transfers) must be used. During an interview, on 3/24/25 at 12:31 p.m., the Director of Nursing (DON) indicated the unit manager told her the resident was transferred by using the wrong lift. The CNA assignment sheet (a document used to guide CNAs care specific to each resident) was incorrect. The resident should not have been transferred using the sit-to-stand mechanical lift. During an interview, on 3/26/25 at 3:38 p.m., CNA 8 indicated the CNA assignment sheet had all the information needed to take care of the residents. The sheet would instruct you how the resident transferred. The facility Certified Nursing Assistant job description, dated as revised 8/2007 and received from the DON on 3/24/25 at 2:00, indicated to correctly follow all unit routines as assigned by a supervisor, secure and maintain resident safety devices as needed, correctly transfer the resident in accordance with the CNA assignment sheet and report changes in the resident's transfer abilities to the Unit Manager. A current facility policy, titled Mechanical Lift-Sit to Stand, dated as revised 3/2022 and received from the DON on 3/24/25 at 2:00 p.m., indicated .To provide guidelines for staff to safely transfer residents .The staff shall safely transfer residents using mechanical lifts .Check assignment sheet for appropriate and approved transfer method .Check the lift and sling before transfer to ensure all safety belts are intact and functioning .Ensure the second staff person required for transfer is present .Apply sling to resident .Fasten leg belts to both legs before transfer takes place Instruct the resident to place hands on handle bars, grip for duration of transfer and use his/her upper body to help support their body .Begin transfer with remote control. The person operating the controls should stand closest to the resident being transferred .Raise the resident only as high as necessary to clear his/her body from the transfer surface .Lower the resident to his/her destination surface .Carefully release resident from sling and leg belts A current facility policy, titled Gait Belt Use, dated as revised 3/2022 and received from the DON on 3/24/25 at 2:00 p.m., indicated .To provide stability for a resident during ambulation or transfer .If the resident is not able to independently self-transfer, the resident shall be transferred utilizing a gait belt 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure residents medications were reviewed monthly by the pharmacist for 3 of 5 residents reviewed for unnecessary medications. (Resident 55, 91 and 92) Findings include: 1. The clinical record for Resident 55 was reviewed on 3/24/25 at 11:49 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, psychotic disorder with delusions, peripheral vascular disease, severe kidney disease, diabetes mellitus with diabetic polyneuropathy, depression, anxiety disorder, and hypertension. The physician's orders indicated Resident 55 received lorazepam (an anti-anxiety medication), sertraline (an antidepressant medication), and Zyprexa (an antipsychotic medication). The clinical record included pharmacy reviews for Resident 55's medications on 3/24, 4/24, 5/24, 6/24, 8/24, 9/24, 10/24, 11/24, 12/24, 1/25, 2/25, and 3/25. There were no pharmacist reviews for July of 2024 between the dates of 6/18/24 and 8/9/24. During an interview, on 3/25/25 at 1:35 p.m., the Director of Nursing (DON) indicated the facility had changed pharmacy providers in August. She could not find a record of a pharmacist review of the resident's medications for the month of July. She contacted the previous pharmacy provider, but they did not have a record of a review for Resident 55 for July. 44598 2. The clinical record for Resident 91 was reviewed on 3/25/25 at 3:18 p.m. The diagnoses included, but were not limited to, seizure disorder, anxiety disorder, and depression. The physician's orders indicated Resident 91 received aripiprazole (an antipsychotic medication) and Cymbalta (an antidepressant medication). The clinical record included pharmacy reviews for Resident 91's medications on 4/24, 5/24, 8/24, 9/24, 10/24, 11/24, 12/2024. There were no pharmacist reviews for 6/24, 7/24, 1/25 and 2/25. During an interview, on 3/26/25 at 3:13 p.m., the DON indicated the facility changed pharmacies and she had contacted the old pharmacy. They provided all the monthly pharmacy reviews the facility had for the Resident 91 and several months were missing. 3. The clinical record for Resident 92 was reviewed on 3/25/25 at 11:05 a.m. The diagnoses included, but were not limited to, hypertension, anxiety disorder, and manic depression. The physician's orders indicated Resident 92 received olanzapine (an antipsychotic medication). The clinical record included pharmacy reviews for Resident 92's medications on 6/17/24, 8/14/24, 9/6/24, 10/17/24, 11/12/24, 12/17/24, 1/17/25, 2/11/25. There were no pharmacist reviews for July of 2024. During an interview, on 3/26/25 at 3:15 p.m., the DON indicated the monthly pharmacy review for July of 2024 could not be found. A current facility policy, titled Psychoactive Medications, dated as last revised in November 2018 and received from the DON on 3/26/25 at 1:05 p.m., indicated .Psychoactive medications shall be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review in accordance with regulatory requirements 3.1-25(h)

Based on observation, interview, and record review, the facility failed to ensure an as needed (PRN) psychotropic medication was limited to 14 days and an Abnormal Involuntary Movement Scale (AIMS) assessment was completed for a resident taking a psychotropic medication for 2 of 5 residents reviewed for unnecessary medications. (Residents 137 and 91) Findings include: 1. The clinical record for Resident 137 was reviewed on 3/24/25 at 10:08 a.m. The diagnoses included, but were not limited to, anxiety disorder, depression, and major depressive disorder. A physician's order, with a start date of 2/27/25, indicated to give lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) every 8 hours as needed with an indefinite stop date. The medication order had gone past the 14 days without changes or a physician's rationale for extending the medication. During an interview, on 3/24/25 at 11:09 a.m., Unit Manager (UM) 6 indicated there was no stop date on the lorazepam order. 2. The clinical record for Resident 91 was reviewed on 3/25/25 at 3:18 p.m. The diagnoses included, but were not limited to, anxiety disorder, depression, and seizure disorder. A physician's order, with a start date of 2/11/25, indicated to give Aripiprazole (an antipsychotic medication) in the evening. An admission/annual/quarterly evaluation, dated 10/30/24, had an open AIMS assessment which was not completed. An admission/annual/quarterly evaluation, dated 11/22/24, had an open AIMS assessment which was not completed. The last completed AIMS assessment was on 2/27/24. During an interview, on 3/26/25 at 3:10 p.m., the Director of Nursing (DON) indicated she could not find any other completed AIMS assessment. During an interview, on 3/26/25 at 3:13 p.m., the Assistant Director of Nursing (ADON) indicated she could not find any other AIMS assessment and they should have been completed. A current facility policy, titled Psychoactive Medications, dated as last revised in November 2018 and received from the DON on 3/26/25 at 1:05 p.m., indicated .PRN orders for psychoactive drugs are limited to 14 days, unless the attending physician/consultant believes that it is appropriate for the PRN medication to be extended beyond the 14 days, he should document the rationale in the medical record and indicate the duration for the PRN order A current facility policy, titled admission Assessment, dated as revised in October 2024 and received from the DON on 3/26/25 at 4:59 p.m., indicated .The admission process will include a complete assessment of the individual in order to determine the care treatment and services that will be required by the resident .Other evaluations include, but not limited to .AIMS-(if on psychotropics) .The above assessments are repeated every 4 months 3.1-48(a)(2) 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure a resident was alerted and awakened when her meal delivery occurred so the meal could be consumed at an appetizing temperature for 1 of 1 resident reviewed for room trays. (Resident 34) Findings include: During an interview, on 3/21/25 at 9:12 a.m., Resident 34 indicated her meals were served cold. During an observation, on 3/25/25 at 1:39 p.m., Resident 34's lunch, which included grilled cheese and tomato soup, had been delivered and was sitting on her bedside table. The surveyor knocked on Resident 34's door and asked permission to enter. Resident 34 was asleep but woke up and gave the surveyor permission to enter. Resident 34 indicated she was unaware her lunch had been delivered and indicated the staff did not always wake her up when they delivered her meals. During an observation, on 3/26/25 at 9:12 a.m., Resident 34 was asleep in her recliner. Her breakfast, which included, two eggs prepared over easy, oatmeal, and French toast, had been delivered and was sitting on her bedside table. The surveyor knocked on Resident 34's door and asked permission to enter. Resident 34 was asleep but woke up and gave the surveyor permission to enter. Once again, Resident 34 indicated she was unaware her meal had been delivered. A request was made to check the food temperature on Resident 34's breakfast tray. During an interview, on 3/26/25 at 9:12 a.m., Unit Manager 3 indicated it was Resident 34's preference not to be woken up for tray delivery. During an interview, on 3/26/25 at 9:15 a.m., Certified Nursing Assistant 2 indicated she delivered Resident 34's room tray. She indicated the resident preferred not to be woken up for meal delivery. During an interview, on 3/26/25 at 9:17 a.m., Resident 34 indicated she wanted the staff to wake her up when they delivered her meal trays. During an interview, on 3/26/25 at 9:30 a.m., Unit Manager 3 indicated the kitchen manager had indicated the kitchen staff were not allowed to enter a resident's room and would not be able to check the temperature of the breakfast tray. During an interview, on 3/26/25 at 9:36 a.m., the Director of Nursing (DON) indicated the Executive Chef would check the temperature of the breakfast tray and they were not sure why the staff member did not check the temperature of the food at the time it was requested to be checked. During an interview, on 3/26/25 at 9:40 a.m., the Executive Chef indicated the breakfast tray had been sitting in the resident's room for a while now and the food would be cold. The tray should not be served to her if the food had been sitting this long. During an observation, on 3/26/25 at 9:40 a.m., with the DON and General Manager, the Executive Chef obtained the temperature of Resident 34's breakfast tray, and indicated the oatmeal was 108.3 degrees, the eggs were 83 degrees, and the French toast was 78.9 degrees. The Executive Chef indicated the food was below the required temperature and more specifically, the eggs should have been over 140 degrees Fahrenheit. The temperature of her food was checked 28 minutes after the request was made. The clinical record for Resident 34 was reviewed on 3/25/25 at 11:41 a.m. The diagnoses included, but were not limited to, anxiety disorder, tracheostomy status, and chronic obstructive pulmonary disease. A care plan, dated 9/12/24, indicated the resident had a self-care performance deficit. Interventions included, but were not limited to, Resident 34 required set-up assistance by staff to eat. The care plan did not include preferences regarding meal delivery. A care plan, dated 10/8/24, indicated Resident 34 had preferences and refusals. Interventions included, but were not limited to, staff would maintain consistency in timing, caregivers, and routine as much as possible. The care plan did not include preferences regarding meal delivery. A care plan, dated 3/25/25, indicated Resident 34 had verbal aggression toward staff. Interventions included, but were not limited to, assessing and anticipating Resident 34's needs, which included food. The care plan did not include preferences regarding meal delivery. During an interview, on 3/25/25 at 10:10 a.m., the resident council attendees indicated they had received cold food delivered to their rooms. They could ask for the food to be reheated but believed they should not have to ask. The food should be served hot. A facility document, titled Meal Delivery, dated 9/7/22 and received from the General Manager on 9/26/25 at 11:37 a.m., indicated .Meals will be delivered to all residents/patients in a timely, organized, safe and sanitary manner .Positions resident/patient to ensure comfort and safety while eating and drinking. Aids with meal set-up as appropriate and assists residents/patients who require assistance A facility document, titled Meal Temperature Records Meal Service, dated 9/7/22 and received from the General Manager on 9/26/25 at 11:37 a.m., indicated .Food is maintained at proper temperatures during services to meet resident expectations for palatability and to ensure that food safety principles are maintained to prevent foodborne illness The facility did not have a policy related to delivery of room trays. 3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 12 residents reviewed for resident rights. (Resident J and K). The deficient practice was corrected on 11/5/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A document, titled Indiana State Department of Health Survey Report System, dated 11/4/24, indicated Resident J had indicated CNA 1 was rough with her when she got her up on 10/31/24 at 9:01 a.m. A facility resident questionnaire document indicated on 10/31/24 at 9:01 a.m., Resident J indicated CNA 1 was grouchy with her. CNA 1 told the resident to do this, do that. Resident J indicated she hurt my feelings. A facility written statement, dated 10/31/24, indicated a telephone interview was conducted with CNA 1. CNA 1 indicated she was not mean, hateful or rough with the resident when she provided care for her. The CNA was suspended pending an investigation. A facility written statement, dated 10/31/24, signed by LPN 2 indicated CNA 1 was asked to get Resident J out of bed. CNA 1 brought Resident J to the nurses' station to sit with LPN 2. While sitting at the desk, Resident J indicated to LPN 2 that CNA 1 was hateful, and CNA 1 ignored her. A document, titled Take off Payroll, dated 11/5/24, indicated CNA 1 was terminated for being mean and nasty with Resident J. The facility yielded on the side of safety to keep their residents safe from perceptions of abuse. The clinical record for Resident J was reviewed on 1/21/25 at 12:43 p.m. The diagnoses included, but were not limited to, major depressive disorder, pain, anxiety disorder, frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, and difficulty walking. Resident J was unable to be interviewed. 2. A document, titled Indiana State Department of Health, dated 11/8/24, indicated Resident K reported she had a care concern with CNA 5 on 11/3/24. A typed facility statement dated 11/3/24 at 8:02 p.m., CNA 5 indicated she took Resident K to the bathroom. Resident K wore a brief with a pull up over the brief. The resident turned on her light at around 10:30 a.m., indicating she was in pain. The CNA informed the nurse the resident was complaining of pain. During the last bed check, CNA 5 took the resident to the bathroom, and she observed the pullup was off. The nurse had removed the pullup because it was too tight with the brief and the resident was complaining of pain in her private area. CNA 5 indicated the resident requested to have two briefs placed on her and CNA 5 informed the resident she was not able to. This was the only conversation she had with the resident. A handwritten statement, dated 11/3/24, CNA 6 indicated when she went to Resident K's room to get her for dinner, the resident started crying and said she was tired of being mistreated. She did not want CNA 5 to take care of her again. Resident K indicated CNA 5 yelled at her roommate as well. A handwritten statement, dated 11/3/24, LPN 7 indicated Resident K did not want CNA 5 to care for her anymore because CNA 5 yelled at her and told her she could not wear two briefs. A typed statement, dated 11/6/24, Resident K indicated CNA 5 yelled at her because she had to go to the bathroom. She scolded her for being wet and wanting to wear two briefs. A document, titled Take off Payroll, dated 11/7/24, indicated CNA 5 was terminated on 11/7/24. The clinical record for Resident K was reviewed on 1/21/25 at 11:36 a.m. The diagnoses included, but were not limited to, psychotic disorder with hallucinations, major depressive disorder, type II diabetes mellitus, dementia, and frontotemporal neurocognitive disorder. On 1/21/25 at 3:03 p.m., Resident K was unable to be interviewed. A current facility policy, titled Resident Rights, dated 10/18 and provided by the Director of Nursing (DON) on 1/21/25 at 12:45 p.m., indicated .The facility shall use Resident's Rights (as identified by the Federal and State Guidelines) as the basis for their services to residents in providing care that meets the needs and rights of the residents The deficient practice was corrected by 11/5/24, after the facility implemented a systemic plan that included the following actions: resident interviews were conducted, facility staff were in-serviced, and CNA 1 and 5 were terminated. This citation relates to Complaints IN00446410, IN00446579, and IN00450262. 3.1-3(t)

Based on interview and record review, the facility failed to ensure two staff members completed a Hoyer lift transfer to prevent an accident for 1 of 3 residents reviewed for accidents. (Resident J) The deficient practice was corrected on 11/11/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A facility typed statement, dated 11/11/24, indicated the Director of Nursing (DON) spoke to CNA 9 regarding transferring Resident J with a Hoyer Lift (mechanical lift machine) without using a second person for the transfer. CNA 9 indicated she knew she was supposed to use a second person to transfer residents with the Hoyer lift. Because of the education CNA 9 had received related to transfers of residents with a Hoyer lift and choosing not to wait for a second person to transfer Resident J, CNA 9 was terminated from the facility. The clinical record for Resident J was reviewed on 1/21/25 at 12:43 p.m. The diagnoses included, but were not limited to, major depressive disorder, pain, anxiety disorder, frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, and difficulty walking. A nursing progress note, dated 11/9/24 at 11:22 a.m., indicated LPN 8 was notified Resident J was on the floor. CNA 8 indicated during a Hoyer lift transfer Resident J moved her hands and slid out of the Hoyer lift onto her recliner, then CNA 8 slid the resident onto the floor due to bad positioning on the recliner. Resident J had complaints of pain all over. The resident was given as needed pain medication. An IDT (Interdisciplinary Team) progress note, dated 11/12/24 at 10:27 a.m., indicated Resident J was assisted to the floor by CNA 9 during a Hoyer lift transfer. The resident repositioned her hand which caused her to slide from the Hoyer lift onto the recliner. The resident's positioning was bad in the recliner, so CNA 9 assisted the resident to the floor. The root cause of the fall was related to CNA 9 performing the Hoyer lift transfer without another staff member to assist with the transfer. A document, titled Employee Communication Form, dated 11/11/24, indicated CNA 9 was terminated, on 11/11/24, because she transferred a resident with a Hoyer lift without a second person as a spotter. She was educated to use two staff members with all mechanical lifts. A document, titled Take off Payroll, dated 11/11/24, indicated CNA 9 was terminated for a significant policy violation resulting in a resident falling from the Hoyer lift on 11/11/24. A current facility policy, titled Mechanical Lift-Hoyer, dated 5/2022 and provided from the DON on 1/22/25 at 11:39 a.m., indicated .To provide guidelines regarding the safe transfer of residents .The staff shall safely transfer resident's using mechanical lifts .Ensure the second staff person is present for transfer .Instruct the resident to place arms and hands inside sling for duration of the lift The deficient practice was corrected by 11/11/24, after the facility implemented a systemic plan that included the following actions: All staff members were in-serviced on ensuring two staff members were present for all Hoyer lift transfers and CNA 9 was terminated. This citation relates to Complaint IN00449484. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a staff member followed the policy and procedure when administering narcotics to 2 of 7 residents reviewed for pharmaceutical services. (Residents C, D and H) The deficient practice was corrected on 10/15/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A document, titled Intake Information, dated 10/14/24 at 2:36 p.m., indicated several residents reported they did not receive their medications from the evening before, on 10/13/24, from RN 10. The agency nurse, RN 10, was placed on the do not return to the facility list. The following Electronic Medication Administration Record (EMAR) did not have the narcotic medication documented for the dates and times the narcotic count sheet indicated the medication was administered: 1. The clinical record for Resident C was reviewed on 1/22/25 at 2:30 p.m. The diagnoses included, but were not limited to, anxiety disorder, hypertension, and vitamin deficiency. Resident C's physician's orders included, but were not limited to, the following: Cyclobenzaprine HCL 10 mg by mouth every six hours as needed for muscle spasms. Norco 5-325 mg by mouth every four hours as needed for moderate-severe pain. The resident's Electronic Medication Administration Record (EMAR), dated 10/1/24 to 10/31/24, had no documentation to indicate the resident received any as needed doses of the medications on 10/11/24. A document, titled Med Script, indicated the Norco was signed out on the narcotic sheet on 10/11/24 at 8:00 a.m., 12:00 p.m., and 5:00 p.m., by RN 10. 2. The clinical record for Resident D was reviewed on 1/22/25 at 2:00 p.m. The diagnoses included, but were not limited to, aphasia, protein-calorie malnutrition, and vitamin deficiency. Resident D's physician's orders included, but were not limited to, the following: Oxycodone HCL 5 mg by G-tube every four hours as needed for severe pain. The resident's Electronic Medication Administration Record (EMAR), dated 10/1/24 to 10/31/24, had no documentation to indicate he received any as needed doses of this medication on 10/11/24. A document, titled Med Script, indicated the Oxycodone was signed out on the narcotic sheet on 10/11/24 at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., by RN 10. A handwritten document, dated 10/15/24 at 10/30 a.m., indicated Resident D and his caregiver had indicated RN 10 acted strange the whole day. Resident D indicated he had received Tylenol during that day and did not receive any Oxycodone. During an interview, on 1/21/25 at 1:30 p.m., Resident D indicated there was a night a while back when an agency nurse did not give him his medications. She lied and said he took narcotics when he did not take them. He only took Tylenol for pain. 3. The clinical record for Resident H was reviewed on 1/22/25 at 2:45 p.m. The diagnoses included, but were not limited to, depression, hypertension, and anemia. Resident H's physician's orders included, but were not limited to, the following: Oxycodone HCL 10 mg by mouth every four hours as needed for severe pain. The resident's EMAR, dated 10/1/24 to 10/31/24, had no documentation to indicate the resident had received any as needed doses of this medication on 10/11/24. A document, titled Med Script, indicated the Oxycodone was signed out on the narcotic sheet on 10/11/24 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., by RN 10. A current facility policy, titled Medication Administration, dated 8/2022 and provided by the Director of Nursing (DON) on 1/21/25 at 12:45 p.m., indicated .To assure that medication and treatments are administered safely and correctly .Documentation of all medications given to the resident shall be documented by the person administering the medicine after the medication has been administered .IF YOU ARE GIVING A PRN NARCOTIC MEDICATION, YOU MUST DOCUMENT IN THE E-MAR AND ON THE NARCOTIC SHEET The deficient practice was corrected by 10/15/24, after the facility implemented a systemic plan that included the following actions: all staff were in-serviced, a medication competency was scheduled to be completed by the pharmacy, and RN 10 was placed on the do not return to the facility list. This citation relates to Complaint IN00445292. 3.1-25(b)(3)

Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a staff member for 1 of 1 resident reviewed for abuse. (Resident B) Resident B was sexually assaulted by a contracted housekeeping staff member. The immediate jeopardy began on 12/21/24, when Housekeeper 2 was observed to be laying on top of Resident B. Housekeeper 2's pants were down, and his private parts were exposed. Resident B's gown was pulled up, her brief was open, and her private area was exposed. The Interim Executive Director (ED) and Interim Director of Nursing were notified of the immediate jeopardy on 12/26/24 at 2:42 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected on 12/22/24, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: An Indiana Department of Health intake form indicated, on 12/21/24, a staff member walked into a resident's room and witnessed a housekeeping employee on top of a resident in the dementia unit. An untimed facility obtained statement, dated 12/21/24, from the Housekeeping Supervisor indicated, at 8:30 a.m., he was doing his rounds and went to the C-wing (the dementia unit) where Housekeeper 2 was working. He witnessed Housekeeper 2 on top of a female resident while she was laying in the bed. He yelled what the f*** are you doing Housekeeper 2 then jumped up with his pants and draws down and his d*** out. Housekeeper 2 then snatched his pants and his draws up. The Housekeeping Supervisor told Houskeeper 2 he was calling the police. The Housekeeping Supervisor then got the nurse for that unit, who checked the resident and noticed her gown was up and her brief was pulled down. An untimed facility obtained statement, dated 12/21/24, from RN 3 indicated the Housekeeping Supervisor called for her and indicated he had found Housekeeper 2 in Resident B's room with his pants down and the resident's brief down. An untimed facility obtained statement, dated 12/21/24, from LPN 4 indicated around breakfast time the Housekeeping Supervisor came to the nurse's station asking to speak to her and RN 3. He had Housekeeper 2 with him and indicated I just caught him having sex with a resident. LPN 4 went to the resident's room and the resident was in bed with her brief down and her vaginal area was exposed. The clinical record for Resident B was reviewed on 12/26/24 at 11:05 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, psychotic disorder with delusions, dementia with psychotic disturbance, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, indicated the resident was severely impaired cognitively, she was rarely understood, and had no issues with her mood or behaviors. The resident had a functional limitation in her range of motion to both lower extremities. A care plan, dated as last revised on 7/17/24, indicated the resident had a self-care performance deficit due to her dementia and she did not always understand how to assist or help with her care. Interventions included, but were not limited to, the resident required maximum assistance with bathing, dressing, personal hygiene and transferring. She required limited assistance with bed mobility and eating. A care plan, dated as last revised on 7/18/24, indicated the resident's primary language was not English and when speaking with a translator, her speech was often unclear, she was rarely understood and could rarely understand others. A care plan, dated as last revised on 7/18/24, indicated the resident was severely impaired cognitively. Interventions included, but were not limited to, to utilize family, communication board, google translate and [NAME] as needed for assistance with translation. A care plan, dated as last revised on 11/14/24, indicated the resident was alert to self and was able to converse in a non-English language with translators and family members. A facility nursing progress note, dated 12/21/24 at 8:30 a.m., indicated staff found another staff member in the resident's bed. The staff member was immediately removed from the resident's room. A skin assessment was performed on the resident with no skin issues found and no signs and symptoms of pain were noted. A facility nursing progress note, dated 12/21/24 at 10:34 a.m., indicated Resident B was transferred to the hospital for further evaluation. A facility nursing progress note, dated 12/21/24 at 5:05 p.m., indicated the resident returned to the facility via ambulance with her son and daughter. The resident's son reported the resident did not recall the incident. A facility social services progress note, dated 12/21/24 at 5:15 p.m., indicated Resident B returned to the facility with family present. Resident B had no recollection from the incident. Family was at bedside and provided interpretation and indicated all Resident B kept saying was help me followed by nonsensical conversation. A hospital progress note, dated 12/21/24, indicated the resident arrived at the emergency room from the nursing home after an alleged sexual assault by a housekeeper. The note indicated the housekeeper was observed lying on top of Resident B with his pants down in the resident's room. A hospital discharge note, dated 12/21/24, indicated the resident was seen for a reported sexual assault and a sexual assault examination was performed. During an observation, on 12/26/24 at 1:30 p.m., Resident B was observed sitting in her wheelchair, in the dining room at a table. Resident B showed no signs of distress. A staff member approached the resident and stated her name, the resident then responded to the staff member in a different language. During an observation, on 12/26/24 at 1:32 p.m., Resident B's room was observed. The resident's bed was not visible from the entrance of the resident's room. During an interview, on 12/26/24 at 10:20 a.m., the Housekeeping Supervisor indicated he was rounding to make sure everyone was doing their job. This was normally something he did. About 8:30-8:40 a.m., he went to the C wing to look for Housekeeper 2 and saw his housekeeping cart at the end of the hallway outside of room [ROOM NUMBER]. The room was dark, but the door was open. He walked in and saw Houskeeper 2 laying on top of the bed. He asked, what the h*** are you doing? Housekeeper 2 jumped up, his private parts were out, and pants/boxer were to his knees. He removed Housekeeper 2 and went for the nurse. The resident's gown was up, and her brief was open. The police were called, and the employee was kept secure away from other residents until the police arrived. During an interview, on 12/26/24 at 1:45 p.m., LPN 4 indicated the Housekeeping Supervisor came to her with Housekeeper 2 and indicated he found Housekeeper 2 with his pants pulled down and laying on top of Resident B. They placed Housekeeper 2 in an empty room and had another staff member guard him while she went to assess Resident B. Resident B was observed lying in bed with her gown pulled up, her brief pulled down and her private area was exposed. The resident was just lying there, staring blankly at the ceiling. She did not appear in any distress. During an interview, on 12/27/24 at 11:27 a.m., the Interim Executive Director indicated the staff on duty kept Housekeeper 2 secured and away from other residents, called the police, and called the weekend supervisor who was on duty and in the building. The weekend supervisor called the Director of Nursing (DON) and the DON called him. They immediately came to the facility and also called two social services staff members to come into the facility along with all unit managers. The management staff began interviewing residents, completing skin sweeps, sent the resident out to be evaluated, and met with the resident's family. The employee file for Housekeeper 2 indicated he began his employment at the facility in August of 2024. He received a verbal warning, on 10/18/24, for excessive tardiness and another verbal warning, on 12/20/24, for unsatisfactory job performance due to not taking care of and cleaning his cart. A current facility policy, titled Abuse, Neglect and Exploitation, dated 1/2024 and received from the Executive Director on 12/26/24 on 10:50 a.m., indicated .Each resident has the right to be free from abuse .The facility shall: a. Not use verbal, mental, sexual or physical abuse The Past Noncompliance Immediate Jeopardy began on 12/21/24. The Immediate Jeopardy was removed and corrected by 12/22/24 after the facility implemented a systemic plan that included the following actions: the facility completed interviews with all cognitively intact residents, skin sweeps on all non-interviewable residents, audits of all employee files to ensure background checks and abuse training had been completed, all staff were in-serviced on abuse, the resident was evaluated at the hospital and placed on 15-minute checks, and the employee was terminated and arrested. This citation relates to Complaint IN00449779. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse related to a staff member who grabbed a resident with dementia, who was residing on the memory care unit, by his ears and pulled him out of another resident's room for 1 of 4 residents reviewed for abuse. (Resident D) The deficient practice was corrected on 9/23/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A document, titled Indiana State Department of Health Survey Report System report, indicated on 9/19/24 at 7:30 p.m., CNA 1 was observed by CNA 2 pulling' on Resident D's ears. CNA 2 intervened to protect the resident. The type of injury was the top of the resident's ears had redness. CNA 1's employment from the facility was terminated. The clinical record for Resident D was reviewed on 10/11/24 at 12:45 p.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease, anemia, and peripheral vascular disease. A nursing progress note, dated 9/19/24 at 10:05 p.m., indicated the resident's left ear was slightly red. A nursing progress note, dated 9/20/24 at 8:19 a.m., indicated the resident had redness to his ear. He denied any pain or discomfort. A nursing progress note, dated 9/20/24 at 8:50 a.m., indicated the Nurse Practitioner (NP) was notified the resident had redness observed to the ear last night. A facility document, untitled and undated, indicated CNA 2 reported to the DON, she witnessed a resident being abused. Resident D had gone into another resident's room to use the restroom. CNA 1 went into that resident's room and grabbed Resident D by his ear and pulled it causing him to become very angry and he started cursing and yelling. CNA 2 immediately told LPN 4, who went to check on the resident. LPN 4 observed redness to Resident D's left ear. A handwritten document written by LPN 4, dated 9/19/24 at 8:00 p.m., indicated she heard Resident D yelling and screaming profanity as if he was angry. He did sometimes have these behaviors as normal behaviors for him. She did not go assess him at that time. She asked the staff what was wrong with him. She received an alleged abuse report from CNA 2 related to CNA 1 pulling on the resident's ear to get him out of a female resident's room. She assessed the resident and observed his left ear to be redder than the right ear. A document, titled Take Off Payroll, indicated CNA 1 was terminated on 9/23/24. Her last day worked was 9/19/24. She was not eligible for rehire. She was terminated related to allegations of abuse. The performance section indicated CNA 1 was witnessed by another aide (CNA 2), pulling the ears of Resident D. CNA 1 indicated she was attempting to shave the resident and was pulling his ear back to shave that area. Both ears were noted by the nurse to be red. During an interview, on 10/11/24 at 1:42 p.m., CNA 1 indicated she did not remember the date of the incident, but it was around 7:00 p.m., and she was putting her residents to bed. She was paying close attention to where Resident D was going because he had already been incontinent of his bowels in another resident's bed twice. She observed him going into a female resident's room and she went to get him out of the room. She took him by the hand and led him out of the room. She had shaved him earlier in the day, so that was why his ears were red because she held his ears back to shave him. CNA 2 reported her for abusing Resident D. During an interview, on 10/11/24 at 2:27 p.m., CNA 2 indicated she had just finished placing a resident to bed and she was able to see Resident D's room. She observed Resident D standing by the bathroom sink with CNA 1 beside him. She observed CNA 1 twisting his ear saying to him, that she had told him not to go into other residents' rooms to pee. CNA 2 immediately went to LPN 4 and informed her of what she observed between CNA 1 and Resident D. She indicated LPN 4 indicated she heard Resident D yelling and cursing, but she did not know why. A facility document, titled Relias Abuse and Neglect: Abuse, dated 2022 and provided by the DON on 10/10/24 at 4:40 p.m., indicated .The goal of this course is to explain how direct care workers can notice and respond to signs of abuse in the home setting. Type of Abuse: Abuse is when someone harms or hurts another person. Abuse can happen by accident. It can also be done on purpose to gain something or control someone. There are many types of abuse. Here are the most common types: Physical which can be: slapping, punching, restraining someone .Reporting Signs of Abuse: Everyone has the right to be safe from abuse. Sadly, anyone can be abused by people they know and by strangers. A current policy, titled Abuse, Neglect and Exploitation, dated as revised 1/2024 and provided by the DON on 10/10/24 at 3:20 p.m., indicated .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Policy Explanation and Compliance Guidelines: 1. The Administrator is the Abuse Coordinator. 2. The facility shall: a. Not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion The deficient practice was corrected by 9/23/24, after the facility implemented a systemic plan that included CNA 1 was terminated for allegations of abuse and all staff was educated on Abuse and Neglect by 9/23/24. This citation relates to Complaint IN00443672. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure services were provided to effectively administer back blows for a choking resident in accordance with treatment guidelines established by the facility and failed to ensure the plan of care was effectively revised with accurate care information (Resident S). This deficient practice resulted in Resident S experiencing a choking episode with a change in the level of consciousness which required emergent treatment. The facility also failed to ensure residents maintained upright positioning while sitting in chairs (Resident V and F), to ensure the physician was notified for blood sugars above specified parameters and to ensure weights were completed daily (Resident 99) for 4 of 4 residents reviewed for quality of care. Findings include: 1. A Facility Reported Incident (FRI) report, dated [DATE] at 12:40 p.m., indicated Resident S was in the dining room eating lunch when the nursing staff observed the resident choking on her food and her color was changing. The resident was not able to cough or clear her airway. The Heimlich maneuver and suctioning were performed. Food particles were suctioned from the resident's mouth. The resident's code status was confirmed as do not resuscitate (DNR). The Power of Attorney (POA) was called to notify of the situation and authorization was obtained to call 911 to send the resident out of the facility for care. The resident was not responsive after the Heimlich and suctioning were performed. The Registered Nurse (RN) manager attempted the sternal rub, elevated the resident's arms above her head and leaned the resident forward in her dining chair. The resident was observed not breathing and two staff verified the resident's respirations had ceased and there was no pulse. The Emergency Management Services (EMS) arrived and confirmed the DNR code status and lack of pulse. No other actions were performed. The report did not include documentation to indicate the specific steps performed by staff during the provision of the Heimlich Maneuver. Google-Merriam Webster-indicated the definition of the Heimlich maneuver was the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea. The website page https://www.redcross.org/content/dam/redcross/atg/PDFs/Take_a_Class/Adult_Ready_Reference_Card.pdf indicated .Conscious Choking Cannot cough, speak, or breathe .Give 5 [five] back blows .Give 5 abdominal thrusts .Continue care Give sets of 5 back blows and 5 abdominal thrusts until the object is forced out, the person can cough forcefully or breathe, or the person becomes unconscious . The clinical record for Resident S was reviewed on [DATE] at 10:56 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, anxiety disorder, and dysphagia (difficulty swallowing). A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the signs and symptoms of a potential swallowing disorder were positive for the resident holding food in her mouth/cheeks or positive for the resident to have residual food in her mouth after meals. A physician's order, dated [DATE], indicated the resident was to receive a regular diet, regular texture, and thin consistency. A physician's order, dated [DATE], indicated speech therapy to evaluate and treat oral dysphagia. A speech therapy note, dated [DATE], indicated the resident's diagnoses included, but were not limited to, dementia and dysphagia. The resident was referred to speech therapy for a swallowing assessment due to an increase in oral pocketing which placed the resident at an increased risk for aspiration and compromised airway protection. The clinical impression indicated the resident was recommended for treatment of dysphagia to facilitate airway protection and to maximize airway protection on the least restrictive diet. The resident's plan of care was not revised to include the swallowing concerns from the speech therapy note. A speech therapy note, dated [DATE], indicated the discharge recommendation were supervision for all meals with meal tray set up and to cut whole foods into bite sized pieces. The diet recommendation was for a regular texture and thin liquids. The resident's plan of care was not revised to include the swallowing concerns from the speech therapy note. A nursing progress note, dated [DATE] at 12:41 p.m., indicated the resident had to be reminded to chew and swallow the food she had left in her mouth once she made it to the television room. The care plans were reviewed and there was no care plan for dysphagia, food pocketing or the need to cut the resident's food into bite sized pieces. A witness statement obtained by the facility, dated [DATE], indicated RN 16 was called by a staff CNA due to Resident S being cyanotic (blue or purplish discoloration due to deficient oxygenation of the blood). The Heimlich maneuver was done by CNA 9 and a chewed piece of meat was dislodged. The resident's color changed to pale although there were still no respirations. The Heimlich was continued, and suction was done. The resident did not have respirations and the code status of DNR was verified. A witness statement obtained by the facility, dated [DATE], indicated CNA 17 was assisting the residents with lunch. CNA 17 heard another CNA ask if Resident S was okay. Resident S's face looked pale, and she was holding onto a walker. CNA 17 went to get a nurse. The nurses came into the dining room to assist, and CNA 17 assisted to take other residents out of the dining room to clear the area. A witness statement obtained by the facility, dated [DATE], indicated CNA 21 was in the dining room during lunch. A staff indicated Resident S was choking and CNA 21 saw CNA 9 had already started doing the Heimlich maneuver on the resident. A witness statement obtained by the facility, dated [DATE], indicated CNA 20 saw Resident S's face turn purplish and yelled for help. Another staff had started doing the Heimlich maneuver. A witness statement obtained by the facility, dated [DATE], indicated CNA 9 had been told Resident S was changing colors in her face. CNA 9 thought the resident was choking so CNA 9 started to do the Heimlich on the resident and kept doing the Heimlich. A witness statement obtained by the facility, dated [DATE], indicated Unit Manager (UM) 8 had arrived onto the unit and saw staff doing the Heimlich on Resident S. The crash cart was present, and suctioning was completed. The staff had suctioned food particles from the resident's mouth. The resident was nonresponsive, had no respiration, and no pulse. A witness statement obtained by the facility, dated [DATE], indicated UM 22 had entered the dining room on [DATE] and saw a CNA administering the Heimlich maneuver to Resident S. UM 22 helped the CNA to try to get the resident to cough the food up. CNA 22 was using the suction machine while the CNA continued to do the Heimlich. CNA 22 was able to get pieces of food and phlegm suctioned from the resident's mouth. The resident had no pulse and no respiration. The witness statements from RN 16, CNA 17, CNA 21, CNA 20, CNA 9, UM 8, and UM 22 did not include documentation to determine the staff had completed back blows in accordance with the Red Cross conscious choking protocol. During an interview, on [DATE] at 11:48 a.m., CNA 9 indicated, on [DATE], he was assisting another resident to eat. Speech Therapist (ST) 10 was in the dining room and indicated Resident S did not look right. Resident S stood up and looked like she was choking. CNA 9 got behind the resident and did the Heimlich. CNA 9 had both hands under the resident's breasts and was pushing up doing the Heimlich. One of the nurses had the tube thing to get the food out of the resident's mouth. ST 10 assisted to do the Heimlich. CNA 9 and ST 10 kept switching back and forth from behind the resident to push up her abdomen. CNA 9 indicated the resident's abdomen continued to be pushed up whether she was sitting or standing. The only time CNA 9 and ST 10 stopped pushing on the abdomen was when the nurse was using the suction machine. CNA 9 indicated the resident was going to eventually choke since she stuffed her mouth so much and was in a rush to eat. CNA 9 indicated he felt since the resident got regular food and stuffed her mouth, she should have received chopped up food. The food she got was too big. During an interview, on [DATE] at 12:09 p.m., RN 15 indicated CNA 9 said Resident S was choking and all the staff went into the dining room right away. RN 15 indicated she thought they had got the food out although the resident did not breathe again. CNA 9 did the Heimlich by pressing on the resident's abdomen. Then RN 15 tried to suction. There was food removed from the resident's mouth which looked like beef or bacon and it was one chunk about the size of a 50-cent piece. The resident had trouble chewing in the past. The resident would hold food in her mouth and the staff had to be careful to make sure she swallowed everything. During an interview, on [DATE] at 11:31 a.m., UM 8 indicated she was at the facility the day the resident choked. The staff was doing the Heimlich when UM 8 arrived at the unit. CNA 9 and another staff were switching back and forth to do the Heimlich. The resident was a DNR, so cardiopulmonary resuscitation (CPR) was not performed. The resident was sitting in the chair and the staff were leaning over the resident and doing abdominal thrusts. When CNA 9 was tired of doing the abdominal thrusts then the other person would do the abdominal thrusts. UM 8 was not familiar with the diet the resident was prescribed. UM 8 reviewed the electronic health record (EHR) and indicated the resident was on a regular diet, regular texture. The care plan only included setting up the meal tray and providing assistance as needed. The care plan did not have any other instructions for Resident S other than to assist with meals as needed. UM 8 indicated if the resident was at high risk while eating then there should be something on the care guide assignment sheet. During an interview, on [DATE] at 1:26 p.m., the ST 10 indicated Resident S had resided on the memory care and was nonverbal. ST 10 indicated she was one of the staff who was alternating doing the Heimlich with CNA 9. The Heimlich standard procedure was to grab the person around the waist and do upward thrusts. The resident's airway was completely obstructed. ST 10 saw a piece of food about the size of a dime. The resident was not able to manipulate a knife or fork to cut up food into bite size pieces. The resident had advanced dementia and had lost awareness of food in her mouth. Resident S ate way too fast and did not chew food adequately to safely swallow. She had the ability to chew although she did not have the cognitive awareness of food being present in her mouth and the need to grind to chew the food. ST 10 indicated she would not change the diet since there was a lot of pleasure with eating. The resident needed supervision since she did not have the cognition to recognize there was food in her mouth. ST 10 educated the charge nurse and the unit manager on the need to cut the food into small bites and to take small sips of fluid. A resident care guide, provided by the Assistant Director of Nursing (ADNS), on [DATE] at 2:32 p.m., indicated the resident needed to be toileted every 2 hours and was incontinent of bowel and bladder. The guide indicated Resident S required the total assistance of for ADLs (Activities of Daily Living). The resident was nonverbal although could understand when spoken to. The resident's care guide did not include interventions for supervision with meals or for cutting the resident's food into bite sized pieces. During an interview, on [DATE] at 2:39 p.m., UM 22 indicated, on [DATE], she saw a CNA doing the Heimlich maneuver on the resident. The CNA kept doing the Heimlich maneuver and the nursing staff grabbed the crash cart. The staff were able to get some of the food particles out of the resident's mouth, but not all of them. The food particles looked like corned beef and were less than half an inch in size. CNA 9 was doing the Heimlich and alternated with ST 10. The Heimlich maneuver was when CNA 9 stood behind the resident with his arms wrapped under her arms and was thrusting up under her breasts and under her sternum. The resident would rush to eat, and we would need to tell her to slow down and chew her food up. The staff had to empty her mouth out and one time she was sleeping and had food in her mouth. The resident had a mechanical soft diet for a while and then went back up to a regular diet. The daughter had requested no turkey sausage or bacon because the resident had trouble with those foods. The staff would only cut up the resident's food if they felt like it needed to be cut up. The staff interviews did not include information to determine CNA 9, ST 10, or RN 10 provided back blows during emergent care for choking for Resident S in accordance with the Red Cross conscious choking protocol. During an interview, on [DATE] at 3:18 p.m., RN 24 indicated she was the facility CPR instructor. The facility utilized the American Red Cross for First Aid and CPR training. The training for the adult choking victim included assessing the person for choking, then doing back blows and abdominal thrust and continue until the person could expel what was in their throat. Then call 911 and do CPR if unconscious. The staff were to start with 5 back blows, then 5 abdominal thrusts and continue to do back blows and abdominal thrusts until the person became unconscious and then do CPR if applicable. The American Red Cross did not use the word Heimlich anymore. The sequence was to use back blows then abdominal thrusts. During an interview, on [DATE] at 3:38 p.m., the ADNS and Administrator indicated the staff should use the method for a choking victim by using back blows and abdominal thrusts as taught at the facility. The Administrator indicated there was no documentation in the care plan or resident care guide to show the resident needed her food cut into bite sized pieces. A current policy, titled First Aid, dated ,d+[DATE] and received by the DNS on [DATE] at 5:05 p.m., indicated .POLICY: See attached procedure from American Red Cross Manual for First Aid CPR and AED An American Red Cross First Aid, CPR and AED Instructor Manual, not dated and received from the ADNS on [DATE] at 4:48 p.m., indicated .Caring for a Choking Adult .Tell participants they will now practice giving back blows and abdominal thrusts to an adult A current policy, titled Caring for Choking by the American Red Cross, not dated and received from the DNS on [DATE] at 5:05 p.m., indicated .If the person is unable to speak, cry or cough, CALL [DATE] and get equipment, or tell someone to do so .Give 5 back blows .Position yourself to the side and slightly behind the choking person. Place one arm diagonally across a person's chest and bend them forward at the waist .Firmly strike the person between the shoulder blades with heel of your hand. Each back blow should be separate from the others .Give 5 abdominal thrusts .Have the person stand up and find their navel with two fingers. Move behind the person and place your front foot in between the person's feet with your knees slightly bent .Make a fist with your other hand and place the thumb side against the person's stomach right above your fingers. Cover your fist with your other hand .Pull inward and upward to give an abdominal thrust. Each abdominal thrust should be forceful and separate from the other .Alternatively, you may give chest thrusts to a person who is too large to wrap your arms around, pregnant or in a wheelchair .Continue giving sets of 5 back blows and 5 abdominal thrusts until .The person can cough forcefully, speak, cry or breathe .The person becomes unresponsive .If the person becomes unresponsive, gently lower them to the floor and begin, CPR, starting with compressions .After each set of compression and before attempting breaths, open the person's mouth, look for the object and, if seen, remove with a finger sweep 2. During an observation, on [DATE] at 2:11 p.m., Resident V was sitting up in her Broda chair (chair for positioning) and her body was leaned to the left. She was trying to grasp a cup of water with her right hand and was not able to pick up the cup. During an observation, on [DATE] at 3:45 p.m., the resident was sitting up in her Broda chair in the common area at the end of hall 100, she was leaned towards the left side. There were no staff present in the common area. During an observation, on [DATE] at 11:10 a.m., the resident was sitting up in a high back wheelchair. Her head was leaning to the left almost touching the hand piece of the chair and there was a small pillow on the left side of the wheelchair which did not support the resident's head. During an observation, on [DATE] at 11:27 a.m., the resident was sitting up in a high back wheelchair, her head was leaning towards the left with her head tilted towards her chest. There was a pillow by her left arm tucked into the left side of the wheelchair. The pillow did not support the resident's head. During intermittent observations, the resident did not attempt to reposition herself in the Broda or high back wheelchair. The clinical record for Resident V was reviewed on [DATE] at 3:38 p.m. The diagnoses included, but were not limited to, systemic lupus, unspecified fracture of the right pubis (one of three bones which make up the hip bone), displaced fracture of the left femur, and unspecified dementia. A care plan, dated [DATE], indicated the resident had severely impaired cognitive function and decision-making skills related to dementia. The interventions included, but were not limited to, cue, reorient, and supervise as needed. A care plan, dated [DATE] and last revised on [DATE], indicated the resident had an activities of daily living (ADL) self-care performance deficit related to limited mobility, musculoskeletal impairment, pain from a history of a left femur fracture, and lack of coordination. The interventions included, but were not limited to, the resident required extensive staff assistance with turning and repositioning in bed and required extensive staff assistance with personal hygiene and oral care. A care plan, dated [DATE] and last revised on [DATE], indicated the resident was at a high risk for falls related to balance, unaware of safety needs, and unsteadiness on feet. The interventions included, but were not limited to, anticipating, and meeting the resident's needs and a body pillow when in bed. During an interview, on [DATE] at 11:27 a.m., CNA 5 indicated the resident did have a Broda chair, but the facility gave the chair back to the hospice provider. The resident was still able to pivot during a transfer and it was too difficult to get the resident out of the Broda chair. The resident favored the left side and even leaned towards the left while she was in bed. CNA 5 did not try to reposition the resident. 3. During an observation, on [DATE] at 3:53 p.m., Resident F was sitting up in her wheelchair, her head was tilted to the right. There was no positioning cushion in her wheelchair. During an observation, on [DATE] at 11:44 a.m., the resident was sitting up in her wheelchair in the common area, her head was tilted to the right. There was a cushion on the bottom of her wheelchair and no other type of device in the chair. During an observation, on [DATE] at 11:12 a.m., the resident was sitting up in her wheelchair close to the common area. Her head was tilted to the right with her chin tilted towards her chest. There was no positioning cushion in her wheelchair. During an observation, on [DATE] at 3:48 p.m., the resident was sitting up in the common area and her head was leaning to the right. There was no positioning cushion in her wheelchair. During an observation, on [DATE] at 11:14 a.m., the resident was sitting up in the common area in her wheelchair. Her head was tilted down and there was a positioning cushion on the left side of her wheelchair. The clinical record for Resident F was reviewed on [DATE] at 3:04 p.m. The diagnoses included, but were not limited to, unspecified dementia, generalized muscle weakness, and unsteadiness in her feet. A physician's order, dated [DATE], indicated the resident was to always have a right lateral support in her chair to ensure an upright sitting position. An Occupational Therapy (OT) progress report, dated [DATE], indicated the resident was awaiting a neck brace to encourage proper seated alignment and the resident was given a high back chair with a right lateral support. A care plan, dated [DATE] and last updated on [DATE], indicated the resident was at risk for altered range of motion to the bilateral lower extremities due to a diagnoses of muscle weakness and dementia which had progressed. The resident required restorative nursing to walk with a front wheeled walker and to perform trunk flexion before standing. The care plans did not include the resident's positioning and the need for a neck brace or a lateral support in her chair. During an interview, on [DATE] at 3:55 p.m., QMA 6, indicated she did not know what type of support the resident was supposed to have in her wheelchair. The resident did not have any support in her wheelchair. During an observation, on [DATE] at 3:56 p.m., with QMA 6, there was no type of lateral support located in the resident's room. During an interview, on [DATE] at 4:17 p.m., the Occupational Therapist (OT) 7 indicated the resident was seen by OT due to the resident leaning to one side. The lateral support was an L shaped cushion. OT 7 did not know what was going on with the cushion. At the time of exit, the facility did not provide a positioning and mobility policy. 44598 4a. The clinical record for Resident 99 was reviewed on [DATE] at 3:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus (DM), congestive heart failure (CHF), and right above the knee amputee. A care plan, dated [DATE], indicated the resident had diabetes mellitus. The interventions included, but were not limited to, diabetes mellitus medications as ordered per the physician, and fasting serum blood sugar as ordered by the physician. A physician's order, dated [DATE], indicated to obtain blood sugars twice a day and notify the nurse practitioner or physician if the blood sugar was less than 70 or greater than 350. The following blood glucose levels were out of the physician call orders: a. On [DATE] at 5:53 p.m., the blood sugar level was 399. b. On [DATE] at 5:00 p.m., the blood sugar level was 385. c. On [DATE] at 5:18 p.m., the blood sugar level was 358. There was no documentation the physician was notified of the blood sugar out of the call parameter. 4b. A care plan, dated [DATE], indicated the resident had congestive heart failure. The interventions included, but were not limited to, monitoring weights daily as ordered. A physician's order, dated [DATE], indicated to notify the nurse practitioner or physician daily if the resident's weight was greater than 3 pounds in 24 hours or greater than 5 pounds in one week. The following daily weights were missing: a. The daily weights were missing on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. b. The daily weights were missing on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. c. The daily weights were missing on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. There was no documentation the physician was notified of the missing daily weights. During an interview, on [DATE] at 11:18 a.m., the ADNS indicated they did not have a CHF policy and the facility followed the weight policy for residents with CHF. During an interview, on [DATE] at 4:30 p.m., the DNS indicated the staff followed the physician's orders and called the physician if the blood glucose was above the call orders. The staff should follow the physician's order and get a daily weight and chart them. A current policy, titled Glucose Testing, dated ,d+[DATE] and received from the ADNS on [DATE] at 11:30 a.m., indicated .To provide nursing staff with guidelines for the testing of residents glucose level .Verify the physician's orders for blood glucose testing .The nurse shall notify the physician of the results in accordance with physician's orders and/or facility protocols for hyper/hypoglycemia A current policy, titled Physician Orders, dated as revised ,d+[DATE] and received from the ADNS on [DATE] at 1:00 p.m., indicated .All activities (medications, activities, lab orders, x-rays, diet, etc) that effect the resident shall be ordered by the physician/designee. No orders shall be changed or discontinued by anyone other than the physician/designee. Nursing shall follow all orders as written. If there is a question or concern, the physician/designee shall be contacted for clarification A current policy, titled Weights, dated as revised ,d+[DATE] and received from the ADNS on [DATE] at 11:30 p.m., indicated .Residents shall be monitored for adequate nutritional status to ensure each one is able to maintain the highest practicable level of well-being .CHF Diagnoses: Weights for these residents are often performed on a daily basis as ordered by the physician. Any weight change of three (3) pounds (gain) in (24) twenty-four or five (5) pounds in a week shall be documented. The physician shall be notified of any weights changes that exceed the ordered parameters This citation relates to Complaints IN00425592. 3XXX,d+[DATE](a)

Based on observation, interview and record review, the facility failed to protect a resident from injury during a transfer when the CNA did not follow transfer instructions for 1 of 3 residents reviewed for accidents. (Resident 2) Resident 2 sustained a fracture to her femur when she was lowered to the floor. Finding includes: An incident report filed with the Indiana Department of Health indicated Resident 2 sustained a fall, on 06/05/23 at approximately 2:00 p.m., when she became weak during a transfer. The Nurse Practitioner assessed the resident, and a STAT (immediate) x-ray was ordered. The x-ray showed an acute right transverse distal femur fracture (a fracture to the leg bone between the hip and the knee). Per the report, Resident 2 was sent out to the hospital and had to have surgery and rehabilitation therapy before returning to the facility. During an observation, on 07/17/23 at 9:00 a.m., Resident 2 was observed sitting up in bed and leaning slightly to her left. She had a palm protector in her right hand and her right arm was propped up with a pillow. Resident 2 was eating her meal with her left hand. An interview was attempted, but Resident 2 was nonverbal. The record for Resident 2 was reviewed on 07/14/23 at 11:01 a.m. Diagnoses included, but were not limited to, history of falling, difficulty walking, and hemiplegia and hemiparesis affecting the right side (weakness and paralysis on the right side of the body). A nurses' note, dated 06/05/2023 at 3:04 p.m., indicated .Nurse called to residents room due to resident falling on the floor in her bathroom. Writer went into room and observed the resident on the floor with her right leg folded under her. Nurse assessed resident for injuries from fall, stabilized resident's right leg and took vital signs T.97.2, P.89 R.16 B/P 188/83. Resident assisted off the floor by nurse and CNA and into her wheelchair and then into her bed A care plan, undated, indicated Resident 2 was a high risk for falling and to have 2 staff members for weight bearing assist with all transfers using a gait belt. The care plan indicated to use 2 people to assist with toileting. The physician's orders were reviewed and did not include orders on use of a full body mechanical lift or transfers using 2 people and a gait belt. A current CNA assignment sheet, provided by the Assistant Director of Nursing on 07/14/23 at 11:20 a.m., indicated .High fall risk .2 person assist with gait belt/wheelchair .Extensive assist .Rt (right) side hemiparesis During an interview, on 07/14/23 at 11:14 a.m., CNA 1 indicated Resident 2 could be transferred by a full body lift with two (2) staff or by gait belt with two (2) staff. She did transfer Resident 2, in the bathroom, by herself and did not use a gait belt. She indicated the proper way to transfer Resident 2 was documented on the CNA assignment sheet, but she did not have her assignment sheet with her that day, she was in a hurry. She was aware the resident required two (2) people and a gait belt for transfers. It was not the first time she had worked with the resident, prior to the incident. CNA 1 indicated when she was transferring Resident 2 in the bathroom, the resident had her good hand on the assist bar. CNA 1 placed her weak hand on the bar, and when she stood Resident 2 up, the resident went limp, and they both went down. CNA 1 indicated the resident was weak on one side. She did call the nurse and together they assisted the resident to her bed. During an interview, on 07/14/23 at 11:25 a.m., the Assistant Director of Nursing indicated CNA 1 was interviewed to find out why she did not follow the CNA assignment sheet. During an interview, on 07/14/23 at 11:38 a.m., TX 3 (Therapy Staff) indicated Resident 2 was to transfer using two (2) people and a gait belt. She was assessed on 04/24/23 (prior to the event) upon her admit to facility and was totally dependent on staff for transfers, meaning a full body mechanical lift was to be used or two (2) staff members with a gait belt for transfers. How the resident was transferred was determined by the resident's pain level and the resident's weight bearing status. He indicated the CNA assignment sheet needed to be updated. During an interview, on 07/14/23 at 1:01 p.m., LPN 2 indicated she was at her medication cart parked across the hall. She did not hear anything. CNA 1 came out of the room and asked her to come into the room. LPN 2 entered the room and found Resident 2 on the floor with her leg bent behind her. She had the CNA remain with Resident 2 and left to get the vital sign instruments. Once she had finished assessing the resident, both her and CNA 1 transferred the resident to her bed via two people and a gait belt. She indicated it was more of a lift and carry to the bed due to the observation of the leg and the resident was not able to assist with transfer. Once the resident was in bed, she displayed seizure activity. LPN 2 indicated she knew how to transfer the resident because it was documented on the care card. During a telephone interview, on 07/17/23 at 3:15 p.m., the family member of Resident 2 indicated her mother did not self-transfer due to weakness and paralysis on her right side. She was dependent on 2 staff members and a gait belt to be transferred. The resident had at least three (3) gait belts in her room. A facility document, titled Job Description .CERTIFIED NURSING ASSISTANT, dated as last reviewed in August 2007 and received from the Executive Director on 07/14/23 at 1:47 p.m., indicated .To receive and complete resident care assignments .in accordance with facility policies .To perform all nursing procedures in accordance with facility policy .These procedures/tasks include but are not limited to the following .Correctly transfers the resident in accordance with the CNA Assignment Sheet A current policy, titled Transferring Residents, dated as last reviewed in 04/2022 and received from the Executive Director on 07/14/23 at 1:47 p.m., indicated .C.N.A.s assigned to the resident need to review the assignment sheet/care plan to determine if the resident requires more than a one person assist 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident at risk for development of pressure ulcers received the necessary care, treatment, and services, consistent with professional standards of practice, to prevent a pressure ulcer and promote healing and failed to ensure the correct dose of Dakin's (an antimicrobial cleanser) was used during wound care for 3 of 7 residents reviewed for pressure ulcers. (Resident 299, 21, 112) Resident 299 acquired a stage 3 presure ulcer while in the facility. Findings include: 1. The record for Resident 299 was reviewed on 12/19/22 at 3:00 p.m. Diagnosis included, but were not limited to, end stage renal disease, diabetes, and heart failure. An Admission Summary, dated 11/26/22 at 6:35 p.m., indicated Resident 299 was admitted to the facility for rehabilitation due to altered mental status. She ambulated with an assist of two with a gait belt, walker, and wheelchair. A nurse-to-nurse report, dated 11/26/22, indicated Resident 299 had a red area to the coccyx which was blanchable. A skilled evaluation, dated 11/27/22 to 11/29/2022 at 5:04 p.m., indicated Resident 299's skin was warm, dry, normal skin color and turgor. A Braden Scale was conducted, on 11/27/22, and indicated Resident 299 was at risk for skin breakdown. A progress note, dated 11/30/22 at 4:26 p.m., indicated a family member had concerns regarding a cushion patch on Resident 299's coccyx was soiled which was applied at the hospital prior to her discharging to the facility on [DATE]. The patch was removed, and the skin was intact beneath. A wound progress note, dated 12/2/22, indicated Resident 299 had a stage 3 pressure wound on her coccyx which measured 1 cm by 1.3 cm by 0.1 cm with 100 percent granulation, and a small amount of serosanguinous drainage. Treatment indicated to cleanse wound with wound cleanser or normal saline, apply collagen, cover with foam, and secure. Change every Monday, Wednesday, Friday, and as needed. The wound progress notes indicated therapy would be notified to upgrade the wheelchair cushion for Resident 299. A communication progress note, dated 12/2/22, indicated family member was notified of treatment orders to coccyx. A progress note, dated 12/2/22, indicated a coccyx wound was observed, and was facility acquired. The progress note indicated epithelial tissue was present and pink in color. The wound measured 3.2 cm by 3.4 by 0.1 cm. Wound care included applying triad cream and to cover with Duoderm every three days. A care plan, dated 12/6/22, indicated Resident 299 had acquired a stage one pressure ulcer on her coccyx. Interventions included, but were not limited to, administer treatments as ordered, follow facility policies and protocols for prevention and treatment of skin breakdown, monitor nutritional status and serve diet as ordered, monitor intake, and record, and use a pressure relieving device on the bed and in the wheelchair. An Admission MDS assessment, dated 12/7/22, indicated Resident 299 was at risk for pressure ulcers and she currently had a stage 2 pressure wound which was not present upon entry and required extensive assistance from staff for all activities of daily living. She had a pressure relieving device to the chair and bed, was not receiving pressure care and was not on a turning and repositioning schedule. A Care Area Assessment, dated 12/7/22, indicated Resident 299 triggered the CAA due to requiring assistance with bed mobility, incontinence, impaired skin integrity. A care plan would be developed to monitor complications and the risk of developing pressure ulcers. A physician progress note, dated 12/7/22 at 4:00 p.m., indicated it was his first visit for the wound. The pressure wound on the coccyx was due to pressure and classified as a stage 3. A small layer of fat was exposed and measured 1 cm by 1.3 cm by 0.1 cm. A small amount of serosanguineous drainage was noted and a large area of pink granulation within the wound bed. The wound care order included to clean the wound with wound cleanser, or normal saline, apply collagen, cover with foam dressing, and secure. Change Monday through Friday, and as needed. Provide offloading to Resident 299, do not sit for long periods of time, turn, and reposition per policy, and upgrade cushion in her wheelchair. A wound care note, dated 12/15/22, indicated Resident 299 was seen on wound rounds for a stage 3 pressure wound on coccyx which was acquired on 12/2/22. The pressure wound area measured 0.9 cm by 1.2 cm by 0.1 cm and had 100 percent granulation tissue with a small serosanguinous drainage. Treatment to the area included to cleanse with wound cleanser or normal saline, apply collagen powder followed with Triad daily. The facility would notify therapy to upgrade wheelchair cushion. Resident 299's Kardex indicated she required assistance by staff to turn and reposition in bed and as necessary. Physician orders included, but were not limited to: a. On 12/2/22 at 7:00 a.m., to clean area of coccyx, apply triad, and cover with Duoderm change every three days for open area. b. On 12/9/22, to cleanse with wound cleanser or normal saline, apply collagen, cover with foam, and secure. Change one time a day every Monday, Wednesday, Friday, and as needed for pressure wound. c. On 12/15/22 at 3:00 p.m., to cleanse the wound with wound cleanser or normal saline, apply collagen powder, and a layer of triad daily for a pressure wound. A review of Resident 299's Treatment Administration Record, dated 12/22, lacked indication wound care was provided on 12/7/22. A review of Resident 299's Occupational Therapy progress note, dated 11/29/22 to 12/19/22, lacked indication a pressure relieving device for her wheelchair was requested or needed to be upgraded. A review of Resident 299's Physical Therapy progress note, dated 11/30/22 to 12/19/22, lacked indication a pressure relieving device for her wheelchair was requested or needed to be upgraded. During an interview, on 12/14/22 at 2:30 p.m., a family member indicated she came into the facility to visit Resident 299 and she could smell an odor. She observed her back and coccyx area she noticed her bandage was soiled and she had concerned the bandage was the same one when she was discharged from the hospital. During an interview, on 12/20/22 at 3:53 p.m., the ADON indicated no measurement of the redness was documented when Resident 299 was admitted to the facility for the coccyx. The pressure wound was found on 12/2/22. During an interview, on 12/21/22 at 11:12 a.m., the ADON indicated the nurse did not document an accurate assessment and finding of the pressure wound. 2. The record for Resident 21 was reviewed on 12/14/22 at 10:55 a.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), urinary tract infection, kidney transplant, pancreas transplant, diabetes, dementia, and pressure ulcer (injury which breaks down the skin). A care plan, dated 2/28/22, indicated Resident 21 was at high risk for pressure ulcer development related to decreased mobility, nutritional status, and a history of pressure ulcers. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, educate the resident, family, and caregivers as to causes of skin breakdown, including transfer, positioning, importance of taking care during ambulating, mobility, good nutrition, and frequent repositioning, and if the resident refused treatment, discuss with the resident, Interdisciplinary team, and family to determine why, and try alternative methods to gain compliance. Document alternative methods. Inform Resident 21, family, and caregivers of any new area of skin breakdown, provide a low air loss mattress to the bed with settings as ordered by physician, monitor nutritional status, and serve diet as ordered, monitor and record intake, monitor, document, and report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length by width by depth), and stage. Obtain and monitor lab or diagnostic work as ordered. Report results to physician and follow up as indicated. Teach Resident 21 and family the importance of changing positions for prevention of pressure ulcers and encourage small frequent position changes. The care plan indicated he had an unstageable pressure ulcer to the right heel and right ankle. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, and assess, record, and monitor wound healing as ordered. A Care Area Assessment (CAA), dated 5/18/22, indicated Resident 21 triggered for pressure injury and required extensive assist with ADL's, transfers, and mobility, which could lead to or contribute to increased risk of developing pressure ulcers. A care plan would be developed to monitor for complications related to the pressure ulcer risk. A Braden Scale was conducted, on 6/3/22, and indicated Resident 21 was at a high risk for skin breakdown. A quarterly Minimum Data Set (MDS) assessment, dated 11/3/22, indicated Resident 21 was at risk for pressure injuries and had no pressure wounds at the time of assessment. Current treatments were pressure reducing device for the chair, and pressure reducing device for bed. Resident 21 required extensive assistance of two staff to provide physical assist for locomotion, dressing, eating, toilet use, bed mobility. He was totally dependent on staff for personal hygiene and bathing. During an observation, on 12/15/22 at 11:07 a.m., Licensed Practical Nurse (LPN) 15 and LPN 12 entered Resident 21's room to provide wound care to his right heel. Resident 21 was lying in his bed as LPN 15 removed his Prevalon boot (a cushioned bottom boot which floats the heel off the surface of the mattress) from his right lower extremity. Resident 21 made a grunting noise and pointed to his right foot. LPN 15 continued to remove the bandage from his right foot, cleanse the foot, and applied the ointment to the back of the heel/ankle. She placed a foam pad, wrapped with gauze, and secured with that had the date 12/15/22. The Prevalon boot was than replaced on the right foot. Resident 21 begun to grunt out and point to his right foot and shake his head with the look of frustration. During an interview, on 12/15/22 at 11:20 a.m., LPN 15 indicated she performed wound care to Resident 21's left heel. When asked what the order indicated for wound care she did not respond. Resident 21's Medication Administration Record (MAR), dated 12/22, indicated: a. On 12/8/22 to 12/14/22, start betadine solution to his right heel every day related to changes in skin texture. b. On 12/15/22, apply Santyl ointment to right heel wound for dislodgement. c. On 12/16/22 to 12/19/22, apply Santyl ointment to Resident 21's right heel for a pressure ulcer. Physician orders included, but were not limited to, a. On 12/15/22, staff were to apply Santyl ointment 250 unit/gram (Collagenase.) Apply to the right heel wound bed topically, cover and secure one time a day and as needed. A skin/wound progress note, dated 11/24/22 at 1:36 p.m., indicated Resident 21 had a 3.0 cm (centimeter) by 2.5 cm intact firm eschar noted to his right ankle. No signs or symptoms of pain or discomfort. He had a low air loss mattress and utilized Prevalon boots while in bed. A progress note, dated 11/24/22 at 1:40 p.m., indicated Nurse Practitioner gave an order for betadine ointment to right ankle wound and leave open to air. A progress note, dated 11/30/22, indicated Resident 21 presented with an unstageable pressure wound to the right heel measuring 1.8 by 1.6 by 0.1, and 100 percent necrotic tissue with no drainage. Treatment would be betadine daily and pressure reducing boot. A progress note, dated 12/7/22, indicated Resident 21 had an unstageable pressure wound to the right heel measuring 1.7 cm by 1.5 cm by 0.1 cm, and 100 percent necrotic tissue with no drainage. The pressure wound was facility acquired on 11/24/22. A progress note, dated 12/14/22, indicated Resident 21 had an unstageable pressure to right heel measuring 1.4 cm by 1.5 cm by 0.1 cm, and 100% necrotic tissue with no drainage. 38872 3. During an observation, on 12/20/22 at 10:12 a.m., RN 5 was observed to put two 3 milliliter (ml) containers of normal saline into a medication cup. She then poured a one-quarter concentration of Dakin's solution into the cup for a total of 10 ml of fluid. She placed a gauze dressing into the cup and once finished cleaning the wound, packed the wound with the Dakin's and normal saline soaked gauze. The record for Resident 112 was reviewed on 12/19/22 at 2:36 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, disorder of the skin and subcutaneous tissue and muscle weakness. A physician's order, dated 12/1/2022, indicated to use Dakin's (1/4 strength) 0.125 % Solution; cleanse wound with wound cleaner or normal saline and pack lightly with fluffed gauze moistened with 1/4 strength Dakin's, cover and secure daily. During an interview, on 12/20/22 at 1:43 p.m., RN 5 indicated she did add 6 ml of normal saline to the Dakin's because it was to be at 1/4 strength per the order. RN 5 reviewed the label of the solution which indicated the solution was 1/4 strength. She indicated she was not aware the solution (in the bottle) was 1/4 strength. During an interview, on 12/21/22 at 10:25 a.m., the Assistant Director of Nursing indicated she expected nursing to follow the physician's orders and check medications prior to using/administering. A facility policy, titled Skin Management Program, dated 6/22, indicated the facility would ensure each resident received care consistent with the professional standards of practice to prevent pressure ulcers and did not develop a pressure ulcer. The policy described a stage 3 pressure ulcer as a full thickness skin loss were fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. A facility policy, titled Physician Orders, dated as revised in 03/2022 was provided by the Assistant Director of Nursing on 12/20/22 at 2:30 p.m., indicated .No orders shall be changed .by anyone other than the physician .Nursing shall follow all orders as written 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed for catheter care. (Resident 21 and 86) Resident 21 and Resident 86 was not provided care to address concerns which developed after a urinary catheter was not changed for multiple months. Findings include: 1. During an observation, on 12/12/22 at 2:12 p.m., when entering Resident 21's room a strong odor of urine was in the room. He was lying in his hospital bed and his catheter bag hung from the side with dark amber colored urine. The clear extension catheter tubing was lined inside with sediment. During an observation, on 12/13/22 at 1:31 p.m., Resident 21's room had an odor of strong urine as you entered the room. The clear extension catheter tubing was lined inside with sediment and amber colored urine was in the Foley bag. During an observation, on 12/14/22 at 2:30 p.m., Resident 21's urine appeared amber in colored, and sediment lined the inside of the catheter extension tubing. During an observation, on 12/15/22 at 9:33 a.m., Resident 21's room had a strong urine odor. The clear extension catheter tubing was lined inside with sediment and dark amber colored urine was in the Foley bag. During an observation and interview, on 12/15/22 at 9:40 a.m., nursing assistant (NA) indicated she did not smell urine in Resident 21's room and had no concerns to report to the nurse. She indicated maybe the tubing needs to be changed because of the white build up. During an observation and interview, on 12/15/22 at 9:49 a.m., Licensed Practical Nurse (LPN) indicated she had not had any report of concerns for Resident 21's catheter tubing or the odor in his room. The LPN entered his room and indicated there was a strong odor of concentrated urine and Resident 21 may need more fluids. The LPN indicated the catheter extension tubing was coated on the inside with white sediment and the tubing should be changed. The record for Resident 21 was reviewed on 12/14/22 at 10:55 a.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), urinary tract infection, kidney transplant, pancreas transplant, diabetes, dementia, and pressure ulcer (injury which breaks down the skin). A care plan, dated 4/13/21, indicated Resident 21 had an indwelling catheter related to a neuromuscular dysfunction of bladder. Interventions included, but were not limited to, position catheter bag and tubing below the level of the bladder and away from entrance room door, monitor and document intake and output as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, and monitor and document for pain or discomfort due to catheter. Monitor, record, report to the medical doctor signs and symptoms of urinary tract infection such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. A Care Area Assessment, dated 5/18/22, indicated Resident 21 triggered for catheter, and diagnoses of UTI, neuromuscular dysfunction of the bladder, and status post kidney transplant. He required extensive assist with activities of daily living, transfers, and mobility, which could lead to or contribute complications related to catheter. Resident 21's CAA indicated his care plan would be developed to monitor for complications related to a Foley catheter. A Quarterly Minimum Data Set (MDS) dated [DATE], indicated he had an indwelling catheter and was totally dependent on staff for personal hygiene. Physician's orders, included, but were not limited to, a. On 4/13/21, change catheter as needed for leakage or decreased output. b. On 4/13/21, provide catheter care daily. c. On 6/11/21, change catheter on the 8th day of every month one time a day every 30 days related to chronic kidney disease. The order was entered as a diagnostic order. d. On 9/23/21, irrigate the Foley catheter with 60 milliliters (ml) of sterile water as needed every 8 hours as needed for hematuria. e. On 9/24/21, Resident 21 had an order indicating he may have a Foley catheter. The catheter size was a 16 French with a 10 ml bulb for neuromuscular dysfunction of bladder. Staff were to document urine output. Resident 21's hospital progress note, indicated he was hospitalized on [DATE] related to sepsis (life-threatening complication of an infection), pneumonia, and UTI. A physician's progress note, dated 5/13/22, indicated he was seen for a readmission visit after having an UTI. A hospital history and physical, dated 5/20/22, indicated he was diagnosed with sepsis related to aspiration pneumonia and urinary tract infection possible Foley associated. He had a recent Serratia (bacteria in urine) UTI, history of klebsiella (bacteria in urine) UTI, and Enterobacter aerogenes (bacteria in urine) UTI. Resident 21's hospital discharge summary, dated 5/26/22, indicated he was hospitalized from 5/20/22 to 5/26/22, related to sepsis, UTI, positive for Methicillin-resistant Staphylococcus aureus (MRSA), and impacted stool. A hospital history and physical, dated 10/23/22, indicated the resident was treated for sepsis, UTI with a chronic foley catheter. Resident 21 had also had a history of UTI on 5/5/20, and 5/20/22 with hospitalization s. During an interview, on 12/15/22 at 3:54 p.m., the Assistant Director of Nursing (ADON) indicated Resident 21's catheter order was entered as a diagnostic order, nursing staff would not see this, and it would not direct staff to change the order which had been entered 6/11/21. During an interview, on 12/15/22 at 4:34 p.m., the ADON indicated Resident 21 last had his catheter changed when he was admitted in the hospital in 10/22, when he was treated for sepsis related to UTI. Staff should have changed the catheter per the physician's order, and there was no order to specify the frequency to change the catheter. She had observed the catheter tubing and indicated the significant amount of sediment caked on the tubing and this put Resident 21 at risk for urinary tract infection. During an interview, on 12/15/22 at 5:30 p.m., the Director of Nursing (DON) indicated Resident 21 did not have his catheter changed since his last hospitalization in 10/22, when he had been hospitalized for sepsis related to UTI. He had multiple UTI since 5/22, and indicated the catheter not being change put Resident 21 at risk for another hospitalization and UTI. During an interview, on 12/16/22 at 8:57 a.m., the ADON and Risk Management Nurse indicated the nurse should clarify with the Physician upon admission or as needed the frequency of the catheter change if not indicated in the orders. Nursing staff should follow standing orders for on how and when catheter care should be provided. Nursing staff should report concerns immediately when they discover concerns regarding with the catheter such as strong odor or buildup of sediment in the urine. The ADON indicated she was unsure if the provider was notified of the concerns of the buildup in the extension tubing. Resident 21 had been hospitalized for UTI with sepsis and been treated for UTI which put him at risk. During an interview, on 12/19/22 at 9:00 a.m., the Transplant Coordinator indicated Resident 21 was at an increased risk for UTI which could cause an infection in his transplant kidney. She recommended good catheter care was provided including changing the catheter as ordered. During an interview, on 12/19/22 at 11:45 a.m., the Nurse Practitioner indicated she was notified, on 12/15/22, concerns regarding the catheter. Her recommendations for Resident 21 were to have monthly catheter changes because of chronic urinary retention and with his history of UTI with sepsis. She was not made aware Resident 21 had not had monthly catheter changes and his hospitalization s related to UTI and sepsis could have been from not having routine catheter changes. It was a concern for him not having routine catheter care. Staff should notify her if they were made aware of, or observed concerns related to odorous urine, blood in the urine, and sediment. 2. During an observation, on 12/12/22 at 1:30 p.m., upon exiting the second-floor elevator on Unit 2A, a strong foul smell of urine permeated into the hallway. The smell of urine became stronger as you walked towards Resident 86's room. During an observation, on 12/13/22 at 9:49 a.m., a strong foul smell of urine permeated into the hallway outside Resident 86's room. During an observation, on 12/13/22 at 1:30 p.m., a strong foul smell of urine permeated Resident 86's room. During an observation and interview, on 12/13/22 at 2:00 p.m., Resident 86 was observed lying her bed with the Foley catheter bag attached on the left side of the bed facing the door. The strong foul urine smell filled the room. Resident 86 indicated she notified the nurse the other day when staff emptied her catheter the urine had smelled strong. The resident had a history of urinary tract infections and required antibiotics. The record for Resident 86 was reviewed on 12/14/22 at 10:55 a.m. Diagnoses included, but were not limited to, urinary retention, chronic kidney disease, heart failure, urinary tract infections, and diabetes. Physician's orders, included, but were not limited to, a. On 8/12/22, provide catheter care daily. b. On 8/12/22, place a dignity bag. c. On 8/12/12, the order indicated Resident 86 may have a Foley catheter, 16 French bulb size 10 ml, every shift for retention of urine. d. On 12/14/22, give Ciprofloxacin HCL (antibiotic to treat urinary tract infection) by mouth two times a day until 12/21/22. e. On 12/16/22, change catheter as needed. A review of Resident 86's physician orders lacked indication staff were directed to change her catheter from 8/12/22 to 12/16/22. A Care Area Assessment, dated 1/17/22, indicated Resident 86 triggered for catheter and had a diagnosis of UTI and urinary retention. She required extensive assist with activities of daily living, transfers, and mobility, which could lead to or contribute complications related to Foley catheter. Her care plan would be developed to monitor for complications related to Foley catheter. Resident 86's care plan lacked indication she had an indwelling catheter for urinary retention or direction to staff to provide catheter related care. A Treatment Administration Record (TAR), dated 1/22, indicated Resident 86 had her catheter changed on 1/3/22. A TAR, dated 2/22, indicated Resident 86 had refused her catheter change on 2/2/22 and staff did not change of offer any other days in the month. A progress note, dated 2/2/22, indicated Resident 86 refused to have her catheter changed. A progress note, dated 2/24/22, indicated Resident 86 had a catheter inserted related to dislodgement. A TAR, dated 3/22, indicated Resident 86 had a catheter change on 3/18/22. A TAR, dated 5/22, indicated Resident 86 had been hospitalized on [DATE], and no catheter changed was completed. A urine culture, dated 5/9/22, indicated she had a positive urine culture for urinary tract infection. A urine culture, dated 5/26/22, indicated she had a positive urine culture for urinary tract infection. A progress note, dated 7/4/22 at 8:23 p.m., indicated Resident 86 had her catheter changed while in the hospital. A progress note, dated 7/6/22 at 6:16 p.m., indicated Resident 86 was to have her Foley catheter changed once a month. She indicated to staff she had just got back from the hospital where the catheter was changed. A progress note, dated 7/10/22 at 10:02 p.m., indicated Resident 86 had her catheter changed while at the hospital. A progress note, dated 7/13/22 at 10:35 p.m., indicated Resident 86 had her catheter changed while at the hospital. A Long-Term Care Evaluation, dated 7/16/22, indicated Resident 86 last had her catheter changed on 6/27/22. A progress note, dated 7/26/22 at 10:35 p.m., indicated Resident 86 refused to have her catheter changed due to having it changed when she was in the hospital. A Hospital History and Physical, dated 8/9/22, indicated Resident 86 had a Foley catheter related to urinary retention and facility staff indicated it was changed monthly. The progress notes indicated it was unclear when the catheter was last changed. A progress note, dated 9/1/22 at 6:04 a.m., indicated Resident 86 had her catheter changed due to low urine output. A urine culture, dated 9/8/21, indicated she had a positive urine culture for urinary tract infection. A TAR, dated 10/22, indicated she had a catheter changed on 10/14/22, related to leukocytosis. A communication progress note, dated 12/16/22 at 11:11 a.m., indicated the resident was notified she had her catheter changed on 12/13/22, when the nurse sent out a laboratory sample of urine to obtain an analysis, culture, and sensitivity. A TAR, dated 12/22, indicated Resident 86 had a Foley catheter and to document urine output every shift. On four different occasions, the TAR lacked documentation of urine output. An order was placed for staff to change the Foley catheter on 12/16/22. During an interview, on 12/15/22 at 5:04 p.m., the ADON indicated Resident 86 had not had a catheter change since 10/14/22. Resident 86's order did not indicate the frequency of when the catheter should be changed. During an interview, on 12/15/22 at 5:38 p.m., the Director of Nursing indicated the catheter should be change per physician order's and going two months was probably too long not to have the catheter changed. The facility policy, titled Urinary Catheter Insertion and Removal, dated as revised 7/18, indicated an indwelling urinary catheter shall be inserted only, when necessary, based upon physician's order. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision; windows were secure; staff were trained to prevent elopement and respond to actual elopement; codes to elopement alarms were not openly visible and the family and police were notified of an elopement in a timely manner for 3 of 3 residents reviewed with wandering and exit-seeking behaviors (Residents C, D and G). This failure resulted in Resident C successfully exiting the secured dementia unit through a window on 4/26/21. The immediate jeopardy began on 4/26/21 when Resident C, who had Alzheimer's dementia, severely impaired cognitive status, and exhibited exit seeking behaviors and verbalizations since admission on 4/14/21, was not monitored between 3:50 a.m. and 5:00 a.m., when she was found to have exited through another resident's window. The facility notified the family and police after 6:00 a.m. (one hour later). The resident knocked on a stranger's door 1.1 miles away. The stranger called the police at 4:20 a.m. The outside temperature was approximately 42 degrees Fahrenheit (F). The resident was wearing light clothing and did not have her assistive walking device or identification. The resident was known to police from her prior history of elopement from home. After providing her name, police were able to return her to her prior residence. The Administrator, Director of Nursing (DON) and Assistant Director of Nurses (ADON) were notified of the immediate jeopardy at 1:10 p.m. on 5/06/21. The immediate jeopardy was removed on 5/7/21, but noncompliance remained at a lower scope and severity level of isolated, with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident C's medical record was reviewed on 5/05/21 at 9:01 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, disorders of adult personality and behavior, [CONDITION(S)], type 2 diabetes, age-related [CONDITION(S)] and asthma. Resident C's admission screening assessment, dated 4/14/21, reflected she was ambulatory, weighed 182 pounds, and was independent with her activities of daily living. She was oriented only to person and situation, not time or place. She walked independently with a cane. Resident C's admission evaluation, dated 4/14/21, reflected she had a severely impaired cognitive status. She was at risk for elopement because she had a history of elopement or had attempted elopement while at home, had expressed the desire to go home, packed belongings to go home or stayed near an exit door, was a recent admission and was not accepting of the situation. Resident C's progress note, on the day of admission, dated 4/14/21 at 6:39 p.m., indicated she was very upset. At approximately 6:30 p.m., a staff member and the nurse heard an alarm sound at the backdoor. The resident had figured out how to open the back door to the courtyard. She did not go out the door but was attempting to exit. She was not easily directed. One on one supervision had to be done multiple times during the shift to keep her from wandering. She tried again to get off the unit and it was decided, at approximately 7:15 p.m., to place a wanderguard on her right ankle. Resident seems to redirect better when there is a man to speak with her or when she can speak about her past openly. (A wanderguard was a device worn by a resident which sets off an alarm when the resident breaches/crosses an accompanying wall-mounted panel.) Resident C's physician's orders, provided by the DON on 5/5/21, did not include orders for a wanderguard. Resident C's medication and treatment record (MAR//TAR), for April 2021, did not include documentation the staff monitored the placement/presence or function of a wanderguard device. Resident C's progress note, dated 4/15/21 at 7:34 p.m., reflected social services overheard the resident yelling at a Certified Nurse Aide (CNA) talking about leaving to go home. She said she worked there, her shift was over and she was walking home. The social worker tried to intervene, the resident yelled at her and threatened to call the police. According to the staff, she figured out the code to leave the memory unit. She was put on 10-minute safety checks and had a wanderguard. Resident C's progress note, dated 4/15/21 at 8:18 p.m., reflected, per social services, the resident had been actively exit seeking and threatened to sock her out if she didn't let the patient leave. The nurse practitioner ordered [MEDICATION(S)] (an antihistamine used to treat anxiety), but the patient refused it. Resident C's elopement evaluation, dated 4/15/21, reflected she did not have a history of elopement or attempted elopement at home. She had a history of elopement or attempted to leave the facility without informing staff and verbally expressed the desire to go home, packed belongings to go home or stayed near an exit. The evaluation noted her wandering behavior was likely to affect the safety or well-being of self/others and she had been recently admitted . Clinical suggestions included applying a personal safety alarm device, personalizing the room with familiar objects and notifying staff of elopement risks. Resident C's progress note, dated 4/16/21 at 4:14 p.m., reflected follow up from yesterday evening .It was verified today that resident does not know the codes to leave the unit. She accidentally got out the door on the west end because a staff member did not shut it Resident C's progress note, dated 4/20/21 at 7:10 a.m., documented the resident continued exit seeking behavior throughout the entire shift. Resident did not touch her bed the whole night. She went for her suitcase and some belongings and was pacing the hallway the whole night. Resident C's progress note, dated 4/23/21 at 9:08 p.m., documented the resident was pacing in and out of her room saying she was looking for her daughter. She was not easily directed and continued carrying her bags saying she had to leave. Food and beverages were offered but nothing helped. Resident C's undated baseline care plan, signed on 4/23/21, reflected she was at risk for elopement, had a wanderguard and had wandering/exit seeking behaviors. Resident C's progress note, dated 4/26/21 at 8:15 a.m., reflected the resident eloped out of the unit early that morning but was found by police. A second note, on 4/26/21, at 8:24 a.m., documented the physician was paged and the nurse practitioner was spoken to about the incident. Resident C's progress note, documented by Licensed Practical Nurse (LPN) 5 and dated 4/26/21 at 9:24 a.m., reflected at approximately 3:50 a.m., a staff member saw the resident go into her room with her suitcase. She was calm and stated she was tired. She had been up and down since midnight in the common area with her suitcase. At approximately 5:00 a.m., during rounds, resident was not found in her room. Staff began searching the unit. Writer notified nurse on other unit to come and help. Approximate 5:15 a.m., [Resident H's] door was found to be barricaded in by Broda chair [reclining, padded wheelchair] and rocking chair. Staff was able to get in and noticed window screen to be out and chain broken. Window was completely open. ADON notified at 5:17 a.m. Staff still searching the unit. At 5:36 a.m., Code Purple was called. All staff in building began searching entire facility and began head count of other residents. After complete facility search and outside area around facility, 911 was notified at approximately 5:56 a.m. Daughter was called at 6:00 a.m. and informed writer the resident was with her. DON, ADON and Administrator was notified. CNA 3's written statement, dated 4/26/21, reflected the following: Resident [C] was up with us all night. Around 3:45 a.m., 3:50 a.m., she went to her room with her suitcase. At 5:00 a.m., I checked on her and realized she was not in the bed. I checked room by room and realized [Resident H's room] was barricaded. I opened the door and saw window open. Myself and the nurse went out for searching, then we drove around 30 minutes searching. CNA 9's written statement, dated 4/26/21, indicated Resident C was up all night until around 3:45 a.m. when she was seen going into her room with her suitcase. At 5:00 a.m., an aide checked on her and realized she was not in her room. She checked the rooms and realized Resident H's room was barricaded. The CNA notified the nurse, went into the room, and saw the window was open. The chain was broken and the screen was set on the floor inside the room. Two slippers were sitting outside the window. From 5:00 a.m. to 6:00 a.m., they searched outside for 20 minutes, then the nurse, and other CNA and CNA 9 drove around looking for the resident. During an interview, on 5/05/21 at 5:30 a.m., LPN 2 indicated Resident C was at the facility for respite care after being exit-seeking at home. The family was trying to regroup and figure out what to do. Prior to her elopement on 4/26/21, she got out of the secure dementia unit unsupervised and was in the television room of the next unit. LPN 2 indicated Resident C presented well, as oriented and alert. She noticed the resident was sad one day. When she asked what was wrong, the resident said she knew she had dementia and she did stupid things. During an interview, on 5/05/21 at 6:10 a.m., CNA 3 indicated she was the CNA assigned to Resident C the morning she eloped. The resident had been up all-night walking around the unit with her suitcase. She was saying, if they didn't open up, she was going to find a way to get out. Between 3:45 a.m. to 3:50 a.m., she saw the resident go into to her room. The CNA did not see her again until she rounded on her and her roommate around 5:00 a.m. The roommate was a get up, so she went into the room to attend to the roommate. This was when she noticed the resident was out of the room. She looked in the other rooms. When she pushed on the door to Resident H's room across the hall, it was hard to open. Resident C had barricaded the door with two chairs. This was when she saw the window was open. The CNA called the nurse. They looked everywhere for the resident. They went through the window she exited to try to find her. She did not know when 911 was called. CNA 3 indicated the interventions to prevent Resident C from eloping were to keep an eye on her and distract her with activities, but this was a challenge because there was no activity staff person at night or in the early morning to assist with distractions. During an observation of Resident C's room in the dementia unit, on 5/05/21 at 6:10 a.m., with LPN 2, two windows looked out to a gated courtyard. LPN 2 indicated Resident C probably knew she could not get off campus exiting out her window, because she would not be able to get out of the courtyard. So, she went across the hall to Resident H's room to a window which faced the street. The room had two windows which opened to the outside with access to the community. LPN 2 indicated Resident C exited out of the right window in Resident H's room. There was a screen on the window with small latches on the four corners of the screen. The lower, middle portion of the screen could slide open to access a latch which opened the window. The entire screen could be removed from the inside by pivoting the latches. LPN 2 demonstrated the window opened outward by turning the latch at the base of the window. There was no chain on the window. LPN 2 indicated Resident C was a relatively large woman and could not have exited the window if the chains were secured. During an interview, on 5/05/21 at 6:15 a.m., LPN 4 indicated she was working in the unit just outside the dementia unit the morning Resident C eloped. About 5:00 a.m., the nurse from the dementia unit called her and said she had an emergency. A resident was missing and she asked LPN 4 to help her look through the rooms. They started a room count of the dementia unit and then eventually did a room count throughout the entire campus. LPN 4 ran outside with a CNA and searched the road in front of the facility. It was still dark. They could not locate the house supervisor on call, which was why Resident C's nurse contacted her instead of the house supervisor. LPN 4 came back into the building to attend to her residents. By then, the administrative staff had arrived. They discussed calling 911 but the house supervisor had been located and had already called 911. LPN 4 did not know when 911 was called. During an observation and interview, on 5/05/21 at 8:03 a.m., the Maintenance Director indicated when Resident C eloped, there were chains on the windows from the window frame to the bottom of the windows which prevented the windows from opening too wide (approximately six inches) in all the residents' rooms in the dementia unit. Resident C could remove the screens from the inside if she worked with the latches which held them in place. Resident C was able to remove the screen and break the chain. After Resident C eloped, they realized the chains could be broken. There were no alarms on the windows. Prior to Resident C's elopement, they did not routinely inspect the windows or screens of the dementia unit to ensure the windows could not be opened wide enough for residents to exit out of them. During an interview, on 05/05/21 at 8:32 a.m., the DON indicated Resident C had gotten out of the dementia unit prior to her elopement on 4/26/21. Around 8:00 p.m., she followed someone through the doors of the dementia unit into the next unit. They placed a wanderguard on her. LPN 5 was the nurse caring for Resident C on the morning of her elopement on 4/26/21 and was also substituting for the regular house supervisor. He was currently out of the country and unreachable. Either the CNA or LPN 5, called LPN 4 to ask her to call the Code Purple because they were occupied looking for the resident. During a telephone interview, on 5/5/21 at 10:27 a.m., Resident C's family member indicated Resident C lived at home with another relative. The two relatives took turns taking care of her. This relative was going out of state and wanted to place her mother in respite care, someplace safe, while she was gone. The resident had been a flight risk for the last year and a half while living at home. She had a police record over the past two years because she had gotten out from home. The morning the resident eloped from the facility, the police found her on 75th and Meridian, five blocks from the facility. She had knocked on a stranger's door and the stranger called the police. She had arthritis in both knees; one knee was especially bad and jumped out of place, so this relative could not understand how she walked so far without the facility noticing she was absent. Resident C told the police her name and told them she was trying to get home. The police had her information/address in their records, so they were able to determine where she lived and contacted her family. During a telephone interview, on 5/6/21 at 4:12 p.m., a second family member of Resident C indicated she lived with the resident. The police called her and asked her to come pick the resident up at 4:45 a.m., on 4/26/21. The resident was sitting in the police car when the family member arrived. The resident was wearing her glasses, a short-sleeve cotton shirt, pants to the knees, ankle socks and shoes. It was still dark and cold. She did not have her cane, a purse, or identification, she had nothing. She needed a cane to walk because of [CONDITION(S)] arthritis in the right knee. The police said she was confused, very cold and limping when they picked her up. The family member indicated she did not know if the resident knew what she was doing or where she was supposed to be. She just kept saying she wanted to go home and her leg was hurting. During a telephone interview, on 5/05/21 at 12:44 p.m., a local police dispatcher indicated there were two calls to the police on 4/26/21 for Resident C. At 4:20 a.m., on 4/26/21, there was a call from a private residence on West 75th Street, Indianapolis, IN, for a welfare check. There was also a call at 6:06 a.m., from an address matching the facility's for a missing person. A search on Google Maps, on 5/05/21, revealed the house on West 75th street was 1.1 miles from the facility; an estimated 22-to-24-minute walk. A search on wunderground.com, on 05/06/21, revealed the outside temperature on 04/26/21 at 4:54 a.m. was 42 degrees Fahrenheit. The facility was requested to provide all documentation of safety checks, the DON provided the following: Ten-minute safety checks were performed from 8:00 p.m. on 4/14/21 to 7:10 a.m. on 4/15/21. Fifteen-minute safety checks were performed from 7:15 a.m. to 11:00 p.m. on 4/16/21; midnight on 4/17/21 to 6:45 a.m. on 4/18/21; and midnight on 4/18/21 to 3:45 a.m. on 4/26/21. The form documented, on 4/23/21 at 6:30 p.m., the resident was looking for a way out. On 4/26/21, the day of her elopement, the safety check form documented Resident C went back to her room at 3:30 a.m. and was in her room at 3:45 a.m. The form was blank from 4:00 a.m. to 5:00 a.m., when the form documented she was found missing. During an interview, on 5/04/21 at 4:20 p.m., the DON indicated training regarding elopement and wandering behaviors was conducted on-line. She provided the training transcripts for the following three staff members and indicated they were assigned to Resident C's care in the dementia unit on 4/26/21, the night/morning she eloped: CNA 3, CNA 9, and LPN 5. She had highlighted the last date they received training regarding residents at risk for elopement. CNA 3's training transcript reflected her most recent training was 1/31/20, Wandering and Elopement Essentials Self Paced. CNA 9's transcript reflected her most recent training was 4/30/20, Preventing and Responding to Elopement. LPN 5's training transcript reflected his most recent training was 01/29/21, Wandering and Elopement Essentials Self-Paced. 2. Resident D's medical record was reviewed on 05/05/21 at 11:14 a.m. Diagnoses included, but were not limited to, congestive heart failure, dementia, [CONDITION(S)], cognitive communication deficit and difficulty walking. Resident D's admission minimum data set (MDS) assessment, dated 3/18/21, reflected he had a severely impaired cognitive mental status and he had wandered in the last four to six days. He required extensive assistance by one to two persons for activities of daily living Resident D's elopement evaluation, dated 4/1/21, reflected he was at risk of elopement. He had a history of elopement or attempted leaving the facility without informing staff. He had verbally expressed the desire to go home, packed belonging to go home or stayed near an exit door. His wandering behavior was a pattern, goal oriented, aimless and likely to affect the safety or well-being of himself or others. He was recently admitted to the facility. Resident D's progress note, dated 4/02/21 at 10:22 a.m., reflected he was found outside his unit in the parking lot, on 4/01/21 at 4:36 p.m., by a CNA who was taking her break in her car. When she saw him, she immediately got out of her car and asked him where he was going. The resident stated: I'm getting the hell out of here and going home. His elopement incident report, dated 4/1/21, indicated he was oriented only to person, was confused and had impaired memory. Resident D's physician's orders, dated 3/15/21, indicated to check the function of his wanderguard every day shift and to check the placement of his wanderguard on his right wrist every shift. There was no order to apply the wanderguard. During an interview, on 5/05/21 at 3:30 p.m., the DON indicated Resident D was admitted to the facility's assisted living apartments in 10/2021. He transferred to a skilled nursing unit in 3/2021 because of physical decline, for example requiring more assistance with transfers. He was receiving rehabilitation services but did not improve enough to return to his assistive living apartment. When he understood he would not return to his apartment, he began exit-seeking behaviors. On or around 3/29/21 to 04/01/21, they put a wanderguard on him. He pushed on the fire door long enough (15 seconds) and the door opened. He stepped out onto the sidewalk and the edge of the parking lot before staff saw him. He had walked approximately eight feet from the door. A staff member had been sitting in her car and saw the resident and immediately brought him back into the facility. During an observation and interview, on 05/06/21 at 11:00 a.m. LPN 15 indicated she was the manager of the skilled unit Resident D transferred to from his assisted living apartment, prior to moving into the dementia unit. She demonstrated the fire door from which the resident exited. A sign on the door indicated: Push until alarm sounds. Door can be opened in 15 seconds. The LPN indicated Resident D had just moved from the assisted living side of the facility and could see the assisted living apartments from the windows in the unit, including the courtyard he had frequented. He attempted many times to exit for the first few days, trying to return to his apartment. During an observation, on 5/05/21 at 12:00 p.m., Resident D was sitting in a wheelchair in the common area of the dementia unit doing exercises with an unidentified therapist. He had a wanderguard on right wrist. He had difficulty answering questions, such as what he did in the Navy. He began fidgeting and trying to get out of the wheelchair but did not appear to be steady on his feet. CNA 10 assisted him to the bathroom using a gait belt to transfer him from his wheelchair to the toilet. He required multiple verbal cues to back onto the toilet. During an interview, on 5/05/21 at 12:10 p.m., CNA 10 indicated she did not know Resident D had previously tried to exit the facility. He got fidgety when he needed to have a bowel movement. The CNA did not know how to determine a resident had a history of or was at risk of eloping. During an observation, on 5/07/21 at 1:40 p.m., Resident D was sitting in his wheelchair, unaccompanied, at the locked doors of the dementia unit. He was redirected away from the door by an unidentified staff member. 3. Resident G's medical record was reviewed on 5/06/21 at 10:15 a.m. Diagnoses included, but were not limited to fractured femur, dementia, [CONDITION(S)], depressive episodes and muscle weakness. Resident G's significant change MDS, dated [DATE], reflected he had a severely impaired cognitive mental status. He had wandered in the last one to three days. He required extensive assistance by one person for activities of daily living. Resident G's elopement evaluation, dated 3/12/21, reflected he had no history of elopement but had verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. He wandered aimlessly and his wandering behavior was likely to affect the safety or well-being of himself or others. Resident G's behavior note, dated 4/15/21, reflected the resident was walking down the hall in an unstable manner. A nurse and an aid attempted to help the resident by redirecting him. As the nurse stood to the side of the resident trying to get his attention and the aid stood behind him to make sure he did not fall, the resident began to yell, scream, cuss, and swing at the nurse, hitting her in the arm. Another nurse came up the hall because of all the noise and reached out to hold (in a comforting manner) the hand that was swinging back and forth. The resident then began to bend the nurse's fingers back and took the other hand and tried to bend the thumb in the opposite direction. While the resident was busy trying to break the nurse's fingers, the other nurse found a chair with wheels to help the resident sit down in the chair. Once the resident was in the chair, the resident was taken back to his room, he got into the bed and was given a boost until his tray was delivered. During an interview, on 5/6/21 at 10:40 a.m., CNA 14 indicated Resident G was verbally abusive, incontinent and could stand. During the last two weeks he had been lying in bed more. He used to try to leave. He said he wanted to leave and would push the doors exiting the unit. His reasons for wanting to leave would vary. For example, one day he said he wanted to take mail to the mailman. During an observation and interview, on 4/06/21 at 10:45 a.m., RN 11 indicated she was the manager of Resident G's unit. She demonstrated Resident G had a wanderguard device on his ankle. If he was missing, she would pull the Code Purple policy because she did not use it often enough to remember all of it. When asked how she would know if a resident was at risk of wandering or elopement, she indicated she got a list from SW 1 via e-mail and a list of residents was kept in a logbook at the nurses' station. She did not know how to access the information in the residents' electronic records. The RN demonstrated the wanderguard panel for the unit was just outside the unit double doors. The double doors were not locked and did not require a code to enter or exit because it was not a secure unit. Resident G's wanderguard was the only alarm which would alert the staff if Resident G exited the unit. On the side of the wanderguard wall panel was a piece of blue tape with the code to disarm the alarm in easily visible, large letters. During an interview, on 5/06/21 at 12:28 p.m., the DON indicated she was not aware the wanderguard wall panel for Resident G's unit had tape on it with the code to disarm the code. She indicated it was not appropriate. She did not know if Resident G had enough cognitive status to see it and use it, but it should not be there. During an interview, on 5/05/21 at 4:00 p.m., Qualified Medication Aide (QMA) 6 indicated she had one resident on her unit who wandered. She did not know how to look in the medical record or a unit logbook to determine if a resident was exit seeking. She just knew she had a resident at risk by the wanderguard on the resident's ankle. She had received training on caring for residents with dementia, but no recent training on exit-seeking or wandering behaviors. During an interview, on 05/05/21 at 4:10 a.m., Registered Nurse (RN) 7 and RN 8 indicated they were the off-going and on-coming nurses on the dementia unit. They had two residents who were exit-seeking. Both RNs indicated they did not know of a logbook or how to check the medical record to determine if a resident had wandering behaviors or was exit seeking. They had an assignment sheet which contained some information about the residents. It was mostly used to document vital signs and did not include information about behaviors. During an interview, on 5/05/21 at 3:19 p.m., the DON indicated neither Resident C's, D's or G's facesheets or profiles identified the residents were at risk for wandering or elopement. Social Worker 1 completed the elopement assessments and was responsible for updating the residents' profiles and care plans related to wandering and elopement risks. The Social Worker was also responsible for updating the logbooks on each unit which contained a list of all residents with wandering or elopement behaviors and included their picture, facesheet and elopement assessment. During an interview, on 5/07/21 at 1:00 p.m., the DON indicated Resident C did not have a physician's order to apply a Wanderguard or to check its placement or function. Resident D had orders to check the Wanderguard placement and function but did not have orders to apply the Wanderguard. Resident G had orders to check the function of a Wanderguard, but not to apply the Wanderguard or check its placement. A current facility policy, titled Elopement Prevention and Response Program, dated March 2019 and provided by the DON on 5/5/21 at 8:30 a.m., reflected the following.Elopement Prevention. 1. Residents shall be assessed for risk of elopement as follows: a. Residents shall be assessed utilizing the Elopement Risk Assessment .b. A list of residents at risk for elopement is maintained in a logbook with corresponding pictures .c. If a resident is identified as a risk for elopement, information will be provided to direct care staff via [electronic medical records] profile. d. Care plans will be developed and individualized for those residents at risk by Social Services. 2. Residents at risk may utilize a security bracelet per physician's order that will be checked for placement and function no less often than daily. Missing Resident Procedure. 1. Upon determining that a resident cannot be located, the nurse will notify the Unit Manager, Director of Nursing, the Director of Social Services, and the Administrator. 2. The nurse on the unit of the missing resident/or designee shall be coordinator for the search with support from Social Service, DON, etc. 3. The staff nurse shall page a 'Code Purple,' and the unit of the missing resident x 3 on the intercom to alert all departments of the missing resident. 4. A search of all rooms in the facility will be done .7. If the resident is not found within 15 minutes, or after a search of the facility and immediately outside the building, the person in charge/designee shall notify: the police or law enforcement agency, the family or responsible party, the attending physician The immediate jeopardy, that began on 5/06/21, was removed on 5/07/21, when the facility completed the following. An audit was completed by 5/07/21 to confirm all residents on the dementia unit were assessed for elopement risks. On 05/06/21, all residents identified as an elopement risk had alerts entered in the profiles of their medical records, easily visible by staff. They were also identified with new name plates outside their room doors that included a purple star. On 04/26/21, all windows in the dementia unit were secured with L-brackets inside the window frames to prevent them from opening more than 6 to 12 inches. By 05/07/21, windows in the dementia unit leading to an unsecured area also had bolts placed on the outside so residents were unable to push windows open on 05/0621. CNAs caring for residents at risk rounded at least hourly on their assigned residents and completed an hourly observation form, overseen by the charge nurses, beginning 05/07/21. The facility added an additional dementia trained activities programmer focusing on residents at risk for elopement. Most staff were in-serviced on how to identify residents at risk for elopement, the facility's elopement policy and on how to prevent an elopement before exit by 5/06/21. Maintenance staff completed weekly audits to ensure screens and windows were secured on 05/01/21 and began daily audits on 05/06/21. Beginning 05/07/21, social services audited all residents to ensure elopement evaluations were updated, residents at risk were easily identifiable by staff, care plans for elopement were appropriate and individualized and physician orders were entered as indicated for applying wanderguards and monitoring the wanderguards for placement and function. This Federal Tag relates to Complaints IN 838 and IN 564. 3.1-45(a)

Based on observations, interviews and record review, the facility failed to ensure pain was thoroughly assessed, then adequately treated during a pressure ulcer dressing change for 1 of 3 residents (Resident C). This deficient practice resulted in Resident C, with a Stage IV infected pressure wound on his left Ischial bone, who received a dressing change while he was verbally and non-verbally indicating he was having pain at a level 10. Findings include: 1. During the facility tour on 2/25/19 at 8:48 a.m., LPN 1 indicated Resident C had a pressure ulcer on his Left Ischial area, which was facility acquired and found as a stage 2 pressure ulcer, but was a Stage 4 now and he was on an antibiotic for a wound infection. On 2/25/19 at 10:04 a.m., CNA 2 was observed turning and assisting Resident C onto his right side while LPN 3 changed his Left Ischial dressing. LPN 3 removed his foam dressing, then she removed the packing. As she removed the strips of packing from his wound, Resident C had facial grimacing and furrowed brows and grabbed a hold of the bed rail with both hands and shook it while yelling ouch. LPN 3 broke the ends off of two sterile tip applicators and stuck both of the sterile tipped (padded ends) applicators down into the open wound and moved them in a circle inside the wound, then took them out. When she stuck the padded ends of the sterile tipped applicator into his open wound, he grabbed ahold of the bed rail with his right hand and shook it and yelled ouch while hitting CNA 2 hard with a closed left fist in her left rib cage area three times. He had facial grimacing and furrowed brows during this time. CNA 2 attempted to stop him from hitting her by blocking her left rib cage area with her left arm in a bent position and placing her elbow it in front of her rib cage area. CNA 2 told the resident he was hurting her when he hit her with his fist and asked him not to do that and he told her he did not hit her. CNA 2 tried to calm him down by telling him the nurse was almost done and she was only trying to help him by changing his dressing. He grabbed the bedrail and shook it with his bilateral hands when he was not hitting CNA 2 with a closed left fist in the right rib cage area and he indicated removing the old dressing was painful. LPN 3 flushed the pressure wound with a 60 milliliter piston syringe and Resident C did not yell, hit or have facial grimacing during that step of the dressing change. LPN 3 packed the pressure wound to the left Ischial area with three Silver Alginate strips, packing one strip at a time with a sterile tipped applicator. During the dressing change when LPN 3 was placing the first packing strip and he was hitting CNA 2, she was asked about Resident C's pain medication regimen and pain level, but LPN 3 did not stop the dressing change to assess the resident for pain. She indicated at that time, he was scheduled Tylenol routinely twice a day at 8:00 a.m. and then again at 12:00 p.m., on her shift for pain. She indicated she knew he had [MEDICATION NAME] ordered PRN (as needed), but she thought that was for a fever. She indicated he hit staff members whenever he got any kind of care performed; such as bath, nail care or shaving and his (Name of family member) told her that his hitting was a reflex and he hit as a result from his [MEDICAL CONDITION]. She indicated that his daughter was cutting his nails last week and he was hitting her. LPN 3 indicated when he hit staff members with his fist it was a hard punch. At that time, CNA 2 indicated his daughter said he hit staff members as a reflex when staff was providing care for him. During the time the wound was being packed by the LPN 3, the resident was asked what his pain level was between 0-10, with 0 being no pain and 10 being the worst and he indicated his pain level was 10. LPN 3 then used a Skin Prep wipe around the wound on the periwound, covered the wound with an adhesive foam dressing, then applied a [MEDICATION NAME] dressing over the wound while placing her hand over the dressings each time to secure them better On 2/25/19 at 10:28 a.m., the LPN 1 was in attendance while CNA 3 and CNA 4 provided personal care for the resident. CNA 3 gave a partial bath to the resident while CNA 4 stood on the other side of the bed and observed. CNA 3 explained everything she was doing. CNA 3 attempted to wash his face, but he swatted his left arm at her, with an open hand, but not hard. She asked him after three attempts if he wanted to wash it himself and he did it with her cuing him to wash his eyes, face and mouth. The two CNA's attempted to turn him over by using his body (pushing and pulling on his shoulders and hips) instead of using the incontinence pad underneath him and he indicated that it hurt, so they used the incontinence pad under to shift him in the bed. CNA 2 took ahold of his left arm and attempted to pull him over toward her more and he said ouch and she asked him if that hurt and he indicated yes it did and she apologized. She washed under his arms by asking him to raise his arms and he did. He cooperated with the CNA's to wash, rinse and dry underneath his arms and to put his shirt on. He raised his head and arms for them. He yelled out while being turned and hit CNA 2 with his closed fist while being turned and while his brief was being placed on him due to she tried to turn him by herself toward the other CNA by pushing on his left hip bone with the pressure ulcer, which also had an infection in it. At one point he told the CNA's I need a break and they stopped for a minute until he told them it was okay to finish dressing him again. While putting on his pants he yelled out with a pained facial grimace when CNA 2 lifted his right leg, but he did not move either arm. He yelled out with a pained facial grimace when the CNA's were rolling him from side to side to pull his pants up. At that time, each CNA had ahold of his shoulder using it to assist in turning him from side to side to pull up his pants, instead of using the incontinence pad under him to turn him from side to side. As CNA 2 attempted to turn him by taking the incontinence pad and pushing him toward the other CNA to place the Hoyer sling underneath the resident, he yelled out the whole time. CNA 2 stopped and asked if he was hurting and he indicated he hurt all over and she asked if he wanted her to stop and he said yes for a minute. They started again and then he yelled out again and she stopped and asked if she wanted them to stop and he indicated No she asked if she could finish and he indicated Yes, but don't be so rough. During this whole time the residents foot of the bed was elevated and the head of the bed was elevated making it very difficult to turn this resident. At one point when he was being turned to the left side while dressing him his suprapubic catheter was pulled and he yelled out. During an interview on 2/25/19 at 11:18 a.m., CNA 2 indicated the nurses did not stop during the residents dressing changes to ask the resident if he needed a break when he complained of pain. She indicated he complained of pain whenever his dressing was changed and he hit her very hard. She indicated the nurses usually told him they were almost done and continued on with his dressing changes and finished them. During an interview on 2/25/19 at 11:20 a.m., LPN 1 and CNA 2 was in attendance in the resident's room after he was taken to activities. CNA 2 indicated this resident required her to spend a lot of time with him due to he will hit you while caring for him, so you have to go slow with him. LPN 1 indicated his (Name of Family member) did not like to hear the word hit because she said it was his reflexes from his [MEDICAL CONDITION] that made him do that. As of this time, the resident had not received a pain assessment from LPN 3 nor had he received any other pain medication. The record for resident C was reviewed on 2/26/18 at 3:35 p.m. [DIAGNOSES REDACTED]. A Wound-Weekly Observation Tool dated 2/21/19, indicated there resident had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist, and light in color; may be stringy.) or eschar (Thick, leathery necrotic or devitalized tissue, frequently black or brown in color.) may be present on some parts of the ulcer bed. Often includes undermining and tunneling.), on his left ischium, that was facility acquired. The wound had 10% slough in the wound bed, with a moderate amount of serous drainage and a foul odor. The wound measured 1.3 x 1.6 x 3.0 cm with tunneling at 11 o'clock 4.2 cm (centimeters) deep. The wound did have bone involvement, with a foul odor, the base could not be palpated and the barrel was more narrow. The resident's Order Summary Report for his active orders dated 2/26/19, included, but were not limited to the following orders: 1/28/17--[MEDICATION NAME] (a medication used to treat nerve pain) 400 mg give one capsule by [DEVICE] every day and evening shift for neuropathic pain. Mix with 30 milliliters water followed by 5 ml flush. 1/30/17--Pain Level Q (every) shift. three times a day for pain level using the Wong-baker 0-10 pain scale ask resident their pain level Q shift 1/30/17--[MEDICATION NAME] Give 20.3 ml by [DEVICE] every 6 hours as needed for Pain or Temperature 2.4 degrees above baseline 3/2/18--[MEDICATION NAME] (A non narcotic pain medication) 325 mg (milligrams) tablet. Give two tablets by [DEVICE] every four hours for fever and pain crush and mix with 30 ml H2 O followed by 5 ml flush. 7/7/18--[MEDICATION NAME] (a medication used to decreased inflammation) 600 mg give one tablet by [DEVICE] every four hours as needed for mild pain or fever alternate every two hours with [MEDICATION NAME]. Resident C's EMAR (Electronic Medication Administration Record) and ETAR (Electronic Treatment Administration Record) was reviewed for 2/1/19-2/28/19, and there was no orders or records found on either one indicating this resident's pain level was being assessed every shift as ordered on the Order Summary Report. EMAR dated 2/1/19-2/28/19, indicated he received his [MEDICATION NAME] 325 mg (2 tablets) by [DEVICE] every four hours as scheduled. He did not receive any as needed [MEDICATION NAME] and only one as needed dose of [MEDICATION NAME] on 2/26/19 at 1:00 p.m., for a pain rating of a level of 9. The progress notes were reviewed: 12/11/18 at 1:25 p.m.--I noted a 6 by 4 bruise on left hand at 7:15 this am. Resident denies any pain and maybe resident hit his hand on the bed during care related to resident hitting at the CNA 12/17/18 at 4:22 p.m.--Ischial wound .Area filled with santyl and packed with alginate rope .Resident needed support during treatment, due to discomfort (tends to hit/scratch staff), had medication prior to treatment 1/30/19 at 3:31 p.m.-- .Dressing changed to wound; prior to noted old packing had to be pulled out in pieces, causing for several flushes to cleanse the wound. Treatment applied per order, with assistance of CNA, to reassure Resident during care (tends to hit) 2/17/19 at 3:56 p.m.--Treatment change to left Ischial wound .Difficulty removing packing due to breakage, area flush with saline using piston syringe to cleanse area .Writer talked Resident through the procedure to prevent hitting, but Resident hit at writer x (times) 4 (no connection) The resident had a Care Plan dated 11/9/16, which addressed the problem he was at risk for alteration in comfort for the potential for pain related to [MEDICAL CONDITION] with a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, 11/9/16--Administer medications as ordered, Encourage rest periods for resident .Reposition for comfort, Notify MD if pain persists or interventions are ineffective The resident had a Care Plan dated 12/21/18, which addressed the problem he was resistive/combative with care. Interventions included, but were not limited to, 12/21/18--1. Staff will introduce themselves to me and role, 2. Staff will need to approach me calmly because I startle easy (at times). 2. I would like the staff to explain the care that they would like to help me with .7. Reapproach later if I am upset or agitated. The resident had a Care Plan dated 10/5/17, which addressed the problem he had a history of [REDACTED]. Interventions included, but were not limited to, 9/25/17--Administer treatments as ordered and monitor for effectiveness .11/9/16--Provide total assist of one to two persons in shifting weight when in w/c (wheelchair) in am (morning), before and after meals, 9/25/17--Provide total assist of one to two persons with turning and repositioning with each bed check .9/25/17--Treat pain as per orders prior to treatments/turning etc. to ensure The resident's comfort The resident had a Care Plan dated 7/8/18, which addressed the problem he had 2 open areas on each cheek of buttocks due to immobility. Interventions included, but were not limited to, 7/8/18--Use a draw sheet or lifting device to move resident . A current policy titled Pain Assessment and Management dated 7/18, provided on 2/26/19 by the Director of Nursing contained the following, PURPOSE: The purpose of this policy is help the staff identify pain in a resident, and to develop interventions that are consistent with the resident's goals and needs. POLICY: The pain management program is based on a multidisciplinary care process and commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his/her clinical condition and established treatment goals. PR[NAME]EDURE: 1. The staff nurse shall conduct a comprehensive assessment upon admission to the facility, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain, on a quarterly basis and after a fall. 2. Assess the resident's pain and consequences of pain at least on (1) time each shift for acute pain or significant changes in levels of chronic pain. 3. If the resident complains of pain, review the Medication Administration Record [REDACTED]. 4. The nursing staff shall implement appropriate pain management strategies that may be identified in the resident's care plan (i.e. non-pharmacological interventions and/or physician ordered treatments.) 5. The staff nurse or QMA (Qualified Medication Aide) shall be responsible for the monitoring of the resident's pain and/or effects of pain management strategies utilized. Documentation or resident's pain and efforts to alleviate the pain shall occur on the resident's MAR, Nurses Progress Notes and as changes are warranted in the residents's care plan. 6. If pain has not been adequately controlled, the physician shall be notified to notification to reconsider approaches and make adjustments as indicated. This Federal tag relates to Complaint IN 956. 3.1-37(a)

Based on interview and record review, the facility failed to administer a controlled substance at the prescribed dose twice in a six hour time period to ensure a resident was free from significant medication errors for 1 of 12 residents reviewed regarding medication errors (Resident B). This deficient practice resulted in Resident B receiving an accidental overdose of [MEDICATION NAME] Concentrate (a medication used to treat pain),which resulted in the resident requiring hospitalization , where her condition continued to decline and she expired. Finding Includes: On [DATE] at 9:50 a.m., an Indiana State Department of Health Survey Report System report dated [DATE], was provided by the Administrator. The report indicated on [DATE] at 3:30 p.m., RN 6 self reported to nursing administration she believed she gave the resident two incorrect dosage of pain medication. A nursing assessment was completed, which indicated the resident appeared less responsive than her baseline. The resident was a terminally [MEDICAL CONDITION] resident with a declining condition. She was transferred to the (Name of Hospital) emergency room . RN 6 was suspended during the investigation. The report indicated on [DATE], the investigation indicated RN 6 failed to administer the physician ordered dosage of [MEDICATION NAME] on two separate occasions. During the investigation meeting with RN 6 on [DATE], she admitted her mistake. As a result of the investigation, RN 6 was terminated effective immediately. The resident remained in the hospital in a declining condition. A Medication Event Report Form dated [DATE], indicated the date of occurrence was [DATE] at 8:00 a.m. and 2:00 p.m. The report indicated the event reached the resident, more than one dose was effected and extra monitoring was required. The reactions the resident experienced from the incorrect doses were lethargy, sleepiness, slight drop in her BP and complaints of pain. RN 6's employee record was reviewed on [DATE] at 3:30 p.m., which included, but was not limited to the following information: A handwritten statement from RN 6 dated [DATE], indicated she was nearing the end of her shift during the narcotic count and she noticed a discrepancy in the amount of [MEDICATION NAME] sulfate on this resident. She checked the EMAR (Electronic Medication Administration Record) and realized Resident B was to receive [MEDICATION NAME] 5 mg (milligrams) at 8 a.m. and 2 p.m., but after she took a closer look at the resident's routine [MEDICATION NAME] order, she realized she had administered 5 ml (milliliters) instead of 0.25 ml, so she had administered an incorrect dose twice. A typed statement from LPN 7 dated [DATE], indicated RN 6 came to her and indicated I think I made a med error. She indicated during the shift to shift narcotic count Resident B's [MEDICATION NAME] Concentrate Solution count was supposed to be 29.75 ml and it was 20 ml, then she checked her [MEDICATION NAME] order and realized instead of administering 5 mg, she had administered 5 ml twice on her shift. She indicated she went to assess Resident B at that time and when she called her name she opened her eyes sluggishly and upon further stimulating her by calling her name and rubbing her back, she responded verbally, but very sluggishly. A document dated [DATE], titled Take off Payroll indicated RN 6 was terminated on [DATE] and was not eligible for re-employment A document titled Use of Syringes and Destruction of Used Syringes signed by RN 6 on [DATE], indicated It is the responsibility of every Licensed Nurse to follow the manufacturer's instructions regarding the use of syringes for medication administration. It is the responsibility of each Licensed Nurse to know how to use each syringe and how to properly destroy each syringe prior to using the syringe The record review for Resident B was completed on [DATE] at 1:15 p.m. [DIAGNOSES REDACTED]. Resident B's Physician orders [REDACTED]. [DATE]--[MEDICATION NAME] solution 20 mg (milligrams)/1 ml (milliliter) Give 5 mg by mouth four times a day for dyspnea. (Discontinued on [DATE]) [DATE]--[MEDICATION NAME] HCL (a medication given to reverse the effects respiratory depression from an overdose of opiate medications) liquid 4 mg/0.1 ml Inject 0.4 mg/ml subcutaneously one time only for lethargy. [DATE]--[MEDICATION NAME] (Concentrate) Solution 20 mg/ml Give 0.25 mg sublingually four times a day for SOB (shortness of breath)/pain management. A print screen copy of medication administration log times dated [DATE] at 2:08 p.m., indicated RN 6 administered the [MEDICATION NAME] on [DATE] at 9:46 a.m. and 12:38 a.m., to Resident B. A progress note dated [DATE] at 4:58 p.m., indicated Res (resident) given incorrect dose of [MEDICATION NAME], M.D. notified, order received to monitor v/s (vital signs) q (every) 30 min (minutes) x (times) 24 hours. If changes in v/s or L(NAME) (Level of Consciousness) to call MD back immediately . Res arouses easily, but is very sleepy .CURRENT V/S ,[DATE], 102 Pulse, resp (respirations) ,[DATE], unlabored, O2 sat (oxygen saturation) 96%. Res brought out to common area in w/c (wheelchair) for monitoring. A progress note dated [DATE] at 5:17 p.m., indicated [MEDICATION NAME] (Concentrate) Solution 20 mg/ml Give 5 mg orally four times a day for Dyspnea medication not administered. A progress note dated [DATE] at 6:40 p.m., indicated Patient is sleepy and will open her eyes when her name is called and fall back to sleep. (Name of Physician) called about change of condition. Order received for [MEDICATION NAME] 0.4 mg/ml SC (Subcutaneously) and sent patient to (Name of Hospital) ER (emergency room ) for evaluation. 911 ambulance called to for transportation A progress note dated [DATE] at 2:16 a.m., indicated Forgoing (sic) nurse asked writer to correct scheduled [MEDICATION NAME] order in eMar. after verifying written order writer changed order in eMar to correct dosage to be given. Writer called (Name of Hospital) and spoke with ER charge nurse and was told that resident was admitted (Name of Hospital) History and Physical dated [DATE], indicated Resident B was brought to the hospital due to an accidental overdose of [MEDICATION NAME]. Her medications to lower her high blood pressure was held since admission due intermittent episodes of low blood pressure. She was being treated for [REDACTED]. During an interview on [DATE] at 4:03 p.m., the DON (Director of Nursing) indicated the orders can be put in by the residents' Physician or by the nurses, but the Physician must sign off on the order in the computer. Sometimes the Physicians placed the orders in the computer. She indicated the current order for the liquid [MEDICATION NAME] for this resident, when the errors occurred, was placed into the computer (created), confirmed, revised and signed off by the resident's Physician as [MEDICATION NAME] (Concentrate) Solution 20 mg/ml *Controlled Drug* Give 5 mg orally four times day for Dyspnea. She indicated the problem with this order, which may have contributed to the medication errors were there was no mls documented by the ordered mg dosage to indicate how many mls were to be administered. She indicated (0.25 ml) should have been placed in the order to clarify the ml amount, but the Physician placed the order in the computer instead of a nurse. She indicated the the nurses were supposed to check over the orders even when the Physician placed them into the computer. The DON indicated RN indicated she mistook the 5 ml being ordered instead of 5 mg and that was what she administered to the resident twice. During an interview on [DATE] at 10:52 a.m., the Administrator indicated the incident RN 6 was terminated because she indicated she gave Resident B two doses of five mls (100 mg) of [MEDICATION NAME] Concentrate Solution instead of the prescribed amount. A current policy titled Medications and Treatments Policy with a revised date of ,[DATE], provided by the Administrator on [DATE] at 2:31 p.m., contained the following, Purpose: To provide correct administration of physician-ordered medications and treatments, following the standards of practice (medication, time, dose, frequency and route). Policy and Procedure: 2. Medication shall be administered only as prescribed by written order of the physician . 8 . b. Narcotics: Medications should be observed carefully for accurate measurements (liquid, powders and tablets) prior to administration. If medication is measuring lower than what should be remaining per narcotic measurement count, then the Nursing Supervisor and Unit Manager need to be notified immediately to investigate why the measurement count is inaccurate. If medication is measuring lower than one order dose or more per lat narcotic measurement count then Nursing Supervisor, Unit Manager and Nursing Administration need to be notified immediately. c. Measurement tools that are provided for medication administration per pharmacy recommendation should be utilized and not altered in any way unless physician order [REDACTED].>This Federal tag relates to Complains IN 669. 3XXX,[DATE](c)(2)

Based on interview and record review, the facility failed to implement a plan of care for ongoing and repetitive behaviors for 1 of 1 residents reviewed who displayed aggressive behaviors toward other residents. Resident #173 displayed aggressive behaviors and pulled Resident #176 out of a chair and resident # 176 suffered a fractured shoulder. Findings include: On 8/26/15 at 12:06 p.m., the record for Resident #173 was reviewed. [DIAGNOSES REDACTED]. A Fall Analysis note dated 7/31/15, indicated Resident #173 was found sitting on the floor next to another resident. The resident statement indicated the resident was unable to verbalize details. However, the resident had been saying/yelling let's go all day to individuals as she grabbed and pulled at the staff as well as residents. The Nurses Notes indicated: On 7/24/15 at 10:35 p.m., the resident demonstrated the behavior this shift of wandering aimlessly, grabbing other resident's and saying incoherent speech like let's go Come low Common lay down Can lady let's down Staff frequently redirected resident to no avail. The resident displayed no signs and symptoms of pain. The resident was very restless throughout the shift. Staff tried to offer fluids, toileting, snacks, distraction, and sitting 1-1 with patient, but the resident was still restless. This resident was frequently agitated and annoyed the other residents on the unit. On 7/26/15 at 8 p.m., the resident continued to wander in and out of other resident's rooms and saying let's go come on to the residents and staff who were near by. The resident was still grabbing at people, but was not as aggressive as she had been. On 7/28/15 at 3 p.m., the resident was very talkative and was grabbing at anyone's clothing that was near by and their hands and was saying hey come here with me. The resident was easily redirected even though she could be aggressive at times. On 7/28/15 at 8 p.m., the resident was wandering in and out of other resident's rooms and saying hey come on let's go and was pulling and grabbing on anyone she could see. The behavior was not easily redirected. On 7/28/15 during the 11 p.m.-7 a.m., the resident was actively wandering on the unit yelling help me come here let's go did not get any sleep. On 7/30/15 during the 7-3 shift, the nurse indicated throughout the shift the resident had been grabby, constantly saying come here! somewhat aggressive in her attitude. The behavior had not been easily altered. On 7/31/15 at 2:45 p.m., the resident was found on the floor with another resident. The behavior of wandering and grabbing/pulling others, including staff and residents, was continuous throughout the shift. On 8/1/15 at 3 p.m., the resident wandered in and out of resident's rooms and was grabbing on other residents arms and clothing as well as nursing arms and clothing very aggressively, the behavior was not easily altered. On 8/2/15 at 10:25 p.m., the resident remained increasingly confused, grabbing staff and other residents and was not easily redirected as she would return to the behavior. On 8/3/15 at 9 p.m., the resident continued to wander in and out of resident's rooms saying come on let's go pulling and grabbing at anyone who was around her. The resident became very aggressive when others would not go with her, she was not easily redirected. On 8/5/15 at 2:40 p.m., the resident began to wander the hallways in and out of rooms and grabbed the arm of a female resident. She was asked to release the other resident's hand. The nursing staff had to physically remove Resident #173's hand from the other resident. Resident #173 then grabbed the staff's hand and said let's go. The resident would not remain still long at all. On 8/6/15 at 6:51 a.m., the resident was very anxious the majority of the shift and continued to walk around knocking plants on the floor, hitting the writer with a bathroom key and pulled on this writers clothing. The resident calmed down around 1:30 a.m. and fell asleep on the couch. At 2:30 a.m., the resident awakened and was toileted and placed in her bed. At 3:30 a.m., the resident got out of bed and it was reported per another unknown resident's statement that the resident pulled another resident (Resident #176) off of the recliner trying to make the resident walk. Resident # 176 suffered a fractured left distal radius (lower left arm) and a 1.5 x 0.8 laceration. Behavior Incident Report indicated : On 7/23/15 at 4, 5, 6, 7, 8 and 9 p.m., the resident had behaviors of: intrusive wandering, grabbing others, and this was a result of frustration, confusion and dementia with behavioral disturbances. The staff tried interventions of going for a walk with the resident, and removed the resident from the situation and neither of these interventions were effective. The comments section indicated Resident #173 was very aggressive with staff and other residents today. The resident was grabbing at staff and trying to make them go with her and was not easily redirected at all. Resident #173 kept walking on peoples feet and touching them, this made the other residents upset and aggressive towards Resident #173. The nursing staff tried to keep the resident away from the other residents, but she was not easily redirected. On 7/23/15 at 8 p.m., in the middle of the pod dining room area Resident #173 was pulling on residents, grabbing others, and displayed intrusive wandering. The potential cause of the behaviors were frustration and confusion. The staff tried interventions such as; removing the resident from the situation and took the resident to her room and these were effective. The comments section indicated she was pulling another resident down the hallway and was not easily redirected. On 7/25/15 at 12 p.m., the resident was biting and grabbing others. The cause of the behavior was unknown. The interventions tried by staff: Go for a walk with the resident was marked as not effective. Removing the resident from the situation was effective. The comments section indicated: This resident was pulling on another resident's arm and each time staff separated them, this resident either grabbed or pulled on other residents. She was not easily redirected. The staff stayed 1 on 1 with her and sat with her, but she returned to those behaviors when left alone. This resident was found on the couch sitting with another resident, she was pulling her arm stating, come on let's go and biting the other resident's left hand. No apparent injury noted to the other resident. The residents were both separated. On 7/25/15, the nurse indicated all 3-11 p.m. shift!!!! the resident displayed intrusive wandering, repetitive questions, grabbing others, pulling on staff clothes trying to get them to go with her, grabbing other resident's hand and arms telling them to go with her, and was not easily redirected. This happened in the hallway, the resident's room, other resident's room and in pod (small areas of unit) areas. On 8/26/15 at 3:00 p.m., the Executive Director (ED) indicated he had provided all of the documentation related to behaviors for Resident #173 for the month of July through August 2015. The documentation included Social Services Behavior Monitoring dated July 2015, start date 7/23/15. The documentation indicated a behavior of grabbing on staff and other residents, pulling on staff and residents. The interventions were as follows: 1. Remove resident from situation. 2. Offer reassurance. 3. Go for a walk with the resident 4. Alert staff to residents behavior. 5. Show resident where her room is if she is tired. The date boxes for 7/23, 7/25, 7/27, 7/28, 7/29, 7/30 and 7/31/15 indicated the behavior was happening often. Staff documented they tried interventions and they were not effective. A document titled Behavior Committee Review dated 8/20/15, listed the residents behaviors and indicated the current psychotropic medications: 8/4/15, Depakote ( a medication to help stabilize moods)125 milligrams every morning and 250 milligrams every evening. The non pharmaceutical interventions tried was one on one with resident and redirecting. Possible modifications/recommendations for current behavior treatment: sent to psychiatric unit on 8/6/15, an antipsychotic medication of Zyprexa 5 milligrams added and a medication review to be done. During an interview on 8/26/15 at 11:35 a.m., with the ED, he indicated the nurse who was providing one on one with Resident #173 on 8/6/15, had left the room of Resident #173 because she was asleep. He indicated the incident with the residents happened after the nurse had left the room. He indicated typically one on one was done with the staff or assigned person staying in the room with the individual at all times. 3.1-34(a)

Based on observation, interview and record review, the facility failed to follow their policy and procedures regarding wound care to prevent the possibility of wound infections for 2 of 3 residents observed for pressure ulcer dressing changes. (Residents #151 and #202). The facility also failed to implement pressure ulcer prevention interventions for 1 of 3 residents being reviewed for pressure ulcers. (Resident #202) This deficient practice resulted in Resident #202 developing a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but, but does not obscure the depth of tissue loss. May include undermining and tunneling.) to her left upper buttock. Findings include: 1. Resident #202's record was reviewed on 8/24/15 at 10:02 a.m. [DIAGNOSES REDACTED]. The resident's physician's recapititulation orders dated August 2015, included, but were not limited to, the following orders: 8/7/15--Left buttock/Mid sacrum area apply santyl (a medication used to remove dead tissue from a wound) and a foam dressing-change daily 8/7/15--Off-loading boots to bilateral heels/foot The Activities of Daily Living (ADL) Flowsheet Record dated August 2015, indicated the resident was dependent for turning and repositioning herself for every shift from August 7 through August 23, 2015. The resident had a Care Plan dated 8/10/15, which addressed the problem she had an alteration in skin integrity as evidenced by pressure ulcers to her buttocks and heels and a rash under her breasts and buttocks. She was at risk for skin breakdown related to decreased mobility and frequently in bed. Approaches included 8/10/15-- . Turn/reposition every 2 hours The resident had a Care Plan dated 8/13/15, which addressed the problem she had an alteration in skin integrity as evidenced by impaired mobility, cognition, bowel and bladder incontinence related to [DIAGNOSES REDACTED]. Interventions included, 8/13/15-- . Off loading boots to both heels/feet A current document titled CNA Assignment Sheets 6:45 a.m.-3:00 p.m. undated, provided by RN #13 on 8/26/15 at 10:19 a.m., indicated .Offload/Reposition every 2 hours. During a continuous observation on 8/24/15 from 9:58 a.m., through 1:46 p.m., the following observations were made: On 8/24/15 at 9:58 a.m., Resident #202 was observed sitting in her wheelchair in the common area waiting for a musical activity to begin. She had wool heel protectors (a wool fleece lined boot that was opened in the front and layed underneath the lower extremities from mid calf to under the foot to the top of the toes. The boot had velcro wool padded straps in the front, which went across the shin to hold the boot in place) in place while her feet were sitting on the footrests of her wheelchair. On 8/24/15 at 10:16 a.m., the resident was sitting in her wheelchair in the common area listening to a musical activity. On 8/24/15 at 11:15 a.m., the musical activity had concluded and the resident continued to sit in the common area in the dining room. On 8/24/15 at 11:25 a.m., an unidentified activity staff member attempted to place the resident at a dining room table, but she indicated she wanted to go back to her room. The activity staff member told the resident to wait a minute and she would take her back to her room. She sat the resident's wheelchair back up against the wall in the hallway. On 8/24/15 at 11:42 a.m., LPN #9 asked the resident if she was going to eat lunch in her room or if she wanted to eat lunch in the dining room and the resident indicated she wanted to eat in the dining room. LPN #9 sat her at a dining room table to eat lunch. On 8/24/15 at 12:09 p.m., the resident was waiting for her lunch tray to arrive at her table. On 8/24/15 at 12:30 p.m., the resident received her lunch tray. On 8/24/15 at 12:56 p.m., the resident had been assisted with her lunch. She had just finished her lunch and remained at the table. On 8/24/15 at 1:07 p.m., the resident was brought down to her room by CNA's #11 and #12. On 8/24/15 at 1:12 p.m., the resident was transferred to bed by CNA #11 and CNA #12 with the hoer lift. On 8/24/15 at 1:22 p.m., CNA #11 began peri care. LPN #9 came into the resident's room and indicated she was going to give the resident her pain medication, then she would change her dressing to her pressure wounds. On 8/24/15 at 1:46 p.m., LPN #9 came into the resident's room and medicated her with pain medication. She indicated at that time she would return in 30 minutes to complete her dressing change. During an interview on 08/24/15 at 1:54 p.m., CNA #11 indicated she got the resident up at 7:40 a.m., on that day, so she could eat breakfast. She indicated she repositioned Resident #202 at 9:00 a.m. and 10:00 a.m., by using her hoer lift sling and moving her in her seat. She indicated she turned and repositioned her residents every 2 hours. On 8/24/15 at 2:17 p.m., LPN #9 came into Resident #202's room to change her dressing and QMA #12 was going to assist her. LPN #9 and QMA #12 both washed their hands. QMA #12 donned clean gloves and assisted the resident to turn onto her right side. LPN #9 laid a towel down on the bed behind the resident along side her buttocks and back. She prepared her supplies. She sanitized her hands and donned clean gloves. LPN #9 removed the old dressing from the resident's sacral area, then she removed her gloves. The resident's sacral area was observed to have wounds on each side (left and right) with yellow tissue in the center of the wounds with a large amount of redness surrounding the wounds extending onto the buttocks area and in between the wounds. The right wound was in a lower location than the left. The left wound had 75% yellow tissue in the center of the wound and the right wound had 25% yellow tissue in the center of the wound. LPN #9 sanitized her hands and donned clean gloves. She took a Normal Saline (NS) bullet and squeezed NS across the right wound first in a sweeping motion, then she squeezed the NS across the left wound in a sweeping motion possibly contaminating the right wound with the irrigating solution and debris from the left wound, which was sitting above the right wound with the resident laying on her right side. She used the towel laying on the bed and patted the two wounds dry. She removed her gloves and sanitized her hands, then donned clean gloves. She used sterile applicators and applied Santyl to the left wound in a circular motion starting from the inside of the wound outward, then she used a new sterile applicator and applied Santyl to the right wound in a circular motion from the inside of the wound outward. LPN #9 removed her gloves and sanitized her hands. She picked up the Allevyn foam dressing package and dropped it on the floor as she was trying to open the package. She picked the dressing package up off the floor. She opened the package, took the foam dressing out of the package and dated and initialed the dressing and began to apply clean gloves to apply the dressing to the resident's wound. At that point LPN #9 was stopped during the dressing change procedure. She indicated at that time, she needed to get a new dressing to apply to the resident's wound. LPN #9 indicated at that time she thought she could use the dressing she had dropped on the floor because the dressing was in a sterile package. She removed her gloves, got a new foam dressing, donned new gloves and applied the foam dressing to the resident's sacral area. On 8/24/15 at 2:36 p.m., QMA #12 was observed removing the resident's wool boots (heel protectors) while LPN #9 prepared her dressing supplies to complete the treatments to Resident #202's left great toe and left heel. QMA #12 indicated at that time the resident did not have the correct boot on her left foot. The resident had an eschar area to the tip of her left great toe and to her left heel. During an interview on 8/24/15 at 2:57 p.m., LPN #9 indicated she should have cleansed the resident's wounds individually, changed her gloves and washed or sanitized her hands and changed her gloves in between wounds. She indicated she should have gotten a new dressing instead of trying to use the dressing that fell on the floor to place it on the resident's wound. On 8/25/15 at 1:38 p.m., the resident was observed laying in bed with a waffle boot on her left foot and a wool boot on her right foot. During an interview on 8/25/15 at 1:42 p.m., CNA #11 indicated the resident was to have the harder plastic boot (waffle boot) on her left foot and the softer cloth boot (wool boot) on her right foot. She indicated the waffle boot was in her closet and it was placed on the resident's left foot that morning. During an interview on 8/25/15 at 2:26 p.m., RN #13 indicated the resident should have a wool boot on the right foot and a waffle boot on the left foot to prevent pressure on her left heel. She indicated the resident was to be turned and repositioned every two hours and she should have been repositioned in her wheelchair before lunch on 8/24/15. The following Wound/Skin Healing Records dated 8/25/15, indicated the resident was admitted to the facility with the following pressure wounds: The left great toe pressure wound was an unstageable wound (Full thickness tissue loss, in which the base of the ulcer is covered by slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist, and light in color; may be stringy) and/or eschar (Thick, leathery necrotic or divitalized tissue, frequently black or brown in color) in the ulcer bed.) The wound measured 0.8 x 1.2 cm (centimeters) and the wound bed was eschar. The wound had no drainage or odor. The surrounding skin color was normal the skin color. The right buttock pressure wound was a Stage III wound. The wound measured 2.2 x 3.0 x < (less than) 0.2 cm and the wound bed was slough. The wound had no drainage or odor. The surrounding skin color was normal for the skin color The left heel pressure wound was an unstageable wound. The wound measured 3.5 x 2.5 cm. The wound bed had eschar. The surrounding skin color was normal for the skin color. The coccyx pressure wound was a Stage III wound. The wound measured 1.2 x 1.0 x <0.2 cm. The wound bed had slough. The surrounding skin color was normal for the skin color. The following Wound/Skin Healing Records dated 8/25/15, indicated the resident had a Stage III pressure wound to the left upper buttock with an onset date of 8/25/15. The wound measured 0.4 x 0.2 x <0.2 cm. The wound bed had slough. The surrounding skin color was normal for the skin color. During an interview on 8/26/15 at 11:19 a.m., RN #14 indicated the resident's left upper buttock wound was found on wound rounds on 8/25/15 and it was considered a facility acquired wound. During an interview on 8/26/15 at 1:00 p.m., the Director of Nursing indicated LPN #9 should have used gauze dressings to dry the residents wounds instead of the towel and she indicated wounds were to be cleansed individually. 2.) The clinical record of Resident #151 was reviewed on 8/25/2015 at 10:45 a.m. [DIAGNOSES REDACTED]. A Physician order [REDACTED]. During an observation on 8/24/2015 at 11:02 a.m., LPN #7 was observed performing a dressing change to Resident #151's sacral area. LPN #7 removed the dressing applied on 8/23/2015 and reapplied resident #151's new dressing without changing gloves or washing her hands per facility policy and procedure. The resident's wound was observed to measure 0.1 cm x less than 0.2 cm x no depth. During an interview with Unit Manager (RN #8), she indicated LPN #7 should have changed her gloves and washed her hands after she removed the dressing applied on 8/23/2015. She then indicated LPN #7 should have reapplied new gloves before applying the new dressing on 8/24/2015, for Resident #151. A current policy titled Wound Care Policy and Procedure dated 6/4/12, provided by the Director of Nursing on 8/25/15 at 3:05 p.m., indicated Purpose: To provide guidelines for correct technique in completing wound care . 11. Clean the wound according to the physician's orders [REDACTED]. 12. Remove gloves and discard into the bag for contaminated items. 13. Wash your hands. 14. Apply a pair of clean gloves. 15. Apply clean dressing with medication / ointment according to the physician's orders [REDACTED]. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to maintain a safe environment for residents when a resident (Resident #173) was displaying unsafe and aggressive behavior for 1 of 1 resident reviewed for supervision to prevent accidents Resident # 173 displayed aggressive and unsafe behavior toward residents and Resident # 176 was pulled from a chair and had a Left forearm fracture. (Resident # 176) Findings include: 1. On 8/25/15 at 3:00 p.m., the record for Resident #176 was reviewed. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], indicated the resident required physical assistance of another person to walk. During an observation on 8/25/15 at 2:32 p.m., Resident #176 was sitting in the recliner with her eyes closed, her left lower forearm was noted to be in a soft cast, and a yellow/brown colored bruise was observed above her left eyebrow. During an interview on 8/25/15 at 2:34 p.m., LPN #3 indicated there had been an unwitnessed incident with another resident on the overnight shift a few weeks ago. LPN #3 indicated a staff member had heard a boom boom and Resident #176 liked to sleep in a recliner and apparently another resident wanted to get her up and have her come with her and Resident #176 was found on the floor and was complaining of left lower arm pain. A Fall Analysis note dated 8/6/15 at 3:20 a.m., for Resident #176 indicated the resident had an unwitnessed event and was found in the dining room sitting on the floor. Resident #176 was found sitting upright on the floor actively bleeding from a laceration over her left eyebrow and was unable to state what happened. Another resident stated that another resident had pulled Resident #176 up from the recliner stating come on let's go. The resident's statement indicated: When Resident #173 came near Resident #176, she would begin yelling get her away from me, she hurt me and I'm scared of her. The document indicated the resident had a laceration of 1.5 centimeters (cm) x 0.8 cm and complaints of left shoulder pain. There was documentation under the monitoring portion of document that was struck out, it had indicated removed other resident from area and 1:1 with writer. The possible root cause of fall indicated: impaired safety awareness. Other: resident to resident incident. The immediate new interventions: Other: removed other resident from the area. Supervisor notified and Resident #176 was sent out to the emergency room . The nurses notes for Resident #176 dated 8/6/15 at 9:40 a.m., indicated the report from the hospital was called and the resident had a left distal radius (lower left arm) fracture. The resident had a plantar cast (hand and shoulder). 2. On 8/26/15 at 12:06 p.m., the record for Resident #173 was reviewed. [DIAGNOSES REDACTED]. A Fall Analysis note dated 7/31/15, indicated Resident #173 was found sitting on the floor next to another resident, The resident statement indicated the resident was unable to verbalize details, However has been saying/yelling let's go all day to individuals as she grabbed and pulled at the staff as well as residents. The Nurses Notes indicated: On 7/24/15 at 10:35 p.m., the resident demonstrated the behavior this shift of wandering aimlessly, grabbing other resident's and saying incoherent speech like let's go Come low Common lay down Can lady let's down Staff frequently redirected resident to no avail. The resident displayed no signs and symptoms of pain. The resident was very restless throughout the shift. Staff tried to offer fluids, toileting, snacks, distraction, and sitting 1-1 with patient, but the resident was still restless. This resident was frequently agitated and annoyed the other residents in the unit. On 7/26/15 at 8 p.m., the resident continued to wander in and out of other resident's rooms and saying let's go come on to the residents and staff who were near by. The resident was still grabbing at people, but was not as aggressive as she had been. On 7/28/15 at 3 p.m., the resident was very talkative and was grabbing at anyone's clothing and hands that was near by and was saying hey come here with me. The resident was easily redirected even though she could be aggressive at times. On 7/28/15 at 8 p.m., the resident was wandering in and out of other resident's rooms and saying hey come one let's go and was pulling and grabbing on anyone she could see. The behavior was not easily redirected. On 7/28/15 during the 11 p.m.-7 a.m., the resident was actively wandering on the unit yelling help me come here let's go and did not get any sleep. On 7/30/15 during the 7-3 shift the nurse indicated throughout the shift the resident had been grabby, constantly saying come here! somewhat aggressive in her attitude. The behavior had not been easily altered. On 7/31/15 at 2:45 p.m., the resident was found on the floor with another resident. The behavior of wandering and grabbing/pulling others, including staff and residents, was continuous throughout the shift. On 8/1/15 at 3 p.m., the resident wandered in and out of resident's rooms and was grabbing on other residents arms and clothing as well as nursing arms and clothing very aggressively, the behavior was not easily altered. On 8/2/15 at 10:25 p.m., the resident remained increasingly confused, grabbing staff and other residents and was not easily redirected as she would return to the behavior. On 8/3/15 at 9 p.m., the resident continued to wander in and out of resident's rooms saying come on let's go pulling and grabbing at anyone who was around her. The resident became very aggressive when others would not go with her, she was not easily redirected. On 8/5/15 at 2:40 p.m., the resident began to wander the hallways in and out of rooms and grabbed the arm of a female resident. She was asked to release the other resident's hand. The nursing staff had to physically remove Resident #173's hand from the other resident. Resident #173 then grabbed the staff's hand and said let's go. The resident would not remain still long at all. On 8/6/15 at 6:51 a.m., the resident was very anxious the majority of the shift and continued to walk around knocking plants on the floor, hitting writer with a bathroom key and pulled on this writers clothing. The resident calmed down around 1:30 a.m. and fell asleep on the couch. At 2:30 a.m., the resident awakened and was toileted and placed in her bed. At 3:30 a.m., the resident got out of bed and it was reported per another unknown resident's statement the resident pulled another resident (Resident #176) off of the recliner trying to make the resident walk. Behavior Incident Report indicated : On 7/23/15 at 4,5,6,7,8 and 9 p.m., the resident had behaviors of: intrusive wandering, grabbing others, and this was a result of frustration, confusion and dementia with behavioral disturbances. The staff tried interventions of going for a walk with the resident, and to remove the resident from the situation and neither of these interventions were effective. The comments section indicated Resident #173 was very aggressive with staff and other residents today. The resident was grabbing at staff and trying to make them go with her and was not easily redirected at all. Resident #173 kept walking on peoples feet and touching them, this made the other residents upset and aggressive towards Resident #173. The nursing staff tried to keep the resident away from the other residents, but she was not easily redirected. On 7/23/15 at 8 p.m., in the middle of the pod dining room area Resident #173 was pulling on residents, grabbing others, and displayed intrusive wandering. The potential cause of the behaviors were frustration and confusion. The staff tried interventions such as; removing the resident from the situation and took the resident to her room and these were effective. The comments section indicated she was pulling another resident down the hallway and was not easily redirected. On 7/25/15 at 12 p.m., the resident was biting and grabbing others. The cause of behavior was unknown. The interventions tried by staff: Go for a walk with the resident was marked as not effective. Removing the resident from the situation was effective. The comments section indicated: This resident was pulling on another resident's arm and each time the staff separated them, this resident either grabbed or pulled on other residents. She was not easily redirected. The staff stayed 1 on 1 with her and sat with her, but she returned to those behaviors when left alone. This resident was found on the couch sitting with another resident, she was pulling her arm stating, come on let's go and biting the other resident's left hand. No apparent injury noted to the other resident. The residents were both separated. On 7/25/15, the nurse indicated all 3-11 p.m. shift!!!! the resident displayed intrusive wandering, repetitive questions, grabbing others, pulling on staff clothes trying to get them to go with her, grabbing other resident's hand and arms telling them to go with her, and was not easily redirected. This happened in the hallway, the resident's room, other resident's room and in the pod (small areas of unit) areas. On 8/26/15 at 3:00 p.m., the Executive Director (ED) indicated he had provided all of the documentation related to behaviors for Resident #173 for the month of July through August 2015. The documentation included Social Services Behavior Monitoring dated July 2015, start date 7/23/15. The documentation indicated a behavior of grabbing on staff and other residents, pulling on staff and residents. The interventions were as follows: 1. Remove resident from situation. 2. Offer reassurance. 3. Go for a walk with the resident 4. Alert staff to residents behavior. 5. Show resident were her room is if she is tired. The date boxes for 7/23, 7/25, 7/27, 7/28, 7/29, 7/30 and 7/31/15 indicated the behavior was happening often. Staff documented they tried interventions and they were not effective. A document titled Behavior Committee Review dated 8/20/15, listed the residents behaviors and indicated the current psychotropic medications: 8/4/15, Depakote (a medication to help stabilize moods)125 milligrams every morning and 250 milligrams every evening. The non pharmaceutical interventions tried was one on one with resident and redirecting,. Possible modifications/recommendations for current behavior treatment: sent to psychiatric unit on 8/6/15, an antipsychotic medication of Zyprexa 5 milligrams added and a medication review to be done. During an interview on 8/26/15 at 11:35 a.m., with the ED, he indicated the nurse who was providing one on one with Resident #173 on 8/6/15, had left the room of Resident #173 because she was asleep. He indicated the incident with the residents happened after the nurse had left the room. He indicated typically one on one was done with the staff or assigned person staying in the room with the individual at all times. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was transferred according to the resident's assessment of a 2 person transfer with a sit-stand lift for 1 of 3 residents reviewed for accidents in sample of 3. The resident sustained [REDACTED]. (Resident #B) Findings include: The record of Resident #B was reviewed on 1/18/13 at 10:45 a.m. [DIAGNOSES REDACTED]. A physical therapy screen form, dated 6/4/12, indicated Resident #B, "...uses mechanical lift...." A care plan review for Resident #B dated 7/30/12, indicated, "...Requires use of sit/stand lift for transfers...." A Fall Risk Assessment for Resident #B, dated 9/1/12, indicated, "...to evaluate the resident's Gait/Balance, have him/her stand on both feet without holding onto anything: walk straight forward...." The "...N/A - not able to perform function...." was marked for Resident #B regarding gait and balance. A care plan for Resident #B, dated 3/20/12, with a reviewed on date of 10/2012 indicated, "...potential for falling...provide limited staff assist (sign for with) transfers...." A physician's orders [REDACTED]. A nurse's note, dated 11/12/12, at 10:39 p.m., indicated, "Resident alert, resident slid from the stand up lift and knees popped, xray taken...pain pill administered, vital signs taken...resident now sleeping in bed...." A nurse's note, dated 11/13/12 at 2:50 a.m., indicated, "...first set of xrays were 'bad'...here now to retake films...." A nurse's note, dated 11/13/12 at 4:15 a.m., indicated, "xray tech (technician) leaving, results pending." A nurses note, dated 11/13/12 at 6:15 a.m., indicated no x-ray results. A physician's orders [REDACTED]. A hospital triage note, dated 11/13/12 at 11:26 a.m., indicated, "...presents with right knee and hip pain from fall lastnight (sic). nursing (sic) home staff states that she was transferring from wheelchair to cart when her legs gave out....' A hospital nursing documentation, dated 11/13/12 at 11:50 a.m. indicated, "...ECF (extended care facility) reports pt (patient) falling out of hoyer lift last night when transferring pt from wheelchair to bed...pt co (complaint of) RIGHT hip pain pta (prior to arrival) per staff...." A hospital x-ray examination note for Resident #B, dated 11/13/12 at 13:59 (1:59 p.m.), indicated, "...Four views of the right knee were obtained...There is an oblique fracture of the femoral shaft...This fracture is slightly angulated...." A facility investigation for Resident #B provided by the E.D. (Executive Director)on 1/18/13 at 2:40 p.m., indicated, "...Date of Incident: 11/12/12 (sign for and) 11/15/12...Description of Incident: 11/12/12 resident sustained [REDACTED].N.A. in 'sit to stand lift.'...Investigation Findings: CNA failed to follow policy (sign for and) assignment sheet when utilizing mechanical lift...CNA failed to assure leg safety device was in place and failed to seak (sic) out and utilize the assistance of required 'second CNA/nurse.' CNA received Final Written Warning on this incident...." A hand written and signed statement from CNA #1 on 11/16/12 regarding the care of Resident #B, provided by the E.D., on 1/23/13 at 1:55 p.m., indicated, "...She also said she needed to go to the bathroom...I told her I would return in just a second I needed to find help and to retrieve the lift. I found the lift but everyone was busy...I checked the hall once again and didn't (sic) see anyone around. I hesitated but proceeded to use the lift by myself because (Resident #B's first name) needed to use the restroom so bad...The lift that I used was missing the calf straps I was unaware of this because I was never trained to use any lift in the building...(Resident #B's first name) wanted to get down panicked and slipped her feet off the lift while I was pushing the lift to the toilet...I ran to the nurses station (Resident #B's first name) was still connected to the lift not on the floor...(Resident #B's first name) was not responding but crying out in pain...At this point the nurses had took over. When (Resident #B's first name) almost reached the floor everyone heard a loud pop...." An "Acknowledgement of Receipt and Understanding of Hooverwood's resident transfer policy" was provided by the DoN (Director of Nursing) on 1/18/13 at 3:15 p.m. The form was signed by CNA #1 and dated 8/29/12. A "Nurse Aide competency Checklist" was provided by the DoN on 1/18/13 at 3:15 p.m. The competency checklist was for CNA #1 and dated 8/27/12. The checklist indicated, "...Mechanical Lift Sit/Stand...Orientee demonstrates understanding of transfer method listing on assignment sheet...." Both areas were initialed by a registered nurse as demonstrated with acceptable technique and knowledge on 8/29/12. A facility policy provided by the DoN and verified as current on 1/18/13 at 9:00 a.m., titled, " Resident Transfers," indicated, "...Transfers Utilizing Mechanical Lifts...Check lift and sling before transfer to ensure all safety belts are intact, and sling is properly functioning...Always double check to ensure that safety belts are fastened...When using the SARA lift, leg belts must also be fastened before the transfer takes place...All lift transfers, whether sit to stand or full body require the presence of two staff members. One staff member should have control of the lift, while the other monitors the resident during the transfer and positioning of the resident on the new surface...." During an interview on 1/18/13 at 1:45 p.m., the E.D. indicated CNA #1 was transferring the resident alone, and Resident #B required a 2 person transfer. The E.D. indicated all sit-to-stand lifts and hoyer lifts required a 2 person transfer. The E.D. indicated the facility policy requires a 2 person transfer with lifts. During the exit conference on 1/23/13 at 3:45 p.m., the E.D. indicated CNA #1 did not ensure the equipment was ready for use in regards to the leg straps on the sit-to-stand lift. The E.D. indicated CNA #1 could have sought assistance from another staff member or the unit manager to locate the leg straps or find another operating unit. 3.1-45(a)(2)