Every finding on record at Lake Pointe Village

Based on interview, observation and record review, the facility failed to appropriately handle a resident with a diagnosis of dementia and a behavior of figiting for re-positioning for 1 of 3 residents reviewed for dementia care. (Resident B) Findings include: The review of the Reportable Incident to the Indiana Department of Health (IDOH), dated 9/30/24, indicated a family member reported to the Executive Director (ED) that there was rough handling by an aide on the memory care unit (Cottage) which happened on 9/22/24. The record for Resident B was reviewed on 10/17/24 at 3:30 p.m. The resident was admitted to the facility's dementia unit on 8/13/24 from home and was subsequently sent out to a psychiatric facility shortly after admission for behavioral issues. She returned to the facility dementia unit on 9/18/24. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease; mood disorder due to known physiological condition with manic features; dementia in other diseases of moderate with behavioral disturbances; Bipolar disorder of current episode manic with severe psychotic features, delusional disorders, anxiety disorder, depression, syncope and collapse, abnormalities of gait with motility, impulsiveness; and fracture of second thoracic vertebrate. The Admission Minimum Data Set (MDS) assessment, dated 9/25/24, indicated the resident had long and short term memory loss and was severely impaired for cognitive skills for daily decision making. She required two staff for assistance with toileting and ADLs (Activities of Daily Living). A care plan, dated 8/13/24, indicated the resident exhibited cognitive impairment with a BIMS (Brief Interview of Memory) less than 13. The resident's cognition was severely impaired. The long term goal was for the resident to continue to participate in daily decisions as able and will remain alert and oriented at current level. The interventions included, but were not limited to, encourage social interaction; give resident choices throughout the day regarding decisions as able; provide resident with prompts and cues as needed; and provide simple instructions and repeat as needed. A care plan, with a start date of 9/19/24, indicated the resident at times prefered to get onto her hands and knees and crawl on the floor/sleep on the floor. The resident experienced the following behaviors: anxiousness, restlessness, repetitive worries related to a diagnosis of anxiety disorder, severe agitation, delusional behaviors, and intrusive wandering related to diagnosis of Bipolar disorder with manic and severe with psychotic features. During an interview on 10/17/24 at 3:13 p.m., the complaiant indicated he on the day of the incident it was very chaotic and hectic back on the dementia unit. There was a COVID outbreak in the facility and on the unit. Staff were trying to keep the residents with COVID in their rooms and the others out of those rooms. He was visiting his family member in his room and he had to go to the bathroom. He walked out to get the key from the nursing station and went to the bathroom. As he was returning the key, he saw two Certified Nurse Aides (CNAs) were trying to get Resident B to sit down as she kept trying to get up. He then saw a CNA walk by the resident who was sitting in a chair by the nursing station. The CNA used her hand and by the resident's head she shoved her back into the chair. The aide did not speak to the resident, she just pushed her back down into the chair. When she pushed the resident down, the resident screamed, but this resident had a habit of screaming out quite frequently for no reason. He was not sure if she actually hurt her. He did not report it to anyone until a week later. The record indicated, on 9/30/24, CNA 2 recalled the incident between her and Resident B on 9/22/24. The CNA indicated that the only incident she could recall was when she sat with Resident B on the couch in the dining room. Since the resident had been crying so hard, she held her close and took her hand and gently guided the resident's head to her shoulder, which calmed the resident down a little while later. Review of the progress notes, between 9/22/24 and 9/26/24, did not indicate the resident had bruising to her forehead due to allegation of rough treatment by a CNA nor did she appear fearful with staff when helping her. In a second interview with CNA 2, the ED, and Director of Nursing (DON), dated 10/1/24, the CNA was made aware of the allegation by a resident's family. She denied the incident occurring and was not aware of any other staff, including herself, who could have done that. During an interview with Resident C on 10/17/24 at 10:55 a.m., she was asked what she remembered from that day involving CNA 2 and Resident B. She indicated CNA 2 was sitting on different couches with Resident B talking to her.The CNA appeared to be trying to get Resident B to lay her head on the pillow by placing her hand on her forehead and gently pushing her to lay down and rest. She used her open hand and kind of pushed her head back as if trying to get her to lay back on the pillow. During an interview with RN 7 on 10/17/24 at 2:45 p.m., she indicated Resident B may have been leaning forward so much like she does that CNA 2 just put her hand on the resident's forehead to prevent her from falling forward onto the floor and straighten up so she could lay down. She would have used the resident's arms to re-position her or guided her body back. During an interview with the Scheduler on 10/17/24 at 2:53 p.m., she indicated she was also a CNA. Although she believed it was okay for CNA 2 to use her hand on the resident's forehead to guide her back up, she would have used the resident's arms to help guide her into a better position. During an observation of Resident B at 2:55 p.m., the resident was observed sitting in her high back tilt chair (a chair that provides greater upper and lower back support, as well as taking the strain off your neck and shoulders) at a table with other residents and CNA 6. The resident was observed to be fidgety in her chair occasionally leaning forward. During an interview with Licensed Practical Nurse (LPN) 10 on 10/17/24 at 3:00 p.m., she indicated that she felt like the aide was only trying to re-position the resident by placing her hand on the resident's forehead and pushing her back to prevent falling to the floor. She would not have used her hand on the resident's forehead, she would use the resident's arms or another CNA to help re-position her and tilt her back. During an interview with CNA 11 on 10/17/24 at 3:05 p.m., she indicated she was taught to re-position a resident using their arms or body to prevent them from falling forward. This citation relates to Complaint IN00444354. 3.1-37 (a)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to catheter bag and tubing touching the floor for a resident with an indwelling urinary catheter for 1 of 5 residents reviewed for Urinary Tract Infections. (Resident 35) Findings include: During the Resident Council Meeting observation, on 8/28/24 at 1:45 p.m., the Resident 35's indwelling urinary catheter tubing could be heard dragging the floor as the Activities Director was pushing the wheelchair the resident was in, to the table. One of the wheelchair wheels ran over the indwelling urinary catheter tubing. The record for Resident 35 was reviewed on 8/29/24 at 2:51 p.m. The resident's diagnoses included, but were not limited to, dementia, anemia, obstructive and reflux uropathy, stage 3 chronic kidney disease, anuria and oliguria, and urinary tract infection. The care plan, dated 5/2/23, indicated the resident required an indwelling urinary catheter due to obstructive uropathy. The interventions, dated 5/2/23, indicated to avoid obstructions in the drainage, and do not allow tubing or any part of the drainage system to touch the floor. The nurse's note, dated 12/20/23 at 5:16 a.m., indicated the resident's catheter bag was found leaking onto the floor. A new catheter bag was put in place. The nurse's note, dated 1/13/24 at 5:57 p.m., indicated a new indwelling urinary catheter was in place related to the resident's complaints of pain and pressure. Yellow urine was in the BSD (bedside drain). The resident indicated that it was starting to feel better. The IDT (Interdisciplinary team) note, dated 1/15/24 at 3:50 p.m., indicated the resident was admitted to a local hospital with diagnoses of hypoxia and acute UTI (urinary tract infection). The urine culture results from the urine collection, on 1/15/24, reported results, dated 1/23/24, had greater than 2 organisms recovered. There was greater than 100,000 colony forming units. The Quarterly MDS (Minimum Data Set) assessment, dated 4/18/24, indicated the resident was cognitively intact. During an interview and tour with the DON (Director of Nursing) on 8/30/24 at 8:20 a.m., the catheter tubing should be secured with a clip device when residents were in their wheelchairs. The tubing should not be dragging the floor. Staff should check for the tubing location when a resident was in their wheelchair, to make sure the tubing wasn't dragging the floor and to make sure the clip device was holding the tubing. During an interview on 8/30/24 at 8:44 a.m., the IP (Infection Preventionist) indicated the indwelling urinary catheter tubing and bag should be kept off the floor to prevent pinching and infection. She last educated staff on catheter monitoring and care in March, April, July and August 2024. During an interview on 8/30/24 at 8:45 a.m., the Activities Director indicated she would watch for the catheter tubing to make sure it was fastened under the wheelchair. She heard the sound when she pushed the wheelchair up to the table for Resident Council, but thought it was just the brakes making the sound. She would be more mindful in the future of the tubing. During an interview on 8/30/24 at 9:00 a.m., QMA (Qualified Medication Aide) 4 indicated the aides performed catheter care often during their shift. The Nursing policy, last revised June 2024, included, but was not limited to, . b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bag or tubing from touching the ground . 3.1-41(a)(2)

Based on observation and interview, the facility failed to ensure that infection control practices were followed related to placement of the indwelling urinary catheter tubing and bag at the bedside for 1 of 3 residents observed for infection control prevention. (Resident 34) Findings include: During an initial observation on 8/27/24 at 8:31 a.m., Resident 34's indwelling urinary catheter bag was in a bath basin, but the tubing was on the floor. During an observation on 8/29/24 at 10:33 a.m., the resident was asleep in bed and her catheter bag was sitting on the floor. During an observation on 8/29/24 at 2:32 p.m., the resident was asleep in bed with her catheter bag folded in half on the fall mat with her bed in its' lowest position. The tubing was on the fall mat. During an observation on 8/30/24 at 8:17 a.m., the resident's tubing was on the floor under the indwelling urinary catheter bag and the bag was scrunched down. There was orange urine backed up in the tubing up to the resident's upper leg. The record for Resident 34 was reviewed on 8/29/24 at 2:38 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic nephropathy, anemia, obstructive and reflux uropathy, personal history of urinary tract infections with ESBL (extended spectrum beta lactamase), and the need for assistance with personal care. The Quarterly MDS (Minimum Data Set) assessment, dated 3/8/24, indicated the resident was cognitively intact. She required substantial assistance with toileting. The care plan, dated 4/16/24 indicated the resident required an indwelling urinary catheter related to obstructive and reflux uropathy. The intervention, dated 4/16/24, included, but was not limited to, do not allow the tubing or any part of the drainage system to touch the floor. The nurse's note, dated 4/30/24 at 11:13 p.m., indicated the resident's Foley catheter to the bedside drain was in place and patent with dark brown colored urine. The nurse's note, dated 5/5/24 at 1:38 p.m., indicated the CNA (Certified Nurse Aide) notified the nurse of blood in the resident's indwelling urinary catheter bag. The urine was assessed with a moderate amount of hematuria and a small clot in the tubing. The resident denied burning or pain to the area. Hospice was notified and the nurse waited for a return call. The nurse's note, dated 5/5/24 at 2:57 p.m., indicated hospice placed a new order to discontinue the Eliquis and continue to monitor for hematuria or worsening. The nurse's note, dated 5/8/24 at 11:06 p.m., indicated the hematuria was resolving. The resident showed no signs or symptoms of discomfort. During an interview on 8/30/24 at 8:20 a.m., the DON (Director of Nursing) indicated the indwelling urinary catheter bag did not need to be in the position it was in. This could cause infections. The catheter bag was supposed to be placed in a bath basin. Staff should check the catheter bag and tubing every time they go into a resident's room. During an interview on 8/30/24 at 8:44 a.m., the IP (Infection Preventionist) indicated the indwelling urinary catheter tubing and bag should be kept off the floor to prevent pinching and infection. She last educated staff on catheter monitoring and care in March, April, July and August 2024. The Nursing policy, last revised June 2024, included, but was not limited to, . b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bag or tubing from touching the ground . 3.1-18(l)

Based on observation, record review, and interview, the facility failed to ensure staff wore the appropriate PPE (Personal Protective Equipment) for residents on droplet precautions with COVID-19 for 1 of 5 staff observed for infection control. (Dietary Aide 7) Findings include: 1. During an observation on 11/13/23 at 9:20 a.m., Dietary Aide 7 was observed to be in Resident E and F's room with a dry mop. The aide was sweeping the residents' floor. The sign on the door indicated the residents in the room were on droplet precautions. The staff member was not wearing an N95, eye protection, or a gown in the room. She was at the foot of the resident's bed, sweeping the floor and conversing with Resident F. During an interview on 11/13/23 at 9:22 a.m., the IP (Infection Preventionist) indicated Residents E and F were both on droplet precautions for COVID-19. During an interview on 11/13/23 at 11:05 a.m., LPN (Licensed Practical Nurse) 5 indicated Residents E and F had COVID-19 currently and staff had to wear full PPE in the rooms. She believed they were in isolation until 11/14/23. a. The record for Resident E was reviewed on 11/13/23 at 11:20 a.m. The diagnosis included, but was not limited to, 2019-nCoV acute respiratory disease. The nurse's note, dated 11/5/23 at 9:31 a.m., indicated the resident was not feeling well. He had a poor intake and a temperature of 101.7. He was COVID positive upon testing. The physician was notified, and new orders were given for the resident to be in contact droplet isolation precautions. The physician's order, dated 11/5/23, indicated the resident was in contact droplet isolation related to being COVID-19 positive. b. The record for Resident F was reviewed on 11/13/23 at 11:25 a.m. The diagnosis included, but was not limited to, 2019-nCoV acute respiratory disease. The nurse's note, dated 11/6/23 at 10:34 a.m. indicated the resident tested positive for COVID-19. The resident was placed in isolation. The physician's note, dated 11/7/23 at 9:14 a.m., indicated the resident had tested positive for COVID-19 after having a fever of 102 and oxygen saturations that had been on the low side of normal. The physician's order, dated 11/6/23, indicated the resident was on contact droplet isolation precautions related to being COVID-19 positive. The isolation would end on 11/16/23. 2. During an observation on 11/13/23 at 10:35 a.m., Dietary Aide 7 was observed to be in Resident G's room dry mopping the floor. The sign on the resident's room door indicated the resident was in droplet precautions. The aide was wearing a gown, gloves, and surgical mask, but was not wearing an N95 mask or eye protection. During an interview on 11/13/23 at 10:36 a.m., Dietary Aide 7 indicated she normally worked culinary but was cleaning rooms that day. She didn't know if she was supposed to be wearing a different mask in the room she was in. She then looked at the sign on the door and indicated she was supposed to be wearing an N95 mask. She had been educated on the proper PPE to wear in droplet precaution rooms but had forgotten to don an N95. She then exited the room wearing her gown and gloves, walked to the isolation cart on the hall and obtained an N95 to don prior to re-entering the room. The record for Resident G was reviewed on 11/13/23 at 11:56 a.m. The diagnosis included, but was not limited to, personal history of COVID-19. The LTC Respiratory Surveillance Line List indicated Resident G had symptoms of a headache on 11/10/23 and tested positive for COVID-19. The physician's order, dated 11/10/23, indicated the resident was on contact droplet isolation precautions related to being COVID-19 positive. During an interview on 11/13/23 at 10:48 a.m., the DON (Director of Nursing) indicated Dietary Aide 7 had been educated on the isolation policies and procedures by the IP, including garbing up and what to wear after she'd entered Resident E and F's room earlier. She did not have COVID currently and did not have any physician's orders to not wear an N95 mask. She did not typically do Housekeeping, she was pitching in. During an interview on 11/13/23 at 11:06 a.m., RN 4 indicated Resident G had COVID-19. During an interview on 11/13/23 at 11:14 a.m., the IP indicated she educated Dietary Aide 7 on 11/13/23 as soon as it was brought to her attention that she had entered Resident E and F's room without appropriate PPE. She educated her verbally on proper donning and doffing of PPE and isolation rooms. She told her to wear an N95, gown, and gloves. The written education was going to be done when she was less busy. She did a verbal education, and then she went back to the floor. Residents E, F, and G all currently had COVID-19 and staff should be wearing full PPE when entering their rooms. The Isolation Droplet/Contact Precautions Sign included, but was not limited to, Staff and Providers Must . wear all PPE listed below . Gown . N95 Respirator . Eye Protection (Face Shield or goggles) . gloves . The most current Standard and Transmission-Based Precautions (Isolation) policy, included, but was not limited to, . Droplet Precautions . In addition to standard precautions the following should be included . Use of Personal Protective Equipment - Mask and face protection in addition to gown and gloves: Anyone who goes into the room should wear a mask/face protection within 3 feet of a resident . Perform hand hygiene prior to entering the room . Put on mask/face protection (according to procedure) upon entry to room . 3.1-18(b)(2)

Based on record review and interview, the facility failed to ensure residents were free of physical abuse by staff for (Resident 163) and verbal abuse for 25 of 61 residents present in the facility. (Memory Care Unit residents) Findings include: 1. The record for Resident 163 was reviewed on 8/4/23 at 11:44 a.m. The diagnoses included, but were not limited to, dementia, moderate with mood disturbance, psychotic disorder with delusions, major depressive disorder, cerebral infarction, aphasia, muscle wasting and atrophy of the left and right shoulder, generalized anxiety disorder, cognitive communication deficit, weakness, and the need for assistance with personal care. The care plan, dated 7/27/23, indicated the resident was a new admission to the facility and required the implementation of services to promote physical, emotional, and psychosocial well-being including assistance with activities of daily living related to dementia, psychotic disorder with delusions, depression, a history of cerebral infarction, aphasia, muscle wasting atrophy of the left and right shoulder, anxiety, weakness, and a decrease in activities. The interventions, dated 7/27/2023, included, but were not limited to; staff assistance with transfers, ambulation, bed mobility, toileting and/or incontinent care, eating and drinking, bathing and hygiene, including oral or dental care; and staff were to provide assistance devices for vision, hearing impairment or dentures. The nurse's note, dated 7/27/23 at 12:14 p.m., indicated the resident arrived to the facility's locked memory care unit in a personal vehicle from another facility. The 72 hour Follow Up note, dated 7/29/23 at 3:42 a.m., indicated the resident was compliant with taking evening medications. With much encouragement, the resident allowed staff to remove his soiled pull-up, but refused to allow them to remove his wet pants or to replace his pull-up. The nurse's note, dated 7/30/23 at 4:10 p.m., indicated the resident was incontinent of bowels. CNAs (Certified Nurse Aides) 3 and 4 escorted the resident to the spa (shower) room to be cleaned and changed. The resident became very resistive to care while the CNAs tried to shower the resident. The resident hit CNA 3 two times and kneed CNA 3 in the groin. The 72 hour Admission Follow Up note, dated 7/30/23 at 4:16 a.m., indicated the resident was very hard to redirect and was combative with care. The IDT's (Interdisciplinary Team's) note, dated 7/30/23 at 4:45 p.m., indicated that new orders were received by the MD related to the alleged altercation between the staff and resident. The PAINAD (Pain Assessment in Advanced Dementia Scale) assessment was completed and a full head to toe body assessment was completed with zero visible injuries at the time of the incident. Neurological checks were started. Vital signs and a full body head to toe assessment were to be obtained for 72 hours with findings documented. The statement from CNA 4, dated 7/30/23, indicated the resident became combative, hitting and kicking both CNA 3 and CNA 4. CNA 3 then became agitated and open handedly hit the resident on the left side of the face. CNA 4 requested CNA 3 to stop and pushed CNA 3 away from the resident. CNA 3 asked CNA 4 not to tell anyone about what just happened. CNA 4 asked CNA 3 to leave the spa room. The statement from the Unit Manager, dated 7/30/23, indicated at 4:30 p.m. she was notified by CNA 4 about CNA 3 open handedly striking the resident on the left side of his face. Upon arriving to the unit, the Unit Manager observed CNA 3 holding his back and was visibly upset and angry. He was cursing loudly and was trying to explain the event. CNA 3 called the resident an 'old bastard' and indicated the resident became aggressive with him, causing the CNA to injure his back. She asked the CNA to clock out and leave the facility. The Discharge MDS (Minimum Data Set) assessment, dated 7/31/23, indicated the resident was severely cognitively impaired. He required total dependence by staff for bathing. The nurse's note, date 7/31/23 at 5:01 a.m., indicated the neurological checks were continued and were within normal limits. There was no visible injuries observed. The resident was very resistive to care during the shift. The resident denied any pain. The Incident Report sent by the facility on 7/31/23 at 11:48 a.m., indicated on 7/30/23 at 4:30 p.m., Resident 163 was being combative with care in the spa room with 2 CNAs present. CNA 3 became aggressive with the resident. CNA 4 removed the resident from care and reported the incident. A psychosocial assessment and full body assessment were completed. CNA 3 was suspended pending the investigation. The nurse's note, dated 7/31/23 at 2:43 p.m., indicated the resident was discharged back to his previous facility. During an interview on 8/4/23 at 1:40 p.m., the ED (Executive Director) indicated the incident involved the resident being taken into the shower by CNA 4 and CNA 3 was on 7/30/23. The resident had dementia and was not used to having male CNAs and the resident kneed CNA 3 in the groin. CNA 3 started swinging from the knee jerk response and the ED was unsure where the resident was hit. CNA 4 separated the resident from the situation and reported it. CNA 3 lied about the incident and didn't admit to hitting the resident. CNA 3 was terminated, because he did not admit to hitting the resident. During an interview on 8/7/23 at 1:54 p.m., LPN (Licensed Practical Nurse) 6 indicated the CNAs took the resident into the shower room, on 7/30/23, and when they came out, CNA 3 said that the resident had hit him 3 times and he twisted his back. CNA 4 left the unit to talk to the Unit Manager and she came back. That was all he knew about it. CNA 3 was sent home due to his back. The resident was brought out of the shower. It was supper time, so he was brought to the dining room to eat. He did an assessment prior to the resident going into the dining room. During an interview on 8/7/23 at 2:01 p.m., CNA 4 indicated, on 7/30/23, she approached the resident one on one. There was a fowl smell coming from the resident, but the resident became agitated, so she let him be alone for a while. CNA 3 took the resident to the spa room to clean him up anyway. CNA 3 poked his head out and asked for help. The resident was still agitated and began kicking. CNA 3 slapped the resident on the left side of his face. It was because the resident was hitting them both. She could hear the slap and it left red finger marks on the resident's face. The resident didn't react. She told CNA 3 he needed to stop and she finished cleaning the resident up. She took the resident out of the shower room to LPN 6. The Unit Manager was informed of what had happened and the ED was then told about it. They notified the DON (Director of Nursing). CNA 3 slapped him one time. CNA 4 had worked with him before and he had never acted that way. CNA 3 was walked out of the building by the Unit Manager. During an interview on 8/7/23 at 2:05 p.m., the Unit Manager indicated CNA 4 informed her, on 7/30/23, that while she and CNA 3 were cleaning the resident, the resident became aggressive. He was hitting and kicking them. CNA 3 open hand slapped him on the left side of his face. She gave her phone to CNA 4, who called the ED to report the incident. CNA 3 indicated he hurt his back and he needed to clock out. The resident was never alone with CNA 3 after that. She asked CNA 3 to leave. CNA 3 had never been like this before. He filled out an employee incident report before leaving. She didn't read it before handing it to the DON. Full body assessments and neurological checks were completed for 72 hours on the resident. An order then came to discharge the resident to another facility. 2. The statement from the Unit Manager, dated 7/30/23, indicated at 4:30 p.m. she observed CNA 3 holding his back and was visibly upset and angry. He was cursing loudly and was trying to explain the event. CNA 3 called the resident an 'old bastard'. She asked the CNA to clock out and leave the facility. During an interview on 8/8/23 at 10:14 a.m., the Unit Manager indicated residents were in the dining room and sitting or standing in the common area on 7/30/23. CNA 3 was in the common area in front of the nurse's desk, when he was cursing and yelling. He was asked to go behind the desk. At 11:40 a.m., the Unit Manager indicated Resident 163 was still in the shower when CNA 3 was cursing. During an interview on 8/8/23 at 11:45 a.m., CNA 4 indicated she could not hear any yelling from the spa room while she was finishing cleaning up Resident 163 on 7/30/23. During an interview on 8/8/23 at 12:12 p.m., the Unit Manager indicated, on 7/30/23, when CNA 3 was cursing, he was coming towards the nursing station. She asked him to settle down and let him know he was being obnoxious. She asked him to come behind the nurse's station and away from all the residents. She tried to remove him from the hallway/common area and the dining room/activity room, where the residents were located. She could not recall the two specific residents that were directly in the hallway/common area. The other unit residents were in the dining area. The Abuse Prohibition, Reporting and Investigation policy, last revised on January 2023, was provided by the ED on 8/2/23 at 1:25 p.m. The policy included, but was not limited to, . It is the policy of . [company name] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation . [Company name] will not permit residents to be subjected to abuse my anyone, including employees . Abuse includes: 1. Staff to resident abuse of any type . The Past noncompliance began on 7/30/23 and the deficient practice corrected by 7/31/23 after the facility implemented a systemic plan that included the following actions: The facility completed staff education on abuse (7/31/23), physician and police notification completed on 7/31/23, facility wide resident interviews completed related to abuse (7/31/23), a cottage wide skin sweep was completed on 7/31/23, and all employee files were audited to ensure 100% compliance of abuse and dementia training. 3.1-27(a)(1) 3.1-27(b)

Based on observation and interview, the facility failed to ensure removal of expired foods and equipment was clean and in good repair during 4 of 4 kitchen observations. This deficient practice had the potential to affect 60 of 61 residents who received meals from the kitchen. Findings include: During an tour of the kitchen on [DATE] at 9:11 a.m., the following concerns were observed: -The grease drain to the right side of the flat top griddle was caked with a heavy buildup of black grime. - The inside of the griddle, which could be visualized through a large opening under the flat top griddle where the burner knobs were, had a heavy accumulation of food debris and black grime inside of it. - Inside the walk-in freezer there was a buildup of ice on the pipe connected to the fan. An ice formation was approximately 3 inches wide by 6 inches long and was 2 to 3 inches thick. There were smaller ice formations on two white bins below the pipe and forming on the floor below the fan, and on the ceiling above the fan. - Inside the reach in refrigerator there was one bag of sliced turkey which indicated an expiration date of [DATE], two bags which indicated expiration dates of [DATE], and one bag which indicated an expiration date of [DATE]. The turkey in the bags appeared to have ice accumulating on it and did appear dried and freezer burnt. During an interview on [DATE] at 9:15 a.m., the Assistant Dietary Manager indicated the bags of turkey were obviously not in date and did appear to be a little freezer burnt as there was a lot of ice crystals on the turkey. Expired foods were to be removed weekly when they got their food deliveries. They had just received a delivery on [DATE]. Some of the turkey should have been pulled over two months prior. It should not be in there. During an interview on [DATE] at 9:17 a.m., Dietary Aide 7 indicated she had sliced some turkey the week before. She stated, . Apparently I didn't see the turkey in there . During a follow-up observation of the kitchen on [DATE] at 11:02 a.m., the grime to the griddle and the ice formations to the freezer remained the same. During a follow-up observation of the kitchen on [DATE] at 11:26 a.m., the following concerns were observed: -The grease drain to the right side of the flat top remained with a heavy buildup of black grime. - The inside of the griddle remained with a heavy accumulation of food debris and black grime inside of it. - Inside the walk-in freezer, the ice formation appeared to have gotten larger. It was approximately 1 inch longer than it had been on [DATE] and there was ice forming on the inside door handle of the freezer. During an interview on [DATE] at 11:27 a.m., the Assistant Dietary Manager indicated she was not aware of any issues with the freezer. They checked the temperatures, but did not monitor routinely for ice formations. She had seen the ice formations on the handle a few days prior, but had not seen the ice on the pipes, floor, and ceiling. During an interview on [DATE] at 11:32 a.m., the Maintenance Director indicated he had not been aware of any issues with the freezer recently. He would have to come back and used a heat gun to melt the ice off. During an interview on [DATE] at 12:40 p.m., the ED (Executive Director) indicated he had not been aware of any issues with the freezer; it must be a new problem. He inspected the freezer and indicated he could see the ice buildup on the pipe and all other areas. The freezer had just had a brand-new coolant system put in, he would have to call the company that installed it to see what was going on with it. It wasn't something that was going to be fixed with a heat gun. During an observation of the kitchen on [DATE] at 1:42 p.m., with the Dietary Manager the following concerns were observed: -The ice formation on the freezer pipe appeared to have gotten larger and was approximately 9 inches long and 4 to 5 inches in width. The ice remained to the floor, ceiling, and inside the door handle. - The Dietary Manager pulled out the grease trap and it was coated in a heavy buildup of black grime and grease. The Dietary Manager was able to scrape away some of the grease with a scraper. During an interview on [DATE] at 1:42 p.m., the Dietary Manager indicated she had tried to knock the ice off the pipe, but did not want to damage it. She was going to let the company handle it. The grease trap was to be cleaned whenever they used it. They should pull the grease trap out and clean it. It was not on their cleaning list but it was to be completed after each use. The inside of the griddle was something where they would have to unbolt it and take the griddle top off. She did not know when it was last done, but it needed to be cleaned. They cleaned the freezer twice weekly and were supposed to inspect for ice. The Cleaning and Sanitizing Equipment policy, last revised ,d+[DATE], provided on [DATE] at 8:00 a.m. by the ED, included but was not limited to, . Equipment will be cleaned and sanitized as needed . 6. Equipment should be cleaned and sanitized after each use and more frequently as needed. In general, follow these steps . b. Remove food and soil present on, under, and around the equipment . The Food Storage policy, last revised ,d+[DATE], provided on [DATE] at 8:00 a.m. by the ED, included, but was not limited to, . 2 . spoiled foods should be disposed of promptly or separated from other food to prevent contamination . 5. All stock must be rotated with each new order received. Rotation should be based on the First in, First out method or rotated based on the product expiration date . 7. Leftover prepared food and processed meats such as lunch meat, are to be stored in covered containers or wrapped securely. The food must be clearly labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food should be consumed or discarded . 3.1-

Based on observation, interview, and record review, the facility failed to ensure staff to resident abuse did not occur and failed to ensure staff immediately intervened at the time abuse occurred for 1 of 3 residents reviewed for abuse. (Resident B) The Immediate Jeopardy began on 2/12/22 when facility staff, present at the time when the abuse occurred, did not immediately intervene to keep the resident free from abuse, when a nurse pulled a resident to the floor, dragged the resident 20 feet to her room, closed the door, left the resident on the floor, and advised staff not to go in the resident's room. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/25/22 at 3:20 p.m. Findings include: The clinical record for Resident B was reviewed on 2/25/22 at 10:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS (Minimum Data Set) assessment, dated 12/11/21, indicated severely impaired cognition. The incident report, dated 2/12/22 at 10:19 p.m., indicated Resident B had been combative with care, and after care was provided, LPN (Licensed Practical Nurse) 4 assisted Resident B in an allegedly abrasive way from the spa room to the resident's room. On 2/24/22 at 8:04 p.m., the resident was observed resting in bed with her eyes closed. The resident's hands, wrists, and forearms were free of bruising and swelling. The spa room was observed to be 20 feet from Resident B's room. The progress note, dated 2/12/22 at 9:24 p.m., indicated per a witness statement, the resident had been combative with care. The nurse allegedly became rough with care and was removed from patient care immediately. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no signs of acute pain or distress. The written statement from LPN 4, dated 2/12/22 and untimed, indicated he was passing medications when he witnessed the aides trying to get Resident B to her room. They had just exited the spa/bathroom and told the resident she needed to go back to her room. The aides attempted to redirect the resident to her room at which time she became combative, fighting, and attempting to scratch the aides. He grabbed her by the right arm to pull her towards her room, and in the process, she fell to the floor, fighting, screaming, and kicking as he pulled her to her room. She did not get injured or hurt. The resident was very confused and felt she was not abused. If you are trying to keep all the positive residents in their rooms, how else can you do it. During a telephone interview on 2/25/22 at 11:25 a.m., CNA (Certified Nursing Assistant) 5 indicated on the evening of the incident. she and PCA (Personal Care Assistant) 6 were trying to get Resident B back to her room so they could change her. The resident had become combative. CNA 5 did not want PCA 6 to get hurt so she requested assistance from LPN 4. LPN 4 told Resident B that if she did not come with them, he would drag her. CNA 5 continued to rub the resident's right arm, attempting to get her to her room. LPN 4 then grabbed Resident B by her arm, pulled her down to the ground, and dragged her to her room on her backside. The resident screamed for help the whole time. After LPN 4 got her to her room, he shut the door and told CNA 5 and PCA 6 they were not to go in the resident's room. They had called QMA (Qualified Medication Aide) 7 at the time the incident was occurring, and she immediately came over. On 2/25/22 at 11:56 a.m., QMA 7 indicated she had received a call from CNA 5 whom asked her to come to the unit due to an allegation of abuse. She contacted the ED (Executive Director) and when she got over to the unit, she requested LPN 4 to leave the building. RN (Registered Nurse) 3 came to the unit and completed a skin assessment on the resident. On 2/25/22 at 1:30 p.m., CNA 5 indicated when LPN 4 told Resident B that he would drag her to her room if she did not go with them to her room, CNA 5 did not believe he would really do it. The CNA did not intervene at the time LPN 4 dragged Resident B to her room. The CNA indicated she was in a state of shock and all she could think of was reporting the incident to management. On 2/24/22 at 7:25 p.m., the Infection Preventionist provided a current copy of the document titled Abuse Prohibition, Reporting, and Investigation dated 2/2010. It included, but was not limited to, Policy .It is the policy .to provide each resident with an environment that is free from abuse .This includes .verbal abuse .physical abuse .will not permit residents to be subjected to abuse by anyone, including employees .Willful .means the individual must have acted deliberately .intimidation .Physical Abuse .pulling .rough treatment .Verbal Abuse .The use of oral .language The Past noncompliance Immediate Jeopardy began on 2/12/22. The Immediate Jeopardy was removed, and the deficient practice corrected by 2/16/22 after the facility implemented a systemic plan that included the following actions: The facility completed staff education on abuse and intervening in abuse (2/14/22), facility wide resident interviews completed related to abuse (2/16/22), skin assessments completed on all residents (2/15/22), and all employee files reviewed to ensure abuse inservice was provided upon hire (2/16/22). This Federal tag relates to Complaint IN 030 3.1-27(a)(1)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions were developed and implemented to prevent skin breakdown for a resident with a prosthesis for 1 of 1 resident's reviewed for prosthetics. (Resident 50) Findings include: During an observation, on 7/26/21 at 8:30 a.m., Resident 50 was sitting on her bed. A quarter sized dark brown, scabbed area was on her right BKA (below knee amputation) stump. The resident indicated at this time she was waiting on the nurse to come and do the treatment on her leg. The dark brown area was from where she had been wearing her prosthesis more frequently, and it had rubbed a sore on her stump. The clinical record for Resident 50 was reviewed on 7/28/21 at 8:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) Assessment, dated 7/1/21, indicated the resident was cognitively intact, was at risk for pressure ulcers, but had no current pressure ulcers. The care plan, initiated on 7/6/20 and last revised on 7/20/21, indicated the resident was at risk for skin breakdown due to [CONDITION(S)], incontinence, right BKA, and diabetes mellitus. The New Skin event, dated 3/22/21, indicated the resident had a cracked, raised, discolored area to her stump, measuring 2.4 cm (centimeters) in length by 2 cm in width. It was described as darkened area. Intervention included, resident to not wear prosthesis until healed, therapy to evaluate. The IDT (Interdisciplinary Team) note, dated 3/22/21 at 1:07 p.m., indicated the IDT met to review the area to the end of the right stump. The area was noted to be an old callous area with slight irritation related to her prosthesis. The pharmacy adjusted her prosthesis on 3/19/21. The MD was notified with new orders given to keep prosthesis off, except for when transferring until the area resolved. No new interventions were necessary. The prosthetic services Clinical Summary, dated 4/27/21, indicated the resident was complaining of severe pain at the bone and skin break-down and was wearing 15 to 20 ply socks (thick socks to reduce friction). She was having complications with fit, comfort, and function of her below knee prosthesis. She was wearing a 10 and a 5 ply sock, he recommended an additional 5 ply sock and socket replacement. The care plan lacked documentation of any interventions specific to the resident's use of a prosthesis, or history of skin breakdown. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin assessment, dated 7/25/21 at 1:42 a.m., indicated the resident had no skin impairments. During an observation, on 7/26/21 at 9:50 a.m., the resident was observed with a bordered gauze covering the area, and a date of 7/26/21 written on the treatment in black marker. The resident's prosthesis was next to her bed. There was no padding or lining inside of the prosthesis. During an interview, on 7/26/21 at 9:52 a.m., Resident 50 indicated she had a sore to her right BKA stump. It was from where she had been using her prosthesis and walking more frequently since she was getting up to go to the bathroom more. It had rubbed on the inside of her prosthesis and the nurses had been putting a patch on it daily. The Hot Charting event, dated 7/27/21 at 7:38 a.m., indicated the resident's right BKA was to be monitored for signs and symptoms of worsening. Note appearance, color, drainage, amount, odor, pain, and treatment in place. The Wound Management report indicated the resident had a new area of skin impairment on 7/27/21 at 7:37 a.m., measuring 2 cm in length, by 1.5 cm in width to the right knee. It was described as an old calloused area that had reopened, with no drainage. The clinical record lacked documentation of any new treatment orders or preventative measures put into place after identification of the wound by the facility on 7/27/21. The clinical record lacked documentation of any new treatment orders, or assessment of the wound prior to 7/27/21. The Hot Charting event, dated 7/27/21 at 7:38 a.m., indicated the resident's right BKA was to be monitored for signs and symptoms of worsening. Note appearance, color, drainage, amount, odor, pain, and treatment in place. During an interview, on 7/28/21 at 9:05 a.m., Resident 50 indicated she had the spot for a few weeks now, it came from having to take her leg off and on so much. The wound care nurse checked it. They just started the bandage three days ago because it cracked a little bit. A few weeks ago the skin started turning brown, it was . like a really dark brown scab . The last time that it did that they kept a bandage on it and it went away. She had what was described as a . bell syndrome . Due to changes in the fluid status of the limb, some days the prosthesis fit looser and it would float around and rub on her knee. During an observation of wound care, on 7/29/21 at 8:44 a.m., the Wound Care nurse skin prepped a quarter sized round scabbed area to the resident's right BKA stump, which had an open fissure in the center of it. At that time, the Wound Care nurse indicated the resident had an area to the right BKA, which she was treating with skin prep and a 2 inch by 2 inch dressing. She described it as a brown calloused area. She was going to put an order in for the skin prep and 2 inch by 2 inch dressing. During an interview, on 7/29/21 at 1:16 p.m., RN 2 indicated the resident had an area on the bony prominence on top of her stump where there was not as much tissue. It had changed a bit over the past few weeks to a scab texture and he felt the root cause was friction from the prosthetic. The prosthetic pharmacy did visit at times and made adjustments as needed. He had not notified the prosthetic company since it had worsened. During an interview, on 7/29/21 at 1:22 p.m., the Wound Care nurse indicated the first day she was aware of the wound was on 7/27/21. She had put an order in for skin prep a few weeks prior because the resident was complaining of it getting irritated. They had not reached out to the prosthetics pharmacy. She was under the understanding that it was the resident's normal. During an interview, on 7/29/21 at 2:11 p.m., the DON (Director of Nursing) indicated the first time the area popped up, in March, it should have had a plan of care developed. The Skin Management Program policy, last revised 7/2021, provided on 7/30/21 at 11:00 a.m., included, but was not limited to, . Procedure for Alterations in Skin Integrity - Pressure and non-pressure . 1. Alterations in skin integrity will be reported to the MD/NP [Medical Doctor/Nurse Practitioner] . 2. Treatment order will be obtained from MD/NP . 5. The wound nurse will be notified of alterations in skin integrity . 6. A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented . When alteration in skin integrity has healed . 1 . b. Update at risk care plan - including preventative measures in place . 4. Preventative measures and treatments will be implemented as appropriate . 3.1-47(a)(8)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed during the the COVID 19 pandemic, for 1 of 3 observations related to the proper use of personal protective equipment upon entrance into droplet isolation room (Resident 258) and proper perinel care was followed related to infection prevention for 1 of 2 observations of incontinence care. (Resident 259) Findings include: 1. During an observation on 7/26/21 at 8:38 a.m., CNA 3 was in Resident 258 room. There was a sign on the door which indicated the resident was in droplet precautions, and a PPE cart was located outside the door. CNA 3 was not wearing a gown, N95 mask, or gloves as she assisted the resident with moving some of her belongings and her bedside table. She was within 1 to 2 feet of the resident without the proper PPE. The clinical record for Resident 258 was reviewed on 7/27/29 at 9:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 7/22/21 at 2:42 p.m., indicated the resident was a new admission to the facility. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 7/22/21 at 3:55 p.m., indicated the resident stated she could not take the COVID-19 vaccine. During an interview, on 7/26/21 at 8:40 a.m., CNA 3 indicated the resident was a new admit. She wasn't sure if the resident was still on droplet precautions, she thought she'd had her vaccines, but she would have to check and see because the sign for droplet precautions was still on the door and the PPE cart was still there. During an interview, on 7/26/21 at 9:38 a.m., Resident 258 indicated she was on droplet precautions for 14 days since she was a new admission and because she had not received her COVID-19 vaccine. She couldn't take it because she'd had severe allergic reactions to vaccines in the past. During an interview, on 7/30/21 at 9:10 a.m., the Infection Preventionist indicated new admissions or readmits that were not vaccinated were admitted to the yellow zone in droplet plus isolation for 2 weeks. The staff were required to don a N95 mask, eye wear, gown, and gloves. The Standard and Transmission-Based Precautions (Isolation) Policy, last revised March 2021, provided on 7/30/21 at 9:35 a.m., by the Executive Director, included, but was not limited to, . Droplet Precautions . Use of Personal Protective Equipment- Mask and face protection in addition to gown and gloves: Anyone who goes into the room should wear a face mask/face protection within 3 feet of a resident . 2. During an observation of perineal care (cleaning of the genital areas) for Resident 259, on 7/29/21 at 1:32 p.m., CNA 4 and CNA 5 entered the resident's room to provide care. CNA 5, after washing her hands and donning gloves, removed the residents brief and began to provide perineal care using warm water, soap, and washcloths. She cleansed the resident's groin on both sides using the same side of the wash cloth, then swiped the same portion of the rag down the resident's labial crease. She then rinsed the resident using a clean rag. Upon rolling the resident, she indicated the bed was soaked and she would like to perform perineal care once more after the resident's linens were changed. Using a new rag, she cleansed the resident using the same side of the rag for multiple passes down the resident's groin, and then down the labial crease. She then scrubbed back and forth, from the resident's labia to her rectum, multiple times with the same side of the cloth. The resident was then rolled to her side, powder and a brief were applied. The clinical record for Resident 259 was reviewed on 7/30/21 at 9:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment, dated 7/16/21, indicated the resident was moderately cognitively impaired, and required substantial maximal assistance of a helper with toileting hygiene. The resident had no history or no current urinary tract infection. The care plan, dated 7/12/21, indicated the resident required assistance with ADLs (activities of daily living), including toileting. The admission observation, dated 7/9/21, indicated the resident was incontinent. During an interview, on 7/30/21 at 9:24 a.m., the DON (Director of Nursing) indicated, when performing perineal care, she would expect staff to take a clean wash cloth, and with a female, separate the labia, wash the labial area, wash between and outside the labia in downward strokes, alternate from side to side, wipe front to back, and from center of perineum outward. They should use a clean area of the washcloth with each wipe and change the wash cloth as needed. The Skills Validation policy for Perineal Care, last revised 3/2012, provided on 7/30/21 at 11:00 a.m., included, but was not limited to, . Females: 12. Separate labia and wash urethral area first. 13. Wash area between and outside labia in downward strokes. 14. Alternate from side to side - wipe from front to back and from center of perineum outward. 15. Use a clean area of the washcloth with each wipe. Do not re-wipe area, unless using a clean area of the washcloth . 3.1-18(a)

Based on interview and record review, the facility failed to ensure a resident was treated with respect and dignity by a staff member for 1 of 3 residents reviewed for Resident Rights. (Residents B) Findings include: On 1/30/20 at 9:40 a.m., the Director of Nursing (DON) provided an incident report which indicated on 12/12/19 a staff member overheard an activity aide having a conversation with Resident B. The activity aide stated the resident was being rude and she was removing her from the dining room. The staff member had witnessed the activity aide wheel the resident to her room. The Annual MDS (Minimum Data Set) assessment, dated 10/07/19, indicated the resident was moderately cognitively impaired. [DIAGNOSES REDACTED]. The resident required extensive physical staff assistance with locomotion. The resident had no documented verbal or physical behaviors. The Significant Change MDS assessment, dated 12/31/19, indicated the resident was moderately cognitively impaired. The resident required extensive physical staff assistance with locomotion. The resident had no documented verbal or physical behaviors. During an interview on 1/30/20 at 9:32 a.m., Resident B indicated some of the CNAs are rude and .They make me sit in the hallway and that makes me feel like I'm being disciplined . A written statement by Activity Aide 4 was provided on 1/30/20 at 9:40 a.m. The statement indicated Activity Aide 4 told the resident she was being rude and took her back to her room. A written statement by Staff Member 5 was provided on 1/30/20 at 9:40 a.m. The statement indicated Staff Member 5 was in the dining room and overheard a conversation between Activity Aide 4 and Resident B. Resident B expressed displeasure with a craft project and Activity Aide 4 said, you are just plain rude. Staff Member 5 left the area and upon returning to the area, Activity Aide 4 said, Resident B is being removed from the dining room for being rude. This Federal tag relates to Complaint IN 574. 3.1-3(a)

Based on record review and interview, the facility failed to ensure an incident of resident to resident altercation and a major accident with a fall were reported for 2 of 8 reportable incidents. (Residents 7 and 53) Findings include: 1. During the review of the clinical record for Resident 53 on 7/18/19 at 2:53 p.m., the resident's [DIAGNOSES REDACTED]. The care plan, dated 1/20/17, indicated Resident is at risk for fall . Resident risk factors will be reduced in an attempt to avoid significant fall related injury . Use hoyer lift with 2 staff members with all transfers . The physician's orders [REDACTED]. The Fall Event, dated 11/10/18, indicated staff had resident up in hoyer, had previously weighed resident in hoyer over bed to move resident to get her in w/c (wheelchair) and hoyer strap came off of lift and resident fell to floor hitting head on hoyer leg . Resident was laying of floor approx. (approximately) 3 feet from bed laying parallel to bed head lying on hoyer leg . The Patient Health Summary, dated 11/10/18, from the ER (emergency room ) indicated the resident had been seen for a laceration to the back of her scalp. The nurse's note, dated 11/10/18, indicated the resident had returned to the facility from the ER after receiving three staples. The IDT (Interdisciplinary Team) note, dated 11/12/19, indicated IDT met to review fall on 11/10/18. Resident up in hoyer lift with 2 CNA (Certified Nursing Aide) assist transferring from bed to chair. Through investigation and discovery , hoyer strap did not hold weight due to resident shifting self resulting in tear to strap which allowed resident to drop approximately 2 feet to the floor. Resident noted to hit head on hoyer leg resulting in laceration. Nurse immediately notified. First aid provided. MD (Medical Doctor) notified and new order received to send to ER for evaluation and treatment as indicated . Upon return from ER, laceration with 3 staples . During an interview on 7/19/19 at 2:53 p.m., the DON (Director of Nursing) indicated the top right strap had come off of the lift which had caused the resident to go down. The resident's head had made contact with the bar of the lift which resulted in a laceration to the scalp. During an interview on 7/19/19 at 2:55 p.m., the ED (Executive Director) indicated he had not reported the incident to the state. He did not think it had qualified as a state reportable incident. He generally followed the Division of Long Term Care's policy on Reportable Incidents. 2. The clinical record for Resident 7 was reviewed on 7/20/19 at 6:02 p.m. The resident's [DIAGNOSES REDACTED]. During an interview on 7/17/19 at 10:23 a.m., resident 7 indicated A resident complained about my T.V. (television) being too loud. On Friday a nurse came in and told me she (roommate) wanted me to turn off my T.V. I refused, and said her family is loud and I don't complain. She came up to me and said 'Don't mess with me cause I'm a B----'. Then, she threatened me 3 time after that. She said, 'I can hurt you.' The nurse heard her say it. I told her if she said that to me again I would call the police. During an interview on 7/22/19 at 2:20 p.m., the ED indicated, She did say she was threatened 3 times. I thought they had an argument. I didn't make a state report on it earlier. He had thought at the time of the incident the resident's had just had an argument and he was not under the understanding that there was any actual threats made. A policy titled Indiana State Department of Health Division of Long Term Care, dated 7/15/15, was provided by the ED on 7/22/19 at 3:10 p.m. The policy indicated, B. Types of incidents reportable under Federal and State rules .Verbal Abuse - Oral, written, and/or gestured language that includes disparaging and/or derogatory terms to residents or their families, either directly or within their hearing.Resident to resident verbal threats of harm .Types of incidents reportable under state rules only .MAJOR ACCIDENTS - unexpected or unintentional events resulting in any fracture or other outcomes that require medical treatment beyond basic first aid or ER/physician evaluation . 3.1-28(c)(e)

Based on record review and interview, the facility failed to ensure a resident was free from a fall with the use of a lift for 1 of 4 residents reviewed for accident hazards. (Resident 53) Findings include: The Fall Event, dated 11/10/19, indicated, staff had resident (Resident 53) up in hoyer, had previously weighed resident in hoyer over bed to move resident to get her in w/c (wheelchair) and hoyer strap came off of lift and resident fell to floor hitting head on hoyer leg . Resident was laying of floor approx. (approximately) 3 feet from bed laying parallel to bed head lying on hoyer leg . The IDT (Interdisciplinary Team) note, dated 11/12/18, indicated IDT met to review fall on 11/10/18. Resident up in hoyer lift with 2 CNA (Certified Nursing Aide) assist transferring from bed to chair. Through investigation and discovery, hoyer strap did not hold weight due to resident shifting self resulting in tear to strap which allowed resident to drop approximately 2 feet to the floor. Resident noted to hit head on hoyer leg resulting in laceration. Nurse immediately notified. First aid provided. MD (Medical Doctor) notified and new order received to send to ER (emergency room ) for evaluation and treatment as indicated . Upon return from ER, laceration with 3 staples . The clinical record for Resident 53 was reviewed on 7/18/19 at 2:53 p.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 1/20/17, indicated Resident is at risk for fall . Resident risk factors will be reduced in an attempt to avoid significant fall related injury . Use hoyer lift with 2 staff members with all transfers . The physician's orders [REDACTED]. The hand written statement, dated 11/10/18, by CNA 5 indicated .As I moved to help get her in the wheelchair all of a sudden something happened to the hoyer strap and to the floor she went. In a blink, I cannot explain how fast it happened. The hand written statement, dated 11/10/18, by CNA 6 indicated . I went to pull (Resident 53) towards me to get her away from the bed and in her wheelchair when all of a sudden one strap from the hoyer did something and it made (Resident 53) slide out of the sling and fall on the floor . During an interview on 7/19/19 at 2:53 p.m., the DON (Director of Nursing) indicated the top right strap had come off of the lift which had caused the resident to go down. The resident's head had made contact with the bar of the lift which resulted in a laceration to the scalp. During an interview on 7/23/19 at 11:50 a.m, CNA 7 indicated We check to make sure the loops are down below latches because if they're not, if they're sticking up at all, all that loop has to do is push up a bit and it could easily come up and over, could just slide off the lift. The Skills Validation- CNA procedure for Mechanical Lift dated 3/2012, provided on 7/22/19 by the DON, included but was not limited to, .14. Ensure that sling is securely attached to lift device . 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a Social Services follow up concerning the psychosocial well-being for 1 of 3 residents reviewed for Social Services. (Resident 7). Findings include: 1. During an interview on 7/17/19 at 10:23 a.m., resident 7 indicated, A Resident complained about my T.V. (television) being too loud. On Friday a nurse came in and told me she (roommate) wanted me to turn off my T.V. I refused and said her family is loud and I don't complain. She came up to me and said 'Don't mess with me cause I'm a B----'. Then she threatened me 3 time after that. She said 'I can hurt you' the nurse heard her say it. I told her if she said that to me again I would call the police. The clinical record for Resident 7 was reviewed on 7/20/19 at 6:02 p.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 4/12/19, indicated the resident's cognition was moderately impaired. The clinical record lacked documentation of the incident and individualized psychosocial monitoring of the resident by Social Services. During an interview on 7/22/19 at 9:20 a.m., the DON (Director of Nursing) indicated the resident's story had changed three times. She did not chart anything since the resident said she wasn't threatened. During an interview on 7/22/19 at 2:20 p.m., the ED (Executive Director) indicated, She did say she was threatened 3 times . He had thought at the time of the incident the resident's had just had an argument and he was not under the understanding that there was any actual threats made. During an interview on 7/22/19 at 2:34 p.m., the Memory Care Coordinator indicated I was covering for the SSD (Social Service Director) while she was on vacation. This incident happened on a weekend. I learned about it on Monday in the morning meeting that there was an incident with her roommate. I did not do a social service follow-up. During an interview on 7/23/19 at 10:00 a.m., the SSD indicated if we have a resident to resident altercation we will do a psychological evaluation on day one. The following day we do an IDT (Interdisciplinary Team) review about both residents involved. On 7/22/19 at 3:00 p.m., the review of the Social Services Director Position Description, provided by the ED indicated, Summary Of Position Functions The Social Services Director provides medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and shares a responsibility toward creating and sustaining an environment that humanizes and individualizes each resident living area. 3.1-34(a)(1)

Based on record review and interview the facility failed to ensure residents were protected from verbal abuse for 2 of 6 residents reviewed for abuse. (Resident's B and C). Findings include: 1. Review of the clinical record of Resident B, on 03/14/19 at 11:05 a.m., indicated the resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 2/27/19, indicated the resident was alert and oriented. The Care Plan for Resident B, dated 06/27/18 and revised on 03/12/19, indicated Resident requires toileting program r/t frequent incontinent related to weakness secondary to .[MEDICAL CONDITIONS], and history of UTIs. During an interview, on 03/14/19 at 09:32 a.m., Resident B indicated there was one resident who causes problems. He caused verbal and physical abuse toward staff and residents. His name was . (Resident D). He just gets mad and shouts at others. He calls people nasty names. He does it in the hallway and in his room .They try to calm him down. It was stressful .We share a bathroom and he leaves his bathroom door open. He would lock our bathroom door from the inside, so that we can't go in. They changed the handle, so that it wouldn't lock. He came over and asked whose idea it was to remove the lock, and they explained it. He said he was the senior resident in this area and he pulled rank .it had been going on for at least 6 months. The clinical records (Progress Notes, Observations, Social Service Notes, or Event Notes) for Resident B lacked documentation related to the behaviors of Resident D directed towards Resident B. A Progress Note for Resident D, dated 02/22/19 at 4:10 p.m., indicated Res (resident) sitting in bathroom that is shared with others. Res no longer toileting. Res sitting there on his cell phone looking on Internet. Res asked by CNA (Certified Nursing Aide) to exit bathroom to allow for another res to use the bathroom. Res slowly began exiting the bathroom and asked for help for a CNA. The CNA assisted res out of the bathroom. Res then stopped before going completely getting out of the door way and began to yell at the CNAs in the other res room and in his room. Res asked 4 times to let the CNAs move him enough for them to be able to shut the door .Res again asked to move out of the door way so the other res can get into the bathroom. Res began yelling I will do what I want. This nurse asked res to please move out of the door way so the other res can get to the bathrrom (sic) iin (sic) a timely fashion. The res began yelling at this nurase (sic) and stated you aren't supposed to talk to me. This nurse stated I am only asking you to let us get to the other res in the bathroom and allow him his privacy. Res then pushed his wheelchair back forcefully while CAN (CNA) and this nurse were behind him asking him to please move forward. The res began to yell very loud at this nurse. This nurse informed res that she was going to push him up enough for her to shut the res bathroom door to allow the other res to use the bathroom. Res began yelling for the other nurse at that time. The bathroom door was shut and the other res was then toileted while this res began yelling very loudly in a foreign language. Incident was reported to DON (Director of Nursing} at this time. 2. Review of the clinical record for Resident C, on 03/14/19 at 11:45 a.m., indicated the resident's [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 02/18/19, indicated the resident had adequate hearing, he did not speak, and he could not express his ideas or wants. The Care Plan, dated 05/28/18 and revised on 02/11/19, indicated the resident had difficulty making himself understood. He had a communication deficit related to his dementia and cognitive communication disorder, and was at risk for anxiety. The interventions included, but were not limited to, maintain a calm environment, move to a quiet area as needed, observe for non-verbal signs of distress, staff must anticipate needs, and unable to communicate. On 03/14/19 at 11:50 a.m., the clinical records (Progress Notes, Observations, Social Service Notes, or Event Notes) for Resident C lacked documentation of the verbal yelling and cursing from Resident D to Resident C, or any monitoring after the incidents for signs or psychosocial distress in Resident C. Review of the clinical record for Resident D, on 03/14/19 at 11:50 a.m., indicated the resident's [DIAGNOSES REDACTED]. The Social Services note for Resident D, dated 02/19/19, indicated SSD (Social Services Director) met with resident (Resident D) . Discussed roommate rights for care and staff assisting room mate (Resident C) with care. The Progress Note for Resident D, date 02/15/19 indicated, Resident became angry at staff for not sharing information about fell ow roommate (Resident C). Staff explained that residents information was not to be shared with others. Resident stated This is my room and I have a right to know what goes on in here. Again explained to resident that although it was his room, that he shared it with another resident and that said resident was allowed his privacy as well. Resident then pulled open curtain between his bed and roommates bed during patient care and began screaming and cursing at CNAs (Certified Nursing Aides). AT this time one of the present CNAs pulled curtain closed and explained that patient care was being performed. Resident continued to yell in both English and Spanish very loudly. CNAs quickly finished patient care with roommate and exited room to defuse situation. The Progress note for Resident D, dated 02/18/19, indicated resident noted to having increased agitation with staff when they are providing care to roommate (Resident C) r/t (related to) equipment roommate requires for transfers. staff attempts to explain to resident that he needs that equipment to remain safe resident says I DON'T CARE. resident easily agitated . The Progress note for Resident D, on 2/27/19, indicated This nurse was notified by staff members that resident was upset and requesting that staff not enter his room to provide care for resident's roommate (Resident C). This nurse went to resident's room and upon entering room it was noted that resident had family present, family members stated to resident that they were going to go home for the evening. Resident became irritate, screaming and cussing that his family had to leave because people here insisted that they come into his room and care for his roommate. This nurse attempted to deescalate the situation and provide reassurance to the resident that it was not staff's intention to interfere with his family time. Resident continued screaming and cussing and was unable to be redirected at that time. This nurse ensured resident's needs were met at that time and let resident know that staff would return at a later time. Call light within reach at this time. The Progress note for Resident D, dated 03/09/19, indicated Staff entered room with fell ow roommate (Resident C), who needed to be put in bed and have his brief changed. (Resident D) .screamed at them that he was trying to eat and didn't want to smell his roommates a**. Staff attempted to explain to resident that his roommate also needed care provided. Resident would not listen to anything staff was saying. Was continually screaming out that they stupid 'B's' and 'F'n' 'B's'. yelled at them to just quit their job and leave because he would be here tomorrow but they wouldn't. Staff did not respond to screaming except to tell him they would be done shortly and would leave room. Resident continued yelling and screaming at both staff members until they completed care on roommate. At this time staff left the room and resident said nothing further. During an interview on 03/14/19 at 09:46 a.m., the ED (Executive Director) indicated, There clearly was behavioral issues with him. We've addressed them. He's [MEDICAL CONDITION]. He goes through very deep depression stages, and then also very manic. He has a tendency to just talk . and become verbally aggressive and highly agitated. I haven't seen him being verbal towards other residents. The incident that occurred on 03/09/19, I would count that as a verbally aggressive behavior toward that resident. I haven't been made aware of him being verbally aggressive to other residents. I watch him closely. Because of his IQ and where he's at, he's able to understand what we're saying to him. We talk to him about his language and his rights as a resident. That he doesn't have a right to infringe on others rights. When he has these manic episodes is when he starts acting out. We let his therapist know, he's been sent out, they've done some med adjustments. I will not seclude him or do anything against his rights. At the same time he's cognizant enough to understand the rights of others . I would have a duty to report any verbal abuse. I haven't seen that. Regardless of . (Name of Resident C) cognition . I would have a duty to report that. During an interview on 3/14/19 at 11:31 a.m., CNA 3 indicated, It is common for him (Resident D) to yell and curse . I have heard him yell at staff in front of residents . The Abuse Prohibition, Reporting, and Investigation Policy dated (MONTH) 2010, last revised (MONTH) (YEAR), was provided on 03/14/19 at 12:40 p.m. by the ED. It included, but was not limited to, . It is the policy of . (Name of Corporation) to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse .Verbal Abuse- the use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. This includes any episode of staff to resident; and verbal threats of harm by resident to resident . Resident to Resident abuse: 1. Any individual who witnesses resident-to-resident abuse will immediately separate and protect the resident's involved . 3. The individual who witnessed he abuse will report the situation immediately to his/her supervisor and Executive Director . This Federal tag relates to Complaint IN 911. 3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure the medication administration records for a resident (Resident B) reflected the administration of narcotics for 1 of 3 residents reviewed for documentation. Findings include: The clinical record for Resident B was reviewed on 2/20/18 at 1:15 p.m. [DIAGNOSES REDACTED]. The physician order, dated 1/7/18, indicated the resident was to receive [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 5-325 mg (milligrams), half of a tablet every 4 hours as needed for pain. The controlled substance record log, dated 1/7/18, indicated 22 doses of the narcotic pain medication was given as follows: -1/07/18 at 11:00 p.m. -1/08/18 at 4:00 a.m. and 8:30 p.m. -1/09/18 at 4:00 a.m. at 10:15 p.m. -1/11/18 at 4:35 a.m., 5:40 p.m., and 9:45 p.m. -1/12/18 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. -1/13/18 at 12:00 a.m. and 6:30 p.m. -1/14/18 at 9:45 a.m. and 6:30 p.m. -1/15/18 at 5:00 p.m. and 9:00 p.m. -1/16/18 at 1:00 a.m. and 3:15 p.m. -1/17/18 at 7:50 a.m. The January 2018 MAR (medication administration record) for Resident B indicated only 7 doses were administered between 1/7/18 and 1/17/18. During an interview, on 2/20/18 at 3:54 p.m., the Director of Nursing indicated when a narcotic was administered, the nurses sign the medication out on the controlled substance record and sign the medication administration record as administered. On 2/21/18 at 9:55 a.m., the Director of Nursing provided a copy of the document titled Medication Pass Procedure, dated December 2016. It included, but was not limited to, the following Procedure Steps .Medication administration will be recorded on the MAR .after given This Federal tag relates to Complaint IN 693 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents were provided privacy during 2 of 4 observations of care. (Residents 55 and 29). Findings include: 1. On 05/09/17 at 10:40 a.m., LPN (Licensed Practical Nurse) 1 provided wound treatment to Resident 55's heels. She shut the door and pulled the privacy curtains across the side of the resident's bed. There was an opening of six feet toward the entry door not covered. The resident's roommate, Resident 82 was observed sitting in the corner of the room in a chair. The bathroom door was in full view of the resident's heels. The treatment to the heels was completed. The Admission MDS (Minimum Data set) assessment, dated 03/28/2017, indicated Resident 55 was severely cognitively impaired with a BIMS (Brief Interview of Mental Status) score of 03. [DIAGNOSES REDACTED]. 2. On 05/09/17 at 1:17 p.m., Resident 29 was provided suprapubic catheter care by LPN 2. She closed the entry door but left the privacy curtains open. The resident's wheelchair was facing between the entry and the bathroom doors. The bathroom was shared by a connecting room. The bathroom door was left open. The cover was peeled down, and the resident's shirt was pulled up to expose the catheter tubing. The LPN washed and rinsed the skin around the catheter tubing and the tubing on the resident's abdomen. The resident's brief was secured. The cover was pulled back over the resident. During the treatment the resident was looking back and forth around the room. The Admission MDS assessment, dated 03/26/2017, indicated Resident 29 had a BIMS score of 15, which indicated the resident was alert and oriented. The [DIAGNOSES REDACTED]. During an interview on 05/11/17 at 8:30 a.m., the DON (Director of Nursing) indicated she expected her staff to pull the privacy curtains closed during wound care and catheter care. On 05/09/17 at 10:36 a.m., the Administrator provided copies of the Dressing Change (Incision or Wound) and the Suprapubic Catheter Care policies which both indicated, . Provide privacy . On 05/11/17 at 8:48 a.m., the Administrator provided a copy of the Resident Rights which indicated, but was not limited to, All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity . 3.1-3(t)

Based on observation and interview, the facility failed to store and serve food under sanitary conditions during 3 of 3 kitchen observations, in that soiled ice cream scoops were stored in the clean drawer; frozen food was stored in the freezer unsealed; and soiled dishes were stacked as being clean after being run through the dish machine. Findings include: 1. During the initial kitchen tour on 4/6/16 between 8:45 a.m., and 9:15 a.m., while accompanied by the Dietary Manager and the Consultant Dietitian, the following was observed: a. 1 of 5 scoops stored in the clean rack had food debris inside and under the slide. b. 1 box of french toast sticks' bag in the walk-in freezer was not fully sealed - no ice/frost was observed on the food. c. 1 box of cubed ham in the walk-in freezer had a plastic bag with a crack/slit in it which exposed the meat. 2. During the lunch meal observation on 4/6/16 between 11:40 a.m., and 12:30 p.m., with the Dietary Manager and the Consultant Dietitian also observing, the following was observed: a. 1 of 7 scoops to be used for lunch service was observed with food debris inside the scoop and under the slide. b. 5 of 57 dinner plates used for lunch were observed with food debris on them - these had been stored all stacked together in the clean hot dish holder. c. 1 of 3 divided puree dishes under the steam table had food debris inside. d. 11 of 39 stacked plastic cereal bowls were observed with food debris inside. The cook was observed to have stop serving the meal in order to place these items off to the side before she resumed serving the lunch meal. 3. During the lunch meal observation on 4/8/16 between 11:35 a.m., and 12:30 p.m., with the Dietary Manager also observing, the following was observed: a. 1 box of french toast sticks in the walk-in freezer was half closed but the bag was open to air. b.1 box of frozen beef patties was open to air. - no freezer burn/ice was observed on the meat. c. 4 of 12 scoops of various sizes stored in the clean drawer had food debris under the slides. d. 6 of 31 dinner plates stacked in the plate warmer and 2 of 28 cereal bowls stacked on clean trays had dried food food debris inside which the cook had to stop the meal service in order to place them over to the side before she resumed to continue serving the meal. She indicated at this time that The dishwasher has been an issue for awhile. Observation of the dishmachine at 12:30 p.m., noted the water to be cloudy with food particles in the water. The Dietary Manager indicated at this time that This water was from the morning washing of the breakfast dishes. The water in the dishmachine is changed after every meal and will be changed before they start the lunch dishes today. In an interview with the Administrator on 4/8/16 at 2:00 p.m., she indicated the new dishwasher arrived about a week or 2 ago and was supposed to be installed on 4/6/16, but she canceled its installation due to plastic and paper plates were going to have to be used during the State survey process until the new machine was in place. She also indicated she was unsure when the machine will be installed as the electrician and the plumber now have to re-coordinate their schedules as both have to be present at the same time to do the installation. During an interview with Dietary Aide #1 on 4/11/16 at 9:30 a.m., she indicated that when doing the dishes, the protocol was to stack the dishes in the rack, rinse them off, run them through the machine and then check them for cleanliness before stacking. She also indicated she started scrubbing any dishes which had stuck-on food before running them through the dish machine. In an interview with the Dietary Manager also on 4/11/16 at 9:45 a.m., he indicated that since he was aware of the dishwasher issues, the staff were instructed to thoroughly spray off all the food on the dishes, run them through the machine and check them to ensure they were clean before stacking them for use at the next meal. He also indicated the staff were now soaking and scrubbing any dishes with stuck-on food which was unable to be sprayed off. 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure resident bedrooms had full visual privacy, in that curtains were too short when pulled around the resident bed, and/or were hanging off the ceiling tracks. This deficient practice affected 16 of 33 resident rooms observed. (Rooms 100A and B, 405B, 403B, 404A, 400B, 601A and B, 603B, 303B,103B, 205B, 101B, 302A, 504B, and 407B). Findings include: 1. During initial room observations on 4/6/16 between 10:30 a.m., and 11:20 a.m., the following was observed: a. Room 403B - the curtain between the beds was 1 foot too short to provide privacy when fully extended. Bed B's curtain had an 8 inch gap when fully extended with the first hook hanging down off the track. b. Room 404A - the curtain between the beds and Bed A's curtain were each 1 foot too short to provide privacy when fully extended. c. Room 100B - the curtain between the beds and Bed B's curtain were both 7 inches too short to provide visual privacy when fully extended. 2. During initial room observations on 4/7/16 between 9:15 a.m., and 11:00 a.m., the following was observed: a. Room 405B - Bed B's privacy curtain was 9 inches too short to provide visual privacy when fully extended. b. Room 400B - the curtain between the beds and Bed B's curtain were both 1 foot too short to provide privacy when fully extended. 3. During initial room observations on 04/06/16 between 11:19 a.m., and 11:38 a.m., the following was observed: a. The privacy curtains in room 303B, between the two residents beds, was 2 feet short when extended. Resident # 59 indicated being upset by the lack of privacy in the room. The privacy curtains appeared torn at the top right corner, and hooks were missing, leaving the corner of the curtain hanging. b. The privacy curtains in room 100A, between the two residents beds, was 18 inches short when extended. c. The privacy curtains in room 103B, between the two residents beds, was 18 inches short when extended. 4. During initial room observations on 04/07/16 between 8:59 a.m., and 9:20 a.m., the following was observed: a. The privacy curtains in room 303B, between the two residents beds, was 18 inches short when extended. The hooks of the perpendicular privacy curtains were detached from the curtains, preventing the curtains from fully closing, by 20 inches when extended. b. The privacy curtains in room 101B, between the two residents beds, was 18 inches short when extended. c. The privacy curtains in room 302A, between the two residents beds, was 18 inches short when extended. 5. During the initial room observations on 4/6/16 from 11 a.m., to 2 p.m., and 4/7/16 from 9 a.m., to 1 p.m., the following observations were made: a. Observation in room 601 A: The privacy curtain exposed twelve inches on one side of the residents bed. b. Observation in room 504 B: The privacy curtain exposed twelve inches on one side of the residents bed. c. Observation in room 407 B: The privacy curtain exposed twelve inches on both sides of the residents bed. 6. During the intial room observation on 04/11/2016 between 1:33 p.m., and 1:45 p.m., the following was observed: a. In the room 601B the privacy curtain did not extend all the way to the wall leaving an 18 inch gap between the beds which prevented visual privacy. b. In the room 603B the privacy curtain did not extend all the way to the wall leaving an 18 inch gap between the beds which prevented visual privacy. During an observation with the Maintance Director on 04/11/2016 at 1:48 p.m., he indicated I was not aware the curtains were short in some rooms. During an interview with the Housekeeping Supervisor on 04/12/2016 at 9:17 a.m., she indicated yes some of the curtains are too short. I see how short the curtains are. The curtains are a work in progress. 3.1-19(l)(6)

Based on observation and interview, the facility failed to provide a clean, comfortable and functional environment for 8 of 33 resident rooms and 1 of 1 common resident bathroom observed, in that window sills were cracked with missing pieces of wood; ceilings were stained; paint/plaster was chipped and/or missing; and bathroom doors had chipped and missing pieces of wood with edges that were splintered and rough to the touch. (Dining Room Bathroom, Rooms #100B, 405B, 403B, 404A, 601A, 504B, 600A, and 502B). Findings include: 1. During initial room observations on 4/6/16 between 10:30 a.m., and 11:20 a.m., the following was observed: a. Room 403B - the bottom corner edge on the inside inside of the bathroom door had a 1/2 by 1/2 inch chip out of door which was rough to the touch. b. Room 404A - the right edge/corner of the window sill was missing a 3 inch by 2 inch piece of wood which was rough to the touch. The wall to which the wood window sill connected to was missing 4 inch by 3 inch plaster which was also cracking with loose plaster on the window sill. The wall above the window sill had an area of 3 inch by 3 inch missing plaster. The left side of the wall above the window sill had 2 areas of missing plaster. The first area was missing a 1/2 inch by 2 inch piece of plaster. The second area was missing a 2 inch by 4 inch piece of plaster. Multiple brown ceiling stains ranging in sizes from 1 foot by 8 inch, 4 inch by 2 inch, and 6 inches round were observed above Bed B's bed. c. Room 100B - the caulking around the top of the air conditioning unit was cracked 1 foot in length. 2. During an initial room observation on 4/7/16 at 11:00 a.m., the following was observed:. a. Room 405B - 4 of 20 window blind slats were missing - the window overlooked the patio where chairs, a table and a grill was located. The left side of the wall just above the window sill had a 2 inch by 2 inch area of chipped and missing wall plaster. Both sides of the bathroom door had areas of 2 feet missing and splintered wood which was rough to the touch. 3. During the initial room observations on 4/6/16 from 11 a.m., to 2 p.m., and 4/7/16 from 9 a.m., to 1 p.m., the following observations were made: a. Observations in room 601 A's bathroom: Tiles were a black stained in color measuring 12 inches by 24 inches and the baseboard was pushed in 12 inches. b. Observations in room 504 B's bedroom: Window sill broken measuring 3 inches by 2 inches. Scrape up the wall measuring 2 inches by 3 feet. c. Observations in room 600 A's bedroom: Scrape up the wall measuring 4 inches by 6 inches. d. Observations in room 502 B's bedroom: Window sill broken measuring 8 inches by 1 inch. 4. During the initial tour on 04/06/2016 at 11:57 a.m., the facility restroom across the hall from the dining room, had a strong odor of urine. Three residents were observed going in and out of the bathroom while waiting for lunch to be served. During an observation on 04/07/2016 at 10:30 a.m., the facility restroom across the hall from the dining room, had a strong odor of urine. During an interview with the Housekeeping Supervisor on 04/12/16 at 9:30 a.m., she indicated she checks the bathroom often during the day. There are four residents that use the bathroom, across the hall from the dining room, and it's possible one of them will dribble on the floor. She indicated I have asked the CNA's (Certified Nursing Assistance) to help me with this. She indicated they mop the floor and make rounds randomly throughout the day. During a tour of the facility with the Maintenance Director on 04/11/2016 at 1:48 p.m., he indicated he was unaware of the plaster and part of the window sill missing. The Maintenance Director inspected the wooden doors to the bathrooms and indicated the chips and splintered edges would have to be fixed. He indicated there should not be any mold on the tiles in the showers. The Maintaince Director indicated he was unaware that the curtains were too short in some of the resident's rooms. 3.1-19(a)(4) 3.1-19(f)

Based on record review, observations and interview, the facility failed to ensure the residents' drug regimen was free from duplicate therapy, had adequate monitoring of behaviors and mood symptoms and/or was at the lowest effective dose for 4 of 6 residents reviewed for unnecessary medications. (Residents #51, #63, and #59). Findings included: 1. Review of the clinical record for Resident #51 on 4/8/16 at 10:00 a.m., indicated the resident had [DIAGNOSES REDACTED]. The 9/2/15 Quarterly Minimum Data Set (MDS) assessment indicated the resident had a BIMS (Brief Interview Mental Status) score of 9 with some long and short term memory issues and required cueing; frequently felt depressed; trouble sleeping; tired and felt bad about self. The 11/26/15 Annual MDS assessment indicated the resident had a BIMS score of 11 - good recall , but poor temporal orientation; had no behaviors; some trouble with sleep, depression; felt tired and bad about self. The 2/19/16 Quarterly MDS assessment indicated the resident had a BIMS score of 11 - good recall with poor orientation to current surroundings; no mood issues, including no problems with sleep, feeling down, depressed or hopelessness; and no behavior issues. The April 2016 Monthly Physician order [REDACTED]. Progress notes by the Psychiatric Nurse Practitioner and Licensed Certified Social Worker (LCSW) between 8/6/15 and 2/4/16 indicated the following: - 8/6/15 Quarterly Psychiatric note - sitting up in w/c (wheelchair) in room, social this morning mood has been 'Fine'. No c/os pain/discomfort. Hold on course, no changes in medications. - 11/5/15 Quarterly Psych note - sitting up in w/c, she is pleasant and smiling, talks to me about (family member). Denies feeling sad or nervous, no c/o pain. Hold on course with no medication changes. - 12/3/15 Psychiatric note - informed by staff resident has been more tearful. Found sitting in w/c and does report increased depression and anxiety immediately tearful, unable to specify why she is sad 'I don't know'; notes reviewed, denies suicide ideation, no [MEDICAL CONDITION], sleep and appetite ok. Refer to LCSW (Social Worker affiliated with Psychiatrist office) for talk therapy. - 12/4/15 LCSW note: resident mentioned she has had several bouts of crying because she is depressed. Had a stroke causing her to lose use of right side and make her feel useless. These feelings most likely feeding depression. Feels her children support her which helps to keep the depression at bay. Will work on positive ways to cope. - 1/28/16 LCSW note: (Resident's name) began the session by talking about how she was feeling less depressed than she had in our last session. She engaged more in our conversation .Part of the session also talked about her family coming to visit when they have the opportunity, which she feels is not enough This could be part of which is driving her depression . - 2/4/16 Psychiatric note: Resident found sitting up in room in w/c, pleasant today, no mood concerns; chronic sleep disturbance on and off, denies pain. Hold on course, no medication changes. Review of the clinical record facility progress notes between 7/2/15 and 4/8/16 failed to locate any documentation of the resident experiencing issues with sleep or depression i.e. crying, tearfulness, sad facial expressions. Interview with the Social Worker on 4/11/16 at 9:10 a.m., indicated: We do not track residents who are on anti-depressants, only if anti-anxiety and psychotics. Resident has been pretty stable and doing well, does have some depression and sees psychiatrist quarterly and the talk therapist 2 x month. No Gradual Dose Reductions have been tried on the [MEDICATION NAME] and Trazadone. During an interview with the DON (Director of Nursing) on 4/11/16 at 10:05 a.m., she indicated there were no behavior tracking sheets for this resident. A 9/8/15 Care Plan indicated: Resident is at risk for adverse side effects r/t (related to) use of [MEDICAL CONDITION] med. Goal - Will have no adverse side effects. Approaches: Administer meds as ordered, observe for effectiveness; MD (physician) to review routinely to attempt gradual dose reductions, unless contraindicated by MD. Review of the MD and Nurse Practitioner progress notes between 7/1/15 and 4/8/16 failed to indicate the resident was experiencing any issues with sleep or depression. 2. Review of the clinical record for Resident #63 on 4/11/16 at 10:30 a.m., indicated the resident had [DIAGNOSES REDACTED]. The 10/18/15 Quarterly MDS assessment indicated the resident scored a 3 on her BIMS which indicated she had severe impairment of her long and short term memory and cognitive decisionmaking abilities; and occasionally felt depressed and tired. The 1/25/16 Quarterly MDS assessment indicated the resident continued to score a 3 on her BIMS with no change in cognitive functioning and had no mood issues, included symptoms of depression, sleep, appetite issues. A 7/30/15 Social Work note indicated Resident continues to be restless, agitated with repetitive worries regarding family and statements to go home. Is new admission and is currently being txd (treated) with an ATB (antibiotic). Will request an order for [REDACTED]. A 7/30/15 Initial psychiatric evaluation indicated: Seen re: (regarding) new admission, confused, anxiety. Hx (history) of poor living condition at home and non-adherence to medications x (times) 6 months .Will need time to adjust to new environment but insight and judgement limited due to dementia. Change [MEDICATION NAME] XR (for dementia) 28 mg QD (every day) and add [MEDICATION NAME] mg QD for anxiety. A 8/5/15 Social Work Note indicated Continues to have repetitive worries regarding home. Easily re-directed by conversation. Per resident report and chart review, decreased anxiety noted. A 9/3/15 Quarterly Psychiatric visit indicated Resident found in dining room area smiling, assisting another resident put together a puzzle. She is pleasant & calm today, mood good. D/W (discussed with) staff marked improvement in mood and decreased anxiety. She has been socializing with others and ambulates thru facility. Med changes - hold on course. A 12/3/15 Quarterly Psychiatric evaluation indicated Resident up in common area, pleasant, tells me she is here because she wants to be and can go home whenever she wants. Mood has been 'OK'. She enjoys the company of a group of female residents they spend most of their waking hours together. Nsg (nursing) reports exit seeking at times. She does go out with family. Add [MEDICATION NAME] (for dementia) 5 mg Q (every) hs (night) x 4 weeks then 10 mg Q hs. Current meds [MEDICATION NAME] 10 mg QD - anxiety. [MEDICATION NAME] XR 28 mg QD - dementia. A 3/3/16 Psychiatric note indicated Resident sitting in common area, pleasant smiling oriented as above. 'I'm doing great'. No c/os anxiety, no c/o pain. Continue on course no changes. Review of progress notes between 12/1/15 and 4/11/16 lacked documentation the resident was experiencing depression and anxiety. Interview with the Social Worker on 4/11/16 at 9:10 a.m.,indicated: No Gradual Dose Reductions have been tried on the [MEDICATION NAME]. Random observations of the resident throughout the day on 4/6/16 and 4/7/16 indicated the resident was very active in all the daily activity events. Interview with LPN #5 on 4/7/16 at 9:05 a.m., indicated that if the resident's door was closed, then her and her roommate were at the activity program and were very difficult to catch. On 4/11/16 at 10:00 a.m., the Director of Nursing (DON) presented a copy of the facility's current policy titled [MEDICAL CONDITION] Management Policy. Review of this policy at this time included, but was not limited to: Policy: It is the policy of American Senior Communities to ensure that a resident's [MEDICAL CONDITION] medication regimen helps promote the resident's highest practical mental, physical, and psychosocial well-being. These medications are managed in collaboration with the attending physician, pharmacist and facility staff to include behavioral interventions, assessment and reduction as applicable. Procedure: .4, The facility will initiate a request for a Gradual Dose Reduction at least on the following schedule for each drug c. For residents who use sedative/hypnotic medication a GDR must be initiated per the following guidelines: - For as long as the resident remains on a sedative hypnotic, the facility should attempt a GDR quarterly unless contraindicated by the physician. For a resident who uses antidepressant medications a GDR must be initiated per the following guidelines: During the first year that the resident is admitted to the facility on an antidepressant or after the facility has initiated an antidepressant, a GDR must be attempted in two separate quarters with at least one month in between attempts, unless contraindicated by the physician. After the first year, a GDR must be attempted annually unless clinically contraindicated by the physician . 3. On 04/07/16 at 2:33 p.m., the review of the MDS (minimum data set) Quarterly review assessment for Resident # 59, dated 02/03/16, indicated a BIMS (Brief Interview for Mental Status) score of 11 (moderately impaired). The Active [DIAGNOSES REDACTED]. The review of the MDS Assessment Significant Change In Status, dated 12/02/15, the CAAs and Care Planning indicated Cognitive Loss/Dementia, ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential, Urinary Incontinence, Falls, Nutritional Status, Dental Care, Pressure Ulcers, and [MEDICAL CONDITION] Medication Use. The review of the Care Plan on 04/07/16 at 2:46 p.m., did not indicate antidepressant use or monitoring the resident for antidepressant drugs or for [MEDICAL CONDITION]. The review on 04/08/16 at 9:29 a.m., of the admitting [DIAGNOSES REDACTED]. On 04/08/16 at 10:21 a.m., the review of the latest Psychiatric Follow-Up Evaluation, dated 03/18/16, indicated the facility requested an evaluation for the resident's increased confusion/[MEDICAL CONDITION]/behaviors. The resident was reported to have repeated delusional physical and verbal aggression and mental status changes. The Psychiatric Nurse Practitioner also indicated the resident was admitted to a local hospital and returned the same day with a [DIAGNOSES REDACTED]. The Psychiatric Nurse Practitioner indicated the need for medical stabilization, which was indicated as the likely cause of the [MEDICAL CONDITION]. [MEDICAL TREATMENT] was suggested to the resident, but the nephrologist indicated the resident was not appropriate, due to comorbidities. The resident was evaluated by the Psychiatrist every 3 months (09/03/15, 12/03/15, 03/03/16). The review of the Pharmacy Medication Regimen Review on 04/08/16 at 10:49 a.m., indicated monthly reviews. No recommendations for GDR (Gradual Dose Reduction) could be located for the Trazadone or [MEDICATION NAME]. On 04/08/16 at 2:40 p.m., the DON (Director of Nursing) provided a copy of the physician's orders [REDACTED]. On the same date a physician's orders [REDACTED]. A review on 04/08/16 at 2:40 p.m., a Behavior Events New/Worsening Behavior Communication Event, dated 03/14/16, documented/indicated the Resident through out day becoming verbally agitated, resident calling others names and states being upset/angry, unable to express why he is upset/angry. No infections, pain, or psychosocial changes/stressors, were indicated. The Physician and family were not notified. The nursing staff tried interventions of Reassurance, redirection, conversation, redirection. On 04/11/16 at 9:34 a.m., the review of the MDS Quarterly review assessment, dated 02/03/16, the Mood indicated, but was not limited to, No presence of Feeling down, depressed, or hopeless. No presence of Trouble falling or staying asleep, or sleeping too much. No Behaviors were indicated. The review of the MDS Assessment Significant Change in Status, dated 12/02/15, the Mood indicated, but was not limited to, No presence of Feeling down, depressed, or hopeless. No presence of Trouble falling or staying asleep, or sleeping too much. No Behaviors were indicated. The review of the MDS Assessment Annual review assessment, dated 08/27/15, indicated but was not limited to, No presence of Feeling down, depressed, or hopeless. No presence of Trouble falling or staying asleep, or sleeping too much. No Behaviors were indicated. The review of the MDS Assessment Quarterly review assessment, dated 06/30/15, but was not limited to, No presence of Feeling down, depressed, or hopeless. No presence of Trouble falling or staying asleep, or sleeping too much. No Behaviors were indicated. During an interview on 04/11/16 at 10:11 a.m., the DON indicated there was no tracking at the facility for behaviors of depression or [MEDICAL CONDITION]. On 04/11/16 at 1:12 p.m., during an interview with LPN (Licensed Practical Nurse) # 1, she indicated, after looking in the behavior monitoring log, she didn't monitor for any behaviors with Resident # 59. The LPN also indicated the resident sleeps well, but there are times he gets up. During an interview on 04/12/16 at 8:54 a.m., the DON indicated the timeliness for a response back from the physician for a pharmacy recommendation was 60 days. The DON indicated the pharmacist would review the charts, generate recommendations for GDRs, review labs, review medications for interactions, dosage, therapeutic interchanges and files a report within 3 business days. The Pharmacist marks on the yellow sheet (Medication Regimen Review) any recommendations made, and if something needs to be performed, she reports it directly to the her at the exit conference. The DON indicated the facility policy for the pharmacist recommendation, was if a recommendation is made and the physician doesn't follow up, then a second request is made. The DON indicated she interacts with the pharmacist and an exit conference is conducted after the pharmacy review. If an evaluation was not conducted by the pharmacist, she would bring it up with the pharmacist. We will wait a week if necessary for an evaluation, if not made. The pharmacist follows the same policy for all medication as recommended for antipsychotics. The physician should write a reason for declination/acceptance of a medication on the rational lines of the recommendation. This sheet asks the physician to indicate the reason for declining or acceptance of the medication recommendation. 3.1-48(2) 3.1-48(3) 3.1-48(4) 3.1-48(6)(b)(1) 3.1-48(6)(b)(2)

Based on interview and record review, the facility failed to monitor residents receiving diuretic therapy. This resulted in a hospitalization for one resident for low potassium. This deficient practice affected 1 of 2 residents reviewed for hospitalization . (Resident #67). Finding includes: Resident #67's clinical record was reviewed on 6/5/14 at 9:27 a.m. He was admitted to the facility on [DATE] after an impatient hospital stay. He had [DIAGNOSES REDACTED]. Resident #67 was scheduled for surgery on 5/16/14. The residents admission Medication Administration Record [REDACTED]. A physicians order dated 4/18/14 and untimed, indicated [MEDICATION NAME] (a diuretic medication) 2 milligrams twice a day. A physicians order dated 4/26/14 and untimed, indicated Zaroxalyn (a diuretic medication) 2.5 milligrams every day. A physicians order, dated 4/18/14 and untimed, indicated Basic Metabolic Panel (a blood lab test that includes potassium levels) every four days. The Basic Metabolic Panel (BMP) results were reviewed for April 2014 and May 2014. The normal value for potassium is 3.5-5.1 mmol/L (milimoles/liter). The potassium levels for Resident #67 were: -On 4/18/14, the potassium level was 3.7 mmol/L. -On 4/22/14, the potassium level was 3.2 mmol/L -On 4/26/14, the potassium level was 3.1 mmol/L. -On 5/14/14, the potassium level was 2.2 mmol/L. -On 5/15/14, the potassium level was 2.9 mmol/L. -On 5/17/14, the potassium level was 3.0 mmol/L. -On 5/18/14, the potassium level was 2.9 mmol/L. The physician was notified of each lab result. Documentation was lacking of any labs between 4/26/14 and 5/14/14. Documentation was lacking that the physician was notified that no labs had been drawn or that the physicians order had changed between 4/26/14 and 5/14/14. Nurses notes, dated 5/15/15 at 11:00 p.m., indicated..."cancel split skin graft surgery for [REDACTED]." A physicians order, dated 5/15/15 and untimed, indicated to send resident to (named) hospital as direct admit related to [DIAGNOSES REDACTED] (low potassium levels). The History and Physical (H&P) from (named) hospital, dated 5/18/14 at 11:31 p.m., was reviewed. The admitting [DIAGNOSES REDACTED].o. (by mouth) potassium. The H&P indicated the resident had low potassium levels for four days prior to admission. The note also indicated the resident could not have his scheduled surgery because of severe [DIAGNOSES REDACTED]. The Discharge Summary from (named) hospital, dated 5/22/14 at 11:27 p.m., was reviewed. The note indicated the resident received potassium intravenously. On 6/4/14 at 1:45 p.m., RN #2 indicated the resident's surgery was postponed due to low potassium levels. She indicated the date for surgery had not been scheduled. On 6/5/15 at 10:11a.m. the Director of Nursing indicated the BMP should have continued to be drawn unless the physician changed or discontinued the order. She was unable to provide documentation that the order had been changed or discontinued. A copy of the policy titled, " physician's orders [REDACTED]."ensure appropriate departments are aware of applicable orders... confirm accuracy of orders when the new monthly orders arrive from the pharmacy...." 3.1-48(a)(6)