Every finding on record at Majestic Care of Goshen

Based on interview and record review, the facility failed to ensure post fall assessments and monitoring had been completed for 1 of 6 residents reviewed for falls. (Resident B) This deficient practice resulted in Resident B serious injuries due to having a delay in treatment related to a broken occipital bone and subarachnoid hemorrhages in April and a delay of treatment related to a broken humerus bone in June. In addition to the Immediate Jeopardy, the facility failed to ensure 2 of 6 residents reviewed for falls received thorough post fall assessments and monitoring which resulted in the potential for harm, that is not immediate jeopardy. (Resident J and H)The Immediate jeopardy that began on 4/6/2026 when Resident B had an unwitnessed fall and staff failed to complete thorough post fall assessments. The Executive Director and the [NAME] President of Operations were notified of the immediate jeopardy on 7/22/2026 at 2:18 P.M. The immediate jeopardy was removed on 7/24/2026, but noncompliance remained at the lower scope and severity level of isolated with actual harm that is not immediate jeopardy. Findings include: During an interview with Resident B's Power of Attorney (POA) on 7/19/2026 at 2:15 P.M., she indicated Resident B had had two falls that she had been concerned about at the facility. The first fall happened on 4/6/2026, when Resident B was complaining of nausea and vomiting, and had a headache for several days after the fall and was not sent to the hospital for an evaluation. Resident B's POA stated, I am frustrated because when she had reported the resident's headache, on 4/7/2026 to the nurse, the nurse had replied, She is still complaining about that again today? A few days later, the facility sent Resident B to a local hospital related to her kidney function and Resident B told the emergency room (ER) doctor she had fallen a few days before at the facility and was not sure if she had hit her head. A Computed Tomography (CT) scan of Resident B's head indicated the resident had an active brain bleed. The resident was then transferred to larger hospital in a nearby town because she required intensive monitoring and care. She indicated the second fall she was concerned about had occurred on 6/12/2026. Resident B's POA indicated when she had visited the resident, on 6/12/2026, Resident B told her she had fallen the night before and her arm hurt. Resident B reported to the POA that an aide had found her on the floor and put her back into the bed. The POA indicated she had reported the fall to RN 2. The POA indicated RN 2 had told her it would have been impossible for Resident B to have fallen because the resident was not able to walk. The POA indicated RN 2 did not go and assess Resident B and she then had called the Hospice company and had requested a visit from a Hospice nurse. The Hospice nurse assessed Resident B, the next day, and had ordered an Xray and discovered Resident B had broken her arm. The Hospice Nurse also reported to the POA that the resident was able to walk as the facility's third shift staff members had been walking Resident B to the bathroom during the hours of 10:30 P.M. until 6:00 A.M. when they had attended the resident. Resident B's record review was completed on 7/21/2026 at 2:15 P.M. Diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage, anemia, paroxysmal atrial fibrillation, chronic kidney disease stage 5, generalized anxiety disorder and a fracture of left humerus. An admission Minimum Data Set (MDS) assessment, dated 4/8/2026, indicated Resident B had adequate hearing and clear speech and had been able to understand others and make herself understood, had moderate cognitive impairment, had not had any behaviors or rejected any care. In addition, Resident B had no functional limitation in range of motion for any extremity and had utilized a wheelchair for locomotion, and was dependent on staff for toileting, dressing her lower body and putting on/taking off footwear, and had required substantial assistance for toilet transfers. Resident B had had occasional pain that had occasionally interfered with her sleep, therapy activities and day-to-day activities. The resident had used the verbal descriptor of moderate pain to describe her pain at the time the MDS assessment had been completed. A Nursing Progress Note, dated 4/6/2026 at 10:45 AM, indicated Resident B had been found on the floor, laying on her left side with her hand under her head. Resident B was on her roommate's side of the room and had told staff she had been going to the bathroom before she fell. The resident was not wearing shoes or proper footwear at the time of the fall. Resident B had denied having a headache or any pain, and a neurological check had been performed without any abnormal findings, and the provider had been notified. A current Care Plan initiated on 4/4/2026, indicated Resident B was at risk for falls related to impaired mobility, repeated falls and medical diagnoses. A current intervention initiated on 4/4/2026, indicated staff were to encourage and assist Resident B to wear appropriate nonskid footwear. Resident B's record lacked the documentation to indicate Resident B had refused to wear nonskid footwear. A Summary for Providers Note dated, 4/6/2026 at 1:19 P.M., indicated the provider was notified Resident B had had a change of condition related having nausea and vomiting after a fall. A Physician's order was received, on 4/6/2026, to administer 4 mg of ondansetron (anti-nausea medication) every 6 hours as needed for nausea and vomiting. However, Resident B's nausea and vomiting had resolved and the resident was not administered any anti-nausea medication. A review of Resident B's April 2026 Medication Administration Record (MAR) indicated Resident B had not been administered any anti-nausea medication on 4/6 , 4/7 or 4/8/2026. The April 2026 MAR indicated the resident had been administered 50 mg of tramadol on 4/8/2026 at 2:00 A.M. for a pain rating of 6 and on 4/8/2026 at 9:27 AM for a pain rating of 7. The record lacked the documentation to indicate what type of pain or where the pain was located. A review of Resident B's April 2026 Medication Administration Record (MAR) indicated Resident B had been administered 50 mg of tramadol on 4/8/2026 at 2:00 A.M. for a pain rating of 6 and 4/8/2026 at 9:27 AM for a pain rating of 7. The record lacked the documentation to indicate what type of pain or where the pain was located. A Summary for Providers Note dated, 4/8/2026 at 10:50 A.M., indicated the provider was notified that the resident had had a change of condition related to the resident having an altered level of consciousness. However, the vital signs relayed to the Nurse Practitioner were from 4/8/2026 at 5:59 A.M., over 4 hours earlier. Review of Focus Charting assessments in the Nursing Progress Notes on the following dates, 4/6/2026 at 3:40 P.M., 4/6/2026 at 3:38 P.M. and 4/7/2026 at 12:46 A.M., indicated the resident's vital signs were documented on the form and pain had been assessed, however, the vitals signs were exactly identical on all three assessments and were dated 4/8/2026 instead of dated on the specified dates and times of the assessments. There were no neurological assessments documented on the forms. A Nursing Progress Note dated, 4/8/2026 at 11:02 A.M., indicated the Nurse Practitioner had ordered the resident to be sent to Emergency Department related to abnormal labs, low kidney function and an altered mental status. A Nursing Progress Note, dated 4/8/2026 at 2:51 P.M. indicated the resident had been admitted to the local hospital related to a head bleed. A Nursing Progress Note, dated 4/8/2026 at 10:35 P.M., indicated the resident had been transferred to a different hospital and had been admitted to the Intensive Care Unit (ICU) related to a subarachnoid (brain) bleed. A Radiologist Report, dated 4/9/2026 at 5:51 A.M., indicated the resident had had a CT scan at another hospital before being transferred to the current hospital. The CT scan from the original hospital indicated that the resident had displayed multifocal acute intracranial hemorrhage including parenchymal contusions, subarachnoid hemorrhage, subdural hematomas, intraventricular hemorrhage. Local mass effect was noted in the region of contusions. In addition, there was a nondisplaced fracture of the posterior midline occipital bone. The comparison CT scan performed on 4/9/2026 indicated the same injuries found at the previous hospital on 4/8/2026 and did not show any new sites of hemorrhage seen in the comparison CT scan. A Pre-Hospitalization Report from the transport service that transferred Resident B from the original hospital to the second hospital, dated 6/8/2026 at 6:20 P.M. , indicated Resident B had been alert but confused when Medics arrived to transfer her to a different hospital. During an interview with the [NAME] President of Operations (VPO), on 7/21/2026 at 1:50 P.M., she indicated the facility staff had performed neurological assessments for the fall on 4/6/2026, but the facility used paper charting for the neurological assessments and she could not locate any of the neurological assessments for the fall. The VPO indicated on 4/6/2026, the nurse had added a note indicating one neurological assessment had been completed, but she could not find any other documentation in the record to indicate the neurological assessments had been completed. On 7/22/2026 at 11:57 A.M., the Executive Director (ED) provided a Neurological Assessment form dated, 4/6/2026, that contained the first ten hours of neurological assessments and indicated the assessments had been located on 7/21/2026 at 5:00 P.M., and the only missing information on the neurological assessment had been the nurses' initials. The ED indicated after the first ten hours after the fall, the facility nurses had continued neurological assessments, but there was no documentation in the resident's record to indicate the remaining sixty-two hours of neurological assessments had been completed. The ED indicated there should have been documentation in the resident's record to indicate 72 hours of neurological assessments had been completed. During an interview, on 7/22/2026 at 10:30 A.M., the facility's Nurse Practitioner (NP) indicated that she had been notified about Resident B having some nausea and vomiting on 4/7/2026 but it had been reported to her that the nausea and vomiting was after the resident had eaten her lunch and the symptoms had resolved on 4/7/2026. The NP indicated she had seen the resident on 4/7/2026 and the resident was new to her and she did not have a baseline on the resident's mentation to know if the resident had had a change of condition related to her mental status. The resident had not complained to her about pain during the assessment. On 4/8/2026, the NP had been notified by RN 2 indicating the resident had had an altered mental status. The NP had reviewed the lab results from that day and noticed the resident had critical values for labs related to the resident's kidney function. The NP indicated that with the altered mental status and the critical lab values, she had sent Resident B to the hospital to be evaluated. During an interview, on 7/22/2026 at 9:40 P.M., RN 2 indicated when the fall on 4/6/2026 had been reported, she had assessed the resident, had notified the provider and family and had started neurological exams. She indicated the facility completed neurological exams on a paper form and she indicated she had completed her neurological paperwork completely, but had been unsure where the neurological checks form had gone after it had been completed. RN 2 indicated she had not been notified by Resident B or her family about a headache after the fall. RN 2 indicated she had not been able to recall if the resident had reported any nausea, but she believed the resident had not complained about nausea either. RN 2 indicated, on 4/8/2026, Resident B had been sent out to the hospital related to the results of her blood work and not because she had exhibited an altered mental status. When RN 2 had completed Resident B's notification to the physician, she indicated she had made a documentation mistake by selecting the drop down to indicate the resident had had an altered mental status. RN 2 indicated she had not known Resident B for very long and had not witnessed the resident with an altered mental status. During an interview with the VPO, on 7/22/2026 at 11:10 A.M., the VPO indicated the facility did not have a policy specific to Neurological Assessments, but that the facility followed the Standards of Care for Nursing and performed neurological assessments after all unwitnessed falls. The VPO indicated the Neurological Assessment Form was what the facility currently used to track neurological assessments. The form used by the facility nurses included the timeline for the neurological assessment and what was included in a neurological assessment. During an interview on 7/21/2026 10:01 A.M., Resident B indicated she had fallen in April and sustained a brain bleed resulting in hospitalization. However, she had not been able to recall any of the details leading up to the hospitalization, including details of the fall. Resident B indicated she had fallen in June and had broken her shoulder. The resident indicated she had gotten up in the middle of the night, had not used the call light to request help, and had walked by herself to the bathroom. When she had finished in the bathroom, she had attempted to walk back to bed unassisted by staff and had tripped and fallen. She could not recall what she had tripped on, but recalled an aide had helped her to bed a short time later. The resident indicated her shoulder had hurt after the fall and she had told staff multiple times and had reported the fall to her daughter later that same day. A Late Entry Note, dated 6/15/2026, indicated the Interdisciplinary Team (IDT) had met to review a fall for Resident B which had occurred on 6/12/2026. The note indicated the CNA had walked into the resident's room and found the resident sitting upright on floor with her back against the bottom part of the bed, next to the foot board. Resident B had told the CNA she was going to the bathroom when she tripped over trashcan. The CNA indicated Resident B had stated that she was fine, and just needed help up. Resident B had been transferred back to bed with the assistance of the CNA. Resident B's record lacked any documentation before 6/15/2026 to indicate that the resident had fallen on 6/12/2026. However, review of the Hospice Note for Resident B, dated 6/13/2026, indicated the Hospice nurse had visited related to a triage call from the resident's daughter the day before about a fall. The Hospice nurse had spoken with RN 2, and RN 2 had reported that it was unlikely the resident had fallen because she had been non-ambulatory and there had been nothing documented related to a fall in the resident's record. RN 2 went with the Hospice nurse to assess the resident, and the resident was grimacing in pain when she was asked to extend her arm. The resident had not been able to extend her arm and an arm sling was ordered as well as an Xray. The resident had been administered Tylenol for pain after the assessment at the request of the Hospice nurse. A review of the facility's Incident Report, submitted to the Indiana Department of Health, completed on 7/21/2026 at 12:45 P.M., indicated the resident had had a fall that resulted in a fracture to the humeral neck with a mild displacement. During an interview with the [NAME] President of Operations on 7/21/2026 at 1:50 P.M., she indicated there were no neurological assessments completed for the unwitnessed fall on 6/12/2026, but there should have been. During an interview with the ED, on 7/21/2026 at 1:50 P.M., the ED indicated the CNA had failed to notify a nurse of a fall after the CNA had found the resident sitting on the floor. The ED indicated the CNA had moved the resident before a nurse had assessed the resident and should not have moved her. The ED indicated the resident's record lacked any information that the resident had an unwitnessed fall on 6/12/2026 before 6/15/2026. During an interview on 7/22/2026 at 9:40 P.M., RN 2 indicated on 6/12/2026 she had not been notified by anyone, including Resident B or anyone in her family, that the resident had fallen. RN 2 denied telling Resident B's POA that the resident had been non-ambulatory. RN 2 indicated on 6/13/2026, during a Hospice Nurse visit, the Hospice Nurse had asked her if Resident B had fallen on 6/12/2026. After looking through the resident's record, she reported to the Hospice Nurse that the resident had not fallen on 6/12/2026. RN 2 indicated she had gone into the resident's room with the Hospice Nurse to assess the resident. The resident had reported to the Hospice Nurse she had fallen the night before and her elbow hurt. Resident B had been able to fully extend her arm and the nurse had not noticed any change in the resident's facial expressions and had not believed that the resident was in pain. However, a pain reliever was administered, at the request of the Hospice Nurse, and a sling for the resident's arm and an Xray were ordered by Hospice. RN 2 indicated the Hospice Nurse had never reported to her that she had believed the resident had fallen, and that was the reason the fall had not been reported to management or investigated at that time. During an interview on 7/23/2026 at 12:40 P.M , with the Hospice Nurse, who had assessed the resident on 6/13/2026, she indicated she had been notified by the Hospice Company that Resident B's daughter had called and requested a visit from a nurse related to the resident having a fall. The Hospice Nurse indicated that upon her arrival, she had spoken with RN 2 and had been notified there were no falls recorded in the resident's record. When she had interviewed and assessed the resident, it had been the first time the nurse had encountered the resident, but she felt the resident clearly communicated that she had fallen and was complaining of pain to the facility staff. The Hospice nurse indicated the resident's recall of the events related to the fall never changed. The Hospice Nurse indicated it was communicated to RN 2 that the resident had reported an unwitnessed fall and the Hospice Nurse had ordered a sling and a Xray and requested RN 2 administer pain medication to the resident. During an interview on 7/23/2026 at 12:00 P.M., the facility's VPO indicated the facility did not have a policy related to neurological checks and followed the standards of care. The VPO indicated the facility performed neurological checks for all unwitnessed falls. During an interview, on 7/23/2026 at 11:52 A.M., CNA 3 indicated on 6/12/2026 the resident had had a fall in the early morning hours. CNA 3 indicated she had walked into the resident's room and had found the resident sitting on her bottom on the floor. The resident indicated that she was not hurt and the CNA had assisted the resident back into her bed and had not reported the fall to the nurse. CNA 3 indicated she had worked at the facility for almost two years and worked all shifts. CNA 3 indicated Resident B had always walked with her to the restroom prior to the fall on 6/12/2026. 2. A record review was completed for Resident J on 7/23/2026 at 2:30 P.M. Diagnoses included, but were not limited to, unspecified dementia, fall on same level, and generalized anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 4/15/2026, indicated Resident J's cognition was severley impaired, she had hallucinations, required maximum assist for transfers, and had one fall since the last MDS assessment. A Care Plan Problem, dated 1/29/2026 and revised on 2/20/2026, indicated Resident J had a risk for falls. Interventions included, but were not limited to, offer and encourage activities after dinner, keep personal items and touch pad call light in reach, and encourage non-skid footwear. On 6/29/2026 at 5:00 A.M. Resident J was found sitting on the floor facing her bed. The fall was unwitnessed and she was unable to explain what happened. A head to toe assessment was done with no findings. A neurological assessment could be found in the record. During an interview on 7/23/2026 at 2:40 P.M., the ED indicated that a neurological assessment should have been done but was not. 3. A record review for Resident H was completed on 7/23/2026 at 2:01 P.M. Diagnoses included, but were not limited to, vascular dementia, unspecified convulsions, and compression fracture of T11 and T12 (thoracic vertebra number 11 and 12. An admission Minimum Data Set (MDS) assessment, dated 6/5/2026, indicated Resident H had a moderate cognitive impairment, had no behavior problems, required maximum assist for mobility and transfers, and had a fall with a fracture within 6 months before admission. A Care Plan, dated 5/30/2026 and revised on 6/15/2026, indicated Resident H was at risk for falls. Interventions included, but were not limited to, a body pillow to define bed boundaries, encourage and assist to wear appropriate non-skid footwear, and keep the call light and personal items within reach. On 6/6/2026 at 6:51 A.M. Resident H had an unwitnessed fall though documentation indicated staff indicated the resident hit her head. Vital signs were taken and the resident was documented to be at baseline. There were no neurological assessments completed. During an interview on 7/23/2026 at 2:40 P.M., the ED indicated that a neurological assessment should have been done for Resident H but was not. A review of the facility's Neurological Assessment form was completed on 7/23/2026 at 1:12 P.M. The Neurological Assessment form indicated a neurological checks should be performed every 15 minutes for one hour, then every 30 minutes for one hour, then once an hour for four hours, then every four hours for twenty-four hours, and finally once a shift until 72 hours after the fall. On 7/22/2026 at 11:50 A.M., the Executive Director provided a policy dated, 1/2024, and titled, Fall Prevention. The Executive Director indicated the policy was the one currently used by the facility. The policy indicated, .A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or otherlevel, but not as a result of an overwhelming external force (e.g., resident pushes another resident). Theevent may be witnessed, reported, or presumed when a resident is found on the floor or ground, and canoccur anywhere . 9. When any resident experiences a fall, the facility will: a. assess the resident .document all assessments and actions. The immediate jeopardy that began on 4/6/2026 was removed on 7/24/2026 when the facility completed audits of falls for the past 30 days, provided education for nursing staff related to the fall protocols and policies - including completing neurological and nursing assessments and fall follow up assessments and post fall documentation and nursing managers were educated on uploading paper documentation related to falls into the electronic charting system which removed the immediacy of the situation but the noncompliance remained at the lower scope and severity level of harm that was not immediate jeopardy. This citation relates to Intake 3053784. 410 Indiana Administrative (IAC) Code 3.1-37

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the physical environment remained free of vermin and pests and failed to promptly eradicate an ongoing insect infestation. This deficient practice affected the main kitchen and dry storage areas and had the potential to affect all 121 residents who resided in the facility and received food from the kitchen. See F0812 for additional information regarding storing and serving food in a safe and sanitary manner. Findings include:During an observation of the kitchen and dry storage areas on 7/19/2026 at 9:50 A.M., accompanied by the Assistant Dietary Manager 4, dead cockroaches were on the floor behind appliances, on shelves and on a windowsill. She indicated the facility was working on getting rid of the cockroaches. During an additional observation on 7/21/2026 at 10:25 A.M., a dead cockroach remained on the windowsill in the kitchen, on the floor in the kitchen and in the dry storage room.During an interview on 7/24/2026 at 9:29 A.M. with the Maintenance Director (11), he indicated the facility has had a contract with a pest control service since January 2026. He indicated he had followed their recommendations.A service summary report from the pest control company, dated January 20, 2026, indicated. An employee reported cockroaches crawling around the drains in the dishwashing area. The findings reported food residue under appliance/machinery/equipment. The entire area under the dishwasher needs to be deep cleaned. An exterior dumpster/trash can was overflowing. They recommended emptying the garbage can and cover (sic) it securely and cleaning up the surrounding area. This was first observed on 12/24/2025. This still needs addressed. An application of cockroach gel was placed in dishwasher area.A service summary report from the pest control company dated February 14, 2026, indicated. applied cockroach treatment to the locker room area. An exterior dumpster/trash can was overflowing. They recommended emptying the garbage can and covering the can securely. Clean the surrounding area up. This was first observed on 12/24/2025. This still needs addressed. An application of cockroach gel was placed in the locker room.A service summary report from the pest control company dated March 19, 2026, indicated.Applied interior supplemental crawling insect treatment. The findings reported food residue under appliance/machinery/equipment. The entire area under the dishwasher needs to be deep cleaned. This still needs addressed from 1/20/2026. They recommended empty garbage cans and cover securely. Clean up the surrounding area. This was first observed on 12/24/2025. This still needs addressed.A service summary report from the pest control company dated May 11, 2026, indicated.Did a supplemental crawling insect barrier treatment. Treated mop room for cockroach activity.A service summary report from the pest control company dated June 5, 2026, indicated.the mop storage room has excessive holes that need patched. Treated cracks and crevices with cockroach gel bait.A service summary report from the pest control company dated June 20, 2026, indicated.discussed ongoing sanitation issues with the dishwasher area and dirty towels in locker room and breakroom. Did a supplemental treatment of cockroaches in kitchen, break room, mop room, ice machine area and locker room. Recommended having breakroom, locker room, dish washing room areas deep cleaned. The drain by the dishwasher is backing up with food debris. There are dirty towels in the locker room that need picked up. The ice machines are leaking water, and wet towels need to be removed. All areas are harborage for roaches. The hole under the time clock needs to be sealed up. Active harborage, treated it heavily.A policy titled, Pest Control was provided by the Executive Director on 7/20/2026 at 2:45 P.M. The policy indicated.1. Purpose-To maintain an effective pest control program that eradicates and contains common household pests and rodents. 2. Responsibility-This applies to every Care Team Member (including volunteers, providers, contractors, Care Partners, trainees, students and other persons) in the performance of work. 4. Policy-We maintain a report system of issues that may arise in between scheduled visits with the outside pet service and treat as indicated. 410 Indiana Administrative Code (IAC) 16.2-3.1-19(f)(4) This Federal tag relates to Intake 3055774 & 3051678

Based on observation, interview, and record review, the facility failed to store, prepare and serve food under sanitary conditions in to prevent the growth of potential foodborne pathogens and reduce the risk of cross-contamination. Specifically, the facility failed to enforce proper infection control techniques during meal service, failed to maintain appropriate cold storage capacity by over-stacking units, failed to track and remove expired food items, failed to ensure effective chemical sanitization levels, and failed to maintain kitchen floors and areas underneath appliances in a clean, dry, and sanitary manner. This deficient practice had the potential to affect all 121 residents who consumed meals prepared by the facility kitchen. See F0925 for additional findings related to pest control.Findings include:During an observation of the kitchen on 7/19/2026 at 9:50 A.M., with the Assistant Dietary Manager (Employee 4), the following was noted:There was dirt and food on the floor throughout the kitchen. There was an accumulation of old debris, including dead cockroaches, three discarded resident plates, two plastic cups, multiple paper plates, and multiple forks heavily covered in dust and grease lying directly on the floor underneath counters and behind and around appliances.A test of the sanitizer water bucket, that was used to clean and sanitize all kitchen surfaces, measured at 50 parts per million (ppm), which fell significantly below the manufacturer-required effective cleaning range of 100 ppm to 400 ppm. During an interview with [NAME] 6, on 7/19/2026 at 10:15 P.M., she indicated the sanitizer water had not been changed since she had started her shift at 5:00 A.M. The Assistant Dietary Manager 4 indicated the water should have been changed every 2 hours.Observation of the kitchen refrigeration and freezer units, on 7/19/2026 at 10:25 A.M., indicated the following:The temperature logs on all refrigeration and freezer units had the afternoon dates for 7/19/2026 already completed on the logs. The Assistant Dietary Manager 4 indicated these temperatures should not have been recorded yet.Frozen food boxes were stacked directly against the cooling fans and up to the ceiling in the main walk in freezer, completely blocking essential airflow.In the main walk-in refrigerator, multiple boxes were stacked directly against the automated fire sprinkler line and ceiling pipes, exposing the food packaging to potential moisture from pipe condensation and accumulated dust.In the 2-door refrigerator, multiple items were stored past their expiration dates, including 48 cups of poppyseed dressing dated 7/9/2026 and 60 cups of tartar sauce dated 7/15/2026. In the 3-door refrigerator, multiple items were stored past their expiration dates, including 19 cups of yogurt dated 7/18/2026, 4 bowls of tossed salad with hard-boiled eggs with no labeled expiration date. In addition, there were 3 containers of Nectar thickening liquid opened and not dated when opened nor was there any expiration date on them. During an interview with the Assistant Dietary Manager, on 7/19/2025 at 10:35 A.M., she indicated the expired items should have been removed from the refrigerators.On 7/19/2026 at 11:28 A.M., during an observation of the dishwashing operations, a large pool of standing water was observed covering the dish room floor. Loose cardboard was observed under the dishwasher along with several rags. Standing water was also observed under the ice machine. During an interview with the Assistant Dietary Manager 4, on 7/19/2026 at 11:40 A.M., she indicated the pooling water has been an ongoing issue for months. During an interview with the Maintenance Director (11) on 7/24/2026 at 9:29 A.M., he indicated the standing water in the dish room was from a busted water pipe under the dish room floor. He indicated he had requested a quote for repair from a vendor. When asked to provide a copy of obtained quote, no documentation was .provided before the survey exit.During an observation of food service in the main dining room, on 7/19/2026 at 11:42 A.M., Dietary Aide 5 was observed plating entrees onto resident dinner plates. Dietary Aide 5 repeatedly placed her bare thumb directly onto the eating surface of the plates while moving them down the line. She touched the food surface on 28 of 28 plates observed. In addition, although she had washed her hands prior to serving food, she had retrieved items from a refrigerator 5 separate times and had touched her clothes and face without re-washing her hands. During an interview on 7/19/2026 at 12:05 P.M., Dietary Aide 5 indicated she should have re-washed her hands and not placed her thumb on the food surface of plates. Assistant Dietary Manager 4 also indicated the aide should have rewashed her hands and not placed her thumb on the eating surface of the plates while placing food on the plates.On 7/29/2026 at 12:28 P.M., during the lunch dining service, Employee 9 was observed serving plates to residents at Tables 5 and 6 with his bare thumbs directly on top of the food-contact borders of the plates. On 7/20/2026 at 3:00 P.M., Employee 9 was observed carrying an uncovered bowl of ice cream through the lobby with his thumb inside the bowl in contact with the ice cream. During an interview on 7/23/2026 at 2:50 P.M. with Employee 9, he indicated the ice cream was for a resident. He said he understood the concern with placing his thumb on the food surface of meal plates but he strongly denied having done this or having his fingers come in contact with the ice cream he had served. A policy titled Safe Food Handling was provided by the Executive Director on 7/22/2026 at 12:17 P.M. He indicated this is the current policy the facility is using. The policy indicated.Purpose: To provide Care Team Members the best practices for safe handling of food. Policy: B.b. Leftover foods will be protected, labeled, and dated with the date of original preparation and date of discard. D.c. ppm for chemical sanitizing will be monitored throughout the day. A policy for safe food service was requested but not provided prior to the end of the survey.410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)

Based on observation, interview, and record review, the facility failed to properly dispose of cooking grease and maintain refuse storage in a sanitary manner in 1 of 1 kitchen and refuse storage area. Findings include:During an observation, on 7/19/ 2026, at 10:00 A:M., the outside refuse containers' lids were left open and an open trash bag had been placed on the ground next to the dumpsters. There was also trash noted on the ground around the dumpster.During an interview with the FSS, on 7/20/2026, at 9:15 A.M., it was disclosed that the facility frequently poured used grease along the fence line. She indicated sometimes the grease was placed in the dumpster or was ran down the kitchen sinks. Observations of the fence line adjacent to the dumpster, on 7/20/2026 at 9:20 A.M., indicated there was an area devoid of plant life and grass with bare soil exposed. During an interview with the Executive Director, on 7/20/2026 at 10:00 A.M., he indicated the facility maintained a contract with a grease extraction company and he was not sure why the kitchen staff were not following the facility policy regarding grease disposal. 410 IAC 16.2-3.1-21(i)(5)

Based on observation, record review and interview, the facility failed to maintain a sanitary kitchen for 1 of 1 main kitchen observed for sanitation. This deficient practice had the potential to affect 120 of 120 residents who consumed food from the kitchen.Finding includes:During an initial kitchen observation, on 6/12/2026 from 8:48 A.M. through 8:57 A.M., a live cockroach was seen crawling out from underneath the refrigerator, another live cockroach was seen crawling under the stove and two live cockroaches were crawling under the stainless-steel food prep counter that housed a microwave. There was a bag of sleeved bowl lids on the floor against the wall underneath the food prep counter close to the crawling roaches. In addition, there was food and general debris covered in dust and a grease buildup on the floor, along the back of the oven. Dead unidentifiable bugs and dead cockroaches were also noted along the edges of the kitchen walls, including the dish room. Live cockroaches were observed by the refrigerator, behind the stove, by the serving steamtable and along the walls of the kitchen.During an interview, on 6/12/2026 at 8:50 A.M., the Dietary Manager indicated she had not been aware of cockroaches in the kitchen. She indicated there had been a problem in the employee breakroom, which was located close to the kitchen.During an observation of the kitchen, on 6/12/2026 at 9:27 A.M., seven dead cockroaches were observed between the wall and food service steam table on the floor.During an interview, on 6/12/2026 at 9:28 A.M., the Assistant Director of Food Service indicated the back door to the kitchen had a metal pest control box and there was also a cardboard pest control box under the handwashing sink in the kitchen. She indicated cockroaches had been seen in the kitchen for the past year.During an interview, on 6/12/2026 at 10:53 A.M., the Assistant of Dietary Services, confirmed she had been aware of cockroaches in the kitchen for the past year. She indicated she had previously informed the former Director of Maintenance of the cockroach issue about two months ago.During an interview, on 6/12/2026 at 11:38 A.M., the Dietary Director indicated staff had a form for daily cleaning and the floor and equipment should have been cleaned every night for food debris, dust and general dirt.A Daily Cleaning Schedule was provided by the Dietary Director, on 6/12/2026 at 12:16 P.M. The schedule indicated sweep and mop the kitchen, had been signed as completed from 6/1-6/7/2026.Review of facility pest control reports for the past year, indicated the company had checked and performed preventative pest control throughout the building on a monthly basis. However, the reports, dated 6/5/2026 and 6/10/2026 indicated roaches had been noted in the employee break room, mop room and kitchen dish room and drains. The pest control notes for April 2026 had referred to debris in the dietary dish room that needed cleaned. The June pest control company notes included pictures of cockroaches and dirt and debris underneath and around the dish room floor and drains, as well as the mop room.A policy was provided, on 6/12/2026 at 12:16 P.M., by the Dietary Manager. The policy titled, Kitchen Sanitation, indicated, .To ensure a clean, safe, and sanitary food service environment that prevent foodborne illness, promotes resident/patient health, and meets all, federal, and local regulatory requirements, including CMS, FDA Food Code, and State Department of Health regulations.Policy.A. The Culinary Manager is responsible for overseeing the provision of safe food to all residents. A. Cleaning schedules will be posted and followed. b. The Culinary Manager or designee will make regular inspections. J. The kitchen will be kept free from of pests through contracted pest management and Care Team Member vigilance.This citation relates to Intake 3040629.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)

Based on interview, observation, and record review, the facility failed to ensure 2 of 3 residents reviewed for abuse were free from verbal abuse and physical injury when a Certified Nursing Assistant (CNA) was verbally abusive to one resident (Resident R), and physically abusive as evidenced by grabbed another resident's wrist during a transfer which resulted in bruising and skin tears to the resident's arm, (Resident P). Using the reasonable person concept, the abuse likely led to emotional distress related to intimidation and anxiety for both residents (Resident R and P) and actual physical injuries for Resident P.Findings include:On 5/29/26 at 3:00 P.M., an interview with the Administrator indicated he had been informed that earlier in the day, CNA 10 had been rough with a resident. The Administrator indicated CNA 10 had been suspended pending an investigation, and all parties were being notified including the physician and Resident P's responsible party. The Administrator indicated he had observed red speckles to Resident P's wrists where the CNA had allegedly handled the resident roughly. The Administrator indicated he was going to file an incident report with the State Agency.On 6/1/26 at 8:30 A.M., the Administrator indicated he had submitted a report of an allegation of abuse to the Indiana State Department of Health Survey Report System on 5/29/26, regarding an allegation of abuse that had occurred on 5/29/26 at 4:01 A.M. The Administrator indicated Resident P's physician and family had been notified and CNA 10 had been suspended pending an investigation. On 6/1/26 at 2:15 P.M., during an observation and interview, Resident P was observed in the activity area of the facility's memory care unit. Resident P indicated she had an injury to her left forearm. Observation of the resident's left forearm revealed a skin tear in the shape of a uniformed semi-circle approximately 1/2 inch in length approximately two inches above the left wrist. A second skin tear in the same shape and approximate size was observed further up the left arm approximately three inches above the left wrist. The second skin tear had a steri-strip closer (clear plastic bandage designed to pull the edges of wounds together) in place. During an interview at that time, Resident P indicated she did not know how the injuries had occurred but that they felt sore.On 6/1/26 at 2:30 P.M., the Administrator provided Incident Report Number 271, that had been submitted to the Indiana State Department of Health Survey Report System. The report indicated an allegation of abuse that had occurred on 5/29/26 at 4:01 A.M had been reported. The Incident Report indicated CNA 11 had reported the allegation of abuse to the Administrator via telephone indicating that CNA 10 had been aggressive towards Resident P during their last shift together on the memory care unit. The report indicated CNA 11 reported that CNA 10 had grabbed Resident P by the wrist, during a toilet transfer, and had caused bruises and skin tears to the resident. The incident report indicated the type of injuries incurred were bruises to her wrist and a skin tear .05cm x 0.01cm. The Immediate action taken indicated CNA 10 had been suspended pending an investigation and that skin and pain assessments had been completed on the resident, the wound was cleaned and treated, and all parties had been notified. Preventive measures taken indicated immediate education was initiated for staff regarding abuse and abuse reporting. All interviewable residents were interviewed regarding abuse, abuse reporting and safety, and that all non-interviewable residents had received skin assessments.An Incident Interview Form, dated 6/1/26 at 9:00 A.M., indicated CNA 11 had reported that on Thursday night, 5/29/26, at approximately 12:30 A.M., she had observed CNA 10 interacting with multiple residents in a manner that raised concerns. CNA 10 indicated Resident R had not been wearing pants and appeared to have given herself a shower. Resident R asked CNA 10 for assistance and CNA 10 appeared frustrated and had told the resident that she (the resident) could do it herself. The Incident form indicated CNA 10 had raised her voice and told Resident R to go to your f-----g room. Then CNA 11 had assisted Resident R. CNA 11 indicated during rounds CNA 10 and CNA 11 had entered Resident P's room and the resident was on the toilet where she had had a bowel movement. CNA 11 indicated CNA 10 became angry and spoke harshly to Resident P. Resident P appeared unwilling to stand due to the way CNA 10 was speaking to her and then CNA 10 had pulled Resident P up by her wrists. Shortly afterward, Resident P's wrist began bleeding, which CNA 11 indicated were from skin tears. CNA 11 indicated Resident P became upset and was crying and repeatedly asked CNA 10 to leave the room. CNA 11 indicated she asked CNA 10 to leave the room but CNA 10 had remained in the room approximately five minutes longer. CNA 11 indicated, at that time, CNA 10 indicated she was going to get a nurse to assess Resident Ps wrists, but no nurse came to complete an assessment. CNA 11 indicated CNA 10 had informed her that LPN 2 was too busy to assess the resident and then CNA 10 used an incontinence wipe to clean the blood from Resident P's wrists. The Incident Interview Form indicated CNA 11 had reported the incident to the Administrator on 5/29/26.An Incident Interview Form dated 6/1/26 at 10:30 A.M., indicated LPN 2 could not recall all the details of the conversation. However, he indicated on 5/29/26 at approximately 5:30 A.M., during medication pass, CNA 10 had informed him that she had been providing care to a resident and that the resident had become combative. LPN 2 indicated in the documentation, that he was unable to clearly understand all of the details CNA 10 was describing and LPN 2 did not recall whether CNA 10 had stated that she had been scratched or that the resident had been scratched but it had sounded as though the resident may have been physically restrained in some manner. LPN 2 indicated he had not witnessed the incident and could not confirm exactly what had occurred. LPN 2 advised CNA 10 to complete an incident report and provide the information to the first shift so they were aware of the situation. The Incident Interview Form indicated LPN 2 had not reported the incident to a supervisor, or Human Resource Representative and had not documented the incident.An Incident Interview Form, dated 6/1/26 at 11:16 A.M., indicated CNA 10 indicated she had been doing rounds and had observed Resident P with bowel movement residue on and around the toilet seat. CNA 10 indicated she had informed the resident that she had gotten stool everywhere. The resident had became upset and was yelling and using profanity. CNA 10 indicated Resident P had became physically aggressive toward her including scratching, kicking, and spitting. CNA 10 indicated she had sustained multiple scratches to her arms. CNA 10 indicated, at some point, CNA 11, had informed her that the resident was bleeding, so she had cleaned the areas that were bleeding and then had gone to locate LPN 2. CNA 10 indicated she had informed LPN 2 that the resident was bleeding and had requested that he assess the situation but LPN 2 indicated to her that he was passing medications and he had not assessed the resident's injuries.On 6/2/24 at 10:00 A.M., Resident P's clinical record was reviewed. The resident was admitted to Memory Care on 5/27/26 with diagnoses included but were not limited to dementia, chronic kidney disease, repeated falls, chronic obstructive pulmonary disease, and chronic kidney disease. Minimum Data Set Assessment information regarding the resident's cognitive score was not available.Resident P's Care Plans indicated the resident had skin trauma to her left forearm as a skin tear, initiated 6/1/26. Another Care Plan, initiated on 5/27/26 and revision on 5/29/26, indicated the resident required assistance with activities of daily living related to her diagnoses including a history of a fall with laceration to top left scalp, depression, dementia with behaviors, hospice care, cognitive disfunction, restlessness, agitation, and weakness. Interventions included, but were not limited to: needed assistance for personal hygiene, showering, toilet transfers and toileting hygiene.A General Nursing Progress Note, dated 5/29/26 at 4:59 P.M., indicated Resident P had been assessed by the Director of Nursing.A Focused Charting Note, dated 5/29/26 at 5: 49 P.M., indicated Alleged physical contact. Vital were completed and within normal limits.There were no assessments found or provided by the facility prior to 5/29/26 at 4:59 P.M. of Resident P's injuries.On 6/2/24 at 2:00 P.M., Resident R's clinical record was reviewed. Diagnoses included but were not limited to dementia, metabolic encephalopathy, anxiety, schizophrenia, depression, bipolar disorder. Resident R was admitted to Memory Care on 2/9/26.A Minimum Data Set (MDS) assessment, dated 5/26/26, completed for a quarterly review, indicated Resident R was cognitively intact.An Incident Interview Form dated 6/1/26, indicated Resident R reported that Everyone is good to me, except [CNA 10]. If I don't do what she says she'll jump all over my back. She hollers at me-I'm 61 I don't have bosses anymore.There were no documented assessments or specific documentation related to the allegation for Resident R.On 6/1/26 at 1:22 P.M., a policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 7/1/25, was provided by the Administrator who indicated it was the current facility policy. The policy indicated, .Residents have the right to be free from abuse.Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 410 IAC (Indiana Administrative Code) 3.1-27(a)(1)(b)

Based on interview and record review, the facility failed to ensure a resident's physician and responsible party were notified when the resident experienced seizure activity and when antiseizure medications had not been administered in accordance with physician orders for 1 of 3 residents reviewed for notification of change of condition, (Resident N).Finding includes:On 6/1/26 at 10:00 A.M., Resident N's clinical record was reviewed. Diagnoses included but were not limited to epilepsy, dysphagia following cerebrovascular disease, psychosis, anxiety, and intellectual disability.Resident N's Physician's Orders included but were not limited to:Briviact Tablet 75 MG (Brivaracetam), to give 2 tablets two times a day at 6:00 A.M. and 6:00 P.M., for epilepsy, ordered on 07/01/24 and ongoingClobazam Oral Suspension 2.5 MG/ML, to give 5 ml one time a day for seizures, ordered on 03/24/26 and discontinued on 5/1/26A current Care Plan, initiated on 1/19/17, indicated Resident N was at risk for seizures related to epilepsy. The Care Plan interventions included to give medications as ordered, and to notify the physician and responsible party of seizure activity.Review of the Resident N's Electronic Medical Record (EMR) dated 4/1/26 through 4/30/26, indicated on 4/5/26, 4/6/26, 4/9/26, and 4/10/26, that neither the morning nor evening Briviact tablets had been administered as ordered, and on 4/14/26, 4/15/26, and 4/17/26, the Clobazam oral suspension for seizures had not been administered as ordered.Review of Resident N's Nursing Progress Notes included, but were not limited to the following:On 4/6/26 at 1:33 P.M., Nursing staff reached out to the Neurology physician regarding the Briviact medication and explained issues with the insurance coverage. The note indicated the facility was waiting for a call back from the Neurology physician's office.On 4/6/26 at 1:37P.M., Focused Nursing Charting indicated the following: Note Text: 'seizures.resident was brought back to hall by staff member, stated resident had a seizure resident V/S taken BP 143/67 93% room air 70 Pulse temp 75.6 resp 18. resident went back to activies [activities] had another seizure lasting a few seconds. The nursing note was written and signed by LPN 6.On 4/6/26 at 1:52 P.M., a General Nursing Progress Note indicated resident was brought back to hall by staff member, stated resident had a seizure resident V/S [vital signs] taken.resident went back to activities had another seizure lasting a few seconds. resident crying that her arm hurt Norco (narcotic pain medication) given for pain 10/10. NP notified.On 4/10/26 at 9:57 A.M., General Nursing Progress Note: called pharm [pharmacy] they will stat [immediate] briviact right now.On 5/29/26 at 3:00 P.M. during an interview, the Administrator indicated the resident's physician and responsible party should have been notified that the seizure medications had not been given as ordered and that the resident had experienced seizures.On 6/1/26 at 12:24 P.M., the Administrator provided a policy titled, Seizure Precautions, dated 1/2/24, indicating it was the current facility policy. The policy indicated, .If the resident has a generalized seizure: .Notify the practitioner and family.On 6/1/26 at 12:24 P.M., the Administrator provided a policy titled, Medication Administration, dated 1/2/24, indicating it was the current facility policy. The policy indicated, .Medications are administered.as ordered by the physician and in accordance with professional standards of practice .Physicians will be notified timely of medication omissions. Instructions on how to proceed (example: administer medications when it becomes available) will be followed per physician order. This citation relates to Intakes 3013839 and 3017939. 410IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)

Based on interview, observation, and record review, the facility failed to fully implement their abuse policy regarding timely reporting, timely resident assessments, and immediate removal of an alleged perpetrator, when a Certified Nursing Assistant (CNA) was alleged to be verbally abusive to a resident (Resident R) and verbally and physically abusive to another, (Resident P), for 2 of 3 residents reviewed for abuse. (Resident R and P)Findings include:On 5/29/26 at 3:00 P.M., an interview with the Administrator indicated he had been informed, earlier in the day, that CNA 10 had been rough with a resident. The Administrator indicated CNA 10 had been suspended pending an investigation, and all parties were being notified including the physician and Resident P's responsible party. The Administrator indicated he had observed red speckles to Resident P's wrists where the CNA had allegedly handled the resident roughly. The Administrator indicated he was going to file an incident report with the State Agency.On 6/1/26 at 8:30 A.M., the Administrator indicated he had submitted a report of an allegation of abuse to the Indiana State Department of Health Survey Report System on 5/29/26 regarding an allegation of abuse that had occurred on 5/29/26 at 4:01 A.M. He indicated Resident P's physician and family had been notified. The Administrator indicated CNA 10 had been suspended pending an investigation, but that she had remained on the unit until the end of her shift. The Administrator indicated the allegation of abuse had not been reported to him until CNA 11 had called him, several hours after the incident, and had alleged that CNA 10 had been rough with Resident P and had been verbally abusive to Resident R. The Administrator indicated that CNA 10 had reported to LPN 2 that an incident had occurred, but LPN 2 had not followed up with an assessment nor did he notify the Administrator or the Director of Nursing of an allegation or incident. The Administrator indicated CNA 11 should have reported the allegation of abuse to the Charge Nurse, DON and Administrator, at the time of the incident. The Administrator indicated LPN 2 should have notified the DON and Administrator at the time of the allegation. The Administrator indicated an assessment on the resident was not completed timely and LPN 2 should have initiated an assessment when CNA 10 had requested it. The Administrator indicated Resident R had since been interviewed but had not verbalized any concerns.On 6/1/26 at 2:15 P.M., during an observation and interview, Resident P was observed in the activity area of the facility's memory care unit. Resident P indicated she had an injury to her left forearm. Observation of the resident's left forearm revealed a skin tear in the shape of a uniformed semi-circle approximately 1/2 inch in length approximately two inches above the left wrist. A second skin tear in the same shape and approximate size was observed further up the left arm approximately three inches above the left wrist. The second skin tear injury had a steri-strip (bandage designed to cover and pull wound edges together) closer in place. During an interview at that time, Resident P indicated she did not know how the injuries had occurred but that they felt sore.On 6/1/26 at 2:00 P.M., the Administrator provided Incident Report Number 271, the report he had submitted to the Indiana State Department of Health Survey Report System. The report indicated an allegation of abuse had occurred on 5/29/26 at 4:01 A.M. The Incident Report indicated CNA 11 had reported an allegation of abuse to the Administrator via telephone. The report indicated CNA 11 had reported that CNA 10 had been aggressive towards Resident P during their last shift together on the memory care unit. The report indicated CNA 11 had reported that CNA 10 had grabbed Resident P by the wrist during a toilet transfer and had caused bruises and skin tears to the resident. The report indicated the type of injuries incurred were bruises to her wrist and a skin tear, .05cm x 0.01cm in size. The report indicated the Immediate action taken indicated CNA 10 had been suspended pending an investigation and skin and pain assessments were completed on the resident, and her wound was cleaned and treated, and all responsible parties had been notified. The report indicated the Preventive measures taken included: immediate education started for staff regarding abuse and abuse reporting, all interviewable residents had been interviewed regarding abuse, abuse reporting and safety, and that all non-interviewable residents had received skin assessments.An Incident Interview Form dated 6/1/26 at 9:00 A.M., indicated CNA 11 had reported that on Thursday night, 5/29/26 at approximately 12:30 A.M., she had observed CNA 10 interacting with multiple residents in a manner that raised concerns. CNA 11 indicated Resident R had not been wearing pants and appeared to have given herself a shower. Resident R had asked CNA 10 for assistance and CNA 10 appeared frustrated and told Resident R that she could do it herself. The Incident form indicated CNA 10 had raised her voice and told Resident R to go to your f---ing room. Then CNA 11 indicated she had provided assistance to Resident R. CNA 11 also indicated during rounds, CNA 10 and CNA 11 had entered Resident P's room and the resident was on the toilet, where she had had a bowel movement. CNA 11 indicated CNA 10 became angry and had spoken harshly to Resident P. Resident P appeared unwilling to stand up due to the way CNA 10 had been speaking to her and so CNA 10 had pulled Resident P by her wrists. Shortly afterward, Resident P's wrist began bleeding, which CNA 11 indicated were from new skin tears. CNA 11 indicated Resident P became upset, was crying and repeatedly asked CNA 10 to leave her room. CNA 11 indicated she also asked CNA 10 to leave the room but CNA 10 had remained in the room approximately five minutes longer. CNA 11 indicated, at that time, CNA 10 left the room and told CNA 11 that she was going to get a nurse to assess Resident Ps wrists. However, no nurse came to complete an assessment or care for the wounds CNA 11 indicated CNA 10 informed her that LPN 2 was too busy to assess the resident so CNA 10 used an incontinence wipe to clean the blood from Resident P's wrists. The Incident Interview Form indicated CNA 11 had reported the incident to the Administrator on 5/29/26.An Incident Interview Form dated 6/1/26 at 10:30 A.M., indicated LPN 2 was unable to recall all the details of the conversation, however, he indicated on 5/29/26 at approximately 5:30 A.M., during medication pass, CNA 10 had informed him that she had been providing care to a resident and that the resident had become combative. LPN 2 indicated in the documentation that he was unable to clearly understand all of the details CNA 10 had been describing and LPN 2 had not recalled whether CNA 10 stated that she had been scratched or that the resident had been scratched but it had sounded as though the resident may have been physically restrained in some manner. LPN 2 indicated he had not witnessed the incident and could not confirm exactly what had occurred. LPN 2 had advised CNA 10 to complete an incident report and provide the information to the first shift so they would be aware of the situation. The Incident Interview Form indicated LPN 2 had not reported the incident to a supervisor, or Human Resource Representative and had not completed any documentation regarding the incident.An Incident Interview Form dated 6/1/26 at 11:16 A.M., indicated CNA 10 indicated she had been completing rounds and had observed Resident P with bowel movement residue on and around the toilet seat. CNA 10 informed the resident that she had gotten stool everywhere. The resident became upset and was yelling and using profanity. CNA 10 indicated Resident P became physically aggressive toward her, including scratching, kicking, and spitting at her. CNA 10 indicated she had sustained multiple scratches to her arms from Resident P. CNA 10 indicated at some point CNA 11 had informed her that resident was bleeding. She indicated she had she cleaned the wounds and then had gone to locate LPN 2. CNA 10 indicated she had informed LPN 2 that the resident was bleeding and had requested that he assess the situation but LPN2 had informed her that he was too busy passing medications and had not assessed the resident.A review of CNA 10's Employee Timesheet indicated the CNA had punched-in for work on 5/28/26 at 1:14 P.M. and had punched out on 5/29/26 at 6:11 A.M.On 6/2/24 at 10:00 A.M., Resident P's clinical record was reviewed. The resident was admitted to Memory Care on 5/27/26 with diagnoses included but were not limited to dementia, chronic kidney disease, repeated falls, chronic obstructive pulmonary disease, and chronic kidney disease.Minimum Data Set Assessment information was not available.Resident P's Care Plans indicated the resident had skin trauma to her left forearm as a skin tear. The plan had been initiated on 6/1/26. Another Care Plan, initiated on 5/27/26 and revised on 5/29/26, indicated the resident required assistance with activities of daily living related to her diagnoses including a history of a fall with laceration to top left scalp, depression, dementia with behaviors, hospice care, cognitive disfunction, restlessness, agitation, and weakness. Interventions included needs assistance for personal hygiene, showering, toilet transfers and toileting hygiene.A General Progress Note, dated 5/29/26 at 4:59 P.M., indicated Resident P had been assessed by the Director of Nursing.A Focused Nursing Charting Note, dated 5/29/26 at 5: 49 P.M., indicated: Alleged physical contact. Vital were completed and within normal limits. There were no other assessments found or provided by the facility prior to 5/29/26 at 4:59 P.M. regarding the abuse and injuries incurred from alleged abuse.On 6/2/24 at 2:00 P.M., Resident R's clinical record was reviewed. Diagnoses included but were not limited to dementia, metabolic encephalopathy, anxiety, schizophrenia, depression, bipolar disorder. Resident R was admitted to Memory Care on 2/9/26.A Minimum Data Set assessment dated [DATE] for Quarterly Assessment, indicated Resident R was cognitively intact.An Incident Interview Form dated 6/1/26, indicated Resident R had reported that Everyone is good to me, except [CNA 10]. If I don't do what she says she'll jump all over my back. She hollers at me-I'm 61 I don't have bosses anymore.There were no documented assessments or follow up notes related to the allegation of verbal abuse for Resident R.On 6/1/26 at 1:22 P.M., a policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 7/1/25, was provided by the Administrator who indicated it was the current facility policy. The policy indicated, .Residents have the right to be free from abuse.Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Care Team members should immediately report all such allegations to the Administrator and to the Department of Health in accordance with the procedures in this policy .If an injury is observed /suspected, Care Team Members should not move the resident/patient until an assessment is completed by a nurse supervisor for possible injuries .If a Care Team Member is accused or suspected. Facility should immediately remove that Care Team Member from the facility . 410 IAC (Indiana Administrative Code) 3.1-28(a)(c)(d)

Based on interview and record review, the facility failed to ensure antiseizure medications were available and administered in accordance with physician orders for 1 of 3 residents reviewed for medication administration, (Resident N). This deficient practice resulted in the resident displaying seizure activity.Finding includes:On 6/1/26 at 10:00 A.M., Resident N's clinical record was reviewed. Diagnoses included but were not limited to epilepsy, dysphagia following cerebrovascular disease, psychosis, anxiety, and intellectual disability.Resident N's Physician's Orders included but were not limited to;Briviact Tablet 75 MG (Brivaracetam), to give 2 tablets two times a day at 6:00 A.M. and 6:00 P.M., for epilepsy, ordered on 07/01/24 and ongoing, andClobazam Oral Suspension 2.5 MG/ML, to give 5 ml one time a day for seizures, ordered on 03/24/26 and discontinued on 5/1/26.A Care Plan dated 1/19/17, indicated Resident N was at risk for seizures related to epilepsy. The Care Plan interventions included to give medications as ordered. Review of the Resident N's Electronic Medical Record (EMR) dated 4/1/26 through 4/30/26, indicated on 4/5/26, 4/6/26, 4/9/26, and 4/10/26, that neither the morning nor evening Briviact tablets were administered as ordered, and on 4/14/26, 4/15/26, and 4/17/26, Clobazam oral suspension for seizures was not administered as ordered.Review of Resident N's Progress Notes included but were not limited to the following:On 4/6/26 at 1:33 P.M., indicated Nursing staff reached out to Neurology regarding Briviact and explained issues with insurance. The facility was waiting for a call back.On 4/6/26 at 1:37P.M., Focused Charting. Note Text: seizures.resident was brought back to hall by staff member, stated resident had a seizure resident V/S taken BP 143/67 93% room air 70 Pulse temp 75.6 resp 18. resident went back to activies [activities] had another seizure lasting a few seconds. Signed by Licensed Practical Nurse (LPN) 6.On 4/6/26 at 1:52 P.M., General Progress Note, resident was brought back to hall by staff member, stated resident had a seizure resident V/S [vital signs] taken.resident went back to activities had another seizure lasting a few seconds. resident crying that her arm hurt norco given for pain 10/10. NP notified.On 4/10/26 at 9:57 A.M., General Progress Note: called pharm [pharmacy] they will stat [immediate] briviact right now.On 5/29/26 at 3:00 P.M. during an interview, the Administrator indicated he did not know why Resident N had not received prescribed seizure medications as ordered. The Administrator indicated that the Director of Nursing at the time the medications were not available was no longer at the facility and had not notified him that the resident's seizure medication had not been given as ordered. On 6/1/26 at 12:24 P.M., the Administrator provided a policy titled, Seizure Precautions, dated 1/2/24, indicating it was the current facility policy. The policy indicated, .If the resident has a generalized seizure: administer medications as prescriber or ordered. Notify the practitioner and family.On 6/1/26 at 12:24 P.M., the Administrator provided a policy titled, Medication Administration, dated 1/2/24, indicating it was the current facility policy. The policy indicated, .Medications are administered.as ordered by the physician and in accordance with professional standards of practice.Medications that are not readily available for administration will be obtained from the Emergency Kit, drop shipped from the pharmacy, or obtained from an alternative pharmacy.Physicians will be notified timely of medication omissions. Instructions on how to proceed (example: administer medications when it becomes available) will be followed per physician order. This citation relates to Intakes 3013839 and 3017939.410IAC (Indiana Code) 16.2-3.1-37(a)

Based on record review, observation, and record review, the facility failed to implement their policy related to reporting, two allegations of abuse in a timely manner for 1 of 3 residents reviewed for allegations of abuse, (Resident C). Finding includesOn 1/28/26 at 11:52 A.M., Resident C's clinical record was reviewed. Diagnoses included but were not limited to Alzheimer's Disease, dementia, seizures, weakness, and depression.Resident C's Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident had severe cognitive impairment, utilized a wheelchair for locomotion, and required substantial assistance for eating, dressing, toileting, bathing, transfers, and bed positioning.Resident C's Care Plans included but were not limited to: the resident had a preference for video recording in her room and a STOP sign across the door frame, dated 8/26/25. Interventions included but were not limited to protecting residents' privacy and not capturing other residents or staff in shared or common areas.Facility Incident Number 236 was submitted to the State Agency on 9/17/25 and indicated the incident date was 9/17/25 at 11:30 A.M. The report indicated on 9/17/25 a male resident walked into Resident C's room and sat on the resident's bed. The immediate action taken indicated Resident F was removed from the room and a head-to-toe assessment was completed for Resident C with no findings and the family and the physician were notified of the incident. Preventive Measure indicated Resident F was placed on every 15 minute checks . The Follow up dated 9/24/25 indicated on 9/17/25, Resident C had reported a male resident was in her room but had not reported any physical contact. On 9/18/25 Resident F was discharged from the facility with a return not anticipated.Facility Incident Number 254 was submitted to the State Agency on 2/3/25 and indicated on 2/3/26 at 10:42 A.M., the Administrator was made aware that a report was never filed for an incident that had occurred on 10/20/25 by the previous administrator, and that the incident involved Resident D climbing into bed with Resident C after undressing herself.Review of a Care Plan Conference Summary, dated 12/12/25 at 10:20 A.M., indicated those in attendance included Resident C's responsible parties, Social Services, Nursing Services, the local Ombudsman and the Administrator. The Care Plan notes indicated the meeting was due to Resident C's family's concerns and that the local Ombudsman had been invited to help find appropriate interventions that could be put into place to prevent other residents from wandering into Resident C's room, specifically at night.On 2/2/26 at 11:58 A.M., Resident C's responsible party provided an email dated 9/12/25 at 10:09 P.M., sent to Previous Administrator 2. The email indicated Resident C's responsible party was following up about an incident she had reported earlier. The email indicated the responsible party viewed, via family installed security room cameras, an incident on 9/7/25 at 4:47 A.M. Resident F had entered Resident C's room while Resident C was asleep in her bed, and had attempted to sit on the bed, had opened his robe, had closed the robe, then had sat in a chair in the room. The email indicated Resident F then stood and moved again to Resident C's bed and had sat on the bed, then had sat directly on Resident C's chest and left shoulder, causing Resident C to groan and call out in pain. Resident F then sat on ground next to the bed and fell asleep where nursing staff found Resident F at 4:57 A.M. and escorted him out of the room.A second email dated 10/20/25 at 12:18 P.M., also from Resident C's responsible party to the Previous Administrator, Employee 2, indicated on 10/20/25 at 10:09 A.M., she and notified them that Resident D had entered Resident C's room in the morning of 10/20/25, completely undressed, wiped her genital area with a blanket from Resident C's bed and had then gotten into bed with Resident C.On 2/3/26 at 1:57 P.M., during an interview, the Administrator indicated he was aware of the allegations of abuse that occurred on 9/8/25 and on 10/20/25 and that he assumed both allegations had been reported timely to the State Agency as directed by the facility policy by Previous Administrator, Employee 2, but they had not been reported. The Administrator indicated the allegations of residents wandering into Resident C's room were discussed at a Care Plan meeting on 12/12/25.On 1/29/26 at 2:47 P.M., a policy titled Abuse, Mistreatment, Neglect, Exploitation and Mistreatment, dated 7/1/25, was provided by the Administrator who indicated it was the current facility policy. The policy indicated, .Purpose [was to] investigate all alleged violations.Alleged Violation is a situation or occurrence that is observed or reported by.resident, relative.Care Plan members should immediately report allegations to the Administrator and to the Department of Health.completing ongoing assessments and care planning for appropriate interventions and monitoring of resident.including.wondering into other resident/patient's rooms.if abuse is alleged.the Administrator or his/her designee will notify the Department of Health immediately, but no later than 2 hours after the allegation is made.all other allegations.will be reported to the Department of Health immediately, but in no event later that 24 hours from the time the incident/allegation was made known to the Care Team Member.This citation relates to Intake 2715458.3.1-28(c)

Based on record review, observation, and record review, the facility failed to implement their policy related to investigating, an allegation of abuse for 1 of 3 residents reviewed for allegations of abuse, (Resident C). Finding includesOn 1/28/26 at 11:52 A.M., Resident C's clinical record was reviewed. Diagnoses included but were not limited to Alzheimer's Disease, dementia, seizures, weakness, and depression.Resident C's Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident had severe cognitive impairment, utilized a wheelchair for locomotion, and required substantial assistance for eating, dressing, toileting, bathing, transfers, and bed positioning.Resident C's Care Plans included but were not limited to the following plan: The resident had a preference for video recording in her room and a STOP sign across the door frame, dated 8/26/25. Interventions included but were not limited to protecting residents' privacy and not capturing other residents or staff in shared or common areas.Facility Incident Number 236 was submitted to the State Agency on 9/17/25 and indicated the incident date had occurred on 9/17/25 at 11:30 A.M. The report indicated on 9/17/25 a male resident had walked in Resident C's room and sat on the resident's bed. The immediate action taken indicated Resident F was removed from the room and a head-to-toe assessment was completed for Resident C with no findings and family and physician were notified. Preventive Measure indicated Resident F was placed on every 15 minute checks . The Follow up dated 9/24/25 indicated on 9/17/25, Resident C reported a male resident was in her room and had not reported any physical contact. On 9/18/25 Resident F was discharged from the facility with a return not anticipated.Review of a Care Plan Conference Summary dated 12/12/25 at 10:20 A.M., indicated those in attendance included Resident C's responsible parties, Social Services, Nursing Services, local Ombudsman, and the Administrator. The Care Plan notes indicated the meeting was due to Resident C's family's concerns and that the local Ombudsman had been invited to help find appropriate interventions that could be placed to prevent other residents from wandering into Resident C's room, specifically at night.On 2/2/26 at 11:58 A.M., Resident C's responsible party provided an email, dated 9/12/25 at 10:09 P.M., sent to Previous Administrator (Employee 2). The email indicated Resident C's responsible party was following up about an incident she had reported earlier. The email indicated the responsible party had viewed, via a family installed security room cameras, an incident on 9/7/25 at 4:47 A.M. Resident F had entered Resident C's room while Resident C was asleep in her bed, and had attempted to sit on the bed, had opened his robe, had closed the robe, then had sat in a chair in the room. The email indicated Resident F then had stood back up and had moved again to Resident C's bed and had sat on the bed, then Resident F had sat directly on Resident C's chest and left shoulder causing Resident C to groan and call out in pain. Resident F then sat on ground next to the bed and fell asleep where nursing staff found Resident F at 4:57 A.M. and had escorted him out of the room.On 2/3/26 at 1:57 P.M., during an interview, the Administrator indicated he was aware of the allegation of abuse that had occurred on 9/8/25 and that a thorough investigation had not been completed by the previous administrator. The Administrator indicated the allegations of residents wandering into Resident C's room had been discussed at a Care Plan meeting on 12/12/25.On 1/29/26 at 2:47 P.M., a policy titled Abuse, Mistreatment, Neglect, Exploitation and Mistreatment, dated 7/1/25, was provided by the Administrator who indicated it was the current facility policy. The policy indicated, .Purpose [was to] investigate all alleged violations.Alleged Violation is a situation or occurrence that is observed or reported by.resident, relative.Care Plan members should immediately report allegations to the Administrator and to the Department of Health.completing ongoing assessments and care planning for appropriate interventions and monitoring of resident.including.wondering into other resident/patient's rooms.if abuse is alleged.the Administrator or his/her designee will notify the Department of Health.Once the Administrator and Department of Health are notified, and investigation of the allegation violation will be conducted.This citation relates to Intake 2715458.3.1-28(d)

Based on record review and interview, the facility failed to ensure showers were completed for 2 of 4 residents reviewed for activities of daily living. (Residents C & B)Findings include:1.A record review for Resident C was completed on 1/5/2026 at 9:07 A.M. Diagnoses included, but were not limited to: intertrochanteric fracture of right femur, cerebral palsy, and bipolar disorder.An admission Minimum Data Set (MDs) assessment, dated 9/5/2025, indicated Resident C was cognitively intact, had impairment with range of motion on one side of the upper and lower extremity and required substantial assistance for showering.A Care Plan Conference had been held, on 9/4/2025 at 8:49 A.M. for Resident C. The Care Plan Conference note indicated the family had concerns related to Resident C's care.The medical record indicated Resident C should have received showers on Tuesdays and Fridays. From admission, on 8/29/2025 through discharge on [DATE], Resident C had only received a shower on 9/5/2025, 9/16/2025 and 9/19/2025. The medical record had no indication Resident C had refused showers.A Care Plan, initiated on 8/31/2025, indicated Resident C needed assistance with activities of daily living with the goal of having care needs met on a daily basis. Interventions included, but were not limited to: showers two times per week and as needed per Resident C's preference.During an interview, on 1/6/2026 at 9:13 A.M., Resident C's wife indicated she had spoken to the facility concerning Resident C not receiving his showers and the facility had been apologetic. Resident C's wife indicated the facility indicated Resident C had not received his showers because he had signed documentation he had refused his showers. Resident C's wife indicated Resident C would not have kept asking for a shower had he refused. She indicated the facility social worker had come to Resident C's room and tried to convince Resident C he had signed documentation for refusal of showers, but the paperwork that indicated Resident C's refusal could not be found.During an interview, on 1/7/2026 at 12:54 P.M., LPN 2 indicated resident should receive a shower twice weekly and if a refusal of a shower had occurred, a signature from the resident on a shower sheet, would have been obtained and documented in the nursing progress notes.During an interview, on 1/7/2026 at 1:26 P.M., the Interim Director of Nursing indicated shower sheets had not been utilized in September of 2025. She indicated showers that had been received would be documented in the medical record and refusals would have been documented in the nursing progress notes.2. During an interview, on 1/2/2026 at 11:52 A.M., Resident B indicated he was supposed to have showers on Tuesdays and Fridays on second shift but he had not had a shower in awhile. Resident B indicated when he asked for a shower, he staff would tell him, If we can fit you in. Resident B indicated he had gone weeks without a shower. He indicated the Director of Nursing had asked him if he had been refusing showers. He indicated he refused to sign a shower sheet paper because he had not refused his showers.A record review for Resident B was completed on 1/6/2026 at 11:23 A.M. Diagnoses included, but were not limited to: neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident (stroke) and anxiety disorder.A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/2025, indicated Resident B was cognitively intact and required substantial assistance for showering.The medical record indicated Resident B should have received showers on Tuesdays and Fridays on second shift. Resident B had been absent from the facility due to hospitalization from 12/19/2025-12/24/2025 and 12/27/2025-1/1/2026. The only recorded shower in the medical record had been on 12/9/2025. Shower sheets had been completed for 12/2/2025, 12/12/2025 and an undated sheet. The medical record did not have any documentation that Reisdent B had refused any showers.A Care Plan, initiated on 2/21/2023 and revised on 11/14/2025, indicated Resident B required assistance with activities of daily living with a goal of having daily care needs met. Interventions included, but were not limited to: Showers on second shift on Tuesdays and Fridays and as necessary.During an interview, on 1/7/2026 at 12:54 P.M., LPN 2 indicated residents should receive a shower twice weekly and if a refusal of a shower had occurred, a signature from the resident on a shower sheet would have been obtained and documented in the nursing progress notes.A policy was provided by the Executive Director, on 11/7/2026 at 2:08 P.M. The policy titled, Showers, indicated, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulant circulation and help prevent skin issues as per current standards of practice.1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.This citation relates to Intake 2622065.3.1-38(b)(2)

Based on interview and record review, the facility failed to follow physician orders for 1 of 3 residents reviewed for medication administration and failed to ensure an appointment for a specialized physician had been scheduled for 1 of 3 residents reviewed for resident rights. (Residents C & E)Findings include:1.A record review for Resident C was completed on 1/5/2026 at 9:07 A.M. Diagnoses included, but were not limited to: exocrine pancreatic insufficiency, cerebral palsy, and diabetes mellitus type 2.An admission Minimum Data Set (MDs) assessment, dated 9/5/2025, indicated Resident C was cognitively intact.Home Discharge Instructions from the hospital, dated 8/29/2025, indicated the resident was to receive the medication, pancrelipase (Creon) 36,000 units three times a day with meals and snacks.A Physician's Order, dated 8/29/2025 and discontinued on 9/4/2025, indicated Creon 36,000-114,000 units one capsule three times daily to treat exocrine pancreatic insufficiency.The Medication Administration Record, dated August 2025, indicated pancrelipase had been administered daily, from 8/30/2025-8/31/2025, at 6:00 A.M., 2:00 P.M. and 6:00 P.M. These administration times were outside of the facility's scheduled meal times.The Medication Administration Record, dated September 2025, indicated pancrelipase had been administered daily, from 9/2/2025-9/4/2025, at 6:00 A.M., 2:00 P.M. and 6:00 P.M. These administration times were outside of the facility's scheduled mealtimes.The Medication Administration Record, for August and September 2025, indicated the pancrelipase had not been administered on 8/30/2025 at 2:00 P.M., on 8/29/2025 at 6:00 P.M., on 8/31/2025 at 2:00 P.M., on 9/1/2025 at 6:00 A.M., on 9/1/2025 at 2:00 P.M., on 9/1/2025 at 6:00 P.M., on 9/2/2025 at 6:00 A.M. and on 9/2/2025 at 2:00 P.M. The physician nor the nurse practitioner had been notified of the missed medication administrations.A Care Plan Conference had been held for Resident C on 9/4/2025 at 8:49 A.M. The Care Plan Conference note indicated the family had concerns related to making sure Resident C had been receiving medications before every meal.A Physician's Order, dated 9/8/2025, indicated Resident C was to receive the medication, metoprolol succinate ER 25 milligrams daily for hypertension and the medication was to be held for a systolic blood pressure less than 100 mmHg (millimeters of mercury) and a heart rate of less than 60 beats per minute.The Medication Administration Record, dated September 2025, indicate metoprolol succinate ER had been administered on 9/17/2025 even though the Resident's heart rate was 59 beats per minute and on 9/19/2025 with a heart rate of 55 beats per minute.During an interview, on 1/6/2026 at 9:13 A.M., Resident C's wife indicated she had spoken to the facility concerning Resident C's pancrelipase and the correct administration times for the medication.2. During an interview, on 1/2/2026 at 11:25 A.M., Resident E indicated she had asked the facility staff for a doctor's appointment beyond the facility medical staff onsite and the facility would not make the appointment. Resident E indicated she had asked facility staff for over two months to make an appointment with her neurologist due to new symptoms she was experiencing with her multiple sclerosis illness.A record review for Resident E was completed, on 1/7/2026 at 10:47 A.M. Diagnoses included, but were not limited to: trigeminal neuralgia and multiple sclerosis.A Quarterly Minimum Data Set (MDS) assessment, dated 11/6/2025, indicated Resident E was cognitively intact.A Physician's Order, dated 8/10/2025, included an order to schedule a neurological consultation for Resident EA facility grievance form was submitted, on 10/9/2025, by Resident E that had requested an appointment to be made with a neurologist. The grievance indicated a previous request had been made without a follow-up appointment completed. The response indicated an appointment had been made with a neurologist. However, there was no evidence that an appointment had actually been scheduled.A Nurse Practitioner's Note, on 10/23/2025 at 12:59 A.M., indicated Resident E had been seen for uncontrollable trigeminal neuralgia. Per nursing, Resident E had been screaming out in pain, especially in the evenings. Resident E had requested to return to her neurologist, and a referral had already been ordered. The note indicated the facility was working on setting up the appointment.During an interview, on 1/7/2026 at 12:54 P.M., LPN 2 indicated that all appointments were scheduled through the transportation director.During an interview, on 1/7/2026 at 1:38 P.M., the transportation director indicated all outside doctor appointments came through her for scheduling appointments. The transportation director indicated she had not transported Resident E to any appointments. She indicated the facility nurse practitioner, and the facility nurse, would have informed her if any appointments had been needed or were to have been scheduled. She indicated she had not scheduled any appointments for Resident E.A policy was provided by the Executive Director, on 1/7/2026 at 2:08 P.M. The policy titled, Physician Orders, indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provisions of physician ordered services according to professional standards of quality.A policy was provided by the Executive Director, on 1/7/2026 at 2:08 P.M. The policy titled, Physician Orders, indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provisions of physician ordered services according to professional standards of quality.This citation relates to Intake 2622065.3.1-37(a)

Based on interview and record review, the facility failed to ensure urinary output was monitored for 1 of 3 residents reviewed for urinary catheters. (Resident B)Finding includes:During an interview, on 1/2/2026 at 11:52 A.M., Resident B indicated he had been hospitalized recently for sepsis.During an interview, on 1/6/2026 at 9:59 A.M., Resident B's sister indicated she had been notified that Resident B had been sent to the emergency room for a slight fever. She indicated when Resident B had arrived at the Emergency Room, he had a fever of 104.3 degrees Fahrenheit and had been diagnosed with an infection in his blood and urine. Resident B's sister indicated the emergency room physician had indicated Resident B's Foley catheter had been dislodged or had been incorrectly placed. Resident B's sister indicated Resident B's roommate had reported to her when Resident B's Foley (urinary) catheter had been last changed , there was bloody and purulent urine in the tubing and the nursing staff had shoved another urinary catheter into Resident B's urethra.A record review for Resident B was completed on 1/6/2026 at 11:23 A.M. Diagnoses included, but were not limited to: neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident (stroke) and anxiety disorder.A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/2025, indicated Resident B was cognitively intact, had an indwelling urinary catheter and required substantial assistance for toileting and hygiene.A Physician's Order, dated 6/18/2025, indicated staff were to monitor the urinary (Foley) catheter output every shift. However, this order had been discontinued on 12/15/2025.A Nursing Progress Note, dated 12/17/2025, indicated Resident B had complained of penial pain and there had been pus coming from the head of the penis. Resident B had requested for the urinary (Foley) catheter to be removed and left out. Resident B had complained of severe pain all evening. Tylenol had been administered and lubricant had been placed around the inside of the penis to prevent tugging on the head of the penis when the resident had moved in his bed.A Nursing Progress Note, on 12/18/2025 at 12:10 A.M., indicated Resident B's urinary (Foley) catheter had been changed and a urine sample had been obtained via a clean catch method thru the newly placed urinary (Foley) catheter. A Nursing Progress Note, on 12/19/2025 at 12:02 P.M., indicated a verbal order had been obtained to send Resident B via ambulance to the hospital. Resident B had been found with a temperature of 99.7 degrees Fahrenheit, shaking and turning a gray tone color in his hands and lips. Resident B had complained of pain with his urinary (Foley) catheter and had a white drainage coming from his penis around the urinary (Foley) catheter.An emergency room History and Physical, dated 12/19/2025, indicated Resident B had a chronic indwelling urinary (Foley) catheter and had arrived at the emergency room with lethargy, nausea and vomiting and mild shortness of breath. The Foley catheter had been found to have been displaced with the catheter bulb in the penile shaft. The emergency room workup indicated Resident B had a urinary tract infection with a temperature of 102.6 F. Resident B had been diagnosed with early sepsis with borderline shock related to a urinary tract infection due to a displaced Foley catheter.During an interview, on 1/7/2025 at 12:54 P.M., LPN 2 indicated urinary output from a urinary (Foley) catheter should have been documented in the medical record every shift. It was unclear why the physician's order regarding urinary outputs had been discontinued in December and it was unclear why nursing staff had not obtained urinary outputs every shift.A current policy, dated 12/12/023, was provided by the Executive Director, on 1/7/2026 at 2:08 P.M. The policy titled, Indwelling Catheter, indicated, .It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination. The use of indwelling catheters for managing incontinence is not appropriate and increase the risk of urinary tract infections.4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but not limited to: d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; e. Response of the resident during the use of the catheter; and f. Ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes.This citation relates to Intake 2698825.3.1-41(a)

Based on interview and record review the facility failed to ensure catheter care was completed as ordered for 3 of 3 residents reviewed (Resident B, Resident C, Resident D).Findings include:1. 1. Resident B's record was reviewed on 9/9/25 at 12 PM. Diagnoses included: obstructive and reflux uropathy.An order, dated 6/2/25 -8/14/25, indicated to complete foley catheter care every shift and document output every shift.The Medication Administration Record (MAR), dated 6/1/25 - 8/4/25, indicated the following:June 2025 - 12 shifts had no documentation to reflect catheter care/ urinary output was completedJuly 2025 - 5 shifts had no documentation to reflect catheter care/ urinary output was completedAugust 2025 - 3 shifts had no documentation to reflect catheter care/ urinary output was completedNursing notes, dated 6/1/25 - 8/24/25, were reviewed. The nursing notes indicated Resident B had a urinary tract infection (UTI) on 6/18/25 and 7/23/25.A nursing note, dated 8/14/25, indicated Resident B's catheter was removed.There was no other documentation regarding catheter care or documentation of urinary output.2. 2. Resident C's record was reviewed on 9/9/25 at 11:57 AM. Diagnosis included: neuromuscular dysfunction of the bladderAn order, dated 7/1/2024, indicated to document catheter output every shift.The Medication Administration Record (MAR), dated 6/1/25 - 9/4/25, indicated the following:June 2025 - 8 shifts had no documentation to reflect urinary output was obtainedJuly 2025 - 14 shifts had no documentation to reflect urinary output was obtainedAugust 2025 - 3 shifts had no documentation to reflect urinary output was obtainedThere was no other documentation regarding documentation of urinary output.3. 3. Resident D's record was reviewed on 9/9/25 at 12:10 PM. Diagnosis included: obstructive and reflux uropathy.An order, dated 11/14/2024, indicated to complete foley catheter care every shift and document output every shift.The Medication Administration Record (MAR), dated 7/1/25 - 9/8/25, indicated the following:June 2025 - 2 shifts had no documentation to reflect catheter care/ urinary output was completedJuly 2025 - 4 shifts had no documentation to reflect catheter care/ urinary output was completedAugust 2025 - 6 shifts had no documentation to reflect catheter care/ urinary output was completedThere was no other documentation regarding catheter care/ urinary output.In an interview, on 9/10/25 at 1 PM, Unit Manager 3 indicated there was no other documentation regarding catheter care/ urinary output for Resident B, Resident C nor Resident D.In an interview, on 9/8/25 at 11:27 AM, Resident B's family indicated catheter care was not completed as ordered and Resident B had gotten UTIs with the catheter. In an interview, on 9/10/25 at 10:42 AM, Resident B indicated she no longer had a catheter. Resident B indicated when she did have the catheter she had gotten multiple UTIs.In an interview, on 9/9/25 at 12:47 PM, Registered Nurse (RN) 2 indicated catheter care was completed each shift. RN 2 indicated catheter care included emptying the catheter bag, cleaning around the tube insertion and peri-care. RN 2 indicated catheter output was communicated to the nurse and documented in the MAR. When no documentation existed, there was no way to tell if catheter care was completed or urinary output was obtained.In an interview, on 9/10/25 at 11:59 AM, the Director of Nursing (DON) indicated catheter care was completed during each shift. The DON indicated catheter care included peri-care, output documentation and cleaning the tube around the insertion site. The DON indicated outputs were documented on the MAR. The DON also indicated the MAR documentation was reviewed during daily clinical meetings.In an interview, on 9/10/25 at 1:21 PM, the Administrator indicated nurse staffing consisted of 8 hour shifts: 6 AM - 2 PM, 2 PM - 10 PM and 10 PM - 6 AM.A policy, undated, titled Indwelling Catheter, indicated catheter care was completed as ordered and to prevent infection.This finding relates to Intake 1243215.3.1-37(a)

Based on observation, record review and interview, the facility failed to store and prepare food under sanitary conditions related to foods not sealed appropriately, outdated foods, and dirty kitchen equipment for 1 of 1 kitchen observed. This issue had the potential to affect all 101 residents who resided in the facility and received food from this kitchen. Findings include: On 1/15/2025 at 9:45 A.M., a kitchen tour was conducted with the Dietician. The following was observed in the walk-in freezer: - A opened bag of green beans not sealed appropriately. - A opened bag of corn not sealed appropriately. - A opened bag of sausage patties not sealed appropriately. - A opened bag of eggs not sealed appropriately. The following was observed in the dry storage area: - a opened bag of cream soup base with no open date. During an interview on 1/15/2024 at 9:50 A.M., the Dietician indicated the items in the walk-in freezer should have been sealed appropriately and the bag of cream soup base should have had an open date. During a follow-up tour of the kitchen, on 1/16/2025 at 8:50 A.M. with the Dietary Manager (DM), the following was observed: - a can opener with dried food on it. - a spatula stored in the drawer as clean with dried food on it. - a measuring cup stored as clean with dried food and grease on it. - a knife stored as clean with dried food on it. - a measuring spoon stored as clean with dried food on it. - the utensils drawer had dried food on the bottom of it. During an interview on 1/16/2024 at 8:57 A.M., the DM indicated the kitchen utensils and the drawer should have been cleaned. On 1/16/2025 at 10:42 A.M., the DON provided a policy titled, Kitchen Sanitation, dated 12/12/2023 and indicated it was the policy currently being used by the facility, The policy indicated, Policy: The Dietary Manager will be responsible for overseeing the provision of safe food to all residents. Good sanitary food handling practices with sanitary conditions maintained in the storage, preparation and serving areas will be carried out at all times. The Dietary Manager, Consultant RD and/or designee will make regular inspections. On 1/16/2025 at 10:42 A.M., the DON provided a policy titled, Labeling and Dating Guidelines, dated 12/12/2023 and indicated it was the policy currently being used by the facility. The policy indicated, All opened and leftover items will be labeled with the date of opening/date stored and a discard/use-by date . 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed related to glove use and handwashing for 3 of 3 residents reviewed for perineal/catheter care and for 1 of 1 residents reviewed for nephrostomy care and during 1 of 3 medication administration passes. In addition, the facility failed to follow their policy regarding Enhanced Barrier Precautions (EBP) to ensure residents with wounds and catheters were placed in isolation for 3 of 5 residents reviewed for EBP isolation. Finally, the facility failed to report an illness outbreak to the State Department of Health. These deficient practices potentially affected 101 of 101 residents in the facility. (Residents 18, E, 98, G, 96, 314 & H) Findings include: 1. During an observation, on 1/17/2025 at 9:56 A.M., Certified Nursing Assistant 11 was observed to provide perineal care to Resident 18. CNA 11 obtained a basin with warm water and washcloths. She then applied gloves and washed the Resident's front and inner groin area. CNA 11 rolled the resident over and cleaned the resident's buttocks. Without washing her hands or changing her gloves, CNA 11 applied a clean brief, while touching the residents' legs and the clean brief. She then applied the resident's pants and placed a hoyer sling underneath the resident without removing her soiled gloves and/or washing her hands. During an interview, on 1/17/2025 at 10:00 A.M., CNA 11 indicated she should have washed her hands and changed gloves. 2. The record for Resident E was reviewed on 1/17/2025 at 11:25 A.M. Diagnoses included, but were not limited to: depression, cancer and obstructive uropathy. An Admission Minimum Data Set (MDS) assessment, dated 11/18/2024, indicated the resident required the use of a catheter and needed substantial to maximum assist for toileting. During an observation, on 1/21/2025 at 2:45 P.M., Certified Nursing Assistant (CNA) 18 was observed to provide incontinence/catheter care to Resident E. She placed a paper towel on the floor underneath the urinary drainage bag and emptied the urine into a urinal. She then used a washcloth and cleaned the urinary catheter and tubing. Without changing her gloves or washing her hands, CNA 18 applied barrier cream to the resident's buttocks. Next she rearranged the brief and attached the catheter drainage tubing to the adhesive strip on the residents upper leg. CNA 18 pulled the resident's shorts off and placed them in the closet. Finally CNA 18, with the same gloves still on, applied blankets over the resident and grabbed a computer cord and handed it to the resident. She then removed her gloves and gown and placed them in the trash bag. During an interview, on 1/21/2025 at 3:02 P.M., CNA 18 indicated she should have changed her gloves and washed her hands. 3. During an observation, on 1/22/2025 at 9:27 A.M., RN 19 was observed to complete a pressure ulcer treatment with assistance from CNA 11 for Resident 98. RN 19 placed a barrier on the bed side table. CNA 11 and RN 19 washed their hands and applied gloves. RN 19 cleaned the coccyx area, removed his gloves and applied new gloves. RN 19 applied triad paste (wound dressing) on the coccyx area. RN 19 removed his gloves and then washed his hands. RN 19 was not wearing a gown while completing the pressure area treatment. There was no Personal Protective Equipment (PPE) or a sign indicating the resident was in Enhanced Barrier Precautions (EBP) available on the door or outside of the room. During an interview, on 1/22/2025 at 9:41 A.M., RN 19 indicated he would change his gloves only if he was contaminated and there should have been Personal Protective Equipment (PPE) available and he should have worn a gown. 4. During a medication administration observation, on 1/17/2025 at 12:06 P.M., RN 19 obtained a Lamictal tablet from the medication cart. RN 19 indicated the tablet had to be cut in 1/2 because it was a 200 mg (milligram) dose, and the resident was to receive 100 mg dose. RN 19 indicated the other half will be discarded. RN 19 placed the tablet in a pill cutter and then with an un-gloved hand, touched the pill to move it to the center. During an interview, on 1/17/25 at 12:07PM the RN indicated he should have worn gloves when touching the pill. 45120 5. A record review for Resident G was completed on 1/17/2025 at 9:18 A.M. Diagnoses included, but were not limited to: nephrostomy, obstructive and reflexive uropathy, overactive bladder and carcinoma of the bladder. A Quarterly Minimum Data Set (MDS) assessment, dated 12/23/2024, indicated Resident G was cognitively intact and had an indwelling catheter. A Physician's Order, dated 1/15/2025, indicated to monitor the nephrostomy output every shift. A Care Plan, dated 8/16/2024 and revised 12/17/2024, indicated Resident G was at risk for infection/complications related to the use of nephrostomy tubes. Interventions included, but were not limited to: catheter/peri-care at least every shift and as needed. During an observation, 1/21/2025 at 10:38 A.M., CNA 11 and 12 were providing incontinence care and nephrostomy tube/drainage bag care. CNA 12 brought in a step-by-step instruction guide on nephrostomy tube and drainage bag care provided by the Assistant Director of Nursing, who was also present in the room. CNA 12 indicated she would not have known how to care for a nephrostomy tube if she had not been given the instruction guide. CNA 11 emptied the nephrostomy drainage bag while using a soapy washcloth to release and seal the urinary drainage bag spout. CNA 11 asked, after completing the procedure, if a nephrostomy drainage bag used the same procedure as emptying a Foley urinary drainage bag and using an alcohol prep pad for cleansing the spout. 51598 6. The record for Resident 96 was completed on 1/21/2025 at 10:09 A.M. Diagnosis included but were not limited to: diabetes mellitus type 2 (DM) with chronic kidney disease, iron deficiency anemia, legal blindness, hypertensive heart disease without heart failure, and vitamin D deficiency. A current Care Plan, initiated 6/26/2024 and updated 1/16/2025, indicated Resident 96 had impaired skin integrity stage 3 pressure ulcer to the right heel- goes to [NAME] wound clinic. Interventions included but not limited to, assess and document skin condition, notify MD of signs of infection, assess for pain and treat as indicated, assist with bed mobility to turn and reposition routinely, pressure reducing/redistributing cushion in chair, pressure reducing/redistributing mattress on bed, prevalon boot to right foot at all times as tolerated, supplements as ordered, and wound treatment as ordered. During an observation of the room of resident 96 on 11/22/2025 at 11:55 A.M., there was no sign or personal protective equipment to identify that resident was on enhanced barrier precautions. During an interview conducted on 1/22/2025 at 11:53 A.M., RN 10 indicated that resident 96 had a stage three pressure ulcer to her right heel. She indicated that because of the pressure ulcer, the resident should have been on enhanced barrier precautions. 7. A record review for Resident 314 was completed on 1/22/2025 at 10:09 A.M. Diagnosis included but were not limited to lymphedema, hypertension, and COPD. A current care plan dated 1/15/2025 indicated that Resident 314 has impaired skin integrity: pressure ulcer on left buttocks stage 2, Venous ulcer - right great toe, right 2nd toe, left great toe, left 2nd toe, and left 3rd toe. Interventions included but were not limited to: assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever), assess for pain and treat as indicated, assist with bed mobility to turn and reposition routinely, notify MD of worsening or not improvement in wound, pressure reducing/redistributing mattress on bed, wound treatment as ordered. During an interview on 1/22/2025 at 2:18 P.M., LPN 16 indicated that Resident 314 has wounds that were treated by the wound center and also had wounds on his toes that were treated by the facility. She indicated that with the wounds the resident should have been on enhanced barrier precautions. During an observation on 11/22/2025 at 2:20 P.M., Resident 314 was sitting in his wheelchair with wraps on his bilateral lower extremities. There was no sign or personal protective equipment to identify that resident was on enhanced barrier precautions. 49994 8. The record for Resident H was reviewed on 1/17/2025 at 10:04 A.M. Diagnoses included, but were not limited to: malignant neoplasm of prostate and colon and obstructive and reflex uropathy. During an observation of catheter care on 1/21/2025 at 3:29 P.M., CNA 3 put on a gown and a pair of gloves prior to entering Resident H's room. CNA 3 removed the resident's pants and brief. CNA 3 then changed her gloves began cleaning the resident's catheter tubing. CNA 3 grabbed a clean brief from the bedside table and removed the resident's soiled brief, proceeded to provide perineal care with a soapy rag, placed the clean brief on the resident with the same gloves that had been used to provide perineal care. CNA 3 then pulled the residents pants up and covered the resident with his blankets. CNA 3 removed her gloves and performed hand hygiene. During an interview on 1/21/2025 at 3:43 P.M., CNA 3 indicated she had not changed her gloves after providing perineal care and should have. During an interview on 1/16/2025 at 11:44 A.M., the DON indicated when she was notified of nausea, vomiting and diarrhea in multiple residents on the 200 unit, she notified the Nurse Practitioner and the local Health Department. A review of the facilities monthly infection surveillance report for the month of January indicated 20 residents experienced nausea, vomiting and diarrhea that began on 1/3/2025. A record review was completed for all residents that resided on the 200 hall and indicated an additional six residents, who were not documented on the monthly infection surveillance report for the month of January also experienced nausea, vomiting and diarrhea on 1/3/2025. During an interview on 1/16/2025 at 2:16 P.M., the ADON indicated the cases were not reported to the state and should have been. A policy was provided, on 1/23/2025 at 12:16 P.M., by the Director of Nursing. The policy titled, Nephrostomy-Cystostomy Care, indicated, .Residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .2. The care and maintenance of nephrostomy/cystostomy tubes shall be in accordance with physician orders. The orders shall specify the type and frequency of dressing changes and emptying of collection bags along with special instructions. 3. Nephrostomy/cystostomy tubes shall be managed by licensed nurses. Nurse aides may handle the collection bags in accordance with facility procedures for handling urinary drainage bags A policy for urinary drainage bags was requested, on 11/23/2025 at 11:42A.M. The Executive Director indicated a policy was not available for maintenance of a urinary drainage bag. On 1/16/2025 at 2:33 P.M., the ADON provided the policy titled, Reportable Infections, dated 1/2/2024 and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy of this facility to report possible incidents of communicable disease or infections to appropriate personnel or authorities. 9. The Infection Preventionist will review lab reports. Any infection or communicable disease that is a reportable disease will be reported to public health authorities On 1/21/2025 at 9:22 A.M., the Administrator provided the policy titled, Medication Administration, dated 12/12/2023, and indicated the policy was the one currently used by the facility. The policy indicated .13, Remove medication from source, taking care not to touch medication with bare hand A current policy was provided by the ADON on 1/22/2025 at 10:23 A.M., titled, Enhanced Barrier Precautions, indicated an order for enhanced barrier precautions would be obtained for residents with the following: Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers and/or indwelling medical devices even if the resident is not know to be infected or colonized with a MDRO A policy was requested regarding catheter care but one was not provided prior to the survey exit. This citation relates to complaint IN00451678. 3.1-18(a) 3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to ensure the physician was notified of abnormal blood sugar levels and insulin refusals for 2 of 2 residents reviewed for insulin (Resident 4 & 96) and of new skin issues for 1 of 6 residents reviewed for skin (Resident 5). Findings include: 1. The record for Resident 4 was reviewed on 1/17/2025 at 9:30 A.M. Diagnosis included, but were not limited to: Type 2 diabetes. A Physicians' order, dated 7/1/2024, indicated the physician was to be notified if Resident 4's blood glucose levels were above 400. - On 9/3/2024 at 4:26 P.M., Resident 4's blood glucose level was 403 mg/dl. - On 10/12/2024 at 5:26 P.M., the residents blood glucose level was 411 mg/dl. - On 10/29/2024 at 8:37 P.M., the residents blood glucose level was 479 mg/dl. During an interview, on 1/21/2025 at 9:39 A.M., RN 15 indicated a nursing progress note should have been in Resident 4's chart for the days the physician had been notified of an elevated blood glucose level. A review of Resident 4's nursing progress notes indicated the record lacked documentation the physician was notified of elevated blood glucose levels above 400 mg/dl. During an interview, on 1/21/2025 at 2:46 P.M., the Administrator confirmed there were no nursing progress notes associated with the elevated blood glucose levels. 2. During an interview on 1/15/2025 at 2:07 P/M., the family of Resident 5 indicated they had noticed a discoloration on the resident's right lower arm and were never given an explanation on how it happened. During an observation and interview on 1/17/2025 at 11:11 A.M., with LPN 14, Resident 5 was noted to have two discolored/ecchymotic areas to her proximal right forearm and distal right forearm. LPN 14 indicated she was unaware of the areas and she did not know where they had come from. On 1/17/2025 at 9:20 A.M., a record review was completed for Resident 5. Diagnosis included, but were not limited to: muscle weakness. An Annual Minimum Data Set (MDS), dated [DATE] indicated Resident 5's cognition was severely impaired. A Care Plan, initiated on 7/15/2023 indicated Resident 5 was at risk for skin breakdown. Interventions included, but were not limited to: skin inspection weekly and as needed, document and notify MD of abnormal findings. A review of Resident 5's weekly skin evaluations indicated there were no new skin findings on the following dates: - 12/2/2024 - 12/9/2024 - 12/16/2024 - 12/30/2024 - 1/6/2024 - 1/15/2024 - 1/20/2024 A review of Resident 5's Nursing Progress Notes and weekly skin evaluations lacked documentation LPN 14 identified the residents abnormal skin findings on 1/17/2025 at 11:11 A.M. and reported the findings to the MD. During an interview on 1/22/2025 at 10:26 A.M., the DON indicated a new skin evaluation should have been completed on Resident 5 after the skin abnormality was discovered by LPN 14. She indicated the Nurse Practitioner, MD, and family should have been notified of the resident's abnormal skin findings and they were not. 51598 3. A record review for Resident 96 was completed on 1/21/2025 at 10:09 A.M. Diagnosis included but were not limited to: diabetes mellitus type 2 (DM) with chronic kidney disease, iron deficiency anemia, legal blindness, hypertensive heart disease without heart failure, and vitamin D deficiency. Resident 96's Physician Orders included, the following orders regarding insulin and blood glucose assessments: Insulin Lispro (a rapid acting) insulin- inject subcutaneous before meals per sliding scale of blood sugar results- if 200 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units, subcutaneously before meals and at bedtime for hyperglycemia if less than 60 notify MD. Insulin Glargine (long acting)- inject 20 units subcutaneously daily in the morning. Insulin Glargine (long acting)- inject 10 units subcutaneously daily at night. A current Care Plan, initiated on 6/26/2024 and updated 1/16/25, indicated Resident 96 is at risk for complications and symptoms of hypoglycemia or hyperglycemia due to diagnosis of diabetes, with interventions including but not limited to: diabetes medication as ordered by Medical Doctor (MD), observe for side effects and effectiveness, diet as ordered, educate and remind resident importance of medications and compliance with dietary restrictions, observe for signs or symptoms of hyperglycemia, observe for signs or symptoms of hypoglycemia, blood sugars as ordered by doctor, labs as ordered, document abnormal findings and notify MD A current Care Plan, initiated on 6/26/2024 and updated 1/16/25, indicated Resident 96 refused medications, treatments, glucometer checks, supplements, VS, insulin, and meals. Interventions included, but not limited to: explain to resident what you are doing before initiating task, MD will be notified prn of resident refusals, re-approach when refuses medications, refer to Nurse Practitioner (NP) as needed to do a med review, staff to provide education regarding refusal of medications ,treatments and blood sugar testing, staff will approach at another time if resident refusals The Medication Administration Record (MAR) indicated Resident 96 refused insulin medication for the following dates in: September 2024 156 times out of 178 doses, October 2024 175 times out of 186 doses, November 2024 182 times out of 182 doses, December 2024 186 times out of 186, and January 2025 90 times out of 91 doses. An Interdisciplinary Team (IDT) note dated 10/25/2024 at 12:36 P.M. indicated Resident 96 refused medications regularly, including blood sugar checks and diabetic med's. There was no indication MD and or NP was notified of refusals. A NP visit note, dated 11/15/2024 indicated Resident 96 had Diabetes Mellitus and staff were to continue insulin as ordered. She also indicated that per nursing staff resident often refused insulin. A Nursing progress note dated 1/5/2025 at 10:17 A.M. indicated resident refused blood sugar checks and insulin before breakfast and lunch. There was no indication the MD or NP were notified. The chart lacked documentation to show the MD and/or NP had been notified of resident's refusal of insulin for 789 of the 823 potential doses ordered. During an interview conducted on 1/23/2025 at 9:54 A.M., RN 10 indicated that the facility staff documented resident refusals in the NP communication book for them to review during their visits. She indicated that she could not locate any information for Resident 96's refusals in the communication book. RN 10 also indicated that facility nurses would also call the NP regarding refusals of care, but there was no documentation of any calls with the NP regarding the resident's refusal of insulin. She indicated a conversation with the MD and/or NP should have been conducted earlier due to the resident's excessive refusals. During an interview on 1/23/2025 at 9:22 A.M., the Director of Nursing (DON) indicated that staff were to encourage and educated the resident when he refused insulin, attempt to administer the medication three times, and then chart the refusals. She indicated, usually if a resident refused medications or a treatment for thirty days or more, the facility nursing staff would have a conversation with the MD and/or NP about discontinuing the order. She indicated that they had not had that conversation with the MD or NP. On 1/21/2025 at 9:22 A.M., the Administrator provided the policy titled, Blood Glucose Monitoring,' dated 12/12/2023 and indicated it was the policy currently being used by the facility. The policy indicated, It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders. 20. Report critical test results to physician timely . On 1/22/2025 at 910 A.M., the Administrator provided the policy titled, Wound Management Policy, dated 5/30/2024 and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy of this facility to ensure residents who do not have skin integrity impairments do not develop a new condition affecting the skin. It is the policy of this facility that those residents with impaired skin integrity are recognized by our care team, treated timely, and interventions to heal are not exhausted until the skin is healed On 1/22/2204 at 9:10 A.M., the administrator provided the policy titled, Change in Condition/Physician Notification, and indicated it was the policy currently being used by the facility. The policy indicated The nurse will notify the physician/NP and the resident/resident representative when: Excessive refusal of treatment or medications (typically more than 2-3 times), Notification will be attempted within 24 hours, The nurse will document timely regarding the change in resident's condition, interventions and notifications . 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure corrective action adequately addressed a response to resident council grievances of call light and shower concerns and readily provided grievance forms for residents to utilize anonymously. This practice had the potential to affect 101 of 101 residents. Findings include: 1. During a resident/surveyor meeting, on 1/17/2025 at 1:00 P.M., the residents in attendance, 10 of 12, indicated their grievances brought forward during the monthly meetings were addressed , but the grievances went unchanged . The residents who regularly attended resident council meetings indicated they usually shared their grievances at the monthly meetings. During the resident council meeting with the surveyors, conducted on 1/17/2025 at 1:08 P.M., grievances were voiced about routine showers not being completed and call lights not illuminating outside of their rooms. They indicated they were given bells and whistles to alert staff when assistance was needed. They indicated a laptop was placed at the nurse's station that indicated when a call light was activated, but the CNAs did not have time to go to the nurse's station to see who had activated their call light. Resident 86 indicated the best way to receive help was to go to the resident's room doorway and find a staff member. She also indicated she had been left on the toilet for 30-45 minutes because her call light had not been answered timely. Resident 102 indicated he had been left on the toilet for at least an hour because his call light had not been answered timely Review of the Resident Council Meeting Notes, from 2/6/2024-12/10/2024, included, but were not limited to the following concerns with written responses: -2/6/2024 Old Business: Long call light times. New Business: Call light times too long. Response: 2/23/2024 Call light-received concerns from special residents and will review all call light response times for those individuals. -3/12/2024 Old Business: Long call light times. New Business: Call light times, showers. Response: 4/1/2024 Will be addressed again in the next staff meeting of call light times. Boiler issues have been resolved, and showers should be given on scheduled shower days. -4/9/2024 Old Business: Showers and call lights. New Business: Showers and long call light times. Response: 5/8/2024 Created and hired a position for a shower aide and the shower aide was available, from 10:00 A.M.-6:00 P.M. Tuesday through Saturday, to help with the shower situation. Call light reports were reviewed to ensure call lights were answered timely. -5/14/2024 Old Business: Long call light times and showers not being completed. New Business: Ongoing complaints were heard by the council. Unfortunately, according to those residents, the issues were not getting better. However, some residents claim the issues were better for them, but they were not consistent with all wings. Response: None provided. -6/11/2024 Old Business: Call light times. New Business: Not provided. Response: Undated. The resident council would like to know how the issue of long call light times should be resolved. Met with the CNAs and nurses and discussed the importance of everyone helping to answer call lights in a timely manner. -7/9/2024 Old Business: Call lights and showers on their regularly scheduled shower days. New Business: Not provided Response: Undated. CNAs were instructed not to turn the call light off if the requested task had not been completed. The shower schedule had been reviewed and would be completely revamped to ensure staff were able to complete assigned showers daily. -8/13/2024 Old Business: Please see nursing concern form. New Business: Not provided. Response: 8/15/2024 Revamped shower assignments to be completed by 8/16/2024 to ensure all showers can be completed when scheduled. -9/10/2024 Old Business: Completed grievance reports that addressed individual resident concerns as well as issues with the nursing department. New Business: Questions about the call light system and concerns about showers for a couple of residents. Response: 9/11/2024 Showers would be adapted to resident preference. Interventions with the call light concerns included providing alternative methods (bells and whistles) to all residents to alert staff of needs. Staff were to complete frequent rounding to check on residents. -10/8/2024 Old Business: Residents thanked the Administrator for making the changes needed to get through the call light situation until the call light system could be fixed. New Business: None. Response: 10/9/2024 Laptops had been placed at the nursing stations to alert of call light activation. Bells and whistles were provided to all residents. Staff had increased rounding to ensure laptops were functioning and all residents had a backup method for the call lights, such as the bells and whistles. Daily audits were performed to help ensure timeliness of assisting residents. The shower schedule had been previously revamped and adjusted. Will discuss with residents what their preferences were for showers and adjust accordingly. -11/12/2024 Old Business: Showers and length of time to answer call lights. New Business: Not provided. Response: 11/12/2024 A call to the corporate office was completed and the corporate office would lead the facility to upgrade the call light system. Shower and call light times were monitored to better care for the residents. -12/10/2024 Old Business: Call light concerns and some shower concerns. New Business: Call light times and showers. Response: 12/10/2024 Reassured residents that call lights were signaled at the laptop at the nurse's station. Encouraged residents to point out staff members by name who were not completing showers so discussions could be made with those staff members. Unit managers audited shower sheets the morning after the scheduled shower and added the missed showers to the shower schedule the next day. The call light reports were reviewed. The average call light response time was 17 minutes. During an interview, on 1/23/2025 at 12:56 P.M., the Activity Director indicated concerns reported in the resident council meeting were sent to the respective department for a reply and resolution. She indicated the staff should have been informed of repeated complaints and the Customer Service Representative should have visited residents with reoccurring complaints. 2. During the surveyor/resident council meeting, on 1/17/2025 at 1:08 P.M., the residents indicated they usually shared their grievances at the monthly resident council meetings. The residents indicated they did not know where to find a grievance form to report a grievance independently and anonymously. The residents council indicated they would have to have the assistance of a staff member to file a grievance. During an interview, on 1/23/2025 at 9:04 A.M., Social Service Director 1 indicated the Customer Service Representative, who rounded all day, had grievance forms for residents to complete if needed. She indicated some grievance forms may be at the front desk. She indicated the grievance forms were not in a place a resident could anonymously take a form. During an interview, on 1/23/2025 at 9:15 A.M., the Executive Director indicated grievance forms should have been available for residents to complete During an interview, on 1/23/2025 at 9:13 A.M., the Activity Director indicated she kept grievance forms in a cabinet for her staff to complete if a resident had a grievance to file. She indicated grievance forms were at the nurse's station and the front desk. She indicated she never thought about having the grievance forms available for a resident to anonymously submit a grievance. During an interview, on 1/23/2025 at 9:34 A.M., the Social Service Director 2 indicated grievances were available at the front desk in a folder. However, the forms could not be visualized amongst the other file folders and were not available to a wheelchair bound resident due to the height at which the forms were stored on the wall. A policy was provided, on 1/17/2024 at 10:56 A.M., by the Executive Director. The policy titled, Grievances, indicated, .1. Purpose To support each resident's/patient's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .Policy B. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident/patient; and coordinating with state and federal agencies as necessary in light of specific allegations . I. A grievance may be filed anonymously .Procedure D. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. a. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. b. All Care Team Members involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance .E. The Grievance Official, or designee, will keep the resident/patient appropriately apprised of progress towards resolution of the grievances .J. The facility will make prompt efforts to resolve grievances Although the facility had documented responses to facility grievances from the Resident Council, the facility failed to ensure the interventions to address the concerns were effective and resolved the repeated grievances. 3.1-7(a)(2) 3.1-3(l)

Based on record review and interview, the facility failed to ensure 1 of 2 resident's Level One PASARR (Preadmission Screening and Resident Review) assessment was completed accurately and failed to ensure an updated Level 1 review was completed for 1 of 27 residents reviewed for MDS assessments . (Resident 18) Finding includes: The record for Resident 18 was reviewed on 1/21/2025 at 3:28 P.M. Diagnoses included, but were not limited to: depression, anxiety, post traumatic stress disorder, dementia and on 9/14/2024 a new diagnoses of psychotic disorder with delusions. Resident 18's current medications include: trazadone (antidepressant) 150 mg (milligram) 1 tablet at bed time; Fluoxetine (antidepressant) 20 mg 1 tablet daily; Haloperidol (antipsychotic) 10 mg 1 tablet two times a day and Haloperidol 5 mg 1 tablet once a day. A Preadmission Screening and Resident Review form, dated 4/14/2020, indicated Resident 18's diagnoses included adjustment disorder with mixed anxiety and depressed mood, post traumatic stress disorder, and insomnia. The form indicated there were no known mental health behaviors . and no known or suspected .diagnosis . Under the medications including antidepressants, mood stabilizers, antipsychotics and other mental health medications - only Ativan and Trazadone were documented. A Notice of PASARR Level 1 Screen Outcome form, dated 4/24/2020, indicated Resident 18's Level 1 PASARR showed no Level II was required to be completed. The rationale included the following: The Level 1 screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASARR condition of an intellectual /developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be completed. During an interview, on 1/23/2025 at 1:02 P.M., Social Service Staff indicated another Level 1 should have been completed for Resident 18 when a mental health diagnosis was added and after antipsychotic medications were ordered. On 1/23/2025 at 1:35 P.M., the Administrator provided the policy titled, Preadmission Screening And Resident Review (PASARR), dated 12/12/2023, and indicated the policy was the one currently used by the facility. The policy indicated . 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Examples include: .b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR

Based on observations, record reviews, and interviews, the facility failed to protect a resident's right to be free from verbal abuse from another resident, which resulted in emotional distress, and physical abuse by a staff member, for 3 of 4 residents reviewed for abuse. (Residents 68, 218 & 43) Findings include: 1. During a dining observation, on 2/25/2024 at 12:24 P.M., Residents 218 and 68 were sitting at the assisted dining table, and sitting side by side. Resident 218 was observed yelling at Resident 68. CNA 5 attempted to intervene verbally, but did not move Resident 218 from the table. Resident 218 continued yelling at Resident 68 to get up and walk so they could get out of here. Resident 68 looked at the surveyor, and stated, Can you at least tell her I can't walk so she will stop? Resident 218 continued to escalate at yelling at Resident 68. This resulted in Resident 68 crying. During an interview, on 2/25/2024 at 2:01 P.M., Resident 68 indicated that lady screamed at me, and it made her feel terrible. At 2:28 P.M., Resident 68 continued to cry. A record review for Resident 68 was completed on 2/27/2024 at 11:20 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 2/14/24, indicated Resident 68 was cognitively intact. During the assessment period, she did not display any mood or behavioral issues. Progress Notes, including notes from the nursing and social service departments, indicated no documentation of the incident for Resident 68, or follow-up with her for psychosocial wellbeing for this incident. A Social Service Note, dated 2/25/2024 at 2:26 P.M., indicated staff had reported to social services that Resident 218 went to the large dining room and did eat some of her meal. After lunch, the Social Service Assistant observed Resident 218 yelling and screaming. Resident 218 was observed yelling she wanted to leave to go to school. Resident 218 had agitation with verbal aggression when she realized the staff could not take her outside or accompany her outside of the building. A record review for Resident 218 was completed on 2/28/2024 at 10:03 A.M A Nursing Admission Evaluation, dated 2/15/2024, indicated Resident 218 had a memory problem. She had behavioral issues of wandering, exit seeking, and resisting care. An Admission Minimum Data Set (MDS) assessment was in progress. During an interview, on 3/1/2024 at 9:57 A.M., the Social Service Assistant indicated follow-up with a resident after a verbal altercation depends on the impact to the resident, including if the resident was distressed. She indicated she was unsure if she was aware of the dining room incident, but was informed Resident 218 was becoming disruptive, and unaware Resident 68 was crying. She indicated no one followed up with Resident 68, and if a staff member had told her about Resident 68 crying, she did not recall. She indicated staff should inform Social Services of altercations. During an interview, on 3/1/2024 at 10:55 A.M., the Executive Director indicated Resident 68 was receiving psychosocial visits daily, and those should be documented in the progress notes. During an interview, on 3/1/2024 at 12:40 P.M., CNA 5 indicated Resident 218 was displaying signs of dementia and trying to get Resident 68 to go on a field trip. Resident 218 was getting upset since Resident 68 would not go. She indicated, when she was sitting at the table, Resident 218 grabbed Resident 68's wheelchair and shook it, and got mad at Resident 68 for not getting up from her wheelchair. CNA 5 indicated another CNA was able to separate the residents. Resident 68 was very upset and crying. CNA 5 took Resident 68 to her room, talked with her, and reported the altercation to a nurse. She was unable to identify to whom she reported the incident. 2. During an interview, on 2/25/2024 at 10:10 A.M., Resident 43 indicated she felt CNA 22 was unusually rough, and she could feel herself tensing up knowing she was her aide. When CNA 22 took her to the bathroom, CNA 22 would be complaining and huffed and puffed. Resident 43 indicated this incident occurred 3-4 weeks ago, and she reminded CNA 22 of her colostomy bag so she wouldn't pull her pants down roughly. Resident 43 indicated during the toileting and roughness, she hit her head on the bathroom wall, and that was the last straw that broke the camel's back. During an interview, on 2/26/2024 at 9:12 A.M., Resident 43 indicated she discussed this allegation with the Social Service Director on February 6, 2024, and since that time, CNA 22 had not been taking care of her any more. A record review was completed on 2/27/2024 at 11:07 A.M. Diagnoses included, but were not limited to multiple sclerosis, muscle weakness, and difficulty walking. A Care Plan, dated 9/1/2017 and revised on 11/10/2022, indicated Resident 43 required assistance for activities of daily living related to, but not limited to: multiple sclerosis, muscle weakness, chronic obstructive pulmonary disease, and abnormalities of gait and mobility. An intervention, dated 9/1/2017 and revised on 10/16/2018, indicated Resident 43 to have extensive toileting assistance with one staff member, and to assist with emptying the colostomy every shift as needed while sitting on the commode. A Quarterly Minimum Data Set (MDS) assessment, dated 2/14/2024, indicated Resident 43 was cognitively intact. She required extensive assistance with toileting with on staff member assist. A Social Service Progress Review for Documentation, dated 2/7/2024, indicated Resident 43 was feeling good. There was no documentation in the Progress Notes of the allegation or follow-up documentation. During an interview, on 3/1/2024 at 1:14 P.M., the Social Service Director indicated that Resident 43 complained CNA 22 was gruff and rough. She indicated she spoke with the Executive Director after Resident 43 informed her of the incident. During an interview, on 3/1/2024 at 1:18 P.M., the Executive Director indicated she did not have an investigation of this allegation. She indicated it was just basically CNA's 22 personality and how she talks loudly. She indicated that CNA 22 can no longer care for Resident 43. On 3/2/2024 at 8:45 A.M., the Executive Director provided a policy titled, Abuse, Neglect and Exploitation. The policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations .B. Possible indicators of abuse includes, but are not limited to: 1. Resident, staff or family report of abuse .VI. Protection of Resident .The facility will make every effort to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .B. Examining the alleged victim for any sign of injury, including physical examination or psychosocial assessment if needed .C. Increased supervision of the alleged victim and residents During an interview, on 3/2/2024 at 10:17 A.M., the Executive Director indicated she reported this incident to the Indiana State Department of Health on 3/1/2024. Resident 43's interview aligned with the allegation during the surveyor's interview. The Executive Director indicated Resident 43 indicated the incident was not intentful, but that CNA 22 was rough when pulling her pants up, and she toppled hitting her head on the wall. 3.1-27(a)(1) 3.1-27(b)

Based on interview, record review, and observation, the facility failed to identify and manage an acute change in condition of worsening respiratory symptoms, irregular blood sugar levels, and abnormal laboratory results not addressed. The deficient practice resulted in a delayed hospital evaluation, and hospitalization for pneumonia, acute kidney injury on chronic kidney disease, and cardiac disease (Resident 96). The facility failed to notify the physician of blood sugars outside of ordered parameters (Resident 109), to assess and treat a scabbed skin area (Resident 27), and to identify and notify the physician of bruising and swelling in a resident who received an anticoagulant medication (Resident 64) for 4 of 5 residents reviewed for quality of care. Findings include: 1. During an interview, on 2/25/2024 at 1:35 P.M., Resident 96 indicated she had been hospitalized for ketoacidosis, kidney failure due to diabetes, and two heart stents. A record review was completed on 2/27/2024 at 8:47 A.M. Diagnoses included, but were not limited to: hypoglycemia, diabetes mellitus type 1, chronic obstructive pulmonary disease, and chronic kidney disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/30/24, indicated Resident 96 was cognitively intact. A Nurse's Note, dated 12/1/2023 at 7:23 A.M., indicated Resident 96 was at the nursing station requesting medication, and was observed to be short of breath. Her lungs were diminished, and wheezes were heard. Resident 96 indicated to the nursing staff that the primary care physician told her if she wasn't better by Monday (12/4/2023), he would admit her to the hospital. She refused a chest x-ray at that time. A Nurse's Note, dated 12/1/2023 at 11:35 P.M., indicated the physician ordered a new cough medication. A Nurse Practitioner (NP) Note, dated 12/8/2023, indicated Resident 96 had finished a course of antibiotic therapy of Levaquin and doxycycline from her physician, and continued to have yellowish-tan mucus with a productive cough. Resident 96's lung sounds were course, she had a stuffy nose, and green drainage. The NP gave diagnoses of sinusitis, with prescriptions for Flonase and Linezolid, and pneumonia, with prescriptions for guaifenesin with codeine and a chest x-ray. He also adjusted her insulin medications. No new orders were given for monitoring of Resident 96's condition. A Nurse's Note, dated 12/9/2024 at 6:09 P.M., indicated Resident 96 was on day two of antibiotic therapy due to a diagnosis of pneumonia. She reported being in mild discomfort but requested no pain medication. A Nurse's Note, dated 12/12/2024 at 6:28 A.M., Resident 96 complained of being short of breath. Her vital signs and blood sugar were within normal limits. A Nurse's Note, dated 12/13/2024 at 7:14 A.M., indicated Resident 96's blood sugar measured 60 mg/dl (milligrams per deciliter). The resident refused orange juice, but drank a cola, and stated she didn't feel well. Her blood sugar dropped further to 45 mg/dl after 20 minutes. Resident 96 drank another cola, and her blood sugar increased after an hour to 90 mg/dl. A Nurse's Note, dated 12/15/2024 at 7:07 A.M., indicated Resident 96 was observed in her room snoring loudly and salivating. Her blood sugar was checked and was 47 mg/dl. An as needed Baqsimi (glucagon nasal spray for emergency hypoglycemia) medication was administered, and the Nurse Practitioner notified. After 15 minutes, Resident 96's blood sugar was 43 mg/dl. A second dose of Baqsimi was administered, and as Resident 96 was able to talk, a glass of orange juice was provided. Resident 96's blood sugar was rechecked and recorded as 67 mg/dl. A Nurse's Note, dated 12/16/2024 at 1:03 P.M., indicated Resident 98 was having fatigue and required more assistance with activities of daily living (ADLs). A chest x-ray was ordered and an order for antibiotic therapy received. On 12/17/2024, a chest x-ray indicated, .interval development of platelike atelectatic changes int eh right perihilar middle lung zone and bilateral lower lung fields, and was signed by the nurse practitioner on 12/18/2024. A Nurse's Note, dated 12/17/2024 at 7:49 A.M., indicated Resident 96 complained of not feeling well and nauseated. She was encouraged to drink water and to eat small frequent meals. At 12:35 P.M., Resident 96 indicated she was still not feeling well, and had a stomachache with nausea, and indicated no appetite and coughing. Resident 96 requested to be sent to the hospital. A video call with Resident 96 and a physician occurred and the physician ordered medications, STAT (with no delay) labs, and a chest x-ray. The medication ordered was famotidine. Laboratory results were received in the electronic medical record on 12/17/2023 at 10.23 P.M. The results included a white blood cell count of 10.4 (normal 3.4-15.5), neutrophils 90.2 H (normal 45.0-75.0), lymphocytes 5.3 L (normal 17.0-43.0), bun urea nitrogen (BUN) 2.78 H (normal 0.6-1.1), creatinine 2.278 H (normal 0.6-1.1), and sodium 134 (normal 134-146). The Nurse Practitioner (NP) reviewed the labs on 12/18/2024 at 10:16 A.M. Prior lab results, dated 11/28/2023, indicated a BUN of 19 (normal 7-25), and creatinine 1.38 (normal 0.5-1.03). There was no documentation indicating the NP was notified timely of the STAT test results. An NP Note, dated 12/18/2023, indicated Resident 96 was seen for follow-up of cough and congestion. The NP indicated the chest x-ray showed containment in her right lung and likely aspiration. Her sinusitis could possibly be gastroparesis, and ordered a chest x-ray, computerized tomography scan, and speech therapy. He did not address her STAT laboratory results, which were not within normal levels. A Nurse's Note, dated 12/19/2023 at 10:37 P.M., indicated Resident 96 was complaining of body aches, headache, and cough with congestion. Resident 96 requested to go to the hospital. The facility obtained a Physician's Order to send her to the Emergency Department for evaluation and treatment. A Hospital Health Summary, dated 12/26/2023, indicated Resident 96 presented to the emergency department for complaints of shortness of breath. She had an elevated creatinine reflecting acute on chronic kidney injury and had an elevated troponin. Resident 96 was admitted for further workup. Cardiology felt Resident 96 needed further care for her renal dysfunction before attempting further treatment of the cardiac issues. Diagnoses of non-ST elevation MI (heart attack), and acute kidney injury superimposed on chronic kidney disease were given. During an interview, on 3/1/2024 at 10:51 A.M., the Assistant Director Nursing indicated practitioners have the ability to review lab results via the electronic medical record, and the record indicated the STAT labs had been viewed by the Nurse Practitioner on 12/18/2024 at 10:16 A.M. There was no documentation that the nursing staff had notified the Nurse Practitioner of the abnormal STAT labs. On 3/2/2024 at 10:13 A.M., the Assistant Director of Nursing Services indicated the staff nurses should be reviewing labs also, and indicated the nurses and the nurse practitioner should have addressed the abnormal labs. 2. During an interview, on 2/28/2024 at 9:01 A.M., Resident 109 indicated she received insulin injections. A record review was completed on 2/28/2024 at 9:01 A.M. Diagnoses included, but were not limited to: chronic respiratory failure, diabetes mellitus, type 2, chronic kidney disease, and dependence on renal dialysis. A Quarterly Minimum Data Set (MDS) assessment, dated 2/9/2024, indicated Resident 109 was cognitively intact, and received insulin. Physician Order's, dated 1/2/2024, indicated to call the physician for a blood sugar less than 70 and greater than 400. A Care Plan, dated 1/8/2024, indicated Resident 109 was at risk for complications and symptoms of hypoglycemia or hyperglycemia due to a diagnosis of diabetes with an intervention of to document abnormal findings and notify the physician. Blood sugar documentation for January 2024 and February 2024 indicated the following: - 1/2/2024 11:57 A.M. 412 - 1/10/2024 8:19 A.M. 58 - 1/12/2024 7:39 A.M. 48 - 2/13/2024 12:46 P.M. 412 The medical record did not have any documentation of the Physician being informed of the abnormal blood sugars. During an interview, on 3/1/2024 at 10:29 A.M., the Assistant Director of Nursing indicated Resident 109 had parameters to notify the physician if the blood sugar result was below 60 and above 400. At 10:34 A.M. on 3/1/24, the Executive Director indicated there was no documentation of the physician or nurse practitioner being notified of the blood sugars out of range. A policy was provided on 3/2/2024 at 8:45 A.M. by the Executive Director. The policy titled, Blood Glucose Monitoring, indicated, .It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders The policy does not address notification of the medical professional for blood sugars outside the ordered blood sugar range. 11492 3. Resident 27 was observed on 2/25/2024 at 2:10 P.M., lying in her bed awake. The resident was noted to have a dark colored scabbed area, approximately the size of a thumb nail, on the side of her right nares. The top 2/3 of the scab was very dark and dry and the bottom 1/3 was a lighter dark red color and moist. The record for Resident 27 was reviewed on 2/27/2024 at 10:33 A.M. Diagnoses included, but were not limited to: cerebral infarction, hemiplegia and hemiparesis, unspecific dementia, seizures, generalized anxiety disorder, vascular dementia and muscle weakness. A Significant Change Minimum Data Set (MDS) assessment, dated 1/15/2024, indicated the resident was severely cognitively impaired, had impaired mobility of her upper and lower extremity on one side and had two stage 3 pressure ulcers. The Care Plans for Resident 27 did not mention a large scabbed area on her nose. The care plans did include a plan addressing the resident's risk for altered skin integrity with an intervention to inspect the skin weekly, document and notify the MD of abnormal findings and the resident was at risk for impaired skin integrity related to aspirin use and decreased mobility. A late entry required Physician's Note, dated 1/29/2024, did not mention any skin issues, including the large scabbed area on the resident's nose. A Wound Nurse Practitioner's note, dated 2/12/2024, mentioned the resident's pressure areas on her left ischium, left buttocks and coccyx and assessed the resident's skin as dry, but there was no documentation of the large scab to the resident's nose. There was no documentation or mention of the scabbed nose in the Nursing Progress Notes for February 2024. A Weekly Nursing Summary form, dated 2/7/2024, did not mention any large scabbed area on the section of the assessment to address skin issues. During an interview with CNAs 7 and 8, on 2/27/24 at 11:24 A.M., both CNAs indicated the resident had the spot on her nose since she was admitted , and at times would pick at it and make it bleed. During an interview with LPN 9, on 2/28/24 at 10:17 A.M.she indicated the area on the resident's nose was a scab. LPN 9 indicated she did not know how long the resident had had the scab on her nose. The scab was nothing new, but she did not document herself about the scab because she was focused on pressure ulcers on her wound documentation. During an interview with RN 2, on 2/28/2024 at 11:00 A.M. she indicated impaired skin should be documented and the NP (nurse practitioner) notified of the areas. RN 2 indicated she thought the resident had had the large scab for at least the past 5 months. Although RN 2 was aware of the large scabbed area to Resident 27's nose, she could not explain where documentation regarding impaired skin would be located in the clinical record. During an interview on 2/28/2024 at 2:00 P.M., RN 2 indicated there was no documentation of the scabbed area for Resident 27's nose. The facility policy, titled Skin Assessment provided by the Administrator and indicated as current, on 3/2/2024 at 8:45 A.M. included the following: .h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions .7. Documentation of skin assessment: .b. Document observations (e.g. skin conditions .) c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) 4. During the initial tour of the facility, conducted on 2/25/2024 between 9:30 A.M. - 11:00 A.M., Resident 64 was observed seated in her room in a wheelchair. The resident was noted to have bruising around each antecubital (inner elbow) area, and extensive bruising and slight swelling of the top of her left hand. During an observation and interview with Resident 64, on 2/26/24 at 10:02 A.M. the resident's left hand was again noted to have extensive bruising and was swollen. The resident indicated she thinks she ran into the bathroom doorframe when she was toileting herself and she thought the nursing staff was aware of the bruises. The record for Resident 64 was reviewed on 2/27/2024 at 12:02 P.M. Diagnoses included, but were not limited to: chronic lymphocytic leukemia of B-Cell type, parkinsonism, atrial fibrillation, anemia and atrial flutter. The Physician's Orders for Resident 64 included orders for the medication Apixaban (anticoagulant - a medication to thin the blood). The Care Plans for Resident 64 included a plan to address the resident's use of anticoagulant therapy, which increased the resident's risk for abnormal bleeding. Interventions included inspecting the skin during care for bruising or increased bruising and notify the nurse of abnormal findings and observing the resident for signs of abnormal bleeding including increased frequency of bruising and increased size of bruising, documenting the findings and notifying the physician of abnormal findings. There was no documentation of the bruising or swelling to the resident's hand in the clinical record. During an interview on 2/28/2024 at 1:58 P.M., RN 2 indicated she had noticed the resident's left hand and notified the NP (nurse practitioner) to look at her today. RN 2 indicated she was planning to put the documentation in the nursing progress notes. A Nursing Progress Note, dated 2/28/24 at 2:13 P.M., documented increased swelling left (unable to decipher charting) NP notified and no new orders. The facility policy, titled Skin Assessment provided by the Administrator and indicated as current, on 3/2/2024 at 8:45 A.M. included the following: .h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions .7. Documentation of skin assessment: .b. Document observations (e.g. skin conditions .) c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) 3.1-37

Based on record review, observation and interview, the facility failed to ensure residents were free from abusive sexual behaviors exhibited by an employee for 3 of 3 residents. (Resident B, Resident C, and Resident D) This resulted in psychosocial harm as displayed by Resident C feeling fearful the employee might come into her room at night causing her to have difficulty sleeping and the family decision to move the resident to another facility. Resident B expressed an initial feeling of fear and requested assurance the facility doors were locked at night. Finding includes: Following entrance to the facility, the Administrator provided a copy of an incident and ensuing investigation which was reported to ISDH (Indiana State Department of Health) of sexual abuse by an employee towards a resident, Resident C. The facility substantiated the allegation during their investigation. During an interview, at the time, the DNS (Director Nursing Services) indicated all residents in the facility with a BIMS (Basic Interview for Mental Status) of 8 or greater (8 being the lower parameter for moderately cognitively intact) were interviewed and 2 other residents indicated being approached by the employee, QMA #5 (Qualified Medical Aide), on or about the same time. The DNS indicated residents who were severely cognitively impaired were assessed for any signs of abuse or distress. The employee file for QMA #5 documented the date of hire as [DATE]. The employee worked on a PRN (as needed) basis, approximately 3 days every 2 weeks. The facility terminated QMA #5's employment, on [DATE], following the facility's investigative interview. 1. Following the Initial Tour, Resident C was interviewed on [DATE], at 9:50 a.m., while seated in her wheelchair next to her bed. Resident C resided in the 2nd bed, located next to the room window of a semi-private room. Resident C indicated she was sitting in her bed after dinner on Saturday, [DATE]. The resident's room mate was not in the room at the time. QMA #5 entered the resident's room and drew the privacy curtain between the beds. Resident C indicated QMA #5, whom she had known since a previous stay in the facility during 2015, then engaged her in casual conversation. This was unusual due to the fact there was no medication administration at the time, which is the usual contact the resident had with QMA #5. The QMA then proceeded to unzip his pants and then asked if he could place his penis in her mouth, to which Resident C stated, Oh, Lord, no! Resident C indicated QMA #5, who was standing a minimum of 3 feet away, zipped up his pants and exited the room. Resident C indicated QMA #5 did not expose his penis. Resident C indicated, I wasn't going to tell anyone. However, on Tuesday, [DATE], Resident C indicated she relayed the episode to a friend who had visited her for lunch, who then contacted the daughter of Resident C. Resident C indicated her daughter came to the facility to speak with her and then reported the incident to the staff, which initiated the facility investigation. Resident C indicated the staff assured her the QMA #5 had been terminated from employment. Resident C indicated she had been approached like this before. She had difficulty sleeping at night for fear the QMA might access the facility during the night. The daughter of Resident C was interviewed on [DATE] at 9:40 a.m., in the resident's room while Resident C was sleeping. The daughter indicated although her mother has said she is no longer afraid and that she's been sleeping fine, Resident C asks her how long she will be staying and if she will stay a while. The daughter indicated each time she has assured the resident she will be staying a while, her mother promptly goes to sleep. The daughter indicated she had made arrangements to have her mother moved to another area facility. The daughter indicated while the staff, since the incident, has been supportive, have provided a safe environment and assured her mother QMA #5 will not return, she feels her mother no longer feels safe in the facility. The record of Resident C was reviewed on [DATE] at 11:30 a.m. Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident C was cognitive status as moderately impaired and required extensive assist of one for transfers, dressing, bathing and toileting. 2. Resident B was interviewed on [DATE] at 10:00 a.m., while seated on her bed in her semi-private room. Resident B indicated staff had interviewed her, on [DATE], in regard to QMA #5. Resident B indicated she told the SSD (Social Services Designee) she had no negative encounters with the QMA, then, upon arrival of her son about 15 minutes after the interview, Resident B asked her son to get the nurse or SSD and told them there had been an incident with QMA #5. Resident B indicated she initially did not relay the incident because she was scared to death someone would find out. She indicated she had not told anyone and could not believe anyone knew what had occurred, indicating she initially thought they were referring to the her incident. Resident B had known QMA #5 for over 8 years as she had a relative (now deceased ) who previously resided in the facility and the QMA #5 was a favorite of both Resident B and her relative. Resident B could not recall the exact day of week of occurrence, but indicated she was in her bed on evening shift when QMA #5 entered her room, talking as always to me. Resident B stated, I was shocked! and indicated, all at once he unzipped his pants, started to take his penis out and I told him to get out of this room. Now! Resident B indicated he left the room and that was the last time she saw him. Resident B indicated QMA #5 had his hand around his penis and only a portion was visible. Resident B indicated the distance between the QMA #5 and herself was a minimum of 3 feet. Resident B was queried if she was fearful of staying in the facility or of the staff. Resident B indicated she asked the staff if they locked the facility doors at night and was upset initially but is no longer afraid. Resident B indicated she had never been fearful of staff prior to the incident. The record of Resident B was reviewed on [DATE] at 11:45 a.m. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS assessment, dated [DATE], indicated Resident B required limited assistance of 1 for transfers, and toileting. Resident B's cognitive status was moderately impaired. 3. Resident D was interviewed in his room, seated in his wheelchair, on [DATE] at 10:30 a.m. Resident D indicated he has known and had QMA #5 for his care for over 7 years while residing in the facility. Resident D indicated QMA #5 often interacted with him on a friendly basis. The resident indicated approximately 3 months ago, he noted some changes in the QMA #5's behavior. Resident D indicated the QMA #5 had exposed his penis to him, on 3 occasions. QMA #5 maintained a distance of a minimum of 3 feet between them. Resident D did not report this to any staff member. Resident D indicated on one of the 3 occasions the QMA tried to place Resident D's hand on his penis but the resident explicitly told the QMA NO. Resident D indicated he believed something was not right or had changed with the QMA #5. Resident D indicated despite the QMA being married, he believed the QMA was struggling with sexual identity. The Resident D indicated he was approached by staff about any instances of sexual approach by the QMA. Resident D indicated up to that point, he never considered QMA #5 might be approaching or inappropriate towards other residents. Resident D was aware the QMA was termed from employment. Resident D indicated he would not be afraid of QMA #5 if he saw him again. The record of Resident D was reviewed on [DATE] at 8:40 a.m. Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident D required extensive assist of 1 for transfers, bathing and toileting. Resident D was cognitive for interview. On [DATE] at 11:30 a.m., the DNS provided a copy of the facility's Abuse & Neglect policy, dated 2014. The policy indicated: Abuse & Neglect . Definition of abuse (per Indiana State Department of Health and Center for Medicare and Medicaid Services): .The WILLFULL infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This applies to ALL residents, even those in coma. Abuse can be: * Staff to resident * Resident to resident * Resident's family/relative or visitors to resident . Types of abuse (per ISDH): . *Mental - includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation *Sexual - includes both physical acts (non-consensual or resident is mentally incompetent to consent) or inappropriate verbal conversations/sexual references. Also includes, sexual relationships between staff and residents. This Federal tag relates to Complaint IN 816. 3XXX,[DATE](a)(1)

Based on record review and interview, the facility failed to ensure staff completed an adequate assessment and provide timely services for a resident who had sustained a fall that resulted in a femur fracture and required hospitalization and lower leg amputation for one of three residents reviewed for accidents. (Resident B) Finding includes: On 2/16/16 at 1:00 P.M., the clinical record for Resident B was reviewed. Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, reference date of 12/5/15, indicated Resident B required extensive assist of 2 people for transfers and did not ambulate. The MDS assessment indicated Resident B had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. A care plan, created on 03/30/15, indicated, but was not limited to, . At risk for falls r/t (related to) high risk medication use, impaired memory, incontinence, and inability to stand . Interventions/Tasks . Hoyer Lift for transfers with 2 assist .Date Initiated: 05/05/13 A resident care guide, dated 1/19/16, indicated .(Resident B) Transfer Assist H (Hoyer lift) A nursing progress note, dated 1/20/16 at 01:09 A.M., indicated . Nurse called to room to assess [MEDICAL CONDITION] noted to Left knee. Left knee confirmed swollen. Resident received scheduled dose of [MEDICATION NAME] (a pain medication). MD (medical doctor) notified and received order for x-ray to left knee. POA (power of attorney) notified. Confirmed displacement. MD ordered transfer to ER (emergency room ). Resident sent to (name of local hospital). Report called into (name of local hospital) ER A Fall Scene Investigation Report indicated . Date of Fall: 1/19/16 .Time of Fall: 3:30 PM .Staff witness present .Fall Summary: Fall to the floor (witnessed) . Fall Location: Resident room .What was resident doing during or just prior to fall: Transfer assisted by staff . What type of assistance was resident receiving at time of fall: Assisted less than per care plan .What appears to be the root cause of the fall? CNA (Certified Nursing Assistant) did not use correct mode to transfer resident .Signature (Registered Nurse #1) .Date and Time: 1/19/16 A Fall report, dated 1/19/16 at 19:45 (7:45 P.M.), indicated .Incident Location: Resident's room .Person Preparing Report: (Licensed Practical Nurse #2) . Nursing description: Nurse called to room to assess [MEDICAL CONDITION] noted to Left knee. Left knee confirmed swollen . Immediate Action Taken: Resident received scheduled dose of [MEDICATION NAME]. MD notified and received order for x-ray to left knee. POA notified. Confirmed displacement. Resident sent to (name of local hospital) .Injury type: unable to determine . Level of Pain: PAINAD (sic): 6 .Negative Vocalization:1 .Occasional Moan or Groan .Facial Expression: 2 . Facial Grimacing .Body Language: 2 .Rigid, Fists Clenched, Knees Pulled Up, Pulling or Pushing Away, Striking Out . Consolability:1 .Distracted or Reassured by Voice or Touch .Mental Status: Oriented to Person .Predisposing Situation Factors: Other .During Transfer(sic) .Witnesses: (name of CNA) Relation: Staff .Date: 1/19/2016 .Statement: I was getting resident up for dinner and transferred resident by myself with gait belt. She started sitting down during turn and fell on floor with legs bent. I notified nurse in charge of resident (name of #Licensed Practical Nurse #1) .Agencies/People notified: Family Member (name) 1/19/2016 20:12 (8:12 P.M.) .Physician (name) 1/19/2016 19:50 (7:50 P.M.) A Radiology report, dated 1/19/16, indicated . Conclusion: Acute distal femur displaced fracture A (name of local hospital) consultation report, dated 1/20/16, indicated . [AGE] year old who has been immobile for the last year had an accident at the nursing home fracturing her supracondylar femur. She was evaluated by (name of physician) orthopedics and between her dementia and immobility and brittle bones her rehabilitation potential was essentially 0. After discussing with her caregiver decision was made for an amputation. The patient apparently does not speak On 2/17/16 at 10:15 A.M., an interview was conducted with RN (Registered Nurse) #1. RN #1 indicated she had been notified by CNA #1 around 3:30 P.M. on 1/19/16, of a fall that had occurred during a transfer. Resident B was sitting in her wheelchair upon entry to her room. RN #1 indicated she did an assessment, neuro checks, vitals and range of motion and found nothing abnormal at the time. She further indicated she did not document her assessment in the resident's clinical record or notify the physician and power of attorney of the fall nor did she report the fall to the oncoming nurse at the end of her shift. RN #1 indicated .I was busy at that time, I know it's a poor excuse but it's true RN #1 further indicated she should have notified the unit manager, physician, power of attorney, start an incident report and reassess the resident On 2/17/16 at 11:00 A.M., an interview was conducted with LPN (Licensed Practical Nurse) #2. LPN #2 indicated that on the evening of 1/19/16 around 7:30 P.M., she was requested by CNA #1 to come to Resident B's room to assess her knee, CNA #1 indicated it was swollen and laid funny. LPN #2 indicated that upon assessment she found Resident B's knee to be swollen and displaced but she could not determine at the time how far up the displacement went because Resident B was still wearing her pants and was sitting in a wheelchair. On 2/16/16 at 1:00 P.M., the Director of Nurses provided the policy, Assessing Falls and Their Causes, revision date October 2010, and indicated it was one currently used by the facility. The policy indicated . Steps in the Procedure .After a Fall: 3. Once an assessment rules out significant injury , nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details .Documentation .When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g. resident found lying on the floor between bed and chair) .2. Assessment data, including vital signs and any obvious injuries .3. Interventions, first aid, or treatment administered .4. Notification of the physician and family, as indicated This Federal tag relates to Complaints IN 288 and IN 652. 3.1-37(a)

Based on record review and interview, the facility failed to provide adequate assistance during a transfer to prevent an accident that resulted in a femur fracture that required hospitalization and lower leg amputation for one of three residents reviewed for accidents. (Resident B) Finding includes: On 2/16/16 at 1:00 P.M., the clinical record for Resident B was reviewed. Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, reference date of 12/5/15, indicated Resident B required extensive assist of 2 people for transfers and did not ambulate. The MDS assessment indicated Resident B had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. A care plan, created on 03/30/15, indicated, but was not limited to, . At risk for falls r/t (related to) high risk medication use, impaired memory, incontinence, and inability to stand . Interventions/Tasks . Hoyer Lift for transfers with 2 assist .Date Initiated: 05/05/13 A resident care guide, dated 1/19/16, indicated .(Resident B) Transfer Assist H (Hoyer lift) A nursing progress note, dated 1/20/16 at 01:09 A.M., indicated . Nurse called to room to assess edema noted to Left knee. Left knee confirmed swollen. Resident received scheduled dose of acetaminophen (a pain medication). MD (medical doctor) notified and received order for x-ray to left knee. POA (power of attorney) notified. Confirmed displacement. MD ordered transfer to ER (emergency room ). Resident sent to (name of local hospital). Report called into (name of local hospital) ER A Fall Scene Investigation Report indicated . Date of Fall: 1/19/16 .Time of Fall: 3:30 PM .Staff witness present .Fall Summary: Fall to the floor (witnessed) . Fall Location: Resident room .What was resident doing during or just prior to fall: Transfer assisted by staff . What type of assistance was resident receiving at time of fall: Assisted less than per care plan .What appears to be the root cause of the fall? CNA (Certified Nursing Assistant) did not use correct mode to transfer resident .Signature (Registered Nurse #1) .Date and Time: 1/19/16 A Fall report, dated 1/19/16 at 19:45 (7:45 P.M.), indicated .Incident Location: Resident's room .Person Preparing Report: (Licensed Practical Nurse #2) . Nursing description: Nurse called to room to assess edema noted to Left knee. Left knee confirmed swollen . Immediate Action Taken: Resident received scheduled dose of Acetaminophen. MD notified and received order for x-ray to left knee. POA notified. Confirmed displacement. Resident sent to (name of local hospital) .Injury type: unable to determine . Level of Pain: PAINAD (sic): 6 .Negative Vocalization:1 .Occasional Moan or Groan .Facial Expression: 2 . Facial Grimacing .Body Language: 2 .Rigid, Fists Clenched, Knees Pulled Up, Pulling or Pushing Away, Striking Out . Consolability:1 .Distracted or Reassured by Voice or Touch .Mental Status: Oriented to Person .Predisposing Situation Factors: Other .During Transfer(sic) .Witnesses: (name of CNA) Relation: Staff .Date: 1/19/2016 .Statement: I was getting resident up for dinner and transferred resident by myself with gait belt. She started sitting down during turn and fell on floor with legs bent. I notified nurse in charge of resident (name of #Licensed Practical Nurse #1) .Agencies/People notified: Family Member (name) 1/19/2016 20:12 (8:12 P.M.) .Physician (name) 1/19/2016 19:50 (7:50 P.M.) A Radiology report, dated 1/19/16, indicated . Conclusion: Acute distal femur displaced fracture A (name of local hospital) consultation report, dated 1/20/16, indicated . [AGE] year old who has been immobile for the last year had an accident at the nursing home fracturing her supracondylar femur. She was evaluated by (name of physician) orthopedics and between her dementia and immobility and brittle bones her rehabilitation potential was essentially 0. After discussing with her caregiver decision was made for an amputation. The patient apparently does not speak On 2/17/16 at 10:15 A.M., an interview was conducted with RN (Registered Nurse) #1. RN #1 indicated she had been notified by CNA #1 around 3:30 P.M. on 1/19/16, of a fall that had occurred during a transfer. Resident B was sitting in her wheelchair upon entry to her room. RN #1 indicated she did an assessment, neuro checks, vitals and range of motion and found nothing abnormal at the time. She further indicated she did not document her assessment in the resident's clinical record or notify the physician and power of attorney of the fall nor did she report the fall to the oncoming nurse at the end of her shift. RN #1 indicated .I was busy at that time, I know it's a poor excuse but it's true RN #1 further indicated she should have notified the unit manager, physician, power of attorney, start an incident report and reassess the resident On 2/17/16 at 11:00 A.M., an interview was conducted with LPN (Licensed Practical Nurse) #2. LPN #2 indicated that on the evening of 1/19/16 around 7:30 P.M., she was requested by CNA #1 to come to Resident B's room to assess her knee, CNA #1 indicated it was swollen and laid funny. LPN #2 indicated that upon assessment she found Resident B's knee to be swollen and displaced but she could not determine at the time how far up the displacement went because Resident B was still wearing her pants and was sitting in a wheelchair. She indicated she then notified the Nurse Practitioner, the Power of Attorney and the Director of Nurses. On 2/17/16 at 9:00 A.M., an interview was conducted with the Director of Nurses. The Director of Nurses indicated that CNA#1 had completed the facilities nurse aide training course and was educated on how to perform a Hoyer lift transfer. She further indicated CNA #1 was released from her employment at the facility for improperly transferring Resident B. On 2/16/16 at 1:00 P.M., the Director of Nurses provided the policy, Assessing Falls and Their Causes, revision date October 2010, and indicated it was one currently used by the facility. The policy indicated . Steps in the Procedure .After a Fall: 3. Once an assessment rules out significant injury , nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details .Documentation .When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g. resident found lying on the floor between bed and chair) .2. Assessment data, including vital signs and any obvious injuries .3. Interventions, first aid, or treatment administered .4. Notification of the physician and family, as indicated .5. Completion of a falls risk assessment .6. Appropriate interventions taken to prevent future falls .7. The signature and title of the person recording the data This Federal tag relates to Complaints IN 288 and IN 652. 3.1-45(a)(1)

Based on record reviews and interviews, the facility failed to ensure a Hoyer (a mechanical lift to transfer dependent residents) transfer sling was securely in place prior to transfer, from bed to wheelchair, which resulted in the dependent resident being lowered to the floor and sustaining a fracture, for 1 of 4 residents reviewed for accidents in a sample of 4. (Resident "B") Finding includes: The record of Resident "B" was reviewed on [DATE] at 11:00 a.m. Resident "B" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an MDS Assessment (Minimum Data Set- a tool to assist planning of resident care), dated [DATE], indicated Resident "B" was severely cognitively impaired, required extensive assistance of 2 or more staff for transfers from bed to chair and had limited ROM (Range of Motion: ability to move arms and legs) for both her upper and lower body limbs. Review of Progress Notes indicated: "[DATE] 10:51 (10:51 a.m.) Nurses Note: Weekly skin assessment revealed no new areas...." "[DATE] 16:11 (4:11 p.m.) Social Service Progress Note: During this assessment period... resident is dependent on staff to anticipate all ADL (Activities Daily Living) needs and want. Resident is unable to voice needs. She is dependent on staff to transport her to meals and to feed her her..." "[DATE] 23:21 (11:21 p.m.) Nurses Note: Nurse (name) came to med room where nurse (name) was and states, (Res "B" name) is on the floor. Upon arrival to room, found CNA (name) sitting on floor with residents head in her lap, second CNA (name) was standing next to hoyer lift. I asked what happened and CNA explained that one of the loops that hold the hoyer sling was not placed properly and resident was not being lifted in safe position. So, as one CNA held onto resident and other operated lift, they lowered resident to floor to prevent a fall or injury. So, sling was repositioned under resident, reattached to hoyer and with assist of tree, hoyer lifted resident and placed her in wheelchair. MD notified...." "[DATE] 13:04 (1:04 p.m.) Nurses Note: Res. has red/purple bruising to face and chin measuring 2 cm (centimeters) x 1 cm, 0.7 cm x 0.9 cm, and 0.6 cm x 0.6 cm. Physician notified. Family notified...." "[DATE] 13:30 (1:30 p.m.) Nurses Note: I was told by the CNA to come and look at residents leg and I witnessed a large bruise on her right leg and knee that was blue and purple in color and had blisters in the lower part of bruise on the leg. Resident was assessed and the on call nurse, family and physician were notified..." "[DATE] 15:57 (3:57 p.m.) Nurses Note: Upon assessment of resident's RLE (Right Lower Extremity), weak pedal (foot) pulses intact, temperature of toes comparative r/t (related/to) LLE (Left Lower Extremity)." "[DATE] 16:25 (2:25 p.m.) Nurses Note: Resident care to (EMS name)...Resident transferred to stretcher for transport to (Acute Care Facility: hospital name)." Review of a Radiology (X-Ray) reports from the Acute Care Facility, indicated: "[DATE]...Right knee, 2 views: There is a mildly displaced fracture of distal shaft of femur..." The DNS (Director Nursing Services) was interviewed on [DATE] at 1:08 p.m. The DNS indicated the facility's investigation indicated the CNA noted as the resident was being elevated in the transfer sling one of the loops was not securely in place, resulting in the resident's position being unbalanced. The DNS indicated a CNA supported the resident's body as the sling was lowered to the floor. The resident was then realigned in the sling and transferred back to bed with the Hoyer lift. The DNS indicated Resident "B" was not fully assessed for injury by the nurse following the incident and prior to returning the resident to her bed. The DNS indicated Resident "B" was sent to the emergency room of a local ACF (Acute Care Facility: hospital) on [DATE] after the X-Ray results indicating a fractured femur were received. The resident did not return to the facility and expired while in the care of Hospice. The DNS provided information, on [DATE] at 10:08 a.m., in regards to a facility inservice on [DATE], [DATE] and [DATE], titled, "HOYER: How To Use A Patient Lifter: A Positioning and Transfer Guide". Review of the instruction manual indicated: "...3. Roll the base as far under bed as possible locating the cradle (cross arms which support the sling) over the patient. Take care not to lower the frame onto the patient.... 4. When both sides of the sling are attached to their respective sides of the cradle, raise the patient slowly. If patient is in hospital bed, it will help to raise head of bed. Repositioning of patient may be needed to ensure that a safe sitting position is attained as the patient is raised.... 5. Raise patient until buttocks are just above mattress....Grasp patient's legs and turn patient so her legs dangle off side of bed.... 6. Grasp steering handles and move lifter away from bed. Move the patient into position over the seat of a locked wheelchair...." This Federal tag relates to Complaint IN 255. 3XXX,[DATE](a)(2)

Based on observation, interviews and record review, the facility failed to provide supervision to prevent elopement. This deficiency affected 1 of 2 residents in a sample of 5 who were at risk for eloping from the facility. (Resident B) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 6/7/11 at 2:35 p.m., and began on 6/7/11. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/7/11 at 2:35 p.m. The Immediate Jeopardy was removed on 6/8/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because inservicing of staff, evaluation of the alarm system by safety service technicians and monitoring of staff still needs to be completed. Findings include: During the orientation tour, on 6/6/11 at 9:15 a.m., accompanied by LPN #4, Resident B was identified as being new to the unit and having a code alert alarm bracelet on due to elopement concerns. The resident was observed in the lounge with the bracelet in place on his ankle. The clinical record of Resident B was reviewed, on 6/6/11 at 10:00 a.m., and indicated the resident had been admitted to the facility on [DATE]. Pre-admission information, of 5/3/11, indicated he had been an emergency admission after being found wandering in another city. The 5/3/11 admission note, written at 23:41 (11:41 p.m.) also indicated a code alert bracelet had been applied because he expressed a desire to leave the facility. An elopement assessment, dated 5/25/11 at 12:23 p.m., indicated the resident was at risk for elopement due to cognitive impairment, ambulating independently, having expressed a desire to leave, packed his belongings, wandering aimlessly, being a recent admission and family having voiced concerns that he would try to leave. The admission diagnoses, included, but were not limited to: Alzheimer's disease, congestive heart failure, diabetes, gout and gastric reflux. Nurses notes on 5/6/11 at 20:00 (8:00 p.m.), indicated he had attempted to leave the facility with a visitor, and staff members were able to re-direct him to remain in the facility. Nurses notes, of 5/7/11 at 03:29 (3:29 a.m.) indicated he was up wandering during the night. Nurses notes, dated 5/8/11 at 19:45 (7:45 p.m.), indicated the resident had returned to the facility after being out with family members and had told the nurse his sister had cut the code alert bracelet off. The note indicated a new one was put on. Nurses notes on 5/10/11 at 13:57 (1:57 p.m.) indicated Resident B had told the nurse he was waiting for family to arrive and "get the hell out of here." The note indicated he was also trying to make phone calls with his television remote control and was unable to understand why no one answered. The nurses note for 5/25/11 at 12:15 p.m., indicated he had packed all of his belongings and stated he was "leaving today." 15 minute checks were implemented. Nurses notes of 5/27/11 at 12:29 p.m., indicated the 15 minute checks were continuing. The note indicated Resident B told staff members he was going to leave. Nurses notes on 5/28/11 at 14:13 (2:13 p.m.), indicated Resident B had packed all his personal belongings, stripped the bedding off the bed and unplugged the television set. The note indicated he had told the staff he was waiting for a ride back to his house. Nurses notes of 6/3/11 at 2:44 a.m., indicated he was overheard by an aide telling someone he was going to walk uptown to meet someone. Another note on 6/3/11 at 15:16 (3:16 p.m.) indicated he had packed his belongings and was calling friends for transportation. He also threatened to "kick the door open" and exited the facility when someone came in. The note indicated, "Staff attempted to verbally redirect resident, but resident was adamant so staff shadowed resident outside. Several different staff attempted to redirect resident inside building w/o (without) success. Resident stated he was going to 'walk home' to 'take care of business'." The family was notified and the resident returned to his room when he was told his POA (power of attorney) would meet him there. The POA arrived and helped him unpack. The note indicated a dose of Xanax (an antianxiety medication) was given. Nurses notes of 6/4/11 at 14:23 (2:23 p.m.) indicated resident B was talking of leaving the facility and 15 minute checks were continuing. The note also indicated he was asking for a knife to cut the code alert monitor off. The resident was observed sitting in the lounge at the end of the B wing hall, on 6/6/11 at 11:00 a.m., and when interviewed, he indicated his daughter was coming to take him home. He also indicated he wanted to cut the code alert bracelet off. He stated, "I'm a state police officer and I've been here [AGE] years." Review of Resident B's care plan, dated as initiated on 5/6/11 and in effect at the time of the survey, indicated the resident had a risk for elopement. The goal of the care plan was for the resident to have no successful elopement attempts through the next review of 8/30/11. The approaches included: "1:1 (one to one) when necessary. Encourage activity attendance, Obtain from family interventions that have worked in the past. Place wanderguard (code alert) on resident and check functioning Q (every) shift. 15 minute checks PRN (as needed)." During the approach to the facility, on 6/7/11 at 8:00 a.m., 6 staff members were observed congregated in an area within a block from the facility, along a busy road, near the main highway. The unit manager was observed entering the facility through one of the B wing doors, at 8:05 a.m., and when queried about the group of staff members down the road from the facility, she indicated Resident B had gotten out of the facility and did not want to return. Social worker #2 was interviewed, on 6/7/11 at 9:00 a.m., and indicated she had been on her way to work, when she saw Resident B along the road. She indicated she stopped her van and called the facility to seek help. Social worker #2 was interviewed a second time at 12:20 p.m., and when she checked her phone log to determine the exact time she had made the call to the facility, she determined it had been at 7:44 a.m. She also indicated Resident B had been transported to a local psychiatric facility for evaluation. She indicated his code alert bracelet was still in place when he was found. The 15 minute observation check sheets were reviewed, on 6/7/11 at 1:30 p.m., and indicated RN #12 had signed the 15 minute check sheet at 7:24 a.m., and there were no further entries on the sheet. During an interview with RN #12, on 6/7/11 at 11:00 a.m., she indicated she had checked on Resident B at 7:24 a.m., and then went to the main dining room to assist with breakfast. She indicated she returned to the unit at 7:45 a.m., and he was gone. She indicated she received the call telling her he was out of the facility just after returning to the unit. RN #13 was interviewed, on 6/7/11 at 10:50 a.m., and she indicated she was working on B wing, but was in the main dining room from 7:15 a.m., until 7:30 a.m., and had not heard an alarm until later in the morning. LPN #14 was also working on B wing and was interviewed, on 6/7/11 at 11:05 a.m. LPN #14 indicated she was on the unit at 7:30 a.m., but heard no alarm. CNA (certified nursing assistant) #15 was interviewed, at 11:10 a.m., on 6/7/11 and indicated he had been on the unit, but heard no alarm. The door alarms were observed, on 6/7/11 at 11:30 a.m., with the maintenance man and all were found to be working when a code alert bracelet was near. The doors locked and alarmed when approached by someone wearing the device. Maintenance logs were reviewed, on 6/7/11 at 2:00 p.m., and indicated the door alarms had been checked each week and were working properly. The area around the facility was observed, on 6/7/11 at 1:00 p.m., to be in an urban area with a busy city street to the North of the building and a federal highway to the West. During an interview with the Administrator and Director of Nursing (DON) on 6/7/11 at 2:30 p.m., the Administrator indicated he thought someone had entered or exited the facility using the coded key pad and had turned off the alarm and locking mechanism of the code alert. He indicated they had not been aware the visitor/employee code was also a code which deactivated the system. An Immediate Jeopardy was identified on 6/7/11 at 2:35 p.m. The Immediate Jeopardy began on 6/7/11 when the nurse last initialed the 15 minute check sheet at 7:24 a.m., after having seen the resident; the resident then eloped. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/7/11 at 2:35 p.m., related to the lack of supervision to prevent elopement. The facility staff submitted a plan of action to remove the Immediate Jeopardy and the Immediate Jeopardy was removed on 6/8/11, when through interviews and observation it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility presented a plan of correction, on 6/7/11, and amended it on 6/8/11, to indicate: ? " All Code Alert sensors and doors were checked for sensitivity and adjusted accordingly ? All Code Alert transmitters in the building, both those in use and those in storage, were labeled, assigned to a resident (if appropriate), and logged so as to trigger personnel to replace those that may be nearing expiration-none were found to be near expiration (the soonest a transmitter is scheduled to expire 05/12). ? All residents in the facility were re-assessed for Elopement Risk utilizing the facility's standard assessment. 13 of the 15 utilizing Code Alert transmitters were found to be appropriate; two others had their Code Alert transmitters removed as a result of no longer triggering as "at risk." ? Facility's Elopement Profile book was reviewed and updated to reflect the current residents "at risk" for wandering. ? Residents utilizing Code Alert bracelets were reviewed for their appropriateness for the facility's KIT (Keeping-In-Touch, Activities 1:1 Program)-two were added to the program as a result ? Treatment Administration Records were updated for all those utilizing Code Alert bracelets so that nurses will be "check(ing) placement and function q (every) shift," as opposed to "check(ing) placement q shift and function q day." ? Care Plans for those utilizing Code Alert bracelets were updated ? All doors to the building that are not to be routinely utilized as exits or entrances have been labeled "Not an Entrance" on the outside and "Emergency Exit Only" on the other. ? Code Alert system codes have been changed so that a visitor, staff member, or resident utilizing the MMYY (month and year) code that is "standard" can release the Code Alert mag-lock but cannot take a Code Alert bracelet through the door without the alarm sounding (this is the Visitor Bypass Code). Should this situation occur, the alarm can only be silenced from the inside with a separate code. ? Likewise, a new code has been set up on all transmitters whereby entering this code (confidential number) will disable the Code Alert alarm while releasing the mag-lock. This code is not being made available to staff, who are being asked to utilize the Visitor Bypass Code. As explained to the surveyors, both the Visitor Bypass Code and this second code (the Staff Bypass Code) had both been set to 0611 prior to today when the problem was identified." The plan also indicated all staff members would be educated on the changes prior to work and the electric company and technology company would modify the door access by reducing the number of entrances to the facility. Three of the former exits were turned into emergency only exits and a second set of sensors were added to the back service entrance so the code alert signal would be picked up at 4-5 feet rather than the 18-20 inches previously set. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to complaint IN 504. 3.1-45(a)(2)