Every finding on record at Majestic Care of Connersville

Based on observation, interview, and record review, the facility failed to ensure residents remained free from sexual abuse from Resident C towards Resident B and Resident G, resulting in Resident B experiencing anxiety and fear for 3 of 6 residents reviewed for sexual abuse (Resident C, Resident B and Resident G). Findings include:1a. The clinical record for Resident C was reviewed on 10/27/25 at 10:45 a.m. The diagnoses included, but were not limited to, vascular dementia, depression, anxiety, hypertension, heart failure and epilepsy. The Quarterly Minimum Data Set (MDS) assessment for Resident C, dated 8/22/25, indicated the resident was severely cognitively impaired for daily decision making. The resident was independent with ambulation. The clinical record of Resident C indicated the resident resided on the memory care unit from 4/8/25 until 6/30/25. The resident was moved to the Long Term Care unit on 6/30/25. A progress note for Resident C, dated 6/29/25 at 6:12 p.m., indicated the resident was found with his left hand inside a female resident's shirt and had her right breast in his hand and was physically moving his hand around her breast. The facility staff immediately intervened and separated the residents. Resident C was placed on 15-minute checks and responsible parties were notified. The safety checks for Resident C, dated 10/5/25 through 10/9/25, indicated the resident was being monitored every 15 minutes for sexually acting out. There was no further documentation in the resident's clinical record pertaining to any behaviors that led to the 15 minute checks being initiated. The safety checks for Resident C, dated 10/15/25 through 10/16/25, indicated the resident was being monitored every 15 minutes for sexually acting out. A progress note for Resident C, dated 10/15/25 at 8:11 p.m., indicated a female resident reported to staff that Resident C reached over her shoulder and touched her chest when they were coming inside from a smoke break. Resident C was walking behind the female resident who was in a wheelchair propelling herself. Another resident witnessed the incident and also reported the incident to the staff. Certified Nurse Aide (CNA) 4 had taken residents out to smoke and was inside the door holding it for other residents and did not witness what happened but was immediately alerted once residents were all inside. The nurse immediately alerted the Director of Nursing (DON) and the Nurse Practitioner (NP). Resident C was placed on 15-minute checks and would walk back and forth by a staff member during smoking times. The progress note was electronically signed by Licensed Practical Nurse (LPN) 2. The NP note for Resident C, dated 10/15/25, indicated the resident had increased anxiety and was sexually acting out. The note indicated the medication Lexapro (antidepressant) would be increased to 20 milligrams (mg). The NP note for Resident C, dated 10/16/25, indicated the resident groped a female resident's breast. The facility was to continue to monitor the resident and keep residents separate. The plan of care for Resident C, dated 10/16/25, indicated the resident had a history of approaching female resident and touching inappropriately related to the diagnosis of vascular dementia. The interventions included, but were not limited to, administering medications as ordered, psychiatric (psych) NP to follow as needed, redirect the resident if he attempted to approach a peer while in the wheelchair back to their room, resident needed supervision during supervised smoke breaks and in the dining room, the resident was to be taken out for smoke breaks separate from other residents (dated 10/25/25), and was to be one-on-one supervision at all times (dated 10/25/25). During an interview with Registered Nurse (RN) 1 on 10/27/25 at 11:40 a.m., she indicated she was the nurse, on 10/6/25, and Resident C was on 15-minute checks. RN 1 was unsure why the resident was on 15-minute checks and was unable to find any further documentation besides the 15-minute check sheet for Resident C. During an interview with the DON on 10/27/25 at 1:40 p.m., she indicated, on 10/5/25, it was reported to her that Resident C may have been doing something he should not have been doing. The DON indicated another resident reported that Resident C was being inappropriate with female residents. Resident G might have been one of them. The Social Services Director (SSD) talked with Resident G, and she denied anything happened. There were no further interviews or investigation conducted regarding an allegation pertaining to Resident C. During an interview with LPN 2 on 10/27/25 at 6:40 p.m., she indicated she was the nurse on 10/15/25. LPN 2 indicated Resident B reported to her that Resident C grabbed her chest and it was not the first time he had done this. Resident J also reported the incident as he had witnessed it. LPN 2 indicated she called the DON and reported it; and the DON had LPN 2 put Resident C on 15-minute checks and 1-on-1 supervision during smoke breaks. Resident B reported she felt very uncomfortable, upset, and was fearful he was going to come into her bedroom while she was asleep. LPN 2 indicated she reassured Resident B that the staff would not let Resident C come into her room and provided her with anti-anxiety medication. During an interview with the Regional [NAME] President of Operations on 10/28/25 at 9:43 a.m., he indicated he was the Administrator of the facility, on 10/5/25, and the DON had texted him and said Resident C was touching a female resident and he was unsure who the female resident was. The SSD talked to Resident G, and she did not report anything happened. There were no other residents or staff interviewed. During an interview with the DON on 10/28/25 at 12:45 p.m., she indicated she was unsure why there was no documentation in Resident C's clinical record about the incident on 10/5/25. During an observation on 10/28/25 at 10:10 a.m., there were three female residents and two male residents smoking in the facility's smoking area. Resident C ambulated to the smoking area independently at 10:15 a.m. and sat next to a staff member. 1b. During an interview with Resident J on 10/28/25 at 10:35 a.m., he indicated he had witnessed Resident C, on two different occasions, touching female residents inappropriately. Resident J indicated a few weeks ago, unsure of the date, he witnessed Resident C pushing Resident G's wheelchair and was rubbing her hair. Resident J indicated he was unable to see what else Resident C did because he was walking in front of him. Resident G told Resident J that if Resident C ever touched her like that again she would smack the s--t out of him. The other episode Resident J witnessed a couple weeks ago, unsure of date, was Resident C pushing Resident B in her wheelchair and he put his hands down her shirt and Resident J reported it to LPN 2. Resident J indicated Resident B was trying to push Resident C's hands away. Resident J indicated no one from management had interviewed him about these two incidents. The admission MDS assessment for Resident J, dated 8/5/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. During an interview with RN 1 on 10/28/25 at 10:47 a.m., she indicated she remembered, on 10/5/25, that Resident C was on 15-minute checks because he was sexually acting out towards female residents. RN 1 was unsure who the female residents were. During an observation and interview on 10/28/25 at 10:50 a.m., CNA 4 was sitting outside Resident C's room. CNA 4 indicated she was sitting 1-on-1 with Resident C, but she was unsure why the resident was on 1-on-1. During an interview with the CNA 4 on 10/28/25 at 12:04 p.m., she indicated she was working, on 10/15/25, when there was an allegation of sexual abuse with Resident C. CNA 4 indicated she had taken the residents out to smoke and was holding the door open for the residents to come back into the facility. CNA 4 indicated she did not witness Resident C touch Resident B. CNA 4 indicated Resident B and Resident J was mad and reported to LPN 2 that Resident C had touched Resident B's chest. CNA 4 indicated she was not aware that Resident C had a history of sexually inappropriate behaviors, but she did know he was moved from the memory care unit because he liked to girlfriend everyone. 1c. The clinical record for Resident B was reviewed on 10/27/25 at 1:30 p.m. The diagnoses included, but were not limited to, nicotine dependance, anxiety disorder, and major depressive disorder. A Significant Change MDS assessment, dated 9/19/25, indicated Resident B was moderately cognitively impaired. During an interview with Resident B on 10/27/25 at 11:38 a.m. Resident B indicated a couple weeks prior she was being wheeled back into the facility in her wheelchair after smoking by Resident C. Resident B indicated Resident C while standing behind her started rubbing her shoulder, then reached his hand down the front of Resident B's chest area. Resident B indicated she then swiped Resident C's hand away. Resident B indicated she then informed LPN 2 that Resident C had tried to touch her chest while wheeling her in her wheelchair back into the facility. A progress note, dated 10/15/25 at 8:30 p.m., indicated Resident B alerted staff that another resident had reached over her shoulder and touched her chest when coming inside from a smoke break. Resident B stated she swatted his hand away. Another resident witnessed this happen and also alerted staff of what he saw. The aide that had taken the residents out to smoke was inside the door holding it for others and did not witness what had happened but was immediately alerted once residents were all inside. The nurse immediately alerted the DON. An eCare Triage note, dated 10/16/25, indicated LPN reported that Resident B alerted staff that another resident groped her breast on the way inside from the 8:00 p.m. smoke break. Another resident witnessed the event. The DON was notified. The Medication Administration Record (MAR) indicated Resident B received buspirone HCL 5 mg (milligram) scheduled tablet at bedtime, on 10/15/25, for anxiety. 1d. The clinical record for Resident G was reviewed on 10/28/25 at 9:40 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and depression. The Quarterly MDS assessment, dated 9/19/25, indicated Resident G was moderately cognitively impaired. During an interview with Resident G on 10/27/25 at 1:55 p.m., Resident G indicated a couple weeks prior that she was wheeling herself in her wheelchair down the hallway when Resident C came up behind her and started pushing the wheelchair for her. Resident G indicated Resident C took his hand and started sliding it down the front of her chest. Resident G indicated she swiped his hand away and told him to cut it out. Resident G indicated she had told a couple of staff members. Resident G indicated these sexual behaviors keep happening outside when residents were coming back in from the smoking area with Resident C, but no one ever sees it. Resident G indicated the DON had not come in to speak with her about this event. An Abuse, Mistreatment, Neglect, Exploitation and Misappropriation policy was provided by the DON on 10/27/25 at 11:00 a.m. It indicated .Sexual abuse is a non-consensual sexual contact of any type with a resident .C. Prevention & Identification (b.) identifying, correcting, and intervening in situations in which abuse is more likely to occur .D. Protect the Resident (b.)3) The facility will ensure other residents are protected This citation is related to Intake 2644466. 3.1-27(a)(1)

Based on interview and record review, the facility failed to complete a thorough investigation and ensure protection from further allegations of sexual abuse resulting in a second allegation of abuse where the resident experienced anxiety and fear for 3 of 6 residents reviewed for sexual abuse (Resident C, Resident B, and Resident G).Findings include:1. The clinical record for Resident C was reviewed on 10/27/25 at 10:45 a.m. The diagnoses included, but were not limited to, vascular dementia, depression, anxiety, hypertension, heart failure and epilepsy. The Quarterly Minimum Data Set (MDS) assessment for Resident C, dated 8/22/25, indicated the resident was severely cognitively impaired for daily decision making. The resident was independent with ambulation. The safety checks for Resident C, dated 10/5/25 through 10/9/25, indicated the resident was being monitored every 15 minutes for sexually acting out. There was no further documentation in the resident's clinical record pertaining to any behaviors that led to the 15-minute checks being initiated. The safety checks for Resident C, dated 10/15/25 through 10/16/25, indicated the resident was being monitored every 15 minutes for sexually acting out. A progress note for Resident C, dated 10/15/25 at 8:11 p.m., indicated a female resident reported to staff that Resident C reached over her shoulder and touched her chest when they were coming inside from a smoke break. Resident C was walking behind the female resident who was in a wheelchair propelling herself. Another resident witnessed the incident and also reported the incident to the staff. Certified Nurse Aide (CNA) 4 had taken the residents out to smoke and was inside the door holding it for other residents and did not witness what happened, but was immediately alerted once residents were all inside. The nurse immediately alerted the Director of Nursing (DON) and the Nurse Practitioner (NP). Resident C was placed on 15-minute checks and would walk back and forth by a staff member during smoking times. The progress note was electronically signed by Licensed Practical Nurse (LPN) 2. During an interview with Registered Nurse (RN) 1 on 10/27/25 at 11:40 a.m., she indicated she was the nurse, on 10/6/25, and Resident C was on 15-minute checks. RN 1 was unsure why the resident was on 15-minute checks and was unable to find any further documentation besides the 15-minute check sheet for Resident C. During an interview with the DON on 10/27/25 at 1:40 p.m., she indicated, on 10/5/25, it was reported to her that Resident C may have been doing something he should not have been doing. The DON indicated another resident reported that Resident C was being inappropriate with female residents. Resident G might have been one of them. The Social Services Director (SSD) talked with Resident G, and she denied anything happened. There were no further interviews or investigation completed regarding the allegation. During an interview with LPN 2 on 10/27/25 at 6:40 p.m., she indicated she was the nurse on 10/15/25. LPN 2 indicated Resident B reported to her that Resident C grabbed her chest and it was not the first time he had done this. Resident J also reported the incident as he had witnessed it. LPN 2 indicated she called the DON and reported it. The DON had LPN 2 put Resident C on 15-minute checks and 1-on-1 during smoke breaks. Resident B reported she felt very uncomfortable, upset, and was fearful he was going to come into her bedroom while she was asleep. LPN 2 indicated she reassured Resident B that the staff would not let Resident C come into her room and provided her with anti-anxiety medication. During an interview with the Regional [NAME] President of Operations on 10/28/25 at 9:43 a.m., he indicated he was the Administrator of the facility, on 10/5/25, and the DON had texted him and said Resident C was touching a female resident and he was unsure who the female resident was. The SSD talked to Resident G, and she did not report that anything happened. There were no other residents or staff interviewed regarding the allegation. During an interview with Resident J on 10/28/25 at 10:35 a.m., he indicated he had witnessed Resident C on two different occasions touching female residents inappropriately. Resident J indicated a few weeks ago, unsure of the date, he witnessed Resident C pushing Resident G's wheelchair and was rubbing her hair. Resident J indicated he was unable to see what else Resident C did because he was walking in front of him. Resident G told Resident J that if Resident C ever touched her like that again she would smack the s--t out of him. The other episode Resident J witnessed a couple weeks ago, unsure of date, was Resident C pushing Resident B in her wheelchair and he put his hands down her shirt and Resident J reported it to LPN 2. Resident J indicated Resident B was trying to push Resident C's hands away. Resident J indicated no one from management had interviewed him about these two incidents. The admission MDS assessment for Resident J, dated 8/5/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. During an interview with RN 1 on 10/28/25 at 10:47 a.m., she indicated she remembered, on 10/5/25, that Resident C was on 15-minute checks because he was sexually acting out towards female residents. RN 1 was unsure who the female residents were. During an interview with the DON on 10/28/25 at 12:04 p.m., she indicated the facility got statements from LPN 2 and CNA 4 about the incident with Resident C and Resident G on 10/15/25, and there were no further resident or staff interviews completed. The DON indicated it was the responsibility of the Interdisciplinary Team (IDT) to ensure a complete and thorough investigation was conducted for allegations of sexual abuse. 2. The clinical record for Resident B was reviewed on 10/27/25 at 1:30 p.m. The diagnoses included, but were not limited to, nicotine dependance, anxiety disorder, and major depressive disorder.A Significant Change MDS assessment, dated 9/19/25, indicated Resident B was moderately cognitively impaired.A progress note, dated 10/15/25 at 8:30 p.m., indicated Resident B alerted staff that another resident had reached over her shoulder and touched her chest when coming inside from a smoke break. Resident B stated she swatted his hand away and another resident had witnessed this happen and also alerted staff of what he saw. The aide that had taken the residents out to smoke was inside the door holding it for others, and did not witness what happened but was immediately alerted once residents were all inside. The nurse immediately alerted the DON. During an interview with Resident B on 10/27/25 at 11:38 a.m., Resident B indicated a couple weeks prior she was being wheeled by Resident C back into the facility in her wheelchair after smoking. Resident B indicated Resident C started rubbing her shoulders while standing behind her, then reached his hand down the front of Resident B's chest area. Resident B indicated she then swiped Resident C's hand away. Resident B indicated she then informed LPN 2 that Resident C had tried to touch her chest while wheeling her in her wheelchair back into the facility.3. The clinical record for Resident G was reviewed on 10/28/25 at 9:40 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and depression.The Quarterly MDS assessment, dated 9/19/25, indicated Resident G was moderately cognitively impaired. During an interview with Resident G on 10/27/25 at 1:55 p.m., Resident G indicated a couple weeks prior she was wheeling herself in her wheelchair down the hallway when Resident C was pushing the wheelchair for her. Resident G indicated Resident C took his hand and started sliding it down the front of her chest. Resident G indicated she swiped his hand away and told him to cut it out. Resident G indicated she had told a couple of staff members but was unsure of their names. Resident G indicated these sexual behaviors kept happening outside when residents were coming back in from the smoking area with Resident C, but no one ever sees it. Resident G indicated the DON had not spoken to her about this event.The abuse policy was provided by the DON on 10/27/25 at 11:00 a.m. The policy indicated once the Administrator and the Indiana Department of Health (IDOH) were notified about an allegation of abuse, an investigation would be conducted. The investigation must be completed within 5 working days. The investigation generally would take the following actions: interview the resident/patient, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with resident/patient the day of the incident (residents, family members), employees who worked closely with the accused person and/or alleged victim the day of the incident. Review all relevant medical reports and records. This citation is related to Intake 2644466.3.1-28(d)

Based on interview and record review, the facility failed to report an allegation of sexual abuse to the Indiana Department of Health (IDOH) for 2 of 6 residents reviewed for sexual abuse (Resident C and Resident G). Findings include:1. The clinical record for Resident C was reviewed on 10/27/25 at 10:45 a.m. The diagnoses included, but were not limited to, vascular dementia, depression, anxiety, hypertension, heart failure and epilepsy. The Quarterly Minimum Data Set (MDS) assessment for Resident C, dated 8/22/25, indicated the resident was severely cognitively impaired for daily decision making. The resident was independent with ambulation. The safety checks for Resident C, dated 10/5/25 through 10/9/25, indicated the resident was being monitored every 15 minutes for sexually acting out. There was no further documentation in the resident's clinical record pertaining to any behaviors that led to the 15-minute checks being initiated. During an interview with Registered Nurse (RN) 1 on 10/27/25 at 11:40 a.m., she indicated she was the nurse, on 10/6/25, and Resident C was on 15-minute checks. RN 1 was unsure why the resident was on 15-minute checks and was unable to find any further documentation besides the 15-minute check sheet for Resident C. During an interview with the Director of Nursing (DON) on 10/27/25 at 1:40 p.m., she indicated, on 10/5/25, it was reported to her that Resident C may have been doing something he should not have been doing. The DON indicated another resident reported that Resident C was being inappropriate with female residents. Resident G might have been one of them. The DON indicated the incident was not reported to IDOH. During an interview with the Regional [NAME] President of Operations on 10/28/25 at 9:43 a.m., he indicated he was the Administrator of the facility, on 10/5/25, and the DON had texted him and said Resident C was touching a female resident and he was unsure who the female resident was. The allegation was not reported to IDOH. During an interview with RN 1 on 10/28/25 at 10:47 a.m., she indicated she remembered, on 10/5/25, that Resident C was on 15-minute checks because he was sexually acting out towards female residents. RN 1 was unsure who the female residents were. During an interview with the DON on 10/28/25 at 12:45 p.m., she indicated she was unsure why there was no documentation in Resident C's clinical record about the incident on 10/5/25. 2. The clinical record for Resident G was reviewed on 10/28/25 at 9:40 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and depression.The Quarterly MDS assessment, dated 9/19/25, indicated Resident G was moderately cognitively impaired. During an interview with Resident G on 10/27/25 at 1:55 p.m., Resident G indicated a couple weeks ago that she was wheeling herself in her wheelchair down the hallway when Resident C came up behind her and started pushing the wheelchair. Resident G indicated Resident C took his hand and started sliding it down the front of her chest. Resident G indicated she swiped his hand away and told him to cut it out. Resident G indicated she had told a couple of staff members but were unsure of their names. Resident G indicated these sexual behaviors keep happening outside when residents were coming back in from the smoking area with Resident C, but no one ever sees it. Resident G indicated the DON had not spoken with her about this event.The abuse policy was provided by the DON on 10/27/25 at 11:00 a.m. The policy indicated if there was an allegation of abuse the Administrator would notify the IDOH. This citation relates to Intake 2644466. 3.1-28(c)

Based on interview and record review, the facility failed to implement individualized interventions for a resident with dementia who exhibited behaviors of being sexually inappropriate towards female residents for 3 of 6 residents reviewed for abuse (Resident C, Resident B and Resident G). Findings include:A.) The clinical record for Resident C was reviewed on 10/27/25 at 10:45 a.m. The diagnoses included, but were not limited to, vascular dementia, depression, anxiety, hypertension, heart failure and epilepsy. The Quarterly Minimum Data Set (MDS) assessment for Resident C, dated 8/22/25, indicated the resident was severely cognitively impaired for daily decision making. The resident was independent with ambulation. A progress note for Resident C, dated 6/29/25 at 6:12 p.m., indicated the resident was found with his left hand inside a female resident's shirt and had her right breast in his hand and was physically moving his hand around her breast. Writer immediately intervened and separated the residents. Resident C was placed on 15-minute checks. The clinical record of Resident C indicated the resident resided on the memory care unit from 4/8/25 until 6/30/25. The resident was moved to the Long-Term Care unit on 6/30/25.The safety checks for Resident C, dated 10/5/25 through 10/9/25, indicated the resident was being monitored every 15 minutes for sexually acting out. There was no further documentation in the resident's clinical record regarding behaviors that prompted the initiation of 15-minute checks for Resident C. The safety checks for Resident C, dated 10/15/25 through 10/16/25, indicated the resident was being monitored every 15 minutes for sexually acting out. A progress note for Resident C, dated 10/15/25 at 8:11 p.m., indicated a female resident reported to staff that Resident C reached over her shoulder and touched her chest when they were coming inside from a smoke break. Resident C was walking behind the female resident who was in a wheelchair propelling herself. Another resident witnessed the incident and also reported the incident to the staff. Certified Nurse Aide (CNA) 4 had taken the residents out to smoke and was inside the door holding it for other residents and did not witness what happened, but was immediately alerted once all residents were inside. The nurse immediately alerted the Director of Nursing (DON) and the Nurse Practitioner (NP). Resident C was placed on 15-minute checks and would walk back and forth by a staff member during smoking times. The progress note was electronically signed by Licensed Practical Nurse (LPN) 2. The NP note for Resident C, dated 10/16/25, indicated the resident groped a female resident's breast. The facility was to continue to monitor the resident and keep residents separate. The plan of care for Resident C, dated 10/16/25, indicated the resident had a history of approaching female residents' and touching residents' inappropriately related to the diagnosis of vascular dementia. The interventions included, but were not limited to, administering medications as ordered, psychiatric (psych) NP to follow as needed, redirect the resident if he attempted to propel a peer while in the wheelchair back to their room, resident needed supervision during supervised smoke breaks and in the dining room, the resident was to be taken out for smoke breaks separate from other residents (dated 10/25/25), and was to be one-on-one supervision at all times (dated 10/25/25). The Kardex for Resident C provided by the Regional Nurse Consultant, on 10/29/25 at 11:10 a.m., indicated no documentation or alert for sexually inappropriate behaviors. During an interview with Registered Nurse (RN) 1 on 10/27/25 at 11:40 a.m., she indicated she was the nurse, on 10/6/25, and Resident C was on 15-minute checks. RN 1 was unsure why the resident was on 15-minute checks and was unable to find any further documentation besides the 15-minute check sheet for Resident C. During an interview with the Director of Nursing (DON) on 10/27/25 at 1:40 p.m., she indicated, on 10/5/25, it was reported to her that Resident C may have been doing something he should not have been doing. The DON indicated another resident reported that Resident C was being inappropriate with female residents. Resident G might have been one of them. The Social Services Director (SSD) talked with Resident G, and she denied anything happened. There were no further interviews nor investigation being completed. During an interview with LPN 2 on 10/27/25 at 6:40 p.m., she indicated she was the nurse on 10/15/25. LPN 2 indicated Resident B reported to her that Resident C grabbed her chest and it was not the first time he had done this. Resident J also reported the incident as he had witnessed it. LPN 2 indicated she called the DON and reported it. The DON had LPN 2 put Resident C on 15-minute checks and 1-on-1 during smoke breaks. Resident B reported she felt very uncomfortable, upset and was fearful Resident C was going to come into her bedroom while she was asleep. LPN 2 indicated she reassured Resident B that the staff would not let Resident C come into her room and provided her with anti-anxiety medication. During an interview with the Regional [NAME] President of Operations on 10/28/25 at 9:43 a.m., he indicated he was the Administrator of the facility, on 10/5/25, and the DON had texted him and said Resident C was touching a female resident and he was unsure who the female resident was. During an interview with RN 1 on 10/28/25 at 10:47 a.m., she indicated she remembered, on 10/5/25, that Resident C was on 15-minute checks because he was sexually acting out towards female residents. RN 1 was unsure who the female residents were. During an interview with CNA 4 on 10/28/25 at 12:04 p.m., she indicated she was working, on 10/15/25, when there was an allegation of sexual abuse with Resident C. CNA 4 indicated she was not aware that Resident C had a history of sexually inappropriate behaviors, but she did know he was moved from the memory care unit because he liked to girlfriend everyone. During an interview with the DON on 10/28/25 at 12:45 p.m., she indicated the facility moved Resident C to the long-term care unit because the facility did not feel like Resident C was the instigator. The female residents on the memory care unit gravitated towards Resident C and was encouraging it. The DON indicated staff were made aware of residents with sexually inappropriate behaviors by the care plan and the Kardex.B.) The clinical record for Resident B was reviewed on 10/27/25 at 1:30 p.m. The diagnoses included, but were not limited to, nicotine dependance, anxiety disorder, and major depressive disorder.A Significant Change MDS assessment, dated 9/19/25, indicated Resident B was moderately cognitively impaired.During an interview with Resident B on 10/27/25 at 11:38 a.m., Resident B indicated a couple weeks prior she was being wheeled back into the facility in her wheelchair after smoking by Resident C. Resident B indicated Resident C was standing behind her and started rubbing her shoulder; then reached his hand down the front of Resident B's chest area. Resident B indicated she then swiped Resident C's hand away. Resident B indicated she then informed LPN 2 that Resident C had tried to touch her chest while wheeling her in her wheelchair back into the facility.C.) The clinical record for Resident G was reviewed on 10/28/25 at 9:40 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and depression.The Quarterly MDS assessment, dated 9/19/25, indicated Resident G was moderately cognitively impaired. During an interview with Resident G on 10/27/25 at 1:55 p.m., Resident G indicated a couple weeks prior that she was wheeling herself in her wheelchair down the hallway when Resident C was pushing the wheelchair for her. Resident G indicated Resident C took his hand and started sliding it down the front of her chest. Resident G indicated she swiped his hand away and told him to cut it out. Resident G indicated she had told a couple of staff members but were unsure of the names. Resident G indicated these sexual behaviors keep happening outside when residents were coming back in from the smoking area with Resident C, but no one ever sees it. Resident G indicated the DON had not spoken to her about this event.The dementia care policy was provided by the Regional Nurse Consultant on 10/29/25 at 11:15 a.m. The policy indicated the facility would provide appropriate treatment and services in relation to Activities of Daily Living to ensure all needs are met on a daily basis, while attaining or maintaining the dementia resident's highest practicable physical, mental and psychosocial well-being. The plan of care would describe potential distress triggers or behaviors as related to Activities of Daily Living. The care plan would include strategies and approaches to address distress triggers or behaviors so the level of distress could be minimized. The care plan interventions would be monitored on an ongoing basis for effectiveness. This citation is related to Intake 2644466.3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for 3 of 3 rooms observed with peeling and missing paint on the walls. (Resident 10, Resident 12, and Resident 26)Findings include: During an observation of Resident 26's room on 8/21/25 at 12:15 p.m., missing chipped paint was observed all along the wall adjacent to Resident 26's bed. Another observation of Resident 26's room, on 8/25/25 at 1:56 p.m., displayed missing and chipped paint all along the wall adjacent to Resident 26's bed.During an observation of Resident 12's room on 8/21/25 at 12:39 p.m., missing paint was observed on one wall. Another observation of Resident 12's room, on 8/25/25 at 1:57 p.m., displayed missing paint on one wall.During an observation of Resident 10's room on 8/21/25 at 12:40 p.m., missing paint was observed on one wall. Another observation of Resident 10's room, on 8/25/25 at 1:59 p.m., displayed missing paint on one wall.An environmental tour was conducted on 8/26/25 at 11:26 a.m. with the Executive Director (ED) and Director of Maintenance. During the tour, Resident 26's room had missing and chipped paint all along the wall adjacent to Resident 26's bed. The Director of Maintenance indicated Resident 26's bed was replaced about a month ago and the other bed must have been covering it up. Resident 12's room was observed again with missing paint on one wall. The Director of Maintenance indicated it was from a sticker that was peeled off of the wall. Resident 10's room was observed with missing paint on one wall. The Director of Maintenance indicated the missing paint was from where a window air conditioner was removed about a week ago and the spot was filled with drywall and just needed to be painted.The Resident Rights policy was provided by the Director of Nursing (DON) on 8/27/25 at 9:45 a.m. It indicated, .8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure care plan meetings were held quarterly for 1 of 1 resident reviewed for care planning. (Resident 1)Findings include: The clinical record for Resident 1 was reviewed on 8/22/25 at 12:51 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus and dementia. The Electronic Health Record (EHR) indicated Resident 1 had a care plan meeting, on 8/8/24, and did not have another care plan meeting until 2/6/25. During an interview with the Social Service Director (SSD) on 8/26/25 at 9:56 a.m., she indicated she did not know why Resident 1 did not have a care plan meeting in between the dates of 8/8/24 and 2/6/25. The SSD indicated the memory care social worker who would have been responsible for the meeting was no longer at the facility. The SSD indicated it was social services who were responsible for ensuring care plan meetings were held quarterly for residents. The Care Conferences policy was provided by the Director of Nursing (DON) on 8/27/25 at 9:45 a.m. It indicated, .C. The resident/patient, family and/or the resident's/patient's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's/patient's care plan .D. care conferences will be scheduled routinely .F. Every effort will be made to schedule care plan meetings . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident received showers as preferred for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident 29)Findings include:The clinical record for Resident 29 was reviewed on 8/22/2025 at 11:43 a.m. The medical diagnosis included traumatic brain injury and anxiety.A Quarterly Minimum Data Set assessment, dated 7/2025, indicated Resident 29 was cognitively intact, did not reject care, and needed set-up or cleanup assistance for showers. An ADL care plan, revised 07/25/2025, indicated for staff to assist Resident 29 with activities of daily living as needed. A care task, dated 5/26/2025, indicated Resident 29 was to have showers on Wednesday and Saturday evenings, and as needed. Review of the electronic and paper shower documentation for 8/1/2025-8/26/2025 indicated Resident 29 missed a shower on 8/20/2025.Resident council minutes, dated 8/20/2025, indicated Resident 29 had a concern of, .only getting one shower a week.During an interview and observation on 8/21/2025 at 1:49 p.m., Resident 29 indicated he was missing showers once every week to every other week. Resident 29's hair was greasy at that time. Resident 29 stated the last time he missed a shower was last night because .there was not enough help.During an interview and observation on 8/22/2025 at 1:35 p.m., Resident 29 was noted to have greasy and unkempt hair. Resident 29 said a replacement shower had not been offered to him. During an interview on 8/27/2025 at 1:10 p.m., the Administrator indicated shower sheets were routinely audited, usually on the next business day, and if missed showers were noted, a replacement shower was offered. A policy entitled, Showers, was provided by the Director of Nursing on 8/27/2025 at 12:20 p.m. The policy indicated, .Residents will be provided showers as per request or per facility schedule.3.1-38(a)(2)(A)3.1-38(a)(3)(A)3.1-38(a)(3)(B)

Based on observation, interview, and record review, the facility failed to ensure food items were not stored in a medication storage fridge for 1 of 2 medication rooms observed. Findings include: An observation was conducted of the medication storage room on the rehabilitation hallway with Unit Manager (UM) 20 on 8/22/25 at 10:05 a.m. There were four nutritional shakes located in the bottom pull out drawer of the medication storage fridge. UM 20 indicated the facility utilized the bottom drawer of the medication storage fridge for supplements. An interview was conducted with the Director of Nursing on 8/22/25 at 10:45 a.m. She indicated there was a nourishment fridge meant for supplements and/or food items for the residents. Food items should not be stored in the medication storage fridge. A policy entitled Medication Storage, dated 12/12/23, was provided by the Executive Director on 8/22/25 at 2:17 p.m. The policy indicated ensuring all medications housed on the premises will be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 3.1-25(m)

Based on interview and record review, the facility failed to ensure accurate documentation of a lack of bowel movements, which contributed to not following physician's orders related to PRN (as needed) administration of medications to encourage stooling for 1 of 3 residents reviewed for monitoring of bowel movements. (Resident C) Findings include: The clinical record for Resident C was reviewed on 5-6-25 at 1:30 p.m. His diagnoses included, but were not limited to, unspecified dementia, COPD (chronic obstructive pulmonary/lung disease), left femur/hip fracture (4-3-25) and a history of constipation. His most recent Minimum Data Set (MDS) assessment, dated 4-15-25, indicated he was severely cognitively impaired, used a wheelchair for mobility, and was dependent on staff for bed mobility, toileting, bathing, and transfers. It indicated he was not ambulatory. It indicated he had been hospitalized from 4-1-25 to 4-8-25, related to the recent femur/hip fracture and repair. A review of the progress notes reflected Resident C did utilize narcotic pain medication for pain control during his post-operative period. Resident C had a care plan in place which recognized him as being at risk for constipation. During an interview with the Director of Nursing (DON) on 5-6-25 at 2:50 p.m., she indicated Resident C's BM (bowel movement or stooling) documentation in the facility's electronic medical record (EMR), for the time period of 4-12-25 through 4-16-25, revealed he did not have a BM during this time frame. The DON indicated the BM charting within the EMR provides several selections to indicate a lack of stooling. For this time period for Resident C, the selection was listed as, Response Not Required, referring to a lack of a BM. She indicated a better choice of the available selections would have been, No bowel movement. The DON indicated the EMR system should have sent an alert to the nursing staff to identify this resident had not had a BM within a 72-hour period and she was unable to locate such an alert. The DON indicated the facility does not have a specific policy related to a bowel protocol for lack of stooling. However, the majority of residents do have physician orders for no BM within three consecutive days, the resident should be administered with a PRN laxative, such as Milk of Magnesia. If there was still no stool within the next 24 hours, to administer a laxative suppository, such as Dulcolax suppository. If there was still no stool within 24 hours, to administer a laxative enema, such as a Fleet enema. Then if there was still no response, the nursing staff should reach out to the physician or nurse practitioner for further guidance and/or care orders for the resident. The DON indicated Resident C did not display any symptoms of abdominal discomfort during this time period. The DON indicated when Resident C returned to the facility, on 4-8-25, he was physician ordered to receive routine docusate, a stool softener, twice daily and senna-docusate, a stool softener and laxative stimulant, twice daily. These medications were identified as administered as ordered. A review of the progress notes did not reflect any stooling concerns, including no documentation of the lack of stooling during this time period. It did not indicate the physician or nurse practitioner were made aware of Resident C being constipated and/or without a bowel movement within 72 hours. A review of the medication administration record (MAR) during this time indicated the orders for the following PRN medications were not administered to Resident C: -Glycolax Powder (an osmotic laxative); one scoop by mouth every 12 hours as needed for constipation. -Milk of Magnesia Suspension 400 mg (milligrams) per 5 ml (milliliters), give 30 ml by mouth every 24 hours as needed for constipation if no bowel movement for three days. -Dulcolax Suppository 10 mg (Bisacodyl); insert one suppository rectally every 24 hours as needed for constipation if no result from Milk of Magnesia, administer Dulcolax Suppository rectally at bedtime for constipation. -Fleet Oil Enema (mineral oil); insert one dose rectally every 24 hours as needed for constipation if no results from Dulcolax, administer Fleet enema rectally daily as needed for constipation. This citation relates to Complaint IN00458469. 3.1-37(a)

Based on observation, interview, and record review the facility failed to maintain the entry door into the main kitchen resulting in rodents entering the (west) building for 1 of 2 kitchens observed. This had the potential to affect the 42 residents that resided in the west building. Findings include: The resident listing provided by the Administrator on 9/25/24 at 11:00 a.m., indicated there were 42 residents residing in the west building. During an observation and interview with the Dietary Manager on 9/25/24 at 11:05 a.m., there were mice traps set in the west building kitchen and the east kitchen. The Dietary Manager indicated a pest control company came every month and checked the traps. During an observation on 9/25/24 at 12:30 p.m., the west building kitchen door to the outside was shut and did not have a seal around the door. During an interview with Licensed Practical Nurse (LPN) 1 on 9/25/24 at 1:28 p.m., indicated she had seen a mouse in Resident H's room in the west building last week and reported it to the Maintenance staff. During an interview with the Pest Control Technician on 9/26/24 at 11:32 a.m., indicated he was the technician that serviced the facility monthly, and they had an ongoing problem with mice in the west building. The Pest Control Technician indicated from his assessment of the facility the cause was from the kitchen door from the kitchen to the outside not sealing all the way, shutting all the way and staff propping the door open. The Pest Control Technician indicated he had talked with the head of maintenance about the door. During an observation and interview with the Dietary Manager in Training on 9/26/24 at 1:18 p.m., there was a brick located to the right of the exterior kitchen door in the west building. The Dietary Manager in Training indicated staff used the brick to prop open the kitchen door when dietary staff were coming in and out and the dietary staff did not close the door all the way to latch because it locked. During an interview with the Maintenance Director on 9/27/24 at 11:14 a.m., indicated he had attempted to fix the kitchen door in the west building numerous times, but it needed replaced. There had been multiple times the Pest Control Technician had taken a rock out of the door where staff had propped it open. The dietary staff say they prop the door open because it locks when they shut it, and they cannot get back in. The dietary staff broke the lock mechanism off the doorknob. The pest control report for the west building, dated 5/24/24, indicated the action required was to keep the kitchen door shut to avoid pest entry and/or fix the door so it would fully close. The door was observed to be slightly open and was often propped open. It was unclear if the door could close properly. The door was opened on 3/29/24. The rodent traps had two house mice in them. The pest control report for the west building, dated 6/24/24, indicated there were two deer mice in the rodent trap. The pest control report for the west building, dated 7/29/24, indicated there was one house mouse in the rodent trap. The pest control report for the west building, dated 8/26/24, indicated the action required was to keep the kitchen door shut to avoid pest entry and/or fix the door so it would fully close. The door was observed to be slightly open and was often propped open. It was unclear if the door could close properly. The pest control report for the west building, dated 9/20/24, indicated the action required was to keep the door shut to avoid pest entry and/or fix the door so it would fully close. The door was observed slightly open and was often found propped open. It was unclear if the door could close properly. There was one house mouse in the rodent trap. The pest control policy provided by the Administrator on 9/27/24 at 11:05 a.m., indicated it was the facilities policy to maintain an effective pest control program that eradicates and contains common household rodents. This citation relates to Complaint IN00443547. 3.1-19(f)(4)

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 5 of 7 residents reviewed for environment (Resident 18, Resident 1, Resident 75, Resident 38, and Resident 64). Findings include: 1. During an observation, on 7/23/24 at 12:40 p.m., Resident 18's bedroom was bare. The resident had no personal belongings and no pictures. The resident had a broken clock on the wall. During an observation, on 7/25/24 at 10:52 a.m., Resident 18's bedroom was bare. The resident had no personal belongings and no pictures. The resident had a broken clock on the wall. Review of the record of Resident 18, on 7/29/24 at 10:38 a.m., indicated the diagnoses included, but were not limited to, schizophrenia, hypertension, major depressive disorder, Alzheimer's disease, dementia, and moderate intellectual disabilities. The plan of care for Resident 18, dated 8/3/22, indicated the resident desired to remain in the facility long term. The interventions included, but were not limited to, encourage resident and family to create a familiar and homelike environment. The plan of care for Resident 18, dated 8/4/22, indicated the resident resided on a secured memory care unit due to diagnosis of dementia and benefits from specialized activity care programming. The resident had a diagnosis of Alzheimer's disease. The interventions included, but were not limited to, maintain the room as homelike as possible. 2. During an observation, on 7/23/24 at 12:44 p.m., Resident 1 was lying in bed. The resident had no pictures, a clock, or any personal items in her bedroom. Resident 1 indicated she did not like her bedroom. During an observation, on 7/25/24 at 11:00 a.m., Resident 1 was lying in bed. The resident had no pictures, a clock, or any personal items in her bedroom. Resident 1 indicated she hated her bedroom and did not feel like it was homelike. Review of the record of Resident 1, on 7/25/24 at 11:50 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease (COPD), dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The plan of care for Resident 1, dated 4/13/22, indicated the resident resided on a secured memory care unit due to the diagnosis of dementia. The intervention included, but were not limited to, maintain the room as homelike as possible. The Annual Minimum Data Set assessment for Resident 1, dated 4/4/24, indicated the resident was cognitively intact for daily decision making. During an observation and interview with the Social Service Director (S.S.D.), on 7/26/24 at 11:55 a.m., they agreed that Resident 18 and Resident 1's bedrooms were not homelike. The S.S.D. indicated it was Social Services, Nursing, and Marketing responsibility to ensure resident bedrooms were homelike. 45291 3. The clinical record for Resident 75 was reviewed on 7/26/24 at 2:33 p.m. The medical diagnosis included bipolar disorder. A Quarterly Minimum Data Set assessment, dated 7/4/24, indicated that Resident 75 was cognitively intact. During an observation and interview, on 7/23/2024 at 1:29 p.m., Resident 75 indicated that the blinds in her room had a large break on the right-hand side. A napkin was placed over the opening and per Resident 75 they have been broken for some time. 4. The clinical record for Resident 38 was reviewed on 7/26/24 at 2:34 p.m. The medical diagnosis included COPD and stroke. A Quarterly Minimum Data Set Assessment, dated 6/10/24, indicated that Resident 38 was cognitively intact. During an observation and interview, on 7/23/24 at 12:30 p.m., Resident 38 indicated the over bed light does not work all the time and she has one light out in her bathroom. She demonstrated pulling the cord to her over bed light seven times before it turned on. The right side of the light over the sink the bathroom did not turn on. Resident 38 stated she had told multiple staff about the lights being out, but they have not been fixed. 5. The clinical record for Resident 64 was reviewed on 7/26/24 at 2:37 p.m. The medical diagnosis included heart failure. A Quarterly Minimum Data Set Assessment, dated 4/24/24, indicated that Resident 64 was cognitively intact. During an observation, on 7/24/24 11:05 a.m., the light over the sink in Resident 64's bathroom was noted to have unmatched paint and two holes on either side in the drywall. During a tour of the facility with the Administrator, on 7/26/24 2:38 p.m., indicated he was not aware of the issues as above for Resident 75, Resident 38, or Resident 64's room, but would have them addressed as soon as possible. A policy entitled, Resident Rights, was provided by the Area [NAME] President of Clinical Services on 7/29/24 at 2:10 p.m. The policy indicated, .The resident has a right to safe, clean, comfortable and homelike environment . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to administer residents' medication as ordered; notify the physician of a weight gain, as ordered; clarify a resident's medication order; ensure a resident's compression stockings were in place, as ordered; and follow-up on a physician's order for gastrostomy tube removal for 1 of 1 resident reviewed for dialysis, 1 of 5 residents reviewed for unnecessary medication, 1 of 1 resident reviewed for edema, and 1 of 1 resident reviewed for tube feeding. (Residents 14, 45, 52, and 64) Findings include: 1. The clinical record for Resident 52 was reviewed on 7/26/24 at 2:15 p.m. His diagnoses included, but were not limited to, end stage renal disease and hypotension. The dialysis care plan indicated he required hemodialysis on Monday, Wednesday and Friday. He left the facility at 6:00 a.m. and returned around 11:30 a.m. The goal was for him to be free from complications related to dialysis. An intervention was to administer medications, as ordered. The impaired cardiac output care plan, revised 2/21/24, indicated the goal was for him to be free from complications and symptoms of cardiac dysfunction. An intervention was to observe for signs/symptoms of cardiac dysfunction such as decreased heart rate or blood pressure, initiated 3/20/22. The physician's orders indicated he had dialysis appointments three times a week on Monday, Wednesday, and Friday. The physician's orders indicated to administer a 10 mg (milligrams) tablet of Midodrine one time a day every Monday, Wednesday, and Friday for low blood pressure one hour prior to dialysis, starting 10/18/23. There was no parameter on the blood pressure indicating what constituted a low blood pressure. There was another order to administer a 10 mg tablet of Midodrine every 12 hours as needed for a systolic blood pressure equal to or less than 100 on non-dialysis days, starting 3/28/24. There was no order for blood pressure to be taken on non-dialysis days. The July 2024 MAR (medication administration record) indicated the regularly scheduled Midodrine was not administered on Wednesday, 7/3/24, or Monday, 7/15/24. It indicated the as needed Midodrine was not administered at all in the month July 2024 thus far, but there were no regularly documented blood pressure results for non-dialysis days in the clinical record verifying Resident 52's systolic blood pressure was not equal to or less than 100 and didn't require administration. The 6/26/24 nurse practitioner note indicated Resident 52 verbalized that blood pressure had been low at dialysis and discussion with nursing - HD [hemodialysis] reports SBP [systolic blood pressure] dropping less than 80 during treatment. The Assessment and Plan section of the note indicated to add Midodrine 10 mg the night before dialysis in addition to the prn (as needed) morning dose. The Midodrine orders in this note did not match Resident 52's above physician's orders or July 2024 MAR. An interview was conducted with the DON (Director of Nursing) on 7/26/24 at 12:10 p.m. She reviewed Resident 52's Midodrine orders and indicated she was not sure what his Midodrine orders were supposed to be; why the Midodrine was not administered on 7/3/24 or 7/15/24; or why blood pressures were not being obtained on non-dialysis days, but she would get clarification. 2. The clinical record for Resident 64 was reviewed on 7/29/24 at 10:48 a.m. The diagnoses included, but were not limited to, congestive heart failure and edema. The at risk for fluid imbalance care plan, revised 7/26/24, indicated the goal was to remain free of signs of fluid overload. Interventions were to administer medications as ordered, initiated 10/24/23, and weights as ordered/indicated and to notify physician of significant weight changes, initiated 10/24/23. The physician's orders indicated to obtain daily weight and notify the physician of a weight gain greater than 3 pounds in a day or 5 pounds in a week, starting 10/25/23. They indicated to administer a 2.5 mg tablet of Metolazone one time a day for a diuretic, starting 6/12/24. The July 2024 MAR indicated a 4.7 pound gain on 7/5/24 from the previous day, a 5.8 pound gain on 7/7/24 from the previous day, and a 7.8 pound gain on 7/25/24 from the previous day. There was no information in the clinical record to indicate the physician was informed of these over 3 pounds in a day weight gain. There were no weights recorded on 7/13/24, 7/19/24, and 7/27/24 in the July 2024 MAR. The 7/26/24 progress note indicated, Cardiology called today with lab results for Pro BNP [Brain natriuretic peptide-blood test that detects heart failure]. Pro BNP was elevated, cardiologist wants to increase Metolazone Tablet from 2.5 mg to 5 mg. Get daily weight, call cardiologist if 3 lb weight gain. The current physician's orders indicated the Metolazone was not increased from 2.5 mg to 5 mg, as indicated, in the above verbal order. The July 2024 MAR indicated Resident 64 continued to receive 2.5 mg of Metolazone 7/27/24, 7/28/24, and 7/29/24, after the verbal order to increase to 5 mg. An interview was conducted with the DON on 7/29/24 at 1:00 p.m. She indicated there was no verification the physician was notified of Resident 64's daily weight gain more than 3 pounds on 7/5/24, 7/7/24, or 7/25/24, and she was going to proceed with changing the Metolazone order. 50436 3. The clinical record for Resident 45 was reviewed on 7/24/24 at 2:17 p.m. The diagnoses included, but were not limited to, dependance on respirator (ventilator) status, chronic pain syndrome, depression, morbid (severe) obesity, generalized anxiety disorder, and unspecified cirrhosis of liver. The Quarterly Minimum Data Set (MDS) assessment for Resident 45, dated 4/18/24, indicated the resident was cognitively intact for daily decision making. During an interview with Resident 45, on 7/23/24 at 1:30 p.m., indicated he had a gastrointestinal tube (G-tube) that he had been waiting to be removed. Resident 45 indicated that the g-tube had never been used and it occasionally would bleed. During an interview and observation with Resident 45, on 7/24/25 at 10:38 a.m., indicated that the g-tube would be painful if he laid on it wrong. No redness or drainage was observed from the g-tube site. The physician order for Resident 45, dated 6/28/24 at 12:39 p.m., indicated the resident's g-tube was to be removed. A physician's order and resident face sheet was faxed to the hospital central scheduling office. During an interview with the Corporate Director of Respiratory, on 7/25/24 at 12:27 p.m., they indicated the g-tube removal order was initially placed, on 6/28/24, but did not include the resident's diagnosis. So, the order had to be re-written on 7/2/24. On 7/8/24, the order was faxed again to the hospital central scheduling office clarifying Resident 45's diagnosis, date of birth, and the physician's printed name. During an interview with the Corporate Director of Respiratory, on 7/25/24 12:07 p.m., they indicated the facility called central scheduling to schedule an appointment with a gastro-intestinal doctor [GI doctor] to remove the g-tube, and faxed them all the information, then they get back with us to make the appointment, and the facility was still waiting to hear back from the hospital. The Corporate Director of Respiratory indicated the nurses were responsible to follow up on Resident 45's g-tube removal. An interview conducted with the Regional Nurse Consultant 2, on 7/26/24 at 2:10 p.m., indicated that the facility did not have a policy for following physician's orders. The facility followed the standards of practice. An Appropriate Use of Feeding Tubes policy provided by the [NAME] Nurse Consultant 2, on 7/26/24 at 2:10 p.m., indicated the following, .Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary. 45291 4. The clinical record for Resident 14 was reviewed on 7/24/2024 at 1:20 p.m. The medical diagnosis included chronic obstructive pulmonary disease. The Quarterly Minimum Data Set Assessment, dated 6/14/2024, indicated that Resident 14 was cognitively intact and needed assistance of setup to limited for dressing. A care plan, revised on 2/21/2024, indicated that Resident 14 had impaired cardiac function. An intervention, dated 5/12/2022, indicated for Resident to utilize compression socks as ordered. A physician order, dated 3/16/2020, indicated for Resident 14 to have compression stockings placed in the morning and off in the evening for edema. An interview and observation, on 7/23/2024 at 12:36 p.m., indicated that Resident 14 was sitting in his recliner with his feet elevated. [NAME] tube socks were wrinkled at the ankle and indented the skin. Resident 14 indicated that he had edema for a while, and they have not been placing his compression stockings or ace wraps. He stated the swelling is uncomfortable and that he cannot get his compression stockings on or place them on his own. An interview and observation, on 7/25/2024 at 11:05 a.m., indicated that Resident 14 was sitting in his recliner with his feet elevated. [NAME] tube socks were wrinkled at the ankle and indented the skin. Resident 14 indicated that he had edema that was unchanged, and they have not placed his compression stockings all week. An interview and observation with Licensed Practical Nurse 3, on 7/25/2024 at 11:10 a.m., indicated that she did mark off the treatment record that Resident 14's compression stockings were administered, but she had not placed them yet. She completed an assessment of Resident 14's swelling of plus one pitting edema. She indicated this was baseline for Resident 14 and that compression stockings should have been in place. An interview with Regional Nurse Consultant 1, on 7/26/2024 at 2:10 p.m., indicated there was not a specific policy for following physician orders. The facility would follow the standards of practice to follow physician orders as written unless clinically contraindicated. 3.1-37(a)

Based on observation, interview and record review the facility failed to provide fresh fluids and keep fluids within reach for 3 of 3 residents reviewed for hydration (Resident 54, Resident 18 and Resident 1). Findings include: 1. During an observation, on 7/24/24 at 11:36 a.m., Resident 54 was lying in bed, the resident had a 1/4 a cup of juice on the bedside table, the table was across the room out of reach of the resident, and the resident did not have any water in his room. During an observation, on 7/25/24 at 10:54 a.m., Resident 54 was lying in bed, the resident had no water or any type of fluids in his room. During an observation, on 7/25/24 at 12:53 p.m., Resident 54 was lying in bed, the resident had no water or any type of fluids in his room. During an observation, on 7/26/24 at 11:47 a.m., Resident 54 was lying in bed, the resident had a Styrofoam cup with ice water in it on the bedside table, the table was across the room and out of the resident's reach. Review of the record of Resident 54, on 7/29/24 at 11:28 a.m., indicated the diagnoses included, but were not limited to, Alzheimer's disease, dementia, seizure disorder, anxiety disorder and hypokalemia. The July 2024 physician recapitulation for Resident 54 indicated the resident was ordered thin liquids. The plan of care for Resident 54, dated 3/15/22, indicated the resident had a history of urinary tract infections. The interventions included, but were not limited to, encourage fluids. 2. During an observation, on 7/23/24 at 12:40 p.m., Resident 18 did not have any fluids available in his room. During an observation, on 7/24/24 at 11:40 a.m., Resident 18 did not have any fluids available in his room. During an observation, on 7/25/24 at 10:52 a.m., Resident 18 did not have any fluids available in his room. During an observation, on 7/26/24 at 11:44 a.m., Resident 18 had a Styrofoam cup of ice water in his room. Review of the record of Resident 18, on 7/29/24 at 10:38 a.m., indicated the resident's diagnoses included, but were not limited to, schizophrenia, hypertension, major depressive disorder, Alzheimer's disease, dementia and moderate intellectual disabilities. The July 2024 physician recapitulation for Resident 18 indicated the resident was ordered thin liquids. 3. During an observation, on 7/25/24 at 11:00 a.m., Resident 1 was lying in bed and the resident had no fluids available in her room. During an observation, on 7/26/24 at 11:49 a.m., Resident 1 was lying in bed and had no fluids available in her room. The resident indicated she was lucky if she received one cup of ice water a day. Review of the record of Resident 1, on 7/25/24 at 11:50 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease, dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The Annual Minimum Data Set assessment for Resident 1, dated 4/4/24, indicated the resident was cognitively intact for daily decision making. The resident hydration policy provided by the Director of Nursing, on 7/29/24 at 1:15 p.m., indicated the facility would strive to provide adequate fluids. The Nurse aides would provide and encourage of bedside fluids on a routine basis as part of daily care. 3.1-3(v)(1)

Based on observation, interview, and record review the facility failed to provide in room self-initiated activities for 1 of 3 residents reviewed for activities (Resident 1). Finding include: During an observation and interview with Resident 1, on 7/23/24 at 12:44 p.m., they were lying in bed, awake, and staring at the ceiling. Their television was unplugged with no music, books, magazines, puzzles, daily chronicle, or any type of activity was available for the resident. The resident indicated she did not like her room. During an observation and interview with Resident 1, on 7/25/24 at 11:00 a.m., they were lying in bed, awake, and staring at the ceiling. Their television remained unplugged with no music, books, magazines, puzzles, daily chronicle, or any type of activity was available for the resident. The resident indicated she hated her room. The resident indicated she did not necessarily like to do activities with other people. So, she stayed to herself and did her own thing. The resident refused to tell the writer what her favorite activity was. Review of the record of Resident 1, on 7/25/24 at 11:50 a.m., indicated diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease, dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The Annual Minimum Data Set assessment, dated 4/4/24, for Resident 1 indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. It was very important for the resident to take care of her personal belongings and things. It was somewhat important to listen to music, keep up with the news, and do things with groups of people. It was very important for her to conduct a favorite activity and go outside. The plan of care for Resident 1, dated 9/14/23, indicated the resident preferred to be engaged in independent self-directed activities. The interventions included watching television, reading, provide daily chronical, respect resident's right to decline activity, praise resident's participation in activities and resident needs encouragement, and reassurance to participate in activity. During an interview with the Activity Director, on 7/26/24 at 2:20 p.m., indicated it was the Activity Aides responsibility to ensure Resident 1 had self-initiated activities available in her room. The Activity policy provided by the Director of Nursing, on 7/29/24 at 11:00 a.m., indicated the facility would provide an ongoing activity program to support residents in their choice of activities. Individual and independent activities would be designed to meet the interest of each resident, as well as support their physical, mental and psychosocial well-being. 3.1-33(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter drainage bag and/or tubing remained free of contact with the floor for 1 of 2 residents reviewed for indwelling urinary catheters. (Resident 33) Findings include: The clinical record for Resident 33 was reviewed on 7/26/2024 at 11:35 a.m. The medical diagnoses included obstructive uropathy, urinary tract infections, and dysuria. A Quarterly Minimum Data Set Assessment, dated 5/3/2024, indicated that Resident 33 was mildly cognitively impaired, had an indwelling urinary catheter, and needed extensive assistance of staff for toileting needs. A urinary catheter care plan, revised on 2/23/2023, indicated that Resident 33 was at risk for complications and infection related to utilizing an indwelling catheter for treatment of obstructive uropathy. A physician order, dated 6/11/2024, indicated that Resident 33 utilized an indwelling catheter for obstructive uropathy. An observation of Resident 33, on 7/23/2024 at 2:10 p.m., indicated he was sitting in his wheelchair by the nurses' station. This urinary catheter tubing was contacting the floor. An observation of Resident 33, on 7/26/2024 at 11:09 a.m. indicated that the urinary catheter drainage bag was hanging off the side of the bed and contacting the floor. An observation and interview of Resident 33, on 7/26/2024 at 11:16 a.m., indicated that his urinary catheter bag was hanging off the side of his bed. Certified Nursing Assistant (CNA) 4 verified that the bag was contacting the floor. She did not know how she should ensure the catheter was not contacting the floor. An interview with the Regional Nurse Consultant 1, on 7/26/2024 at 2:25 p.m., indicated that is the current standard of practice for the urinary catheter tubing and drainage bag to remain free of contact with the floor. A policy entitled, Appropriate Use of Indwelling Catheters, was provided by the Regional Nurse Consultant 1 on 7/26/2024 at 2:25 p.m. The policy indicated the following, .Indwelling urinary catheter (urethral or suprapubic) will be utilized in accordance with current standards of practice . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to routinely assess a resident receiving pain medications and administer narcotic pain medication for a resident with chronic pain for 1 of 1 resident reviewed for pain. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 7/25/2024 at 1:15 p.m. The medical diagnosis included chronic pain syndrome. A Quarterly Minimum Data Set Assessment, dated 5/20/2024, indicated that Resident 12 was cognitively intact, received routine and as needed pain medication, and was almost constantly in pain. A pain care plan, revised on 3/8/2024, indicated Resident 12 was at risk for pain related to her chronic pain syndrome. A care planned intervention of administering medications as ordered was dated 5/3/2021. A physician order, dated 7/11/2024, indicated for Resident 12 to receive tramadol 50 milligrams (mg) three times a day routinely for pain. A physician order, dated 5/18/2023, indicated for Resident 12 to receive Tylenol 650 mg by mouth every six hours routinely for pain. During an interview, on 7/23/2024 at 12:55 p.m., Resident 12 indicated that last week she went without her pain medication for two days. During that time, her pain was elevated, but it did not keep her from doing her usual routine. Family Member was present during the interview. He indicated Resident 12 appeared uncomfortable those two days when he was visiting and that the staff told him the facility could not get the pain medication because of the outage. Review of the July 2024 medication administration record for Resident 12 indicated that she did receive her routine Tylenol as ordered, but not receive her routine tramadol for four doses as follows: 7/18/2024 - 6:00 p.m., 7/19/2024 - 7:00 a.m., 7/19/2024 - 3:00 p.m., & 7/19/2024 - 6:00 p.m. A rounding document, dated 7/19/2024, indicated that pain was managed with tramadol. No pain scale or assessment were documented between, 7/18/2024 at 5:36 p.m., and 7/20/2024 at 6:11 a.m. A policy, entitled Pain Management, was provided by the Regional Nurse Consultant on 7/26/2024 at 2:10 p.m. The policy indicated the following, .Residents receiving routine pain medications should be assessed each shift by the charge nursing during round and/or medication pass . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely follow-up on scheduling a resident's appointment for a CT (computerized tomography-diagnostic imaging procedure that uses x-rays and computers to create detailed images of the inside of the body) scan for 1 of 2 residents reviewed for skin conditions. (Resident 52) Findings include: The clinical record for Resident 52 was reviewed on 7/26/24 at 2:15 p.m. His diagnoses included, but were not limited to, osteoarthritis and end stage renal disease. An observation and interview was conducted with Resident 52 on 7/25/24 at 2:29 p.m. He was lying in bed in his room. He indicated he knew he was supposed to have a CT scan of his back, but the facility never followed up with him on when the appointment would be. The physician's orders indicated a referral for a CT scan of the spine without contrast including cervical, lumbar, and thoracic spine with a local hospital provider, effective 7/10/24. The 7/10/24 order note indicated the following, New order received by NP (nurse practitioner) for a CT scan of the spine with no contrast. Including the cervical, thoracic, and lumbar spine. Referral was sent to [name of local provider] central scheduling. The note included a fax and phone number for the provider. There was no information in the clinical record to indicate a CT scan appointment was scheduled or follow-up with the local provider after the referral was sent on 7/10/24. An interview was conducted with the DON (Director of Nursing) on 7/26/24 at 11:06 a.m. She indicated the process for scheduling CT scans was to call the local provider to let them know they needed an appointment and send the order to the provider. The provider would call back with an appointment or to let them know if they needed any additional information. She knew staff called to schedule the appointment, but there was no verification of any follow-up before now. She spoke with central scheduling at the local provider to which Resident 52's CT scan referral was sent. They needed a diagnosis code, so they were going to get that today, on 7/26/24, and get the appointment scheduled. 3.1-49(g)

Based on observation, interview and record review, the facility failed to ensure a resident was seen for routine dental services for 1 of 4 residents reviewed for dental services. (Resident 1) Findings include: During an observation and interview with Resident 1, on 7/25/24 at 11:00 a.m., she indicated it was difficult for her to eat because she did not have any teeth. The resident indicated she would like to have dentures. The resident was observed to have no lower or upper teeth. Review of the record of Resident 1, on 7/25/24 at 11:50 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinsonism, chronic obstructive pulmonary disease, dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The Annual Minimum Data Set assessment for Resident 1, dated 4/4/24, indicated the resident was cognitively intact for daily decision making. The resident was edentulous (no natural teeth). During an interview with Social Services 1, on 7/26/24 at 11:04 a.m., indicated Resident 1 had not seen a dentist since June 2023. The dentist made impressions for the resident to get dentures at that time. The dentures were not made because the dentist did not hear from the Power of Attorney (POA). Social Services would be responsible for following up with the POA and dentist. The resident now has an appointment for next month. The Dental policy provided by the Director of Nursing, on 7/29/24 at 1:15 p.m., indicated the facility would obtain routine dental services. 3.1-24(a)(1)

Based on interview and record review, the facility failed to document treatments were completed, or refused, and failed to document if enteral feeding were administered, or refused, for 1 of 23 residents reviewed for documentation (Resident C). Finding include: Review of the record of Resident C, on 7/26/24 at 2:14 p.m., indicated the diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, quadriplegia, dependence on respirator (ventilator) status, neuromuscular dysfunction, tracheotomy and gastrostomy (g-tube) status. During an interview with the Corporate Director of Respiratory, on 7/29/24 at 2:42 p.m., he verified the following treatments were not documented as completed, or refused on the May 2024 Treatment Administration Record (TAR) and verified that the enteral g-tube feeding was not documented as provided or refused. The May 2024 TAR for Resident C indicated Dakins (1/2 strength) external solution to left buttock every shift. Apply wound cleanser, Dakins moistened fluffed gauze, and cover with an ABD (abdominal) pad. There was no documentation the treatment was completed, or refused, for 5/19/24 for day shift and nightshift; 5/20/24, 5/21/24, 5/31/24 for day shift; and 5/28/24 for nightshift. The May 2024 TAR for Resident C indicated Dakins (1/2 strength) external solution to the right buttock every shift. Apply wound cleanser, Dakins moistened fluffed gauze, and cover with an ABD pad. There was no documentation the treatment was completed, or refused, for 5/19/24 for day shift and nightshift; 5/20/24, 5/21/24 and 5/31/24 for day shift; and 5/28/24 for nightshift. The May 2024 TAR for Resident C indicated to cleanse right lateral foot with wound cleanser, apply betadine, and leave open to air two times a day for wound care. There was no documentation the treatment was completed, or refused, for 5/4/24, 5/7/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24 and 5/18/24 for day shift; and 5/8/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24 for evening shift. The May 2024 TAR for Resident C indicated to cleanse with wound cleanser, apply calcium alginate, and cover with a border dressing two times a day to the right lateral leg. There was no documentation the treatment was completed, or refused, for 5/7/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24, 5/18/24 for day shift; and 5/8/24, 5/12/24, 5/13/24, 5/14/23, 5/15/24 for evening shift. The May 2024 TAR for Resident C indicated to cleanse with wound cleanser, apply collagen to wound, and cover with ABD pad to the right elbow. There was no documentation the treatment was completed, or refused, for 5/4/24, 5/7/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24, 5/18/24 for day shift; and 5/8/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24 for evening shift. The May 2024 TAR for Resident C indicated to cleanse the coccyx wound with wound cleanser, apply alginate, and cover two times a day. There was no documentation the treatment was completed, or refused, for 5/4/24, 5/7/24, 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24, 5/18/24 for day shift; and 5/8/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24 for evening shift. The May 2024 TAR for Resident C indicated to cleanse the left and right buttock and right ischium with wound cleanser, apply alginate, and cover. There was no documentation the treatment was completed, or refused, for 5/9/24, 5/11/24, 5/12/24, 5/15/24, 5/16/24 for day shift; and 5/8/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24 for evening shift. The May 2024 TAR enteral feed order indicated Resident C was to have g-tube feeding formula at 55 milliliters (ml) every hour for 12 hours. There was no documentation the resident received the formula, or refused, the feeding formula for 5/9/24, 5/11/24, 5/19/24. The documentation policy provided by the Assistant [NAME] President of Clinical Services, on 7/29/24 at 2:10 p.m., indicated each resident record shall contain an accurate representation of the actual experiences of the resident to include accurate and timely documentation. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review the facility failed to provide colostomy care in a manner to promote dignity for 1 of 3 residents reviewed for colostomy care (Resident G). Findings include: Review of the clinical record of Resident G on 5/22/24 at 11:55 a.m., indicated the resident's diagnosis included, but was not limited to acute and chronic respiratory failure, dysphagia, colostomy status, and depression. During an interview with Resident G on 5/21/24 at 3:00 p.m. indicated that 3 to 4 days ago, a nurses aide ran out of the correct fitting nursing supplies during the evening shift and placed a regular clear plastic trash bag over his stoma site and it was not changed with a correct fitting colostomy bag until the following morning. The resident indicated that my dignity was crushed when they did this and it made me feel worthless. During an interview with CNA 7 on 5/22/24 at 12:05 p.m., indicated she was working second shift and Resident G did not have a colostomy bag over his stoma. She indicated that she was told that they had ran out of the colostomy bags and had nothing to put on it. CNA 7 indicated that stool was running all over Resident G and she placed a small trash bag over the stoma and taped it. The resident's rights policy provided on 5/24/24 at 10:30 a.m., by the Executive Director (ED) indicated that all care team members recognize the rights of residents at all times and residents assume their responsibilities to enable dignity, respect, and proper delivery of care. This federal tag relates to Complaint IN00434793. 3.1-3(t)

Based on interview, observation, and record review the facility failed to check placement and identify potential signs of displacement for Resident B, and failed record residual gastric contents of a gastrostomy tube (g-tube) prior to administration of tube feedings and medications for 2 residents (Resident B and C) resulting in hospitalization for septic shock and [CONDITION(S)] of the abdominal wall, rectus abdominus, and rectus sheath, resulting in death (Resident B), and failed to ensure a follow-up with a gastroenterologist (GI) or replacement of a dislodged g-tube (Resident E) for 3 of 5 residents reviewed for g-tube management. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when Resident B experienced a change in condition resulting in hospitalization with a displaced g-tube and findings consistent with [CONDITION(S)] and infection in the peritoneal cavity that resulted in Resident B dying on [DATE]. The Executive Director (ED), Director of Nursing Services (DNS), and Administrator in Training were notified of the Immediate Jeopardy on [DATE] at 4:37 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The clinical record for Resident B was reviewed on [DATE] at 2:19 p.m. The clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS, dated [DATE], indicated that Resident B did not have memory issues, did not reject care, and dependent on staff members for all care that included tasks of feeding, hygiene, and bed mobility. Resident B received her nutrition via tube feeding at least 51% of more of her daily needs and had four stage 2 pressure ulcers. A brief interview for mental status to assess cognitive status was not completed due to resident is rarely/never understood. No MDS Assessment documented after return to facility on [DATE]. A hospitalist note, dated [DATE], indicated that Resident B would not be able to communicate even with a translator per her son. An eternal feeding care plan for Resident B, dated [DATE], indicated the intervention of checking for tube placement and gastric contents/residual volume per facility protocol and record. A ventilator care plan, dated [DATE], indicated an intervention of Provide alternated methods of communication for the resident (Specify) with no further specification for Resident B. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No order present to check or document placement or to check residual of g-tube prior to administration or initiating feedings for Resident B. Neither the medication administration record (MAR) nor treatment administration record (TAR) for [DATE] indicated checking placement of Resident B's g-tube. Neither the MAR nor TAR indicated documentation of residual volume for Resident B. The MAR indicated the order for decreased feeding 25 ml for 72 hours was not signed off on [DATE]. The orders for decreased feeding 25 ml for 72 hours and for Glucerna 1.2 at 50 ml/hour were signed off on [DATE]. The Glucerna 1.2 at 50 ml/hour continued to be signed off on [DATE]. The MAR indicated that Resident B's enteral feeding volume was recorded every shift (twice a day) as follows: [DATE] as 1200 ml for day shift and 1200 ml for night shift, [DATE] as on for day shift and 600 ml for night shift, [DATE] as 1200 ml for day shift and 50 ml for night shift, [DATE] as 1200 ml for day shift and 50 ml for night shift, [DATE] as 50 ml for day shift and 50 ml for night shift, and no documentation for [DATE]. A change of condition assessment, dated [DATE] at 9:00 a.m., indicated Resident B had abnormal vital signs, altered mental status, new/worsening [CONDITION(S)], functional decline, skin wound or ulcer, unresponsive, seems different than usual, talks/communicates less, tired, weak, confused, or drowsy, and change in skin color or condition. This assessment further indicated that Resident B was diaphoretic, had no cough reflex, was very edematous, and staff were unable to assess her blood pressure. In the 24 hours prior to the change of condition note on [DATE] at 9:00 a.m., no documentation of diaphoresis, intervention, or change in condition. A hospitalist emergency room (ER) note for Resident B, dated [DATE] at 9:53 a.m. indicated that .nursing from extended care facility reports the patient was clammy and diaphoretic and cool to the touch all night . Later during med pass this morning she was noted to have decreased responsiveness. They performed aggressive suctioning without gag reflex . was noted to be pale . Her temperature was listed as 100.3 Fahrenheit (normal is 97.6 F), and blood pressure was listed as ,d+[DATE] (normal is ,d+[DATE]). White blood cells were indicated 34.3 × 109/L with a normal range of 4.,d+[DATE] × 109/L. An elevated white blood cell count can be indicative of an infection. Her lactic acid was listed as >9.9 MMOL/L (millimoles per liter) with a normal of 0.5 to 2.2 MMOL/L. Elevated lactic acid can be indicative of [CONDITION(S)] or a severe [CONDITION(S)] response syndrome. The ER documentation further indicated, .patient [Resident B] presents here with unresponsiveness and has finding suggestive of septic shock . A computed tomography (CT) scan abdomen and pelvis with intravenous (IV) contrast, dated [DATE], indicated that Resident B had a gastric tube present with the tip located in the anterior abdominal wall at the level of the left rectus abdominus. There is extensive air within the left rectus extending to the right rectus inferiority as well as fat and peritoneal cavity consisting with [CONDITION(S)] and infection. A hospitalist note from [DATE], indicated that Resident B had a g-tube in malposition. The note stated, .Give the location of the cuff under the skin, it is likely that the tube has been dislodged for some time and patient was getting tube feeds and medications until yesterday. [[DATE]] I removed the G-tube and there is no foul odor emanating from the site .this is likely subcutaneous infection from tube feed .: A CT scan of abdomen and pelvis without IV contrast, dated [DATE], indicated .There is a ventral abdominal wall air due to malpositioned G-tube along the left abdominal rectus muscle and extending across the lower ventral abdominal wall in the pelvis with generalize [CONDITION(S)] changes . A CT scan of abdomen and pelvis without IV contrast, dated [DATE], indicated .There is again seen air in within the subcutaneous soft tissue rectus muscle consistent with [CONDITION(S)] extending down into the anterior lower pelvis and deep fascial plane within the pelvis itself. When compared to the previous study appears slightly worse. Physician physical examination of Resident B, dated [DATE], indicated, .Patient was evaluated early in the morning .She had bilateral upper and lower extremity [CONDITION(S)], she had [CONDITION(S)] was been turning darker in the abdomen and groin our areas as well as upper thighs, she was in a [MEDICATION(S)] drop, she was grimacing [sic] A discharge summary hospitalist note for Resident B, dated [DATE], indicated that .she developed septic shock requiring pressure support due to [CONDITION(S)] infection of the abdomen. GI consulted, patient needs to high risk for any intervention at this time. General surgery on board due to [CONDITION(S)] of the abdominal wall, rectus abdominus rectus sheath .General surgery, intensivist, report that treatment is futile .family agreed patient should be made comfort care. Patient expired with presence of family on [DATE] at 14:53 p.m . [sic] Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed direct care staff present on unit during investigation were not employed at the time of the event on [DATE] for Resident B. 2. The clinical record for Resident C was reviewed on [DATE] at 3:39 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The non-comprehensive Minimum Data Set Assessment, dated [DATE], indicated that Resident C was cognitively intact, needed extensive assistance of staff for bed mobility, locomotion, dressing, toileting, and hygiene. Resident C was totally dependent on staff for transferring and bathing tasks. Resident C was indicated as having a [CONDITION(S)] present and to have received 51% or more of her daily national value by gastric tube. An eternal feeding care plan for Resident C, dated [DATE], indicated the intervention of checking for tube placement and gastric contents/residual volume per facility protocol and record. A [CONDITION(S)] care plan for Resident C, dated [DATE], indicated the potential for difficulty with communication with the interventions of provide means of communication and use alternative communication tools as needed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . May be left open to air if no drainage. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No order to document residual indicated on Resident C's chart. The MAR and TAR for Resident C were reviewed and no documentation present for total volume of feedings located on the MAR. The order to check placement for the g-tube were signed off on [DATE] and [DATE] without documentation of residual. A nursing progress noted, dated [DATE], indicated that the Resident C was having an elevated blood pressure, increased respirations, and abdominal labored breathing. Family wanted Resident C sent to the hospital because they are tired of farting around and waiting for everyone to come to the facility and they are wasting precious time. [sic] Resident C's provider was contacted and updated before the order was received to send Resident C to the ER. An ER physician note, dated [DATE] at 6:37 a.m., indicated that Resident C had [CONDITION(S)] with acute [CONDITION(S)]. A computed tomography scan of the chest without intravenous (IV) contrast on [DATE], indicated Resident C patent of the g-tube does not appear to be within the lumen of the stomach, but appears to be within the wall. It was recommended the g-tube be repositioned and no medications/feedings through the tube until then. Resident C's g-tube was located in the anterior wall of the stomach. A hospital discharge note containing the hospital course summary, dated [DATE], indicated Resident C was admitted from the facility .with several says of increase [CONDITION(S)] secretions, increased work of breathing, blood around [CONDITION(S)], and hemoptysis [bloody sputum] .Patient [Resident C] was admitted to the hospital for septic shock due to pneumonia and peritonitis associated with her g-tube .Her g-tube was removed and replaced by IR [[MEDICATION(S)] Radiology] successfully as this was a concern for source of infection . An interview with the DNS, on [DATE] at 1:20 p.m., indicated that it is their standard practice to have the placement of g-tube check at least every shift and prior to anytime it is accessed. Staff are to check placement by checking for residual and this should be documented on the medical record. An interview with LPN 3 on [DATE] at 1:44 p.m., indicated she had taken care of Resident B the morning she was sent to the ER. She indicated usually the resident could nod yes or no, but that was about it, but she was unresponsive that morning. In report, the off going nurse stated her urinary catheter was leaking and Resident B had a rough night, but LPN 3 did not get any other information in report. When asked about the procedure to check placement of a g-tube, she indicated that they should auscultate a 30-cc air bolus and then check for residual. The residual should be documented on the MAR/TAR, but not every resident had the order placed on their MAR/TAR. She indicated if the residual was more than 30 ml then she would hold the feeding and that no residual was an indication of an empty stomach. She did not check the residual of Resident B on the morning of [DATE] due to her change of condition and not being time for medications. An interview with DNS on [DATE] at 2:20 p.m., indicated that the staff would check the placement with residual and that no residual would indicate the resident's body is absorbing the feeding as intended. Indications for a displaced feeding tube would be issues with flushing, leaking, or feeding coming back up in the tube. A policy entitled, Enteral Nutrition, was provided by the Administrator on [DATE] at 11:00 a.m. The policy indicated that staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube such as tube misplacement or migration and preformation of the stomach or small intestine leading to peritonitis. A policy from the pharmacy services entitled [Name of Pharmacy], was provided by the DNS on [DATE] at 2:20 p.m. The policy indicated, Assess for gastric residual volume a. Not recommended for resident(s) who are alert and able to report symptoms indicating enteral feeding is not being tolerated well b. Check prior to mediation(s) administration . 3. The clinical record for Resident E was reviewed on [DATE] at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS assessment, dated [DATE], indicated she was comatose and required total assistance with two staff person for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. She had a feeding tube. A care plan for g-tube feedings, revised [DATE], indicated interventions to administer tube feeding and water flushes per physician orders, check for tube placement and gastric contents/residual volume per facility protocol and record, document abnormal findings and notify the physician, and observe for complications such as tube being dislodged. An observation conducted of Resident E, on [DATE] at 12:00 p.m., with a urinary catheter tube present in the abdomen as a temporary feeding tube indicated by the Assistant Director of Nursing Services (ADNS). The ADNS indicated Resident E's feeding tube became dislodged with the balloon still inflated and caused trauma to the opening where the feeding tube entered. This incident occurred on [DATE]. They are waiting to see if the urinary catheter works and then ask for a gastroenterology consult in the case there was excess drainage or other complications that warrant the consult. An anonymous interview conducted during the survey from [DATE] to [DATE], indicated the opening to Resident E's g-tube site is the size of a half dollar and was draining excessive amounts of tube feeding when the tube became dislodged. The dressing was removed during the interview and the dressing was saturated with a brown and black substance with a half dollar size opening to the stoma site. The resident needed the g-tube replaced or a consult with a GI specialist but that hasn't been conducted. When they asked about replacing the feeding tube at the facility the response was where can we get one of those? This was referring to the feeding tube. A progress note, dated [DATE] at 1:17 p.m., indicated the following, .nurse was in at 1100 [11:00 a.m.] to flush feed tube and G-tube was out .Physician gave order to replace G-tube with 18F [size of catheter] Foley. ADON [Assistant Director of Nursing] inserted 18F foley without complication. Checked placement via auscultation and checked residual. Patient's feed was restarted with excessive leaking. This nurse notified physician and was given an order to place 22F [larger size catheter] foley catheter. Per physician a small amount of leakage is to be expected until the stoma site begins to close which should happen within a few hours. Physician ordered that facility either order a j-peg to be placed at facility or sent patient to GI [gastroenterology] for new placement, 22F foley is intact, checked residual and auscultation. Feed is currently restarted with minimal drainage. Another progress note, dated [DATE] at 6:35 a.m., indicated the following, .This nurse examined stoma site, I visualized what looks like obvious trauma from G-tube being dislodged completely, stoma looks like it has signs of ripping with excessive leaking, looks to be like it may need suturing. GI [gastrointestional] consult is definitely warranted. Applied moist dressing on stoma site with dried dressing on top, paper tape was used to secure dressing remains patent [sic]. Will require NP [Nurse Practitioner] to assess for further treatment. An observation was conducted of Resident E's care with Certified Nursing Assistant (CNA) 5 and CNA 6 on [DATE] at 11:10 a.m. Both CNA 5 and CNA 6 commented that Resident E cannot move on her own. Her hands were observed to be contracted bilaterally with palm protectors in place. CNA 6 stated she worked on [DATE] and didn't have any concerns regarding Resident E's g-tube and no staff asked her questions regarding Resident E's g-tube. She was not aware Resident E's g-tube became dislodged. An interview conducted with the Director of Nursing Services (DNS), on [DATE] at 1:13 p.m., indicated Resident E does not move. She was unaware of what occurred and lead to the dislodgement of Resident E's g-tube. The site looked traumatized when it first happened. An order was obtained to place a Foley catheter until a PEG tube (feeding tube) placed. They got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The hole would close until the PEG tube can be placed. Resident E came to the facility with the PEG tube in place. The DNS spoke with Licensed Practical Nurse (LPN) 8, who was working the morning of the incident, and asked her to speak to the aides caring for Resident E the morning of the incident. She wanted to know when the aides were in to care for Resident E last and she could hear the aides speaking in the background answering the questions. The aides responded, it was around 10:00 a.m., was when the last time they cared for Resident E before the dislodgement of the g-tube, and it was intact to the best of their knowledge. She doesn't believe Resident E was capable of manipulating the g-tube. She was in a comatose state. A physician order, dated [DATE], for a KUB until g-tube was replaced. A physician order, dated [DATE], was noted to replace feeding tube with a 22 Fr foley catheter until resident can be seen by gastroenterology. This order was not entered until [DATE] but had a start date of [DATE]. An interview conducted with Unit Manager 10, on [DATE] at 11:25 a.m., indicated he investigated Resident E's g-tube being dislodged and couldn't determine the cause of it becoming dislodged. The Nurse Practitioner was here the evening of [DATE] and ordered a KUB to check for placement and if that cannot get completed then possibly send Resident E to the emergency room for replacement of her feeding tube. He was reaching out to schedule a gastroenterology consult for Resident E on [DATE]. A progress note, dated [DATE] at 2:01 p.m., indicated a KUB was able to be conducted on Resident E related to not having contrast material available. The KUB was discontinued and if residual from g-tube was greater than 150 milliliters then call the Nurse Practitioner and update about the situation involving the KUB not being completed. As of [DATE] at 10:00 a.m., there were no other progress notes in Resident E's clinical record about follow-up with a GI consult or replacing her g-tube from the urinary catheter that was in place at that time. This Federal tag relates to Complaint IN 410. 3.,d+[DATE](a)(2)

Based on interview and record review the facility failed to ensure a resident with an ongoing odor to a wound and elevated temperatures was followed-up with that resulted in hospitalization with [CONDITION(S)] (Resident D), ensure a resident with increased respiratory workload and blood tinged secretions was followed-up with timely that resulted in hospitalization with [CONDITION(S)] and respiratory failure (Resident C), and ensure a resident who was reported as diaphoretic overnight was followed-up with timely resulting in hospitalization with septic shock (Resident B) for 3 of 5 residents reviewed for change in condition. Findings include: 1. The clinical record for Resident D was reviewed on 4/27/22 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D was admitted to the facility on [DATE]. An admission assessment, dated 1/7/22, indicated Resident D had an unstageable pressure ulcer to the coccyx upon admission. There were no measurements or further assessment included. Resident D was hospitalized from 1/7/22 to 1/11/22. A readmission assessment, dated 1/11/22, indicated an unstageable pressure ulcer to the coccyx but no measurements or further assessment included. A wound assessment, dated 1/26/22, indicated an unstageable pressure ulcer to the coccyx measuring 12 x 6 x 0.2 centimeters in depth that was acquired on 1/25/22. It was listed currently as a Stage 1 and originally a deep tissue injury. Resident D was hospitalized from 1/26/22 to 1/27/22. A readmission assessment, dated 1/28/22, indicated a wound to the coccyx but no staging, measurements, or further assessment included. Resident D was hospitalized from 2/9/22 to 2/11/22. A readmission assessment, dated 2/11/22, indicated a wound to the coccyx but no staging, measurements, or further assessment included. A pressure ulcer assessment, dated 2/18/22, indicated covers coccyx and continues to bilateral buttocks. Acquired on 1/25/22 and measured 12.5 x 13 x 0.2 centimeters. It was listed as unstageable and worsening with 95% necrotic tissue and 5% granulation tissue. The treatment was to apply Santyl to necrotic areas. A pressure ulcer assessment, dated 2/23/22, indicated an unstageable wound to coccyx that measured 13 x 13.5 x 0.2 centimeters in depth. The wound was unchanged. The treatment was to apply Santyl to the necrotic tissue and calcium alginate to the small areas to the outer wound bed that were granulated. A pressure ulcer assessment, dated 3/2/22, indicated an unstageable wound to coccyx measuring 12.2 x 14.2 x 4 centimeters in depth. the date acquired was 2/18/22 and the wound consisted of 25% slough, 50% necrosis, and 25% granulation tissue. Infection was suspected due to fever, slight greenish color to some areas. A progress note, dated 3/3/22 at 4:01 p.m., indicated the following, .resident was seen 1 week ago by this writer and wound consultant nurse with wound to coccyx measuring 12.5 L [length] x 13.0 W [width] x 0.2 D [depth] and having 95% necrotic tissue and 5% granulation. Orders were put in to resident's record of [MEDICATION(S)] to necrotic tissue and Calcium Alginate to the granulated area. Wound re-evaluated today with significant changes noted .Call placed to wound consultant nurse as she was not on site today and explained all of the above. It is her belief that this may be a Kennedy Wound as resident did recently code and this may be the result d/t [due to] the quickness that this wound presented in such a large area .Treatment to area changed to applying Santyl Ointment to all necrotic and slough areas and cutting strips of Calcium Alginate to size for areas of granulation, then cover and secure daily A Medical Director (MD)/Nurse Practitioner (NP) Progress Note, dated 3/3/22 at 12:52 p.m., indicated a sacral ulcer with tunnelling and blackened tissue. Treatment with 1/4 dakins solution, wet to dry every 8 hours. Wound care for debridement for placement of wound vac. The note indicated that nursing was aware of orders. A progress note, dated 3/7/22 at 4:28 p.m., indicated the following, .noted large amount of purulent [consisting of pus] drainage coming from the wound during wound care today. She also stated that resident had temp [temperature] of 99.9 earlier in shift, but came down following administration of Tylenol .[name of Nurse Practitioner] was notified of concern over wound with possibilities of [CONDITION(S)] and/or [CONDITION(S)] developing. Explained that facility had notified Wound Healing Services as it was felt the wound needed debridement, but unable to get resident to an appointment due resident relies on ventilator for airway and they do not have a traveling nurse that would be able to come to the facility. He stated that another NP [Nurse Practitioner] within their network was Wound Certified and would be notified to come and assess the wound with possible debridement to take place her [sic] at the facility. Awaiting notification for when to expect NP to come to facility for assessment. A pressure ulcer assessment, dated 3/9/22, indicated an unstageable wound to coccyx measuring 14.8 x 11 x 4.8 centimeters in depth. There was 40% slough, 40% necrotic, and 20% granulation tissue. There was infection suspected marked possible with intermittent low-grade fevers. Treatment was to add Dakins 1/2 strength with a wet-moist dressing along with Santyl and calcium alginate. A pressure ulcer assessment, dated 3/16/22, indicated an unstageable wound to coccyx measuring 14.6 x 13.5 x 0 centimeters in depth with 75% necrotic and 25% slough tissue. There was a foul odor with infection suspected due to foul odor, intermittent fever. The treatment was changed to Santyl and calcium alginate. Resident D was discharged to the hospital, on 3/22/22, due to having a low hemoglobin level. There was no mentioning of the wound. A physician order, dated 3/22/22, was noted for [MEDICATION(S)] (antibiotic) 300 milligrams every 6 hours for infection until 3/28/22. There was no indication on what infection the antibiotic was used to treat. A progress note, dated 3/29/22 at 6:36 a.m., indicated the following, .remains on atb [antibiotic] for buttock wound A progress note, dated 3/30/22 at 3:40 p.m., indicated the following, .Patient had a temp [temperature] this am [A.M.] of 99.5. this afternoon she spiked up to 102.3 .Sent a message to [name of NP]. I am waiting for his response A pressure ulcer note, dated 3/30/22, indicated an unstageable to coccyx that measured 13.5 x 12 x 4.2 centimeters in depth. There was documentation of purulent drainage and foul odor. The antibiotic was completed for the buttock wound and documentation consisted of Resident D's skin remaining diaphoretic. A pressure ulcer note, dated 4/6/22, indicated an unstageable to coccyx that measured 11.1 x 11.6 x 2.7 centimeters in depth. There was no odor documented. A pressure ulcer note, dated 4/13/22, indicated an unstageable to the coccyx measuring 13.7 x 13.4 x 2.4 centimeters in depth. There was a foul odor documented with moderate drainage. A progress note, dated 4/14/22 at 12:14 a.m., indicated Resident D's skin was pale and diaphoretic. There was no follow-up to the progress note, dated 4/14/22, about Resident D's pale skin and being diaphoretic. A progress note, dated 4/19/22 at 12:01 p.m., indicated Resident D was sent to the emergency room (ER) due to having a low hemoglobin level. An emergency room note, dated 4/19/22, indicated Resident D arrived at the ER with an elevated temperature of 104.4 and a very large and deep sacral wound with packing with purulence material. An abdominal CT (Computed Tomography) scan, completed 4/19/22, indicated a Large sacral decubitus ulcer with [CONDITION(S)] of the distal sacrum and coccyx. A hospital admission note, dated 4/19/22, indicated the following, .Impression and plan .2. Large sacral decubitus and [CONDITION(S)] .3. Probably right pelvic abscess possibly related to fistula formation .Recommendation .Surgical evaluation of sacral decubitus .[MEDICATION(S)] radiology to drain right pelvic abscess .Palliative care evaluation A Palliative Care Note, dated 4/21/22, indicated the following, .She was evaluated by surgery on 4/20/22 for a large stage IV sacral decubitus ulcer with exposed bone. Unfortunately, the area cannot be debrided-there is only pelvic muscle. Orthopedics was consulted and recommended IR-guided aspiration of left hip joint effusion. Orthopedics and General surgery do not recommend surgical interventions, and wound Care will follow the patient An interview conducted with the Director of Nursing Services (DNS), on 4/29/22 at 2:15 p.m., indicated the slough tissue, which is dead tissue, does have an odor to it. They were treating Resident D's wound aggressively. If someone had a wound that wasn't odorous, and it suddenly developed an odor that would be a change in the status of the wound. 2. The clinical record for Resident B was reviewed on 4/27/2022 at 2:19 p.m. The clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident B did not have memory issues, did not reject care, and dependent on staff members for all care that included tasks of feeding, hygiene, and bed mobility. Resident B received her nutrition via tube feeding at least 51% of more of her daily needs, had four stage 2 pressure ulcers, and utilized oxygen and a ventilator in the presence of a [CONDITION(S)] ([CONDITION(S)]). A brief interview for mental status to assess cognitive status was not completed due to resident is rarely/never understood. A change of condition assessment, dated 3/9/2022 at 9:00 a.m., indicated Resident B had abnormal vital signs, altered mental status, new/worsening [CONDITION(S)], functional decline, skin wound or ulcer, unresponsive, seems different than usual, talks/communicates less, tired, weak, confused, or drowsy, and change in skin color or condition. This assessment further indicated that Resident B was diaphoretic, had no cough reflex, was very edematous, and staff were unable to assess her blood pressure. In the 24 hours prior to the change of condition note on 3/9/2022 at 9:00 a.m., no documentation of diaphoresis, intervention, or change in condition. A hospitalist emergency room (ER) note for Resident B, dated 3/9/2022 at 9:53 a.m. indicated that .nursing from extended care facility reports the patient was clammy and diaphoretic and cool to the touch all night . Later during med pass this morning she was noted to heave decreased responsiveness. They performed aggressive suctioning without gag reflex . was noted to be pale . Her temperature was listed as 100.3 Fahrenheit (normal is 97.6 F), and blood pressure was listed as 40/0 (normal is 120/80). The ER documentation further indicated, .patient [Resident B] presents here with unresponsiveness and has finding suggestive of septic shock . An interview with LPN 3 (Licensed Practical Nurse) on 4/28/2022 at 1:44 p.m., indicated she had taken care of Resident B the morning she was sent to the ER. She indicated usually the resident could nod yes or no, but that was about it, but she was unresponsive that morning. In report, the off going nurse stated her urinary catheter was leaking and Resident B had a rough night, but LPN 3 did not get any other information in report. An interview with LPN 11 on 4/29/2022 at 12:30 p.m., indicated Resident B was diaphoretic on and off since she returned from the hospital in early March, but was more so during the end of her stay (3/9/2022) and that diaphoresis would be an acute symptom to warrant intervention such as vital signs and at least a note due to her clinical complexity. She felt Resident B was never the same after her first round of being hospitalized in February and March of 2022. An interview with RT 2 (Respiratory Therapist) on 4/29/2022 at 12:43 p.m., indicated he had cared for Resident B during her stays at the facility and if she ever had a fever or was diaphoretic, he would have reported it to the nurse. 3. The clinical record for Resident C was reviewed on 4/27/2022 at 3:39 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The non-comprehensive Minimum Data Set Assessment, dated 4/13/2022, indicated that Resident C was cognitively intact, needed extensive assistance of staff for bed mobility, locomotion, dressing, toileting, and hygiene. Resident C was totally dependent on staff for transferring and bathing tasks. Resident C was indicated as having a [CONDITION(S)] present and to have received 51% or more of her daily national value by gastric tube. Resident C utilized oxygen with the presence of a [CONDITION(S)]. A nursing admission/readmission evaluation, dated 4/7/2022, indicated that Resident C's respirations were regular/unlabored and only have shortness of breath with exercise. A nursing assessment, dated 4/11/2022 at 3:31 a.m., indicated Resident C's respirations were labored/accessory muscles used, had abnormal lung sounds of diminished, and shortness of breath with lying flat. Assist control ventilation is a form of ventilation that provides a fully supported breath with oxygenation given via ventilator. A speaking value is a one-way valve opens to let air in through the [CONDITION(S)] when the patient inspires. The valve closes during expiration, causing the air to follow the normal route and permitting speech. Oxygen given by [CONDITION(S)] collar is given by a small plastic mask that is placed over the exterior end of a [CONDITION(S)] that allowed the resident to receive humidified oxygen without breath support. A ventilator flow sheet, dated 4/10/2022 at 8:00 a.m. to 4/11/2022 at 6:00 a.m. indicated think white secretions and resident was on a speaking valve with 10 liters of oxygen via [CONDITION(S)] collar from 8 a.m. to 6 p.m. then increasing oxygen flow rate to 20 liters on the speaking valve with [CONDITION(S)] collar at 8 p.m. The resident was switched to assist control ventilator at 12:00 am on 4/11/2022. A ventilator flow sheet, dated 4/11/2022 at 8:00 a.m. to 4/12/2022 at 6:00 a.m., indicated blood-tinged secretions and was on assist control throughout the whole day. A nursing progress note, dated 4/12/2022 at 9:00 p.m., indicated New orders for .D-Dimer [lab to test a certain clotting factor] and 2 view CXR [chest x-ray] .High pressure alarm continues to go off but a lot [sic] of blood is being suctioned out and attempting to not place to much negative pressure into resident lungs. Will continue to monitor . A nurse practitioner note, dated 4/12/2022 at 9:50 p.m., indicated .Anxious appearing, respiratory rate elevated. Reported not feeling she was getting complete breaths, mild diaphoretic .[CONDITION(S)]- stat CXR . d-dimer. A nursing progress note, dated 4/12/2022 at 11:30 p.m., indicated .resident continues to high pressure with prn suctioning of blood and clots. SpO2 @ [Saturation pulse oxygen level at] 98% on 14L [Liters]. respirations at 38 with abd [adnominal] labored breathing .daughters updated on labs and stated they are tired of farting around [sic] and waiting for everyone to come to facility and that they are wasting precious time. They are wanting their mother sent to hospital. Contacted [Name of nurse practitioner] updated on everything nurse has done to keep resident at facility and to give in house treatment but family is persistent of resident being transferred to hospital. Order received at this time to send resident to ER [emergency room ] .ER. 911 contacted to transport resident to ER. A hospital discharge note containing the hospital course summary, dated 4/21/2022, indicated Resident C was admitted from the facility .with several says of increase [CONDITION(S)] secretions, increased work of breathing, blood around [CONDITION(S)], and hemoptysis [bloody sputum] .Patient [Resident C] was admitted to the hospital for septic shock due to pneumonia . An interview with LPN 11 on 4/29/2022 at 12:30 p.m., indicated she only took care of Resident C one time right after her admission and that Resident C's condition was very touchy. An interview with RT 2 (Respiratory Therapist) on 4/29/2022 at 12:43 p.m., indicated he had cared for Resident C and in his opinion, she was the most clinically unstable resident he had cared for in regard to her respiratory status. Resident C would go from a low demand on [CONDITION(S)] collar to needing to requiring high flow or assist ventilation rapidly. Resident C would state, She can't breathe, was noted to have high anxiety, and prior to her going out [to the ER] that she wouldn't sync with her ventilator. He recalled having multiple conversations with nursing staff about his concerns for her anxiety and respiratory status. A policy entitled, Change in Condition, was provided by the Director of Nursing Services (DNS) on 4/28/2022 at 11:00 a.m. The policy indicated that for a life-threatening change in condition, the licensed nurse will initiate appropriate first aid until emergency response arrives, the licensed nurse will inform the attending physician or medical director, the responsible party of the residents, and notify the DNS and Executive Director (ED). An acute change of condition was any sudden or serious change in the resident's condition that would be communicated to the physician and the responsible party would be notified. This Federal tag related to Complaint IN 410. 3.1-37(a)

Based on interview and record review, the facility failed to ensure adequate supervision was in place when a cognitively impaired resident with dementia exited the facility on 3/17/22 without supervision through an unknown point of exit. The resident was picked up by a stranger with a medical transportation company and transported back to the facility. The resident exited the facility, again, on 3/21/22 through the window of an unoccupied room and found 1.6 miles away by facility staff and transported back to the facility. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on 3/17/22 when a cognitively impaired resident with dementia exited the facility without facility knowledge. The Executive Director (ED) and Regional Vice President of Operations (RVPO) were notified of the Immediate Jeopardy on 3/28/22 at 5:17 p.m. The Immediate Jeopardy was removed on 3/29/22, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record for Resident H was reviewed on 3/25/22 at 3:42 p.m. The diagnoses included but were not limited to, dementia, major depressive disorder, anxiety disorder, [CONDITION(S)] disorder, and [CONDITION(S)] disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 2/7/22, noted Resident H with moderate cognitive impairment. Resident H required extensive assistance with one staff person for transfers, walking in room and locomotion on unit, limited assistance with one staff person for bed mobility, and impairment on one side of his lower extremity. A document titled Social Service Progress Review for MDS Documentation, dated 3/3/22, indicated Resident H had severe cognitive impairment. A Wandering/Elopement Risk Scale assessment, dated 7/30/21, indicated Resident H was a high risk for elopement. He exhibited the inability to follow instructions, the ability to ambulate, and a medical diagnosis of dementia/cognitive impairment. The interventions listed were for Resident H to remain on a locked unit. A Wandering/Elopement Risk Scale assessment, dated 1/21/22, indicated Resident H was at risk to wander. He exhibited the ability to ambulate, had a history of wandering, and a medical diagnosis of dementia/cognitive impairment. The interventions listed were for Resident H to remain on a locked unit. The care plan, revised 1/21/22, indicated Resident H was an elopement risk due to exit seeking, impaired safety awareness. The goal for the resident was to not leave the facility unattended. Interventions included, but were not limited to, redirect resident when wandering or when exit seeking, place resident profile in elopement book, assess for unmet needs when wandering/exit seeking, Secure Care Wander Guard on his left ankle (added 3/24/22), and ask resident if he would like to go for a walk when the weather was nice around 3:00 p.m. (added 3/22/22). A Psychology Progress Note, dated 3/10/22, indicated Resident H was oriented to person with memory deficit noted. His comprehension, executive function, and insight noted mild impairment along with fair judgement. The document further indicated Resident H appeared confused and mildly disoriented. An anonymous interview was conducted during the survey from 3/25/22 to 3/29/22. They indicated Resident H had eloped from the facility on two occasions. The two occurred on 3/17/22 at 3/21/22. Resident H's progress notes were reviewed for March of 2022. Dated 3/17/22 at 7:03 p.m., indicated a .Late Entry .Called residents sister made her aware of incident. She states it does not surprise her and that she is happy with care. Resident was assessed at 1555 no injury was noted at this time The progress note was created on 3/28/22 at 10:06 a.m. There was no further information regarding the incident on 3/17/22 in Resident H's clinical record. A progress note, dated 3/21/22, indicated contact was made with a family member but no indication of any incident occurring. No further indication of any incident occurring in Resident H's clinical record for 3/21/22. An interview with Qualified Medication Aide (QMA) 3, on 3/25/22 at 3:22 p.m., indicated she was working on the secured dementia care unit as the only care staff, instead of the usual two Certified Nursing Assistants (CNAs), and it was time to take the three residents out to smoke. There were three smoking residents and two non-smoking residents that went outside with me. This included Resident H. The smoke break was at approximately 3:09 p.m. and it usually lasted for 20 minutes or the duration of smoking two cigarettes. Around 5-10 minutes after the smoke break the staff noticed Resident H was missing. He returned later that evening because QMA 3 indicated she saw him at dinner. An interview with the Director of Marketing (DOM), on 3/25/22 at 3:10 p.m., indicated the facility received a call around 3:20 p.m. on 3/21/22 that an elderly gentleman was walking along the highway by an employee and it was believed to be a resident. She went to go check Resident H's room and could not locate him. She and Maintenance Director (MD) went to see if it was Resident H. It was Resident H walking along Highway US 44 in the grass and gravel area. He was alternating between a walk and a trot before stopping. Resident H was very confused and didn't know where he was going. This was the second time Resident H had left the building. Before this he was walking along the sidewalk on US 44, about a quarter of a mile. An interview with the MD, on 3/28/22 at 10:17 a.m., he indicated Resident H was found just past the gas station on the right side of US 44. He approximated it was a quarter of a mile. A transportation service noticed him walking and transported him back to the facility, on 3/17/22. The following day, 3/18/22, he was trying to get out of a window and was partially noted outside the window exposing his head and leg. On Monday, 3/21/22, someone from the therapy department believed they saw Resident H walking down US 44. He went with the DOM and Resident H was located by the sign that read 9 miles to Liberty. It was located 1.6 miles from the facility. MD indicated he pulled up beside Resident H and he just kept walking. When we asked if he wanted a ride he responded okay and got into the vehicle. Resident H didn't seem to know who the DOM and myself were. There were already screws in the windows to allow for 4 to 6 inches of opening. Resident H put enough force to snap the screws off or loosen them to remove them himself. An interview conducted with the Executive Director (ED) on 3/25/22 at 4:00 p.m., indicated the incident on 3/17/22, Resident H's guardian was notified. He had a BIMS (Brief Interview for Mental Status) of 11 and it was his choice to go. It was a nice day and he wanted to go for a walk. He got down the road about one mile. The MD screwed down the windows on 3/17/22. On 3/21/22, he knocked out the screens and the window by removing the hex screws that prevented the window from opening completely. On 3/24/22, the extra brackets were placed on the windows for additional security. On 3/23/22 the Wander Guard was added and he had already cut it off and thrown it away. He loved being outside and with him having a BIMS of 11 and the acting with purpose I didn't believe it was a reportable incident. We are looking into the situation to see if he's even appropriate for the secured unit. He was placed on a 72 hour one-on-one observation from 3/21/22 at 4:00 p.m. to 3/24/22 at 5:00 p.m. They had attempted to reach the guardian but no response. They were not 100% sure how he got out on 3/17/22. After the incident on 3/17/22, the facility staff just observed him closer, like every hour, over the weekend and that wasn't expected to be documented. It wasn't reported as an unusual occurrence because he was purposeful and his BIMS was 11. An interview conducted with the Memory Care Facilitator, on 3/25/22 at 5:10 p.m., indicated she spoke with Resident H on 3/17/22 about letting the facility know when he would like to go out and they would be happy to go out with him. On 3/24/22, she asked Resident H why he didn't ask for supervision on 3/21/22 and he just stared at me. She interpreted it as the resident was trying to remember the conversation she had with him on 3/17/22 but he couldn't recall. An interview with the ED and RVPO on 3/28/22 at 4:50 p.m., indicated they do not believe Resident H eloped from the facility but had an unusual occurrence to where he purposefully went for a walk due to the nice weather that occurred on that day. An interview conducted with Resident H, on 3/29/22 at 10:25 a.m., indicated he walked out the door to go for a walk a couple of times in the past week or so. He wanted to go to where his home was located in (name of city that was located approximately 16 miles away from the facility). He further indicated when he went for these walks he went to his home and walked back to the facility each time. A policy titled Elopement, dated October 2019, was provided by the ED on 3/28/22 at 1:53 p.m. The policy indicated the following, Purpose .Care Team Members who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action is taken .1. Residents identified to be at risk for elopement will be identified as follows .d. Care plans will be developed and individualized for residents who are at risk for elopement .5. Care Team Members will be educated to check the surrounding outside area when the door alarms to ensure no residents have exited the facility unattended .7. ISDH will be notified per the Unusual Occurrence Reporting Policy in regards to Elopement This Federal tag relates to Complaint IN 246. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to implement timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident D). Findings include: The clinical record for Resident D was reviewed on 3/25/2022 at 3:05 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set for Resident D, dated 1/30/2022, indicated that she was at risk for pressure areas, but did not have skin impairments. Resident D needed extensive assistance with eating, toileting, hygiene, and bed mobility. For transferring, walking, dressing, and locomotion, Resident D needed limited assistance of one staff member. A nursing note, dated 2/11/2022 at 2:16 p.m., indicated that Resident D was complaining of left lower extremity pain and had redness with [CONDITION(S)]. A new order for venous doppler to rule out DVT was ordered. A venous doppler is a special ultrasound used to assess the blood flow through blood vessels. A nursing note, dated 2/14/2022 at 8:28 a.m., was added to the chart on 3/28/2022 at 5:31 p.m. The note indicated that Resident D had not had her venous doppler to rule out DVT completed, that nurse practitioner (NP 6) was aware, and NP 6, stated to make her aware once completed. A nursing note, dated 2/16/2022 at 11:40 a.m., indicated that Resident D still had not had her venous doppler completed and that the diagnostic test provider would reach out to the facility with an estimated time. A nursing note, dated 2/17/2022 at 1:13 p.m., indicated that doppler results of 2 DVT in the lower extremity, one DVT in the upper left extremity, and one in the upper right extremity. New order for [MEDICATION(S)] 5 milligrams (mg) twice a day for 7 days for DVT. A radiology report, dated 2/17/2022, indicated conclusion of acute DVT in the lower extremity, and it was recommended dedicate right leg venous doppler. Radiologist conclusion was reported by the diagnostic company on 2/17/2022 at 4:37 p.m. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per dosing guidance set forth on 7/2018 by Bristol-[NAME] Squibb, the manufacturer of [MEDICATION(S)], treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 2/19/2022 at 5:39 p.m., indicated the family reported to the facility that Resident D had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The medication administration for Resident D, indicated the first dose of [MEDICATION(S)] was given on 2/18/2022 at 9 p.m. at a dose of 5 mg. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] No nursing note or evaluation present on chart to document the condition of, including pain, redness, or swelling, of Resident D's legs from discovery on 2/11/2022 until 2/17/2022 when multiple DVTs were diagnosed . An interview with DON on 3/29/2022 at 4:37 p.m., indicated that it would be an expectation that if a resident had redness, pain, and swelling, the nursing staff should be assessing and documenting their findings to monitor the condition. An interview with NP 6 on 3/29/2022 at 6:22 p.m., indicated that she kept all of her notes from the nursing facility and had no record of being contacted via phone or message in regard to Resident D on 2/14/2022. To her knowledge, her only interaction with Resident D was on 2/19/2022 regarding the status of wounds. NP 6 did not recall giving guidance to continue to wait for diagnostic testing to rule out a suspected DVT, and in her opinion, a delay of 6 days from order to completion, would be a significant delay. A policy entitled, Change in Condition, was provided by the DON on 3/29/2022 at 3:05 p.m. The policy indicated that with any sudden or serious change in a resident's condition, the physician and family will be notified of the change in condition. This Federal tag relates to Complaint IN 643.

Based on interview and record review, the facility failed to conduct wound assessments completely and accurately on a facility acquired unstageable pressure area, resulting in the coccyx pressure area increasing in size and developing seropurulent drainage (Resident D) for 1 of 3 residents reviewed for pressure areas. Findings include: The clinical record for Resident D was reviewed on 3/25/2022 at 3:05 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Discharge Minimum Data Set for Resident D, dated 2/21/2022, indicated that no pressure wounds were present at the time of assessment. An Admission Minimum Data Set for Resident D, dated 1/30/2022, indicated that she was at risk for pressure areas, but did not have pressure wounds. Resident D needed extensive assistance with eating, toileting, hygiene, and bed mobility. For transferring, walking, dressing, and locomotion, Resident D needed limited assistance of one staff member. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A pressure wound care plan, dated 2/9/2022, indicated that Resident D had a stage 2 pressure ulcer to the sacrum. Interventions were indicated as nursing staff to assess and document skin, notify MD of signs of infection, notify md of worsening or no improvements in wound, resident to utilize pressure reducing/redistributing mattress on the bed, and wound treatment as ordered. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 2/9/2022, indicated Received new orders today from NP [Nursing Practitioner]. Cleanse sacrum with normal saline, pat dry, medical honey to wound bed, cover with border foam change daily and PRN [as needed .Air mattress for pressure relief of unstageable sacral wound. No associated wound assessment documented on 2/9/2022 to indicate size, characteristics, pain associated with, or if drainage was present in the sacral wound. A paper form, dated 2/10/2022, was provided by Director of Nursing on 3/28/2022 at 3:05 p.m. The form was entitled, Wound Rounds. The document indicated Resident D had an acquired pressure wound to the coccyx measuring 1.2 x 1.5 x 0.1 centimeters (cm). No descriptions of the staging, wound bed, surrounding tissue, drainage, pain, or odor were present on the form. A paper form, dated 2/16/2022, was provided by the Director of Nursing on 3/28/2022 at 3:05 p.m. The form was entitled, Wound Rounds. The document indicated that Resident D had an acquired pressure wound to the coccyx measuring 1.25 x 1.5 x 0.1 cm. No descriptions of the staging, wound bed, surrounding tissue, pain, or odor were present on the form. A nursing note, dated 2/19/2022, was added to the medical record on 3/28/2022. The note indicated that Resident D had a facility acquired pressure area to the right elbow measuring 0.4 x 0.7 x 0.1 cm with a scant amount of serosanguinous drainage and irregular borders. The medication and treatment administration record indicated on 2/20/2022 and 2/21/2022, Resident D received treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication and treatment administration record indicated blanks for weekly nursing summaries on 2/7/2022 and 2/21/2022. The nursing assessment for 2/14/2022 indicated it was not completed due to drug refused. An interview with MDS on 3/28/2022 at 2:15 p.m., indicated that the Discharge Minimum Data Set did not include pressure areas because there were no documented pressure areas on the chart at the time of the discharge assessment being completed. An interview with LPN 4 on 3/28/2022 at 5:45 p.m., indicated she was the regular nurse that cared for Resident D. She indicated during her time here, she had gradual decline. The resident was only alert to self. An interview with LPN 4 on 3/29/2022 at 2:32 p.m., indicated that the wound order for the coccyx was changed on 2/19/2022 to Dakin's. She was unsure why it was changed, but Resident D did not utilize [MEDICATION(S)] to the wound after that date. She had discovered the wound to Resident D's elbow, but initially did not have time to document the assessment at the time of discovery, 2/19/2022, so she entered the assessment as a late entry on 3/28/2022. An interview with Assistant Director of Nursing, on 3/29/2022 at 12:20 p.m. She indicated she assumed the wound responsibilities on 2/8/2022. She remembered taking care of Resident D's wound. She indicated she used the paper form entitled, Wound Rounds as a personal reference. This is a form she developed for herself during training for her own tracking purposes. She indicated that just last week, she was educated on documented in the wound in the evaluations in the resident's record. She indicated she is not wound care certified, but she has resources and contract staff to reference for complicated wounds. When asked about Resident D's coccyx wound as being listed as unstageable in the original nursing note but having a measured depth of 0.1 cm on the Wound Round documents, she indicated she would have documented that differently now that she's had more education with wounds. Per her recollection, the 0.1 cm was the measured indention from wound edge to the top of the eschar located on the wound bed and not the true depth of the wound. Resident D discharged on [DATE] directly to another extended care facility (FACILITY 2) per family request. Supplemental documentation from the FACILITY 2 indicated that Resident D admitted to the facility on [DATE]. An admission document, dated 2/21/2022 at 11:54 a.m., indicated a coccyx pressure ulcer with full thickness loss through the dermis, down to subcutaneous tissue and muscle. The coccyx ulcer measured 7.5 x 10 cm with an unidentifiable depth due to slough, necrotic tissue, and eschar with odorous seropurulent drainage. The wound on the right elbow measured at 1.3 x 0.8 cm with an unmeasurable depth. A hospice agreement indicated that Resident D resided at FACILITY 2 and admitted to hospice services on 2/22/2022 for end-of-life care. A policy entitled, Skin Management, was provided by the DON on 3/28/2022 at 3:05 p.m. The policy indicated that a head-to-toe assessment will be completed upon admission/readmission and no less than weekly, the licensed nursing is responsible for assessing any and all skin alternations as reported by the direct caregivers, all alternations in skin integrity will be documented in the medical record, and a plan of care will be initiated to include resident specific risk factors with appropriate interventions. This Federal tag relates to Complaint IN 643. 3.1-40(a)(2)

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent a cognitively impaired resident who had been exhibiting exit seeking behaviors from exiting the locked memory care unit, obtaining a staff members vehicle and wrecking approximately 1.5 miles from the facility and being sent to the local emergency room for 1 of 3 residents reviewed for elopement (Resident C). The Immediate Jeopardy began on January 21, 2022, when a cognitively impaired resident with dementia exited the locked memory care unit unsupervised. The resident obtained a facility staff' members vehicle, driving the vehicle approximately 1.5 miles from the facility on a state highway where she had wrecked the vehicle and was sent to the local emergency room . The local weather on 1/21/22 was between 14 degrees and 25 degrees. The resident was missing approximately 40 minutes from the facility and where she had driven was unknown until the local police was dispatched to her accident on the local highway. The Executive Director and the Director of Nursing Services (DNS) were notified of the Immediate Jeopardy on 2/1/22 at 3:57 p.m. The Immediate Jeopardy was removed on 2/2/22 at 12:55 p.m., but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record of Resident C reviewed on 1/31/22 at 12:05 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, [CONDITION(S)] and [CONDITION(S)] following [CONDITION(S)] disease affecting the left dominate side, [CONDITION(S)], [CONDITION(S)] disease, diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, [CONDITION(S)], repeated falls and weakness. The Quarterly Minimum Data (MDS) assessment, dated 12/6/21, indicated the resident was severely cognitively impaired for daily decision making. The resident utilized a wheelchair and walker for mobility. The resident required extensive assistance of one person to transfer and ambulation in her room and corridor happened once or twice with the assistance of one person. The resident was admitted to the facility on [DATE]. The elopement risk assessment, dated 9/10/21, indicated the resident was low risk for elopement. The elopement risk assessment, dated 1/21/22, indicated the resident was high risk for elopement. The plan of care for Resident C, dated 1/21/22, indicated the resident was at risk for elopement due to exiting seeking behaviors. The resident had a history of attempting to leave the facility unattended and had impaired safety awareness. The interventions were as follows: assess for unmet needs when wandering/exit seeking, such as the need to use the restroom, hunger and thirst. Place the resident's profile in the elopement book. There was no further documentation in the resident's Electronic Health Record (EHR) or hard chart of the incident of Resident C eloping on 1/21/22. During an observation on 1/31/22 at 12:51 p.m., Resident C was sitting in a wheelchair in the main dining room eating lunch independently. During an interview with the Social Service Director (S.S.D.) on 1/31/22 at 12:55 p.m., indicated she was working at the facility on 1/21/22 when Resident C eloped from the memory care unit. The Human Resource staff had found a wheelchair in the parking lot between the memory care unit and the Ventilator unit. The facility found the resident at the local emergency room Department. The resident had taken the Respiratory Therapist's van and drove it down the state highway and wrecked in front of another local long-term care facility. The local police department was called, and the resident was sent to the hospital. During an interview with the Human Resource Staff on 1/31/22 at 1:37 p.m., indicated on 1/21/22 she was going from the memory care unit over to the Ventilator unit and noticed a wheelchair sitting in the south back parking lot. There were no residents observed and this occurred at 3:39 p.m. She knew the exact time because the DNS had called her about an unrelated matter when she found the wheelchair. The Human Resource Staff had used the code on the memory care unit door to exit and did not know it was not working. The wheelchair was brought back into the memory care unit and reported to LPN 1 and the Marketing Director that it had been found in the parking lot and they knew immediately that the wheelchair belonged to Resident C. The Executive Director and the President of the facility was also notified. The staff began searching room to room and outside of the building. During an interview with the Maintenance Director on 1/31/22 at 2:45 p.m., indicated the protocol was he checked doors on Mondays to ensure they were working properly and changed the codes on the doors monthly. The facility did not keep log documentation on when the doors were checked. He would just go around and check the doors. The Maintenance Director indicated the outside exit doors on the memory care unit did not have an alarm system when opened. The facility was in the process of installing security doors that would alarm on the memory care unit and had a security company come out to give the facility an estimate. The Maintenance Director was working on 1/21/22 when the resident eloped from the memory care unit. The facility was unsure how the resident was able to exit the door. He stated it could have been the weather, a vacuum from the wind that did not let the door shut all the way, or maybe the resident had followed someone out of the door. The Maintenance Director checked the door on 1/21/22 and could not find anything malfunctioned on the door. He changed the code to the door that evening. During an interview with LPN 1 on 2/1/22 at 10:33 a.m., indicated he was the dedicated nurse for the memory care unit and was working on 1/21/22 when Resident C eloped the facility. LPN 1 had seen the resident approximately 15-20 minutes prior to the wheelchair being found. The resident had been propelling herself in the wheelchair prior to the incident. Resident C could ambulate but was unsteady. The resident did have a history of talking about wanting to go home and hovering around the exit doors. LPN 1 indicated the exit door to the outside on the memory care unit did not always close all the way unless you physically closed it. There was about an inch gap that kept the magnet from activating to lock it, but the door would look like it was closed. The door started doing this in late fall and got worse as the weather got colder. The staff utilized the door to go from the memory care unit over the Ventilator unit but were not allowed to any longer since this incident happened. When queried if the Maintenance Director was aware that the door had been malfunctioning, LPN 1 indicated anyone who used the door knew that it had to be physically shut. During an interview and observation with Resident C on 2/1/22 at 11:10 a.m., indicated she had drove a van from the facility and had hit a large rock and wrecked it. The resident indicated she was able to leave the memory care unit because the door was open. The resident indicated she did not remember where all she had drove or where she was going, but knew she wanted to go anywhere but the facility. The resident indicated she did not belong at the facility, and she had been dropped off there for no reason. The resident began crying and indicated she wanted to go home. The resident was observed to be lying in bed and sat up on the side of her bed during the interview. The S.S.D. was notified of the resident becoming tearful. During an interview with the DNS on 2/2/22 at 11:21 a.m., indicated on 1/21/22 Respiratory Therapist 1 had gone to his van for a break and thought his keys to the van may have dropped out of his jacket when he was getting out of the van to come back into the facility and that was how Resident C was able to take the van from the facility. During an observation and interview with the Executive Director and the Maintenance Director on 2/1/22 at 11:35 a.m., the exit door to the outside on the memory care unit had a keypad code that only the Executive Director and Maintenance Director had now was activated by the Maintenance Director. The door was opened 6 times on both sides of the door and the magnet that locked the door would activate between 9 to 16 seconds after the door was closed. The back south parking lot was observed where the wheelchair was located, and it was located behind the memory care unit and the ventilator unit. There was a sidewalk leading from the memory care unit to the Ventilator unit and a sidewalk leading to the parking lot, there was grassy areas between the sidewalk and a field behind the parking lot. The Maintenance Director indicated staff used to park in the back parking lot because it was closer to the unit and now, they were not. During an interview with the DNS on 2/1/22 at 12:01 p.m., indicated she went to the local emergency roiagnom on [DATE] and stayed with Resident C unit she returned back to the facility. The DNS had completed an assessment on Resident C upon return to the facility but had not documented it. The DNS was going to document a late entry of the assessment at this time. During an interview with the Administrator on 2/1/22 at 12:15 p.m., the facility did not document Maintenance logs for repairs. The facility did not have documentation of a repair requisition for the memory care unit exit door. During an interview with Resident C's family member on 2/1/22 at 12:28 p.m., indicated the facility had notified him on 1/21/22 that his family member Resident C had eloped the facility and they were unsure how. The family member indicated every time they visited the resident, the resident expressed her desire to leave the facility. The resident did not comprehend that she was unable to leave the facility. The family member was notified by the Marketing Director that the resident had a history of going to the doors on the memory care unit and would yank on the exit doors to attempt to open them. The resident was unable to tell him where she had drove to or where she was going. She told him she was lost. The resident was able to tell him that she hit a rock and wrecked the van. The family member indicated the facility obviously failed the resident because she was in a locked memory care unit and was able to get out in a wheelchair. The keys had to be left in the vehicle because how else would she have known what vehicle to take and get the keys. The family member indicated he was unable to wrap his mind around how she got out and left the facility and drove away. During an interview with the Executive Director on 2/1/22 at 12:49 p.m., indicated he was unable to locate the last elopement drill the facility had completed. The Executive Director indicated there was no family members who had screened in the facility to access the memory care unit on 1/21/22 when the resident eloped. During an interview with the Marketing Director on 2/2/22 at 12:52 p.m., indicated she had worked with Resident C and the resident had a history of exit seeking. The resident would wheel her wheelchair up to the exit door and pull and push on the lever to check the door repeatedly. The resident would wheel around the unit and check the doors and often tried to trail out behind people when they leave the unit. The local police report, dated 1/21/22 at 3:59 p.m., indicated a deputy was dispatched to a local address on the state highway in reference to an unknown accident. Upon arrival Emergency Medical Services (EMS) was speaking with Resident C. Resident C appeared to have no idea where she was at and appeared to be having a medical issue. Upon looking at the vehicle it had struck a rock and had caused damage to the front passenger side headlight are and front passenger side tire. The vehicle had been parked in the parking lot of a local facility. Dispatch received a call from the local long-term care facility advising a patient had escaped from their facility and had taken a workers van. Dispatch advised the patient was transported to the local emergency room for medical treatment and that she had been involved in an accident. This indicated the resident was missing approximately 40 minutes from the facility when LPN 1 visualized the resident on 1/21/22 at 3:19 p.m. and was not seen until the local police found her on 1/21/22 at 3:59. The local hospital emergency room report for Resident C, dated 1/21/22 at 5:41 p.m., indicated the resident had run over a small decorative rock and had no apparent injuries. The resident was able to state where she was and her birth date. The resident's orientation waxes and wanes. She indicated she was on her way to see her parents, getting married and was pregnant. She denies any complaints and states that she feels well. Apparently, she was found by another local long-term facility that was not familiar with her and they called EMS. Apparently, patient is a resident at the local Extended Care Facility (ECF) and was on their dementia unit and they had just called dispatch due to patient escaping the facility. Apparently she had stolen a therapist's van somehow and they found her wheelchair in the parking lot. The resident had absolutely no complaints or obvious injury. According to Accu Weather the local weather where the facility is located was between 14 degrees and 25 degrees on 1/21/22, https://www.accuweather.com/en/us. The elopement policy provided by the DNS on 1/31/22 at 2:30 p.m., indicated the care team members who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action was taken. Elopement drills would be conducted quarterly. The Immediate Jeopardy that began on 1/21/22 was removed on 2/2/22 at 12:55 p.m., when the facility implemented checking all doors to ensure proper functioning two times a day and documenting the door checks, changing door codes every 30 days, implementing audible door alarms to the memory care unit exit doors, monitoring all residents at a minimum of every two hours and implementing audits for completion, and educating staff on reporting of issues with the locking/securing of doors. This Federal tag relates to Complaint IN 572. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 1 resident (Resident C) was free from physical abuse by staff feeding him in a rough manner, and 2 residents (Resident C and D) were free from verbal and psychosocial stress by staff talking in a derogatory manner to both residents, for 2 of 4 residents reviewed for abuse and neglect. Findings include: A. Resident C's record was reviewed on 3-2-18 at 5:05 p.m. His [DIAGNOSES REDACTED]. His most recent Minimum Data Set assessment, dated 12-13-17, indicated he is significantly cognitively impaired with long-term and short-term memory problems, is nonverbal and requires extensive assistance with dining. His care plans reflected the need for assistance with dining, having difficulty with communication and cognitive impairment, related to dementia and [MEDICAL CONDITION]. In an interview with Dietary Staff 3 on 3-6-18 at 9:58 a.m., he indicated he was working on the serving line of the dining room on the evening of 2-17-18 and was able to see into the dining room. Dietary Staff 3 was able to provide a physical description of CNA 4. The one aide, don't know her name, was practically shoving the spoon into (name of Resident C)'s mouth, real fast, so fast, he was practically choking with his spoon. He was even trying to push her hand away and turn his head away. He got some food on his face and she took his napkin and cleaned his face and was rubbing his lips so hard I thought she was going to rip his lips right off. The aide seemed upset about being there and was in a big hurry. Normally, most of the aides will take 15 minutes or so to feed (Resident C). She was done in less than 5 or 6 minutes and had a fair amount of food and his drinks left. Usually, he eats nearly all or all of his meals. I had never seen anybody before or since treat the residents like that. I did not leave the area, so I could keep my eyes on her. (CNA 4) had said something when she came into the dining room about she had gotten into it earlier in the day with (name of Resident C, regarding care issues) .Well, she even asked me if I had ever seen her be abusive towards a resident. After I saw her shoving food down (name of Resident C)'s throat, I went out there and told her, the aide, what I had just seen and that I thought that was being abusive. It was really weighing on my mind, but at that time, was not sure who I should talk to about reporting this. It just so happened, a lady, I think the Assistant Administrator, came in about a half hour later to talk to some of us who had not gotten the abuse inservice and I was able to report all this to her about the aide shoving the food down his throat and what she had said about (name of Resident C) .I guess I had never really gotten trained on what to do or who to let know if you see or hear something that could be abuse. Now, I know what to do. If we see or suspect someone is being abused, we are supposed to call the Administrator immediately and then make sure our Supervisor knows. But, I'm not sure how we are supposed to get in touch with the Administrator if she is not here. Will have to find that out. In an interview on 3-2-18 at 7:15 p.m., with Dietary Staff 2, she indicated during the evening meal on 2-17-18, she noticed the one aide feeding (name of Resident C). Normally, he needs spoon fed, but with some help, he can feed himself or drink okay. I've noticed in the past, he will use his hands to try to find his tray. That evening, I noticed the aide was seeming to be in a big hurry and was trying to keep him from grabbing at his tray. She kind of put her one hand on his arm to keep him from grabbing at stuff, not really hard, but just enough to keep him from grabbing his tray. But what I noticed the most was that while she was trying to feed him, she was doing some kind of paperwork at the same time, and not really paying much attention to what she was doing. To me, it looked like she was being kind of rough and hurrying to finish up with him and kind of shoving the food in with the spoon. I said something to (name of Dietary Staff 3) .He noticed the same thing and ended up saying something to the lady that was here doing the abuse training that evening. The aide might have spent 2-5 minutes feeding the patient and normally it takes 12-15 min to feed him and he eats all. I would say there was about half or less of his tray left when she set the tray over to another table. He also had been reaching for his orange drink and she took that away, too. He acted like he was still hungry to me. So, it was actually (name of Dietary Staff 3) that told the lady (that was here doing the abuse training that evening), not me. I've never noticed any of the other staff hurry through feeding him. I don't know if the patient can talk, but I do know he normally eats real good. I can't say how that aide did with other patients. Around that time, this patient was about the only one that needed fed around that time, maybe one or two others. Normally the aides are real good to help any of the patients that need help with their meals. I believe we ended up getting him more to eat and drink after it was reported. In an interview on 3-5-18 at 3:37 p.m., with Resident C, he indicated he observed CNA 4 providing dining assistance to Resident C on 2-17-18 at the evening meal. He indicated he had an unpleasant encounter with CNA 4 earlier the same day. This is the same aide that was supposed to be helping (name of Resident C). She got him (Resident C) upset by just shoving the spoon in his mouth and ended up taking his tray away before he was done eating. I was in the dining room and saw all of it. His family ended up moving him to another nursing home over it. That (name of CNA 4) didn't work here too long and that's a good thing, because she didn't seem to give a hoot. I will say this new Administrator took things serious . B. The clinical record of Resident D was reviewed on 3-6-18 at 9:28 a.m. His [DIAGNOSES REDACTED]. His most recent Minimum Data Set assessment, dated 12-30-17, indicated he is cognitively intact, requires extensive assistance with toileting, dressing and hygiene, is frequently incontinent of urine and occasionally incontinent of bowels. His care plans reflected his cognitive status and requiring staff assistance with all activities of daily living, including, but not limited to, toileting, incontinence of his bowels and bladder and hygiene. In an interview with Resident D on 3-5-18 at 3:37 p.m., he indicated, Not too long ago, an aide by the name of (CNA 4) was supposed to be helping me get my clothes changed because I had wet them. Instead of doing her job, she decided to spend 10 or 15 minutes arguing with me about sitting on the toilet and told me she was tired of having to change me, that I needed to learn how to use the toilet. I finally told her she was supposed to be helping me, not complaining about me. Well, one of the bosses came in later that evening and I told her what happened and they ended up firing her. This is the same aide that was supposed to be helping (name of Resident C, describing an incident the same evening in the dining room) .That (name of CNA 4) didn't work here too long and that's a good thing, because she didn't seem to give a hoot. I will say this new Administrator took things serious But it still makes me mad every time I think about how she wasn't doing her job, just kept arguing with me and then how she treated (name of Resident C) that evening at supper. In an interview with Dietary Staff 3 on 3-6-18 at 9:58 a.m., he indicated he was working on the serving line of the dining room on the evening of 2-17-18 and was able to see into the dining room. Dietary Staff 3 was able to provide a physical description of CNA 4. He indicated, referring to CNA 4, She had said something when she came into the dining room about she had gotten into it earlier in the day with (name of Resident D), about him always wetting himself and why didn't he quit doing that and just go to the bathroom. Well, (name of Resident D) can't do that, he has had a stroke. Well, (name of Resident D) was in the dining room and saying kind of mean things to her and she said things back to him. She really hated having to take his tray to him, because he just kept it up, saying stuff to her. Would guess there were at least 10 or more other residents in the dining room at the time .She was talking about what had happened with her and (name of Resident D) earlier in the day, right out in the dining room, where all the residents that were there could hear her It was really weighing on my mind, but at that time, was not sure who I should talk to about reporting this. It just so happened, a lady, I think the assistant administrator, came in about a half hour later to talk to some of us who had not gotten the abuse inservice and I was able to report all this to her about . (Resident C) .and what she had said about (name of Resident D) .Until that lady came in, I wasn't really sure who I should report any of this to. It worked out good that she came in that evening .I guess I had never really gotten trained on what to do or who to let know if you see or hear something that could be abuse. Now, I know what to do. If we see or suspect someone is being abused, we are supposed to call the Administrator immediately and then make sure our Supervisor knows. But, I'm not sure how we are supposed to get in touch with the Administrator if she is not here. Will have to find that out. On 3-2-18 at 5:18 p.m., the Administrator provided a copy of a policy entitled, Policy and Procedure Abuse Prevention. This policy was undated, but indicated to be the current policy utilized by the facility. This policy's purpose was specified to be, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, or other individuals .This also includes the facility's responsibility to screen out all potential employees prior to hire who personal histories render them at risk for abusing residents. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, have the potential to cause physical harm, or pain or mental anguish . This Federal tag relates to Complaint IN 802. 3.1-27(a)(1) 3.1-27(a)(3) 3.1-27(b)

Based on observation, interview and record review, the facility failed to ensure staff supervision of 8 residents during smoking for 3 of 6 observations of resident smoking. (Residents B, C, G, J, K, L, M and N) The Immediate Jeopardy began on 09-22-17 when 8 residents were observed to be in the facility's designated smoking area without staff supervision, with 7 of the 8 residents observed to be smoking. The Corporate Vice President, Corporate Nurse and Director of Nursing were notified of the Immediate Jeopardy on 9-22-17. The Immediate Jeopardy was removed on 9-25-17 when the facility instituted staff supervision of residents during designated smoking times, educated staff and residents on the facility's smoking policies, including designated smoking times, but the noncompliance remained at the lower scope and severity of pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, related to incomplete notification of the families and/or responsible parties of each resident of the facility's current smoking policies. Findings include: On 09-20-17 at 10:05 a.m., Resident B was observed wheeling himself in his wheelchair in one of the halls of the west building, one cigarette tucked behind his right ear. On 9-20-17 at 4:10 p.m., an observation of Resident G indicated he was seated in his wheelchair, outside of the west building. Resident G was observed to be smoking a cigarette and unsupervised by any staff. Resident G was observed to hold the cigarette in his left hand, when not smoking the cigarette, which would be difficult to visualize from the main entrance. At 4:20 p.m., the resident was observed to discard his cigarette butt into the grass and wheel himself towards the main entrance. At 4:30 p.m., Resident G was observed to return to the same location with a lighted cigarette. He continued to hold the cigarette in the same manner as before. He remained in the same location until 4:40 p.m. No staff were observed in the area during this time. In an interview with Resident G on 9-22-17 at 9:17 a.m., he indicated he had been a resident at the facility for less than one year, Got kicked out of (name of an area facility) because I got caught smoking when I wasn't supposed to a couple of times. Like it here a lot better, because you can smoke anytime you want . I usually go over that direction to smoke (pointing to the west of the west building.) I keep all my smoking stuff at the nurse's station and just ask for it and get it when I want to go smoke. On 9-22-17 at 9:40 a.m., Resident K was observed at the west building's nurses station, requesting a cigarette. At the time, multiple facility staff persons, including licensed nurses and CNA's, were present in the area. A contracted environmental services staff person was observed to hand Resident K two cigarettes, and he walked toward the main entrance. An interview with LPN 5 on 9-22-17 at 10:05 a.m., indicated, We are supposed to do quarterly assessments on each resident. Those assessments include one for AIMS, falls, the Braden (type of skin assessment) and smoking. We used to get them on a clip board, from somebody, as a reminder. That hasn't been done much lately. An interview with Resident N on 9-22-17 at 10:32 a.m., indicated his understanding of the facility's smoking policy was that residents may smoke every 2 hours. He added, But, some of us can go and smoke on our own. I usually keep my smokes with me (resident patted his shirt pocket). Now, there's only one guy that I worry about that will go out to smoke with some of us. Sometimes it's just us guys (residents) and sometimes a worker will be with us. But he falls asleep at the drop of a hat. He'll sit still for just a minute or two and will be asleep and sometimes will have a cigarette in his hand. He identified this resident as Resident B. An observation of Resident N's shirt pocket indicated a rectangular-shaped outline, similar to a cigarette package. On 9-22-17 at 11:07 a.m., an observation of the facility's designated smoking area was conducted with LPN 2. LPN 2 was observed to unlock the secured door of the southeast corner of building of the west building. Resident N was inside the building and wanting to exit. LPN 2 allowed him to do so. Six resident were observed in/around the designated smoking area of a small building, in which Resident K was present in the building and five other males were observed at or around an adjacent picnic table, which included Residents B, C, J, K, L, M and N. All, with the exception of Resident L, were smoking at the time of the initial observation. No staff were observed to be present, prior to LPN 2 entering the area. Resident N immediately entered the small building and lit a cigarette and began to smoke. Resident B was observed to have a protective apron on, but no protective device on his hands. At 11:10 a.m., Activity Staff 3 exited the building and walked toward the designated smoking area, carrying a small locked box, labeled, west building smoking supplies, and commented, You guys were in a hurry today and beat me here. An observation on 9-22-17 at 11:07 a.m., of the small building in the designated smoking area indicated a fire extinguisher on the north wall, with small plastic trash can under the extinguisher. Across from the smoking area was a large trash can with a self-closing lid that appeared to be of a hard plastic material, as well as a hard plastic device with a large base and long neck, approximately 30-40 inches tall in which one can place a cigarette for safe extinction. A fire blanket was not observed in the area. No signage was observed to alert persons with oxygen of possible smoking or potential fire hazard was in the area. An interview with LPN 2 on 9-22-17 at 11: 20 a.m., indicated Residents B, C, J, K, L, M and N were in the outdoor designated smoking area of the facility and unsupervised by facility staff. She indicated she was unsure how the residents would have obtained the smoking materials in order to be able to smoke without staff intervention. She added the activity aide should have been here present at the beginning of the smoke break time and that time did not normally begin until around 11:30 a.m. LPN 2 explained nursing assessments conducted at admission and the admission nursing assessment include a safe smoking assessment. She was unaware of any other times in which a safe smoking assessment would be conducted. In an interview with a Corporate Vice President (VP) on 9-22-17 at 11:45 a.m., he indicated he had no idea residents were smoking unsupervised at the facility. He shared, We have a policy and obviously it is not being followed. An interview with RN 4 on 9-23-17 at 5:16 p.m., indicated the smoking supervision for the residents has been kind of lax for a while now. Some of the residents have been able to sign themselves out and may bring smoking materials back with them and not report it. Even though it seemed inappropriate, they have been kind of supervising one another. Like for example, if a fairly responsible resident was going out to smoke and another resident wanted to go that might need closer supervision, the more responsible resident would offer to keep an eye on them. In a confidential interview, he/she indicated he/she was a current smoker. He/she revealed some are able to keep our cigarettes and stuff in our rooms and go out and smoke pretty much whenever we want to .they (the facility) don't let very many people do that. I don't feel like they let just anybody do that. Most of the people who smoke only do that when the workers are able to go out with them to smoke. Resident B's clinical record was reviewed on 9-21-17 at 4:35 p.m. His [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 7-31-17, indicated he was cognitively intact. This MDS assessment, for Section J, question J1300, regarding current tobacco use, was blank. A previous MDS assessment for this section, dated 4-6-17, indicated he did use tobacco. A care plan, related to being a smoker, dated 3-28-17, indicated, I have the potential for injury because I am a smoker. I am not always compliant with facility smoking policy. Approaches indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. On 8-8-17, a nursing note specified, Needing finger protectors during smoke breaks. Neither of these devices were identified on Resident B's care plans. Resident C's clinical record was reviewed on 9-21-17 at 4:55 p.m. His [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 6-25-17, indicated he was cognitively intact. This MDS assessment, for Section J, question J1300, regarding current tobacco use, was blank. A previous MDS assessment for this section, dated 4-6-17, indicated he did use tobacco. A care plan, related to being a smoker, dated 3-28-17, indicated, The potential for injury because I am a smoker. I am not always compliant with facility smoking policy. Approaches, dated 4-12-17, indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. Resident G's clinical record was reviewed on 9-22-17 at 9:35 a.m. His [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 6-25-17, indicated he was cognitively intact. This MDS assessment, for Section J, question J1300, regarding current tobacco use, was blank. A previous MDS assessment for this section, dated 1-11-17, indicated he did use tobacco. A care plan, related to being a smoker, dated 1-2-17, indicated, I have the potential for injury because I am a smoker. I'm not always compliant with facility smoking policy. Approaches, dated 1-2-17, indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. However, the portion of the assessment, Section N, related to safety issues, including Safe Smoking Evaluation, was blank. The most current physician's note, dated 7-13-17, identified Resident G as a former smoker. Resident J's clinical record was reviewed on 9-22-17 at 3:15 p.m. His [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 7-30-17, indicated he was cognitively intact. This MDS assessment, for Section J, question J1300, regarding current tobacco use, was blank. A previous MDS assessment for this section, dated 3-30-17, indicated he did use tobacco. A care plan, related to being a smoker, dated 3-21-17, indicated, Res (resident) has the potential for injury because I am a smoker. I'm not always compliant with facility smoking policy. Approaches, dated 3-21-17, indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. Section N of this form included a Safe Smoking Evaluation, and indicated Resident J was determined to be a safe smoker. Resident K's clinical record was reviewed on 9-22-17 at 2:52 p.m. His [DIAGNOSES REDACTED]. This MDS assessment, for Section J, question J1300, regarding current tobacco use, was blank. A previous MDS assessment for this section, dated 11-14-16, indicated he did use tobacco. A care plan, related to being a smoker, dated 3-21-17, indicated, Res (resident) has the potential for injury because I am a smoker. I'm not always compliant with facility smoking policy. Approaches, dated 12-11-15, indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. Resident M's clinical record was reviewed on 9-22-17 at 3:23 p.m. His [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 7-30-17, indicated he was moderately cognitively impaired. This MDS assessment, for Section J, question J1300, regarding current tobacco use, was blank. A previous MDS assessment for this section, dated 11-29-16, indicated he did not use tobacco. A care plan, related to being a smoker, dated 07-30-15, indicated, I have the potential for injury because I am a smoker. I am not always compliant with facility smoking policy. Res (resident) is to keep his chewing tobacco at nurse's station, and is not to chew while in bed. Approaches, dated 7-30-15, indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. Resident N's clinical record was reviewed on 9-25-17 at 11:40 a.m His [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 6-29-17, indicated he was cognitively intact. This MDS assessment indicated he uses tobacco products. A care plan, related to being a smoker, dated 8-31-15, indicated, I have the potential for injury because I am a smoker. I often don't follow the facility smoking policy. Approaches, dated 8-31-15, indicated to educate the resident on the facility's smoking policy and schedule, to conduct a smoking assessment as per facility policy, to keep all smoking materials at the nurse's station and to supervise the resident while smoking. Review of the recapitulation orders for September, 2017, did not reveal any physician orders [REDACTED]. On 9-22-17 at 10:30 a.m., the Director of Nursing provided a copy of a policy entitled, Smoking Policy. This policy had a revision date of 1-25-17 and was identified as the current policy utilized by the facility. The policy's Statement was stipulated to be To maintain the safest possible smoking environment for those residents who have chosen to and are physically able to smoke. The policy's Interpretation and Implementation listed the following guidelines: 1. No cigarettes, lighters, or smoking products (pipes, vaping devices, cigars, etc.) are to be kept in resident rooms. 2. Smoking is only permitted under the supervision of a staff member in the facility's designated smoking area during the facility's designated smoking times, this includes the use of vaping devices as well. 3. The designated smoking area will use ashtrays made of noncombustible material and safe design, will have metal containers with self-closing covers for emptying ashtrays, and have fire extinguishers and smoking blankets available. 4. Oxygen use is prohibited in the resident smoking area, and a sign will be posted stating this. 5. The smoking area will limit second hand smoke exposure to other residents . 7. The supervising staff member will: a. Hand out and assist with lighting the resident's cigarettes and supervise and maintain the safety of the residents during smoking. b. Ensure that all cigarettes are safely extinguished at the end of the smoke time. c. Notify the Unit Nurse when a resident's ability to smoke safely is in question. 8. Pre-admission, the admission director will: a. Ascertain the resident's wishes about smoking. b. Instruct the resident about the facility policy on smoking: locations, times and safety concerns. c. Instruct the resident/responsible party that the facility is not financially responsible for the resident's smoking supplies. 9. On admission, the Charge Nurse will: a. Assess the resident's ability to smoke safely by completing a smoking assessment that includes an evaluation of the resident's safety awareness, judgement, cognitive ability, and manual dexterity. b. Obtain physician order [REDACTED]. c. Mark the resident's cigarettes or other smoking products with the resident's name and keep them locked in the supply room. d. Instruct staff members to notify the Charge Nurse immediately if it is suspected the resident has violated the facility smoking policy or if the resident's clothing or skin has signs of cigarette burns. 10. Each resident who smokes will be evaluated for smoking safety upon admission and with the quarterly assessments thereafter, and the resident's need for supervision will be documented in the resident's care plan. The information will be available to staff members, and will be updated with any change in the resident's capabilities and needs. 11. The facility's safety committee will review the facility's smoking policy, procedures, and designated smoking area annually and as needed. The Immediate Jeopardy began on 09-22-17 was removed on 9-25-17 when the facility instituted staff supervision of residents during designated smoking times, educated staff and residents on the facility's smoking policies, including designated smoking times, but the noncompliance remained at the lower scope and severity of pattern no actual harm with potential for more than minimal harm that is not immediate jeopardy, related to incomplete notification of the families and/or responsible parties of each resident of the facility's current smoking policies. This Federal tag relates to Complaint IN 150. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for (UTI's) received the appropriate treatment and care which resulted in the residents admission for six days in the intensive care unit with [DIAGNOSES REDACTED]. (Resident C) Findings include: The clinical record of Resident C was reviewed on 6-21-17 at 4:15 p.m. Her [DIAGNOSES REDACTED]. She had been a resident of the facility for more than five years and resided on the memory care unit of the facility. Her most recent Minimum Data Set (MDS) assessment, dated 3-24-17, indicated she was severely cognitively impaired, but was able to understand others and she was able to be understood by others with no impairment to her speech or hearing. She required extensive assistance to complete dependency on others for ambulation, transfers, dressing, bathing, hygiene, eating and toileting needs. In interview with a family member of Resident C on 6-21-17 at 2:50 p.m., she indicated in the approximate 3-4 days prior to Resident C's hospitalization on [DATE], another family member had visited with Resident C and had notified the nursing staff of his concerns in regards to something wasn't right, (Resident C was) just staring at the ceiling and not talking .he finally called me and told me what was going on. I called there at 10:00 a.m., (on 4-4-17) and told them I wanted her sent out (to the emergency room ) and spoke with (name of RN #1). She said she noticed she (Resident C) wasn't acting quite her normal self. She shared she exchanged multiple phone calls with the facility, before Resident C was sent to the local emergency room . This all happened around the time of (this facility was) being bought out and (there were) lots of new people who were not familiar with (Resident C). Review of the Interdisciplinary Progress Notes reflected no documentation in Resident C's clinical record from 3-21-17 at 2:00 p.m., until the next entry on 4-3-17 at 5:00 p.m. The entry at this time was documented as follows: Resident received n/o (new order) for a straight cath (catheter) for UA and CNS (sic; urine sample for urinalysis and culture and sensitivity testing for a UTI) family notified. The associated telephone order form, specified, Straight cath x1 (one time only) for UA and CNS. No associated documentation could be located as to the reason a urine test was to be conducted. The following day, 4-4-17, documentation included, but was not limited to, the urine sample being obtained, telephone conversations with the daughter and nurse practitioner with associated orders received. An entry on 4-4-17 at 12:00 p.m., denoted, Resident was feeling pretty bad this A.M. She was staring into space, not eating or drinking. An SBAR (Situation-Background-Appearance-Review) form, dated 4-4-17 at 6:00 p.m. was present in the clinical record which specified, Was reported that over the weekend resident was getting weak and wanted to sleep all the time. Yesterday, her VS's (vital signs) were WNL (within normal limits), but she still wouldn't eat much or drink. Today, she just would stare blankly and not eat or drink. Started an IV, drew blood and got a UA. She has a UTI that hasn't been cultured yet, but we started IM (intramuscularly injection) [MEDICATION NAME] (antibiotic) 1 gm (gram) tonight. She had no other meds today. The SBAR relayed staff concerns of diminished mental status, weakness, critical labs and cloudy urine with foul odor, with a request to send her to the emergency room . A telephone order form, dated 4-4-17 at 6:00 p.m. indicated the physician's response was to send Resident C to the local emergency room for evaluation and treatment. The local emergency room documented Resident C's time of arrival on 4-4-17 as occurring at 6:50 p.m. On 6-22-17 at 12:35 p.m., the Director of Nursing provided a copy of the facility's 24-hour report for 4-1-17 through 4-4-17, which she clarified was not a part of the resident's official clinical record. Nothing was documented for Resident C on 4-1-17, and 4-2-17. This report identified on the 11:00 p.m., to 7:00 p.m., or first shift for the date of 4-3-17, Resident C staring into space, did respond to verbal stimuli-small, dry couth, T )temp) 98.9. An entry denoted for the second shift of 4-3-17 of 7:00 a.m., to 3:00 p.m., Straight cath, order by tonight, encourage fluids, straight cath UA (and) C+S. Listed under the resident's name was a comment of 72 hr charting D/T (due to) urine (for) 4-3 (through) 4-6. A review of the 4-17 Medication Administration Record [REDACTED] -[MEDICATION NAME] 10 milligrams (mg) daily by mouth after breakfast. -[MEDICATION NAME] 0.5 mg, 1/2 tablet (0.25 mg) daily after breakfast by mouth. -[MEDICATION NAME] 0.5mg, two 1/2 tablets (0.50 mg) daily at bedtime by mouth. -namzaric 28 mg-10 mg daily at bedtime by mouth. -[MEDICATION NAME] 20 mg daily before breakfast by mouth. -Refresh [MEDICATION NAME] Eye Drops 1 drop in each time twice daily, after breakfast and after supper. -[MEDICATION NAME] 75 mg daily after supper by mouth. -[MEDICATION NAME] sodium 100 mg two tablets (200 mg) daily at bedtime by mouth. -[MEDICATION NAME] 300 mg twice daily after breakfast and after supper by mouth, with the evening dose documented as administered. Review of the CNA ADL (activities of daily living) Tracking Form, for 4-17, identified Resident C's meal intakes as follows: 4-1-17: breakfast-poor; lunch-poor; dinner-poor; evening snack-accepted; dietary substitute offered if less than 50% (percent) of meal consumed: 100% consumed for each meal. 4-2-17: breakfast-poor; lunch-poor; dinner-good; evening snack-accepted; dietary substitute offered if less than 50% (percent) of meal consumed: 100% consumed for two meals. 4-3-17: breakfast-poor; lunch-poor; dinner-poor; evening snack-not accepted; dietary substitute offered if less than 50% (percent) of meal consumed: 100% consumed for each meal. 4-4-17: breakfast-good; lunch-good; dinner-at hospital. The accompanying legend identified meal consumption of good as consuming 75-100% and poor as consuming 25-49%. The CNA ADL (activities of daily living) Tracking Form, for 4-17, identified Resident C was offered fluids as follows: 4-1-17: twice on each shift, nights of 11:00 p.m., to 7:00 a.m., days of 7:00 a.m., to 3:00 p.m., and evenings of 3:00 p.m., to 11:00 p.m. 4-2-17: twice on each shift of nights, days and evenings. 4-3-17: twice on night shift, three times on day and evening evening shifts. 4-4-17: twice on night and day shifts; the evening shift listed the resident as being at the hospital. This form did not specify if the resident accepted the offered fluids or amounts accepted. In review of Resident C's weights, the facility listed her weights for 10-16, at 117 pounds, for 11-16, at 125 pounds, for 12-16, at 119 pounds, for 1-17, at 125 pounds, for 2-17, at 123.5 pounds, for 3-17, at 122 pounds, for 4-1-17, at 107.6 pounds with a re-weight the next day on 4-2-17, at 118.6 pounds. Resident C's weight was documented at admission to the emergency roiagnom on [DATE] at 6:55 p.m., as 106.5 pounds. Due to varying discrepancies of weight, the one month weight loss from March, 2017, of 122 pounds to emergency room admission suggested a significant weight loss of 15.5 pounds or 12.7%. Resident C was identified as being at risk for dehydration and electrolyte imbalance as signified by a care plan, dated 10-11-11, and updated on 1-3-17, which included the risk associated with diuretic use. Approaches recommended for this risk were stated as, encourage fluids, labs and diagnostics as ordered, administer medications as ordered , observe for any signs or symptoms of dehydration and water available in room. The care plan did not specify what particular signs and symptoms of dehydration might be. In an interview with RN #1 on 6-22-17 at 2:45 p.m., she indicated she could not recall any specific details regarding the events surrounding Resident C being sent to the emergency roiagnom on [DATE] due to the event happening several months ago. All I can say is we simply must have missed it (signs and symptoms of UTI and dehydration). RN #1 recalled Resident C had resided on the memory care unit for a long period of time, was one who kept to herself, was very quiet and enjoyed visits from her family. In an interview with the Director of Nursing (DON) on 6-22-17 at 6:01 p.m., she indicated she was unable to locate any documentation regarding any assessments of Resident C prior to 4-4-17, was unable to determine why an order to obtain an urinalysis would have been written without some type of assessment, without documented notification of the physician regarding health concerns or the [DIAGNOSES REDACTED]. weights. The DON explained these events took place prior to her being in the position of DON, as well as prior to the current Executive Director being in his current position. On 6-22-17 at 6:01 p.m., the DON provided a copy of a policy entitled, Notification of Change in Resident Change. This policy had a revision date of 12-2012 and was identified as the current policy utilized by the facility. This policy stipulated, Our facility shall promptly notify the resident, his or her Attending Physician or Practitioner, and responsible party of changes in the resident's medical/mental condition and/or status. For changes in resident condition, the Nurse will notify the resident's Attending Physician or On-Call Practitioner and Responsible Party of the resident when there has been .A significant change in resident's physical/emotional/mental condition; A need to alter the resident's medical treatment significantly; Instructions to notify the physician of changes in the resident's condition. A significant change of condition is a decline or improvement in the resident's status that .Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, Requires interdisciplinary review and/or revision to the care plan .The SBAR communication tool will be completed for all non-emergent significant changes in condition prior to notifying the Physician or Practitioner .The Nurse will document in the resident's medical record information relative to changes in the resident's medical/mental condition or status .Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; for example, history of present illness and previous and recent test results for comparison . On 6-22-17 at 6:01 p.m., the DON provided a copy of a policy entitled, Charting and Documentation. This policy had a revision date of 4-2008 and was identified as the current policy utilized by the facility. This policy specified, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record .Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment provided; the name and title of the individual's who provided the care; The assessment data and/or any unusual findings obtained during the procedure/treatment .Notification of family, physician or other staff, if indicated; The signature and title of the individual documenting .In cases where the resident requires treatment outside of the facility, the Nurse will communicate report to the location who will be receiving resident for treatment. The Nurse will document a summary of events along with condition of resident at the time of transport from facility, as well as mode of transport from facility. This Federal tag relates to Complaint IN 435. 3.1-37(a)

Based on observation, interview and record review the facility failed to thoroughly investigate the root cause of falls, implement fall interventions (Resident B and Resident C) and transfer a resident in a safe manner (Resident N) resulting in one resident acquiring a hematoma and facial fractures (Resident B) for 3 of 3 residents reviewed for accidents (Resident B, Resident C and Resident N) Findings include: 1.) Review of the record of Resident B on 04/13/2017 11:09 a.m., indicated the resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment for Resident B, dated 12/21/16, indicated the resident was severely impaired for daily decision making. The resident required extensive assistance of one person for bed mobility and walking in her room. The resident required extensive assistance of two people for transferring. The Significant Change MDS assessment for Resident B, 2/3/17, indicated the resident was severely impaired for daily decision making. The resident required extensive of two people for bed mobility and transfers. The resident did not walk in the room. The fall root cause investigation report for Resident B, dated 12/4/16 (no time) indicated the resident was sitting in the hallway in her wheelchair and slid out to the floor. The potential cause was patient scoots down in wheelchair and this time scooted too far. The intervention was to encourage the resident to stay upright in her wheelchair. The fall root cause investigation report for Resident B, dated 1/19/17 at 2:00 p.m., indicated the resident fell trying to get another confused resident out of her personal belongings. The intervention was to try to keep other residents out of her room. The fall root cause investigation report for Resident B, dated 2/12/17 (no time) indicated the resident was found on the floor in her room. There was blood on the floor but noticeable cuts. The resident stated she hit her head on the floor. The resident had a medium/large hematoma on the left side of her head above the temple. The nursing note for Resident B, dated 2/12/17 at 9:00 p.m., indicated the resident was found on the floor and had blood on the floor. The resident had a medium/large hematoma above the left temple and her left eye was swollen. The resident complained of a headache and left shoulder pain. The resident's left side pupil response was sluggish compared to the right side. The resident was unable to follow simple instructions. The resident was sent to the emergency room at the local hospital. The local hospital called the facility at 12:00 a.m., and notified the resident was being sent to a regional hospital due to he had a subdural hematoma. The fall care plan for Resident B, dated 6/17/15, indicated the resident was at risk for falls related to decreased cognitive awareness secondary to dementia and she gets up without assistance at times. The interventions included, but were not limited to, (2/13/17) staff education on fall prevention interventions and (2/16/17) low bed. There were no interventions implemented on the careplan for the fall on 12/4/16 or 1/9/17. The regional hospital notes for Resident B, dated 2/13/17, indicated the resident fell at the extended care facility and had a subdural hematoma and orbital and nasal fractures. The resident was admitted to the Intensive Care Unit (ICU). During observation on 04/11/2017 1:49 p.m., Resident B had a large area on her forehead bruised and healing, yellowish in color and small purple area above the right eyebrow, a purple area on the right eye lid and under right eye. She had a small cut across her nose. Interview with the Director Of Nursing on 4/19/17 at 11:47 a.m., in regards to the fall Resident B had on 12/4/16, the intervention of encouraging the resident to stay upright in her wheelchair was not an appropriate intervention for severely cognitively impaired resident and there was no Interdisciplinary team (IDT) investigation or follow up completed for this fall. The fall Resident B had on 1/9/17, there had not been any intervention implemented to keep other residents out of her room. There was not an IDT investigation or follow up done for this fall. For the fall on 2/12/17, the DON was unable to find documentation of staff education about the resident fall interventions and was unsure why education had to be done or what education was done with the staff. The DON indicated there was not an IDT investigation completed or follow up for this fall. 2. Resident C's record was reviewed on 4/13/17 at 11:06 a.m. His [DIAGNOSES REDACTED]. with behavioral disturbances, insomnia, depression, and anxiety. Resident C's quarterly MDS assessment dated [DATE], included he was understood and had the ability to understand others. He was severely impaired in his cognitive daily decision making skills. He required extensive assistance of 1 person for bed mobility, transfer, walking, and dressing. He required total assistance of 1 person for toileting and personal hygiene. He had experienced 2 falls with no injury and 2 falls with injury. A plan of care for Resident C initiated 5/20/16, and reviewed by the facility on 3/7/17, included he was at risk for falls related to a history of falls, noncompliant with safety issues, got up without assistance, and had an unsteady gait/balance. An intervention was a self releasing seat belt to his wheelchair. Fall/Root Cause Investigation Reports for Resident C included the following: On 11/26/16, he was found on the floor with 2 lesions noted on his right elbow. No investigation or root cause analysis was documented. A resolution/intervention for minimizing future occurrences was a parameter mattress. On 12/17/16, he was found on the floor in the doorway of his room. No investigation or root cause analysis was documented. No resolution/intervention for minimizing future occurrences were documented. On 12/22/16, he was found on the floor next to his bed. A potential cause listed on the investigation indicated he wanted to get up for a snack. No investigation or root cause analysis was documented. A resolution/intervention to minimize future occurrences included non-skid strips next to his bed. Non-skid strips had not been added as an intervention on his plan of care. An Interdisciplinary (IDT) Progress Note for Resident C dated 2/24/17, explained he had been found sitting in the front of his wheelchair on his buttock. An IDT Review Worksheet for Resident C dated 2/24/17, explained he had a fall. The immediate intervention was to discontinue his clip alarm. The new intervention was to utilize a pad alarm at all times. The pad alarm intervention had not been updated on his plan of care. An IDT Progress Note for Resident C dated 4/10/17, explained he had been found sitting on the floor on his buttocks in front of his wheelchair. An IDT Review Worksheet for Resident C dated 4/10/17, explained he was offered a snack as an immediate intervention after his fall. His new intervention included he would be offered a bedtime snack. A bed time snack had not been added as an intervention on his plan of care. On 4/13/17 at 10:22 a.m., Resident C's bedroom was observed for safety. No skid strips were visible on the floor next to his bed. At 10:28 a.m., he was observed seated in his wheelchair in the hallway with his feet on the floor. An alarm box was on the back of his wheelchair and a clip for the alarm attached to his shirt. A seat belt was attached to his wheelchair but the seatbelt was not around his waist. At 1:25 p.m., he was observed seated in his wheelchair. An alarm box was on the back of his wheelchair and a clip for the alarm attached to his shirt. A seat belt was attached to his wheelchair but the seatbelt was not around his waist. At 3:00 p.m., CNA 1 voiced Resident C wore a clip alarm when he was up in his wheelchair and he used to wear a seat belt. She was informed by the nurses of what type of alarms residents utilized. On 4/17/17 at 12:18 p.m., Resident C was observed seated in his wheelchair with his feet on the floor. He had an alarm box on his wheelchair and the clip to the alarm attached to his shirt. A seatbelt was fastened and fitted loosely around his waist. On 4/18/17 at 12:25 p.m., Resident C was observed seated in his wheelchair with his feet on the floor. An alarm box was on his wheelchair and the clip to the alarm attached to his shirt. Another alarm box was attached to his wheelchair and the pad to the alarm was on top of his wheelchair cushion. He was not wearing a seat belt. At 12:27 p.m., CNA 8 voiced Resident C had a clip alarm and a pad alarm on his wheelchair. Night shift must have placed both alarms in his wheelchair because he hadn't had the pad alarm in his wheelchair the day before. On 4/18/17 at 2:06 p.m., RN 3 clarified Resident C's clip alarm had been discontinued and should utilize a pad alarm when up in his wheelchair. On 4/19/17 at 10:31 a.m., Resident C was observed seated in his wheelchair with his feet on the floor. He had a clip alarm box on his wheelchair and the clip to the alarm attached to his shirt. Another alarm box was attached to his wheelchair and the pad to the alarm was on the seat of his wheelchair. On 4/19/17 at 3:30 p.m., the DON explained he was unable to locate any investigation or root cause analysis documentation related to Resident C's falls on 11/26/16, 12/17/16, and 12/22/16. No skid strips had been put down next to Resident C's bed. Offering Resident C a snack had not been added to the plan of care and the alarm pad intervention had not been updated. For Resident B and C, the Assessing Falls and Their Causes procedure was provided by the DON on 4/13/17 at 11:37 a.m., included the following: Purpose: The purposes of this procedure are to provide guidelines for reassessing a resident after a fall and to assist staff in identifying causes of the fall . Steps in the Procedure: .3. Identifying Causes of a Fall or Fall Risk: a. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc.c. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found.Documentation: When a resident falls, the following information should be recorded in the resident's medical record: .5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls 3. Resident N's record was reviewed on 4/12/17 at 1:53 p.m. Her [DIAGNOSES REDACTED]. A Transfer/Mobility Status Criteria for Resident N dated 2/27/17, included she required extensive assistance of 2 plus persons to transfer, and a gait belt should be utilized with assistance of 2 staff. Resident N's significant change MDS dated [DATE], included she was sometimes understood and she sometimes had the ability to understand others. She was severely impaired in her cognitive daily decision making skills. She required extensive assistance of 2 plus persons for bed mobility and transfers. She didn't walk and utilized a wheelchair for mobility. On 4/12/17 at 1:26 p.m., Resident N was observed being transferred from her geriatric chair to her bed with the assistance of CNA 9 and CNA 10. CNA 9 and CNA 10 placed one of their arms under Resident N's underarms and grabbed the back of her slacks with their other hand. They lifted Resident N out of her geriatric chair and placed her in her bed without Resident N's feet touching the floor. CNA 9 explained Resident N should be transferred that way. Resident N couldn't bear weight and would go into a fetal position which made it difficult to use a gait belt when transferring her. Resident N also became combative at times. CNA 10 explained Resident N was transferred with 2 staff assistance. With Resident N being combative she didn't feel comfortable transferring Resident N with the use of a gait belt. On 4/12/17 at 3:26 p.m., LPN 7 explained she had not been informed Resident N could no longer bear weight. She would do an evaluation and determine how Resident N should be transferred. If Resident N was no longer able to bear weight she would probably require the use of a Hoyer Lift. If a resident was able to bear weight and was transferred by 2 staff the staff should always use a gait belt. The Transfer To Wheelchair procedure provided by the DON on 4/13/17 at 11:37 a.m., included a gait belt should be utilized. The rationale for the gait belt included reduced strain on the staff's back and provided security for the resident. The gait belt helped enable the resident to turn. This federal tag relates to complaint IN 163. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide dignity to 1 resident by not giving timely incontinence care which resulted in the resident being observed in a public area with wet clothes and urine on the floor under him. This affected 1 of 3 residents reviewed for dignity. (Resident #H) Findings include: Resident #H's record was reviewed on 7/1/2016 at 10:10 a.m. The record indicated Resident #H was admitted with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment, dated 6/10/16, indicated Resident #H was severely cognitively impaired, and was frequently incontinent of bladder. A care plan, with an onset date of 6/1/16, indicated a problem of: Incontinent of bowel & bladder at times. Goal & Target Date: Will be kept as clean & dry as possible through next review. Approaches .Peri care after each incontinent episode. Check & change resident PRN (as needed) .Incontinent products for dignity. A Nurse Tech Information Kardex indicated Resident #H was incontinent at times and required assist of 1 for perineum care. An EMS (Emergency Medical Service) Care Report, dated as arrived on 6/27/16 at 8:18 p.m., indicated: called to ecf (extended care facility) for a pt (patient) that had fallen .while walking past nurses station found a pt. on his knees with his face in the wheel chair, asked ecf staff is this the pt. they stated no that pt. was having a temper tantrum and does that all the time. pt. had also voided all over the floor. continued to pt. room, loaded pt. on cot and upon returning towards amb (ambulance) found pt. still face down in the wheel chair, pt. lips appeared cyanotic (bluish), again asked ecf staff if we need to check on that pt. they stated no emergency room Notes from a local hospital, dated 6/27/16 at 8:45 p.m., indicated: .Self care assistance: Cleaned of incontinence, linen changed During an interview, on 7/1/16 at 10:20 a.m., LPN #1 indicated the resident had 20 more minutes before he could smoke, and he was taken to the nurse's station on the 800/900 unit. When he was at the nurse's station, he got on the floor, they were trying to get him in the chair, and he urinated on the floor. QMA #4 told LPN #1 he was mad at them and was looking for CNA #3 so they could change him. Then EMS was here to pick up a resident and asked if he was alright. During an interview, on 7/1/16 at 11:02 a.m., CNA #3 indicated she was passing snacks and was asked to help Resident #H because he had an incontinence accident. He was crawling around on the floor and when she got back to him he had coded. This Federal tag relates to Complaint IN 006. 3.1-3(t)

A. Based on record review and interview, the facility failed to immediately assess a resident when the resident was observed with his knees on the floor and his head on the seat of his wheelchair and then found approximately 5 minutes later not breathing. This affected 1 of 3 residents reviewed for assessments. (Resident #H) B. Based on record review and interview, the facility failed to supervise a resident who was a choking risk while consuming a snack. This affected 1 of 3 residents reviewed for modified diets. (Resident #H) Findings include: A. Resident #H's record was reviewed on [DATE] at 10:10 a.m. The record indicated Resident #H was admitted with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment, dated [DATE], indicated Resident #H was severely cognitively impaired, required supervision and assistance of one for eating, had no natural teeth or tooth fragments, and required a therapeutic diet. Interdisciplinary Progress Notes, dated [DATE] at 8:10 p.m., indicated: Res (resident) anxious, taking off clothes wanting to smoke .Res dressed & taken down next to back nurses station & given a snack to wait for smoke time. An EMS (Emergency Medical Service) Care Report, dated as arrived on [DATE] at 8:18 p.m., indicated: called to ecf (extended care facility) for a pt (patient) that had fallen .while walking past nurses station found a pt. on his knees with his face in the wheel chair, asked ecf staff is this the pt. they stated no that pt. was having a temper tantrum and does that all the time. pt. had also voided all over the floor. continued to pt. room, loaded pt. on cot and upon returning towards amb (ambulance) found pt. still face down in the wheel chair, pt. lips appeared cyanotic (bluish), again asked ecf staff if we need to check on that pt. they stated no so we continued towards amb. we were at the end of the hall getting ready to exit when the ecf staff yelled and stated they needed assistance. i called dispatch to send (two other units) my partner went back towards wheel chair pt. with our current pt. on the cot. An ecf aid stayed with our pt. on the cot so she would not be left alone. I proceeded to amb to obtain monitor and drug bag. arriving back at wheel chair pt. was pulseless and apneic (not breathing). cpr (cardio-pulmonary resuscitation) had been initiated. pt. was being ventilated with (hand held ventilation mask), placed pt on monitor with defib(rillator) pads showed asystole (no heart beat). continued cpr .(local fire department) arrived on scene to assist .intubated (placed breathing tube in trachea) pt .confirmed tube placement by auscultating (listening to) lung sounds, pt. had equal bilat (both sides) lung sounds .medic (number) arrived on scene .placed pt. on backboard for ease of movement, stopped cpr, pt. showed sinus tach on monitor confirmed pt. had return of spontaneous circulation by palpating carotid (neck), femoral (upper leg) and radial (wrist) pulses. loaded pt. in amb On [DATE] at 10:20 a.m., LPN #1 indicated when Resident#H was at the nurses station he got on the floor, they were trying to get him in the chair and he urinated on the floor. LPN #1 went into a resident's room to give medication, and QMA #4 came up the hall and EMS was here to pick up a resident and asked if Resident #H was alright. LPN #1 said she looked down to see what Resident #H was doing and he was messing with the wheels on his wheel chair and she thought he was trying to get back in the wheel chair. She went in another resident's room and they yelled for her to ask if he was a full code, she checked and when she got back the nurse and 2 cna's had laid him down and put a back board under him. The EMT (Emergency Medical Technician) asked if they wanted his help and they said yes. On [DATE] at 3:15 p.m., LPN # 1 indicated when the EMT first came in, Resident #H was sitting on the floor and she looked at resident and he looked ok, his color was normal and he was alert and acted normal. The second time the EMT passed the resident, only 3 or 4 minutes had passed and she wasn't present at that time, CNA #3 was present and called for the other nurse that was with the EMTs. A Policy and Procedure for Change in Resident Condition was provided by the Director of Clinical Services on [DATE] at 4:25 p.m. The policy included, but was not limited to, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible Party will be notified as soon as possible B. Resident #H's record was reviewed on [DATE] at 10:10 a.m. The record indicated Resident #H was admitted with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment, dated [DATE], indicated Resident #H was severely cognitively impaired, required supervision and assistance of one for eating, had no natural teeth or tooth fragments, and required a therapeutic diet. The Nurse Tech Information Kardex indicated this resident received a therapeutic diet, had supervision (cueing), set up, dependent on staff, and was watched during all meals. On [DATE] at 11:02 a.m., CNA #3 indicated on [DATE] at 8:10 p.m., she placed Resident #H in the dining room between the ,[DATE] hall where he had a snack of an 8 ounce cup of animal crackers. CNA #3 indicated she was passing snacks. and was later called to assist the resident because he had an accident (urinary incontinence), and when she got back there, about 5 minutes later, he had coded (stopped breathing, no heartbeat). During an interview, on [DATE] at 10:58 a.m., the Speech Therapist indicated when she evaluated Resident #H, he was edentulous (had no teeth) and she recommended a mechanical soft diet so he would not have to chew it. She recommended he have supervision during meals and whenever he was eating; as long as someone was near him. This Federal tag relates to Complaint IN 006. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse by a staff member who smacked the resident on his face with her hand and with a pillow and used the pillow to cover his face for 1 of 3 residents reviewed for abuse in a sample of 3. (Resident #G) The Immediate Jeopardy began on 1-21-16 at approximately 8:00 a.m., when a staff member slapped a resident with her hand and with a pillow, and then placed a pillow over the resident's face. On 2-1-16 the Executive Director and the Director of Clinical Services were notified of the Immediate Jeopardy related to abuse. The Immediate Jeopardy was removed on 2-3-16 at 4:50 p.m., but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on abuse and immediate reporting of abuse. Findings include: In an interview with CNA #2 on 2-1-16 at 10:55 a.m., she indicated she and CNA #1 were providing care to Resident #G to assist him from his bed and into a geriatric chair, using a mechanical lift on 1-21-16, around 8:00 a.m., prior to breakfast. She continued that after the resident was placed into the geriatric chair, CNA #1 shoved his face back into the chair, aggressively, by placing her outstretched hand over his face. She indicated, I didn't do anything (report this to her superiors) at the time and I should have. CNA #2 indicated on the same morning, around 9:30 a.m., she and CNA #1 were assisting Resident #G back to bed from the geriatric chair with the mechanical lift. CNA #2 indicated, once the resident was in the bed, she observed CNA #1 in which CNA #1, slapped his face kind of hard on one side (of his face), then took a pillow and hit him with it a couple of times and pushed the pillow with both hands onto (his face) for a second or two. She indicated at this time she stopped CNA #1 from interacting with the resident in this manner. She indicated, I didn't report it until around 3:00 p.m. I guess because I was so worked up (upset) about it. I know I should have (reported it) sooner. CNA #2 indicated she had worked with CNA #1 previously and had never seen her do anything like that before. CNA #2 indicated in the past, she had heard CNA #1, be kind of hateful-sounding sometimes when she'd talk to some residents. CNA #2 indicated at the end of her shift that day, around 3:00 p.m., she informed her charge nurse of what had transpired earlier in the day. CNA #2 indicated the charge nurse then immediately notified the Unit Manager, the Director of Clinical Services and Executive Director, who then spoke with her about the incident. CNA #2 indicated she also was interviewed by the local police department the same evening regarding the events. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of a written statement from CNA #2 regarding this incident. The statement, dated 1-21-16, and signed by CNA #2, indicated, After lunch at approximately 1:30 p.m., (name of CNA #1) & I were in (name of Resident #G)'s room doing care. I observed her hitting/smacking him in the face. Also taking the pillow to his face. Acting like she was smothering him with pillow for a few seconds. Hitting the pillow on his face. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of a written statement from CNA #1 regarding this incident. The statement, dated 1-21-16, and signed by CNA #1, indicated, Today, 1-21-16, while transferring (sic) (name of Resident #G) we 2 person assisted him to his chair from his bed. While getting in his bed, (name of Resident #G) had 2 pillows, one on bed, one leaning on heard board. (sic) the pillow leaning on headboard fell over face. Care taker fixed pillow for one to be under head one to be on side. In an interview with the Executive Director on 2-1-16 at 11:50 a.m., she indicated when she interviewed CNA #1 regarding the incident, She acted like it was a joke, that what she did was a joke and had no remorse whatsoever .she did not seem to take this seriously. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of CNA #1's time card. It indicated the employee worked from 6:56 a.m. until 3:02 p.m. on 1-21-16. In an interview with the Executive Director on 2-1-16 at 11:50 a.m., she indicated CNA #1 had only worked the day of 1-21-16 in the last month as she was currently employed on a prn (as needed) basis and only worked on the secured unit on which Resident #G resided. Resident #G's clinical record was reviewed on 2-1-16 at 9:55 a.m. His [DIAGNOSES REDACTED]. It indicated he resided on a secured dementia unit of the facility. His most recent Minimum Data Set assessment, dated 12-21-15, indicated he was significantly cognitively impaired. It indicated he rarely was able to understand or be understood and had no speech. It indicated he required extensive assistance of 2 or more persons with transfers and dressing, did not walk and used a wheelchair for mobility, and was dependent on others to move the wheelchair. In an interview with RN #3 on 2-1-16 at 10:25 a.m., she described Resident #G as a quiet, non-verbal, non-combative and a very gentle man. On 2-1-16 at 11:45 a.m., the Executive Director provided a copy of a policy entitled, Resident Abuse. This policy had a revision date of 6-1-15, and was indicated to be the current policy utilized by the facility. This policy indicated, It is inherent in the nature and dignity of each resident at The Company that he/she be afforded the basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property .Employees of The Company are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatments, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatments, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal . The Immediate Jeopardy that began on 1-21-16 was removed on 2-3-16 at 4:50 p.m., when the facility completed physical examinations on all residents, educated staff regarding abuse and immediate reporting of abuse and terminated the employment of CNA #1 on 1-27-16, but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on abuse and immediate reporting of abuse. This Federal tag relates to Complaint IN 804. 3.1-27(a)

Based on interview and record review, the facility failed to ensure an allegation of physical abuse by an employee towards a resident was promptly reported to the Executive Director, in order to protect the resident and other residents in the facility from potential abuse, as well as to the Indiana State Department of Health (ISDH), for 1 of 3 residents reviewed for abuse in a sample of 3. (Resident #G) The Immediate Jeopardy began on 1-21-16 at approximately 8:00 a.m., when a staff member slapped a resident with her hand and with a pillow, and then placed a pillow over the resident's face. On 2-1-16 the Executive Director and the Director of Clinical Services were notified of the Immediate Jeopardy related to abuse. The Immediate Jeopardy was removed on 2-3-16 at 4:50 p.m., but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on abuse and immediate reporting of abuse. Findings include: In an interview with CNA #2 on 2-1-16 at 10:55 a.m., she indicated she and CNA #1 were providing care to Resident #G to assist him from his bed and into a geriatric chair, using a mechanical lift on 1-21-16, around 8:00 a.m., prior to breakfast. She indicated that after the resident was placed into the geriatric chair, CNA #1 shoved his face back into the chair, aggressively, by placing her outstretched hand over his face. She indicated, I didn't do anything (report this to her superiors) at the time and I should have. CNA #2 indicated on the same morning, around 9:30 a.m., she and CNA #1 were assisting Resident #G back to bed from the geriatric chair with the mechanical lift. CNA #2 indicated, once the resident was in the bed, she observed that CNA #1, slapped his face kind of hard on one side (of his face), then took a pillow and hit him with it a couple of times and pushed the pillow with both hands onto (his face) for a second or two. She indicated at this time she stopped CNA #1 from interacting with the resident in this manner. She indicated, I didn't report it until around 3:00 p.m. I guess because I was so worked up (upset) about it. I know I should have (reported it) sooner. CNA #2 indicated she had worked with CNA #1 previously and had never seen her do anything like that before. CNA #2 indicated in the past, she had heard CNA #1, be kind of hateful-sounding sometimes when she'd talk to some residents. She indicated at the end of her shift that day, around 3:00 p.m., she informed her charge nurse of what had transpired earlier in the day. CNA #2 indicated the charge nurse then immediately notified the Unit Manager, the Director of Clinical Services and Executive Director, who then spoke with her about the incident. CNA #2 indicated she also was interviewed by the local police department the same evening regarding the events. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of a written statement from CNA #2 regarding this incident. The statement, dated 1-21-16, and signed by CNA #2, stated, After lunch at approximately 1:30 p.m., (name of CNA #1) & I were in (name of Resident #G)'s room doing care. I observed her hitting/smacking him in the face. Also taking the pillow to his face. Acting like she was smothering him with pillow for a few seconds. Hitting the pillow on his face. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of a written statement from CNA #1 regarding this incident. The statement, dated 1-21-16, and signed by CNA #1, stated, Today, 1-21-16, while transferring (sic) (name of Resident #G) we 2 person assisted him to his chair from his bed. While getting in his bed, (name of Resident #G) had 2 pillows, one on bed, one leaning on heard board. (sic) the pillow leaning on headboard fell over face. Care taker fixed pillow for one to be under head one to be on side. In an interview with the Executive Director on 2-1-16 at 4:40 p.m., she indicated the facility began an immediate investigation, once CNA #2 notified the facility around 3:00 p.m., on 1-21-16 of the events with Resident #G. She indicated CNA #2 indicated verbally and in her written statement that the events took place after lunch, not around breakfast. She indicated by the time the facility was informed of the events, CNA #1 had already clocked out for the day and has not worked since that time. She indicated Resident #G was immediately assessed by the Nurse Practitioner and was found to be with no concerns. She indicated the family, attending physician and local police department were immediately notified of the events. She indicated the facility immediately began interviews with other residents regarding abuse and education was initiated with all staff regarding abuse that same evening. She indicated she filed a report of the incident with ISDH within the 24 hour window, on 1-22-16, at 2:55 p.m., electronically. On 2-1-16 at 11:45 a.m., the Executive Director provided a copy of a policy entitled, Resident Abuse. This policy had a revision date of 6-1-15, and was indicated to be the current policy utilized by the facility. This policy indicated, It is inherent in the nature and dignity of each resident at The Company that he/she be afforded the basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property .Employees of The Company are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatments, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatments, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal .Procedure for Reporting Abuse. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse to is a resident is obligated to report such an information immediately to their supervisor. If the immediate supervisor is not available, the employee is to notify the designated Nursing Supervisor on duty at the time of the event. Additionally, the supervisor must immediately report to the Executive Director, who is the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State officials, including notification of Law Enforcement if a reasonable suspicion of crime has occurred . The Immediate Jeopardy that began on 1-21-16 was removed on 2-3-16 at 4:50 p.m., when the facility completed physical examinations on all residents, educated staff regarding abuse and immediate reporting of abuse and terminated the employment of CNA #1 on 1-27-16, but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on abuse and immediate reporting of abuse. This Federal tag relates to Complaint IN 804. 3.1-27(a) 3.1-28(a) 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on interview and record review, the facility failed to ensure their policies regarding abuse were implemented regarding immediate reporting of an allegation of physical abuse by an employee towards a resident to the Executive Director, as well as to the Indiana State Department of Health (ISDH), for 1 of 3 residents reviewed for abuse in a sample of 3. (Resident #G) The Immediate Jeopardy began on 1-21-16 at approximately 8:00 a.m., when a staff member slapped a resident with her hand and with a pillow, and then placed a pillow over the resident's face. On 2-1-16 the Executive Director and the Director of Clinical Services were notified of the Immediate Jeopardy related to abuse. The Immediate Jeopardy was removed on 2-3-16 at 4:50 p.m., but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on abuse and immediate reporting of abuse. Findings include: In an interview with CNA #2 on 2-1-16 at 10:55 a.m., she indicated she and CNA #1 were providing care to Resident #G to assist him from his bed and into a geriatric chair, using a mechanical lift on 1-21-16, around 8:00 a.m., prior to breakfast. She indicated that after the resident was placed into the geriatric chair, CNA #1 shoved his face back into the chair, aggressively, by placing her outstretched hand over his face. She indicated, I didn't do anything (report this to her superiors) at the time and I should have. CNA #2 indicated on the same morning, around 9:30 a.m., she and CNA #1 were assisting Resident #G back to bed from the geriatric chair with the mechanical lift. CNA #2 indicated, once the resident was in the bed, she observed that CNA #1, slapped his face kind of hard on one side (of his face), then took a pillow and hit him with it a couple of times and pushed the pillow with both hands onto (his face) for a second or two. She indicated at this time she stopped CNA #1 from interacting with the resident in this manner. She indicated, I didn't report it until around 3:00 p.m. I guess because I was so worked up (upset) about it. I know I should have (reported it) sooner. CNA #2 indicated she had worked with CNA #1 previously and had never seen her do anything like that before. CNA #2 indicated in the past, she had heard CNA #1, be kind of hateful-sounding sometimes when she'd talk to some residents. CNA #2 indicated at the end of her shift that day, around 3:00 p.m., she informed her charge nurse of what had transpired earlier in the day. CNA #2 indicated the charge nurse then immediately notified the Unit Manager, the Director of Clinical Services and Executive Director, who then spoke with her about the incident. CNA #2 indicated she also was interviewed by the local police department the same evening regarding the events. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of a written statement from CNA #2 regarding this incident. The statement, dated 1-21-16, and signed by CNA #2, stated, After lunch at approximately 1:30 p.m., (name of CNA #1) & I were in (name of Resident #G)'s room doing care. I observed her hitting/smacking him in the face. Also taking the pillow to his face. Acting like she was smothering him with pillow for a few seconds. Hitting the pillow on his face. On 2-1-16 at 1:15 p.m., the Executive Director provided a copy of a written statement from CNA #1 regarding this incident. The statement, dated 1-21-16, and signed by CNA #1, stated, Today, 1-21-16, while transferring (sic) (name of Resident #G) we 2 person assisted him to his chair from his bed. While getting in his bed, (name of Resident #G) had 2 pillows, one on bed, one leaning on heard board. (sic) the pillow leaning on headboard fell over face. Care taker fixed pillow for one to be under head one to be on side. In an interview with the Executive Director on 2-1-16 at 4:40 p.m., she indicated the facility began an immediate investigation, once CNA #2 notified the facility around 3:00 p.m., on 1-21-16 of the events with Resident #G. She indicated CNA #2 indicated verbally and in her written statement that the events took place after lunch, not around breakfast. She indicated by the time the facility was informed of the events, CNA #1 had already clocked out for the day and has not worked since that time. She indicated Resident #G was immediately assessed by the Nurse Practitioner and was found to be with no concerns. She indicated the family, attending physician and local police department were immediately notified of the events. She indicated the facility immediately began interviews with other residents regarding abuse and education was initiated with all staff regarding abuse that same evening. She indicated she filed a report of the incident with ISDH within the 24 hour window, on 1-22-16, at 2:55 p.m., electronically. On 2-1-16 at 11:45 a.m., the Executive Director provided a copy of a policy entitled, Resident Abuse. This policy had a revision date of 6-1-15, and was indicated to be the current policy utilized by the facility. This policy indicated, It is inherent in the nature and dignity of each resident at The Company that he/she be afforded the basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property .Employees of The Company are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatments, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatments, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal .Procedure for Reporting Abuse. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse to is a resident is obligated to report such an information immediately to their supervisor. If the immediate supervisor is not available, the employee is to notify the designated Nursing Supervisor on duty at the time of the event. Additionally, the supervisor must immediately report to the Executive Director, who is the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State officials, including notification of Law Enforcement if a reasonable suspicion of crime has occurred . The Immediate Jeopardy that began on 1-21-16 was removed on 2-3-16 at 4:50 p.m., when the facility completed physical examinations on all residents, educated staff regarding abuse and immediate reporting of abuse and terminated the employment of CNA #1 on 1-27-16, but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on abuse and immediate reporting of abuse. This Federal tag relates to Complaint IN 804. 3.1-27(a) 3.1-28(a) 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on observation, interview and record review the facility failed to accurately assess, identify and document a stage III pressure ulcer, provide pressure relieving devices to prevent pressure ulcers, to turn and reposition a resident who required assistance and failed to apply barrier cream for a resident who was bedfast resulting in the resident acquiring four pressure ulcers and causing the resident discomfort, for 2 of 2 residents reviewed for pressure ulcers (Resident #L & Resident #J). Findings include: 1. Resident #L's record was reviewed on 1/8/15 at 9:15 a.m., [DIAGNOSES REDACTED]. Review of the Admission/Readmission Data Collection dated 10/29/14 indicated Resident #L was admitted with pressure ulcers on the right outer malleous, left inner malleolus, left lateral lower leg, sacrum and right ischium, no measurements documented. Current skin treatments: Pressure reduction devices were check marked, chair or bed had no check mark, float heels and application of dressing - with or without topical medications were check marked. A Non- Pressure Ulcer Record, dated 11/7/14, indicated: present on admission, Location: left ischium, Type: moisture associated skin disorder. Measurements on 11/7/14 measured 7.0 cm x 8.9 cm x 0.1 cm. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. left ischium, Santyl to blackened area, apply calcium alginate, change BID . A Non- Pressure Ulcer Record dated 1/7/15 indicated, Location: left ischium, Type: moisture associated skin disorder. Measurements were 7.5 cm x 5.5 cm x 0.4 cm. A care plan, dated 10/29/14, indicated: Problem/Need: Potential for skin breakdown. Goal and Target Date: Will be free of skin breakdown within 3 months. Approaches: Pressure reducing mattress on bed, pressure reducing cushion on chair, provide preventative skin care per policy, observe for changes, 1/2 siderails, consults per order, update MD per order, wound treatments per order On 1/9/15 at 1:47 p.m., an observation of the pressure ulcer dressing change was done with RN #2. RN #2 washed her hands and donned gloves, removed the dressing on the left ischium area, gloves removed and hands sanitized, and the area was cleaned with wound cleanser. Observation of left ischium area indicated slight drainage on dressing, blacken area noted left of center of ulcer, Santyl ointment applied, calcium alginate dressing applied, ABD pad applied dressing initialed and dated. Interview with the Assistant Director of Nursing, on 1/9/15 at 2:56 p.m., indicated I received the moisture associated skin disorder information from the Hospice nurse, it is not information I had received from the facility. This is how I know it is a non-pressure area, stage III. I did not see this area until 11/7/14 but I'm sure it was there on admission. On 1/13/15 2:56 p.m., an interview with the Assistant Director of Nursing indicated No, she does not have a pressure relieving cushion in her wheelchair, Hospice is working to get a cushion for her chair. We try to get her off her left side. 2.) During interview with Resident #J on 1/5/15 at 2:23 p.m., indicated she had pain and discomfort without relief on her bottom. Resident #J indicated on 1/2/15 she was admitted to the facility from the local hospital. Resident #J indicated when she was admitted she was left in bed on bedpan for an hour, the resident indicated she had timed it. Resident #J indicated it was very uncomfortable for her. Resident #J stated my bottom is a mess and being left on the bedpan for an hour caused her bottom to be sore. Resident #J indicated she had turned her call light on to get off the bedpan and no staff answered it. Resident #J indicated her and her family member would put barrier cream on her bottom three times a day when she was home. Resident #J indicated since she had been at the facility there were days the staff did not put any barrier cream on her bottom and this had caused her bottom to be raw and sore. During observation on 1/8/15 at 9:40 a.m., Resident #J was laying in bed with her eyes closed. The resident's head of the bed was at 30 degrees and she was laying on her back. During observation on 1/8/15 at 11:47 a.m., Resident #J was laying in bed with the head of her bed at 30 degrees laying on her back. Resident #J was crying out in pain that her bottom was hurting. CNA #1 indicated the resident's bottom was red. When queried if Resident #J could have barrier cream applied CNA #1 indicated yes the resident could. During observation on 1/8/15 at 12:07 p.m., Resident #J was laying in bed with the head of the bed at 30 degrees laying on her back. CNA #3 and LPN #2 removed Resident #J's brief to apply barrier cream. Resident #J's entire buttocks was bright red, had two open red areas on the right buttocks and two open red areas on the left buttocks, all of the areas had red and brown drainage. The resident had no barrier cream visible. The resident had dried bowel movement on her buttocks including the open areas and the inside of both thighs. CNA #3 and LPN #2 indicated they were not aware Resident #J had open areas. CNA #3 indicated the resident's bottom had been red. LPN #2 cleaned the stool off of the resident's buttocks with a cleansing wipe, the resident was crying out in pain during the care observation. CNA #3 indicated the resident does not use the bathroom, but did use the bedpan sometimes and was sometimes incontinent. Interview with the Assistant Director Of Nursing (ADON) on 1/8/15 at 3:00 p.m., indicated she did not consider Resident #J's open area's to be pressure ulcers. The ADON indicated she coded the area's as moisture associated skin disorder and shearing because the resident had laid urine and in feces and it tore the skin. The ADON indicated she did not consider the resident's red buttocks being a stage one pressure ulcer but did want barrier cream on it to prevent it from opening up. Review of the record of Resident #J, on 1/9/15 at 10:13 a.m., indicated the resident's [DIAGNOSES REDACTED]. The admission care plan for Resident #J dated 1/2/15, indicated the resident was to be turned every two hours and as needed. The admission data collection for Resident #J dated 1/2/15 at 5:20 p.m., indicated the resident was alert and oriented to person, place and time, short and long term memory ok, independent with cognitive skills for decision making was independent, bed mobility- assistance of two people, transfer- assistance of two people, ambulation-bedrest and the resident was at moderate risk for pressure ulcers. The daily skilled nurse's note for Resident #J dated 1/8/15 (incorrect time), indicated the resident complained of pain to the bottom area. Ulcers noted to bilateral buttocks. The non-pressure skin condition record for Resident #J dated 1/8/15, indicated the resident had shearing/moisture associated skin disorder on the inferior coccyx measuring 2.0 centimeters (cm) by 0.1 cm by 0.1 cm, the wound was pink and red with a small amount of serous drainage. The non-pressure skin condition record for Resident #J dated 1/8/15, indicated resident had shearing/moisture associated skin disorder on the right gluteus fold measuring 2.0 cm by 2.0 cm by 0.1 cm, the wound was pink and red with a small amount of serous drainage. The non-pressure skin condition record for Resident #J dated 1/8/15, indicated the resident had shearing/moisture associated skin disorder on the left superior buttocks measuring 2.5 cm by 0.7 cm by 0.1 cm, the wound was pink and red with small amount of serous drainage. The non- pressure skin condition record for Resident #J dated 1/8/15, indicated the resident had shearing/moisture associated skin disorder on the left inferior buttocks measuring 5.5 cm by 5.6 cm by 0.1 cm, the wound was pink and red with a small amount of serous drainage. The Centers for Disease control www.cdc.com indicated the a pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear/or friction. A stage one pressure ulcer is skin with non-blanchable redness of a localized area usually over a bony prominence. A stage one may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. A stage two is partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. 3.1-40(a)(1)