Every finding on record at Majestic Care of West Allen

Based on interview and record review the facility failed to ensure a bed hold policy was provided to a responsible party for 4 of 4 residents reviewed (Resident 29, Resident 9, Resident 2, and Resident 85).Findings include: 1) Resident 29's record was reviewed on 04/13/2026 10:38 AM. Diagnoses included dementia with behavioral disturbance, psychotic disorder, and autistic disorder. A current quarterly Minimum Data Set (MDS) assessment, dated 3/30/2026, indicated Resident 29 had a Brief Interview for Mental Status score of 0 (severe cognitive impairment). The MDS indicated Resident 29 had a difficulty focusing attention or difficulty keeping track of what was said. Progress notes, dated 2/10/2026 at 12:30 PM, indicated the physician was notified of x-ray results and provided orders for Resident 29 to go to the hospital. The notes indicated the guardian was notified but made no mention of a bed hold policy. There was no documentation the bed hold policy had been provided to the responsible party. A document, titled Notice of Transfer or Discharge, dated 2/10/2026, provided by the Director of Nursing (DON) on 4/14/2026 at 12:31 PM, indicated a copy of the bed hold policy was sent with Resident 29. 2) Resident 9's record was reviewed on 04/12/2026 1:04 PM. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia. Resident 9's current, quarterly, Minimum Data Set (MDS) assessment, dated 2/11/26, indicated Resident 9 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). A progress note, dated 2/15/2026 at 12:16 PM, indicated Resident 9 was not acting like himself, and was dropping items. The progress note indicated Resident 9's oxygen saturation at the time was 87%. A progress note, dated 2/15/2026 at 2:39 PM, indicated Resident 9's condition had worsened and he was being sent to the hospital by ambulance. Family notification did not include documentation of discussion of the bed hold policy. In an interview, on 04/14/2026 at 12:37 PM, the Social Services Director (SSD) indicated when a resident was experiencing a serious medical condition, the bed hold policy should be provided to the resident's family or guardian. A document, titled Notice of Transfer or Discharge, dated 2/15/2026, indicated a copy of the bed hold policy was sent with Resident 9 when he went to the hospital. 3) Resident 2's record was reviewed on 04/15/2026 10:49 AM. Diagnoses included altered mental status and cerebral infarction. A current quarterly Minimum Data Set (MDS) assessment, dated 3/17/26, indicated Resident 2 had a Brief Interview for Mental Status score of 10 (moderate cognitive impairment). The MDS indicated Resident 2 had difficulty recalling the current month and short-term memory impairment. Progress notes, dated 3/1/2026 at 06:50 AM, indicated Resident 2 had an altered mental status, fever, and weakness. The physician was notified of Resident 2's changes in condition. The notes indicated Resident 2 was their own responsible party and no other notification was completed. Progress notes, dated 3/1/2026 at 08:42 AM, indicated Resident 2 had improved, but was below baseline mental status. Progress notes, dated 3/1/2026 at 2:26 PM, indicated Resident 2 was transferred to the hospital by EMS for fever, abdominal pain and distention. The note indicated that Resident 2 was their own responsible party, and Power of Attorney or family notification of transfer was not completed. Transfer documentation did not include the bed hold policy. A document, titled Notice of Transfer or Discharge, dated 3/1/2026 and untimed, indicated a copy of the bed hold policy was signed by Resident 2. A document, titled Indiana Durable (Financial) Power of Attorney, dated 2/3/2026 indicated Resident 2 designated an agent to act in consent or refusal of health care as referenced in 30-5-5-17 of the Indiana Code. 4.) Resident 85's record was reviewed on 4/15/26 at 9:59 AM. Diagnoses included dementia and osteomyelitis. A Notice of Transfer of Discharge, dated 3/9/26, indicated a copy of the bed hold policy was sent with Resident 85. A Transfer Form, dated 3/9/26 at 8:20 AM, indicated a copy of the transfer form and bed hold policy were sent with the resident. The form indicated Resident 85 required a proxy for decision making. A current policy, dated 1/2/2024, provided by the DON, on 4/14/2026 at 12:31 PM, indicated at the time of transfer to a hospital, the facility should provide a written notice which specifies the duration of the bed-hold policy and addressed information explaining the return of the resident to the next available bed. The policy indicated the facility should keep a signed and dated copy of the bed hold notice information given to the resident or resident representative in the resident file.

Based on observation, interview and record review, the facility failed to identify resident trauma and incorporate into the plan of care for 2 of 5 residents reviewed (Resident 57 and Resident 67).Findings include: On 4/12/26 at 1:44 PM, Resident A was observed in the smoking section. Resident A was sitting in their wheelchair waiting for a staff member to light their cigarette.In an interview, on 4/12/26 at 1:46 PM, Resident A indicated they had smoked 2 packs of cigarettes a day prior to their admission to the facility. Resident A indicated they were now restricted to 3 cigarettes a day and that was a hard adjustment.Resident A's record was reviewed on 4/16/26 at 9:25 AM. Diagnoses included seizure disorder, sleep disorders, psychoactive substance abuse, homelessness, major depressive disorder, anxiety disorder and chronic pain syndrome.Resident A's quarterly Minimum Data Set, (MDS) date 4/6/26, indicated their Brief Interview for Mental Status (BIMS) score was 12 (no cognitive deficit). The MDS indicated Resident A displayed behaviors of verbal aggression towards others and rejection of care. The MDS indicated Resident A had diagnoses of seizure disorder, depression, chronic pain syndrome, homelessness and anxiety disorder.A Social Service History Initial Review, dated 2/26/25, indicated Resident A had been homeless prior to admission to the facility, had a history of substance abuse and had been in a severe car accident.A progress note, dated 5/14/25 at 1:00 PM, indicated Resident A had a history of depression, polysubstance abuse disorder and opioid seeking behaviors. The progress note indicated Resident A had been a nurse prior to having viral encephalitis. Resident A had been in a coma for 3 months due to viral encephalitis. Resident A's first husband gained custody of their son when they divorced. Resident A had been married and divorced 4 times. Resident A had been physically abused by their second husband. Resident A had a fiance that was killed by a car while in their wheelchair. Resident A had a broken back, jaw, neck and leg in a car accident. Resident A had no family contact. Resident A had a past suicide attempt of overdosing on Valium.A progress note, dated 11/19/25 at 6:36 PM, indicated Resident A had a visit for an initial psychiatric evaluation. Resident A had been physically abused by a previous husband for 5 years. The progress note indicated Resident A had been raped by her brother when she was 8 years old.A progress note, dated 12/5/25 at 10:34 AM, indicated Resident A had been placed under direct supervision with administrative staff as a precaution related to suicidal ideation. Resident A's BIMS score was 15 (no cognitive deficit). Resident A had indicated all their actions with peers had been consensual.A progress note, dated 12/5/25 at 4:32 PM, indicated Resident A had been aware that all sexual contact required consent. Resident A was placed on 15-minute checks.A progress note, dated 12/6/25 at 1:52 PM, Resident A understood boundaries with sexual contact and relationships. 15-minute checks were discontinued.A progress note, dated 12/9/25 at 2:225 PM, indicated Resident A had not had any further issues with unwanted advances.Resident A's care plan, dated 8/27/25, indicated they desired intimate relationships with consenting male residents. The target goal was for Resident A's right to consensual intimate relationships to be respected through 5/26/26. Interventions included assessment and education related to consensual intimate relationships.Resident A's care plan, dated 4/1/25, indicated they displayed drug seeking behaviors. The target goal was for Resident A to demonstrate effective coping skills and seek staff support through 5/26/26. Interventions included identification and reduction of behavioral triggers. The care plan did not indicate any identified triggers.Resident A's care plan, dated 8/6/25, indicated they pretended to have seizures to gain attention or medication. The target goal was for Resident A to demonstrate effective coping skills through 5/26/26. Interventions included identification and reduction of behavioral triggers. The care plan did not indicate any identified triggers. Resident A's care plan, dated 3/26/26, indicated they had a behavior of making false allegations. The target goal was for Resident A to seek staff support when feeling frustrated or provoked through 5/26/26. Interventions included identification and reduction of behavioral triggers. The care plan did not indicate any identified triggers.Resident A's care plan, dated 2/25/25, indicated they had a behavior of verbal aggression when they were unable to smoke. The target goal was for Resident A to comply with the facility smoking policy through 5/26/26. Interventions included education related to the smoking policy and supervision while smoking. The care plan did not indicate any identified triggers.Resident A's care plan did not indicate they had a history of physical trauma, a history of sexual trauma, a history of homelessness, a history of substance abuse, a history of medical trauma or a history of attempted suicide.In an interview, on 4/15/26 at 11:44 AM, Certified Nurse Aide (CNA) 5 indicated Resident A had displayed sexual behaviors ever since they had been admitted to the facility. CNA 5 indicated on one occasion; Resident A had voiced anger at another resident for not buying them a soda after they had engaged in sexual acts with the other resident.In an interview, on 4/15/26 at 3:20 PM, the Administrator indicated they had been made aware of Resident A's alleged unwanted advances by another resident's son in December of 2025. The Administrator indicated the situation had been resolved.2. On 4/12/26 at 1:52 PM, Resident 67 was observed sitting in their wheelchair in the smoking area.During an interview, on 4/12/26 at 1:52, Resident 67 was verbally aggressive to another resident who had joined the conversation. Resident 67 indicated they had transferred from another facility last year. Resident 67 indicated they were thankful for the opportunity to smoke.Resident 67's record was reviewed on 4/13/26 at 9:34 AM. Diagnoses included dementia, seizure disorder, traumatic brain injury, (TBI) borderline personality disorder, tobacco use, anxiety, intermittent explosive disorder and other specified behavioral and emotional disorders with onset usually in childhood and adolescence (adhd).Resident 67's quarterly MDS dated [DATE], indicated their BIMS score was 15 (no cognitive deficit). The MDS indicated the resident had not displayed any behaviors.A Social History and Assessment, dated 7/30/25 at 2:28 PM, indicated Resident 67 acquired a TBI after they were hit by a semi-truck while riding his bicycle when he was 18. The resident was in a coma for 11 months. The resident lived in a state hospital for 13 years, then transferred to a group home setting.A progress note, dated 8/25/25 at 4:53 AM, indicated Resident 67 displayed inappropriate sexual behavior towards staff. Resident 67 had been touching themselves intimately during personal care and refused to stop when redirection was attempted.A progress note, dated 9/5/25, indicated Resident 67 was in a coma for 11 months following a crash between their bicycle and a semi-truck when they were 18. The progress note indicated Resident 67 was diagnosed with TBI and intermittent explosive disorder. Resident 67 allegedly shot their father when they were 26 due to their father swearing at them. Resident 67 resided at a state hospital for 13 years.A Preadmission Screening and Resident Review (PASRR), dated 11/22/22, indicated Resident 67 had diagnoses of TBI, intermittent explosive disorder and borderline personality disorder. Resident 67's PASRR indicated they were triggered by hearing the name of the current United States President.Resident 67's care plan, dated 7/31/25, indicated the resident had explosive disorder and a history of altercations with other residents. The target goal was for the resident to seek staff support and demonstrate effective coping skills through 5/4/26. Interventions included identification and reduction of triggers. The care plan did not indicate any specific triggers.Resident 67's care plan, dated 7/31/25, indicated the resident was at risk for decreased psychosocial well being due to anxiety, TBI, depression, borderline personality disorder and seizure disorder. The target goal was for the resident to verbalize feelings and adjust to the facility through 5/4/26. Interventions did not include identification of resident specific behavioral triggers.Resident 67's care plan, dated 7/31/25, indicated the resident had a history of refusal to bathe or shower. The target goal was for the resident to verbalize feelings and adjust to the facility through 5/4/26. Interventions did not include identification of resident specific behavioral triggers.Resident 67's care plan did not indicate they had a history of traumatic events such as being hit by a truck or shooting their father.Resident 67's care plan did not indicate they had displayed inappropriate sexual behavior.In an interview, on 4/15/26 at 9:20 AM, the Administrator indicated all residents should be screened for trauma upon admission.In an interview, on 4/15/26 at 1:15 PM, the Administrator indicated Resident 67's inappropriate sexual behavior towards a staff member was reported by another resident. Resident 67's inappropriate sexual behavior was never verified by staff. The Administrator indicated Resident 67 had not been involved in any physical altercations with other residents since they have been at the facility. The Administrator indicated they were unaware of Resident 67's specific behavioral triggers.In an interview, on 4/16/26 at 1:35 PM, the Social Service Director (SSD) indicated each resident was screened for trauma upon admission and quarterly. The SSD indicated trauma responses and posttraumatic stress disorder (PTSD) should be added to each resident's care plan. The SSD indicated life threatening medical events, abuse, and homelessness could be traumatic events.A current facility policy, dated 11/18/25, indicated trauma was an event or circumstance that was perceived as physically or emotionally harmful or life-threatening. The policy indicated the facility would ensure resident specific behavioral health plans of care.This citation is related to Intake 2976724410 IAC (Indiana Administrative Code) 16.2-3.1-

Based on interview and record review, the facility failed to ensure and investigation and interventions for suicidal ideation for 1 of 1 resident reviewed (Resident 6).Findings include:Resident 6's record was reviewed on 04/12/2026 12:21 PM. Diagnoses included schizophrenia, cerebral edema, hemiparesis and hemiplegia following cerebral infarction affecting right, dominant side.A current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 6 had a Brief Interview for Mental Status (BIMS) score of 12 (mild cognitive impairment).A progress note, dated 3/11/2026, indicated Resident 6 told the Social Services Director (SSD) he was feeling down and wanted to kill himself. The note indicated the SSD offered assistance, activities, and initiated 15-minute checks. The note indicated the care plan was updated. The note did not mention asking if Resident 6 had a plan to kill himself. No additional notes pertaining to suicidal ideation or follow-up were available for review.A review of Resident 6's current care plan, initiated 2/26/2026, did not address depression or suicidal ideation.Progress notes, dated 3/11/2026 to 4/13/2026, did not include any documentation of physician notification of suicidal ideation.A care plan conference summary, dated 3/17/26, did not include any documentation of interventions provided for suicidal ideation.In an interview, on 04/13/2026 3:00 PM, The Social Services Director (SSD), indicated upon hearing a resident verbalize suicidal ideation, she would report the occurrence to the nurse, suggest 15 minute checks and request a team meeting to decide if the resident should be sent out to the hospital. The SSD indicated she would ask the resident why they wanted to kill themselves. The SSD indicated she did not normally ask if the resident verbalizing suicidal ideation if they had a plan. The SSD indicated Resident 6 had admission paperwork mentioning suicidal ideation, related to his depression due to a stroke. The SSD indicated Resident 6 vocalized suicidal ideation during a care plan meeting with his father on 3/17/2026. The SSD indicated she offered emotional support, and his father took him out of the facility for a leave of absence after the meeting. She indicated Resident 6's mood had improved when he returned. The SSD indicated she did not recall any other occurrence. After reviewing her documentation for 3/11/2026, the SSD indicated since it was the first occasion of a verbalization, she recommended nursing initiate 15-minute checks and reported the occurrence to the Director of Nursing. The SSD indicated no further visits or follow up was needed and was not done.In an interview, on 04/13/2026 3:09 PM, the Director of Nursing (DON) indicated upon notification of a suicidal verbalization, staff should assess the resident, notify the SSD, ask the resident if they had a plan, and remove anything from the immediate area that could be used for self-harm. The DON indicated the psychiatric nurse practitioner should be notified immediately, and the occurrence should be documented. The DON indicated she recalled an occurrence of Resident 6 verbalizing suicidal ideation. Resident 6's father spoke with Resident 6, and Resident 6 told his father he wanted to live and was upset when he made the statement. The DON indicated Resident 6's father took him out of the facility for a leave of absence that day and 15-minute checks were not initiated. The DON indicated a progress note should have detailed staff interventions, the outcome, and family and physician notification. The DON indicated the care plan should have been updated.In an interview, on 4/14/2026 at 10:25 AM, the Administrator indicated upon a statement indicating suicidal ideation, staff should ask if the resident had a plan to determine the severity of the situation and provide interventions accordingly. The Administrator indicated interventions should be documented, the physician and family should be notified, and the care plan should be updated. The Administrator indicated Resident 6 should have had a care plan addressing his depression with suicidal ideation.A current policy, titled Suicidal Thoughts and Ideation, dated 11/1/2024, provided by the Administrator on 4/14/2026 at 11:02 PM, indicated the DON, SSD, and physician should be immediately notified of any suicidal verbalization by a resident. The policy indicated the DON or SSD should immediately interview the resident, asking if there was a plan, assessing the resident's mood and means for self-harm. The policy indicated the resident's mood and behavior, and all actions taken should be thoroughly documented in the medical record.410 IAC (Indiana Administrative Code) 16.2-3.1-43(a)(1)

Based on interview and record review, the facility failed to ensure accurate and complete documentation was provided for 1 of 2 residents reviewed (Resident 6).Findings include:Resident 6's record was reviewed on 04/12/2026 12:21 PM. Diagnoses included schizophrenia, cerebral edema, hemiparesis and hemiplegia following cerebral infarction affecting right, dominant side.A current admission Minimum Data Set (MDS) assessment, dated 3/6/2026, indicated Resident 6 had a Brief Interview for Mental Status (BIMS) score of 12 (mild cognitive impairment)A review of Resident 6's current care plan, initiated 2/26/2026, did not address depression or suicidal ideation.A Social Services progress note, dated 3/11/2026, 1:54 PM indicated: Visited [NAME] as it was reported that [NAME] is feeling down today and said he wants to kill himself. Had a chat, offered help, talked to Activities to encourage participations in activities or offer 1:1 activity time. [NAME] appears to agree. Advised if feels like to talk to call SSD or nurse. Resident scheduled for 15 mins checks. Care plan updated. On 4/14/2026 at 10:04 AM, the following progress notes were reviewed:A Social Services progress note, created on 4/13/2026 at 3:52 PM, with an effective date of ,3/12/2026 at 3:46 PM, labeled as a late entry indicated: Follow up meeting with resident, who stated he has no plan and does not have any suicidal ideation anymore. Resident father present and aware. Resident much calmer and present without any psychosocial distress or mood changes. Resident continues his daily routine and attends therapy. After conversation and 1:1 time with the writer resident stated that he feels much better and has no suicidal ideation or intend (sic).A Social Services progress note, created on 4/14/2026 at 7:58 AM, with an effective date of 3/13/2026 at 7:58 AM, labeled as a late entry indicated: Visited resident today, who stated he has no plan and does not have any suicidal ideation anymore. Care plan meeting is set up on 3/17/26. After conversation and 1:1 time with the writer resident stated that he feels much better and has no suicidal ideation or intend (sic). A Social Services progress note, created on 4/14/2026 at 7:59 AM, with an effective date of 3/14/2026 at 7:58 AM, labeled as a late entry indicated: Visited resident today, who stated he has no plan and does not have any suicidal ideation anymore. Care plan meeting is set up on 3/17/26. After conversation and 1:1 time with the writer resident stated that he feels much better and has no suicidal ideation or intend (sic). In an interview, on 04/13/2026 3:00 PM, The Social Services Director (SSD), indicated upon hearing a resident verbalize suicidal ideation, she would report the occurrence to the nurse, suggest 15-minute checks and request a team meeting to decide if the resident should be sent out to the hospital. The SSD indicated she would ask the resident why they wanted to kill themselves. The SSD indicated she did not normally ask if the resident verbalizing suicidal ideation if they had a plan. The SSD indicated Resident 6 had admission paperwork mentioning suicidal ideation, related to his depression due to a stroke. The SSD indicated Resident 6 vocalized suicidal ideation during a care plan meeting with his father on 3/17/2026. The SSD indicated she offered emotional support, and his father took him out of the facility for a leave of absence after the meeting. She indicated Resident 6's mood had improved when he returned. The SSD indicated she did not recall any other occurrence. After reviewing her documentation for 3/11/2026, the SSD indicated since it was the first occasion of a verbalization, she recommended nursing initiate 15-minute checks and reported the occurrence to the Director of Nursing (DON). The SSD indicated no further visits or follow up was needed.In an interview, on 04/14/2026 at 10:01 AM, the DON indicated late entries had been added to the medical record to address concern of suicidal verbalization. In an interview, on 4/14/2026 at 10:25 AM, the Administrator indicated upon a statement indicating suicidal ideation, staff should ask if the resident had a plan to determine the severity of the situation and provide interventions accordingly. The Administrator indicated interventions should be documented, the physician and family should be notified, and the care plan should be updated. The Administrator indicated Resident 6 should have had a care plan addressing his depression with suicidal ideation. In an interview, on 04/16/2026 at 10:00 AM, the Administrator indicated he believed the late entry documentation provided by the SSD was not intended to be inaccurate.In an interview, on 4/16/2026 at 10:04 AM, the SSD indicated she did not personally provide individual visits with Resident 6 for follow up regarding suicidal ideation.In an interview, on 4/16/2026 at 10:05 AM, the Administrator indicated the SSD's documentation was indicative of interdisciplinary team visits with Resident 6. A current policy, titled Documentation in the Medical Record, dated 1/2/2024, provided by the Administrator on 4/16/2026 at 10:14 AM, indicated staff should document all assessments, observations and services provided in the medical record. The policy indicated documentation should be completed at the time of service, but no later than the shift in which assessment, observation, or care service occurred. The policy indicated documentation should be factual and based on first-hand knowledge of the assessment, observation, or service provided.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure staff used the correctly sized sling, in good working condition, when transferring a resident with a mechanical lift for 1 of 3 residents reviewed for assistive device use (Resident G). This failure resulted in the resident falling from the lift when a strap on the sling broke causing the resident to fall sustaining multiple fractures of neck, lower back, and pelvis. This resulted in Resident G's death. The immediate jeopardy began on [DATE] when the facility failed to ensure a lift sling was properly sized and in good working condition. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Nurse Consultant Director were notified of the Immediate Jeopardy on [DATE], at 1:45 P.M. The immediate jeopardy was removed on [DATE], and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include:A hospital report, dated [DATE], alleged Resident G was being lifted using a Hoyer lift. While transferring, the resident fell out of the lift, striking his head against the bed frame and landing directly onto the floor. He was sent to the hospital where he was diagnosed with multiple fractures. According to the report, the resident succumbed to his injuries and died in the hospital. This resulted in Immediate Jeopardy/ Substandard Quality of Care. On [DATE] at 1:08 P.M., Resident G's record was reviewed. Diagnoses included hemiplegia affecting left side and above knee left leg amputation. There was no evidence in the record of terminal illness, hospice, or bone density issues. A Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident G's height was 78 inches (6 feet 6 inches) and his weight 252 pounds. A current care plan, revised [DATE], indicated Resident G required staff assistance with transfer into and out of his Broda chair using a Hoyer (mechanical) lift and 2 staff. The care plan did not indicate the size of the sling to be used when transferring Resident G. There were no notes to indicate there were concerns with smoking, falls, injuries or altercations. A current physician order, dated [DATE], was to utilize a Hoyer lift for transfers with 2 staff. There were no other notes related to diagnosis contributing to multiple fractures. There were no physician orders to indicate the size of sling to be used when transferring Resident G. There was no assessment by the Interdisciplinary Team to indicate sizing of the sling had been evaluated prior to utilizing the lift. A progress note, dated [DATE] at 11:55 a.m., indicated the Licensed Practical Nurse (LPN) 2 and Certified Nurse Aid (CNA) 4 were transferring Resident G from his bed to chair with the Hoyer lift when the transfer sling strap on the left side by the left leg malfunctioned. The resident fell from the Hoyer lift, hitting his head on his roommate's bed frame. He had a short loss of consciousness followed by alertness with lethargy and complaints of pain. He was assessed immediately and vital signs taken with the following results: Blood Pressure (B/P) 107/63 (normal B/P-120/80); Pulse (P)-65 (normal 60-100 beats per minute); Respirations (R)-16 (normal 16-20); Temperature (T) 97.0; and Blood Oxygenation 95% (normal 90% and higher). He had no visible injuries. The Nurse Practitioner (NP) was notified and gave orders to send the resident to the hospital for further evaluation. Hospital notes, dated [DATE], indicated the resident complained of pain in his neck and back. CT scans indicated the resident had multiple fractures to his lower back, pelvis, and neck. On [DATE] at 10:30 A.M., the Administrator provided a copy of Joerns Hoyer HPL500 user instruction manual. The manual indicated the user should always check the sling to ensure suitability for the particular patient, was of the correct size, capacity, and to always fit the sling according to the instructions provided (user instructions). On [DATE] at 11:33 A.M., Certified Nurse Aid (CNA) 4 was interviewed. She indicated the sling straps were inspected prior to utilizing the lift, but did not show any wear. She indicated she and LPN 2 were transferring Resident G using the mechanical lift when the sling strap broke. CNA 4 indicated the resident used a blue colored sling with 4 straps, each with colored rings. The rings attached to the mechanical lift bar using the the color coding to provide stability. Prior to the transfer, the sling pad was placed under the resident, and the straps were attached to the lift bar by the last black ring on each strap. After securing the resident with the straps, CNA 4 lifted Resident G off the bed and began moving the lift backward when the black ring of the left bottom strap came apart in the middle of the strap, causing the resident to fall. CNA 4 indicated the sling and sling straps had not appeared in poor condition but were old. When asked, she indicated there was no specific sized sling to use for Resident G or any of the residents and all the slings in the facility were the same. On [DATE] at 11:45 A.M., Licensed Practical Nurse (LPN) 2 was interviewed. LPN 2 was present in the resident's room when he was transferred with the mechanical lift. The sling strap came apart in the middle on the left leg side causing Resident G to fall from the sling, striking his head on his roommate's bed frame and landing on his back. The resident immediately complained of pain in the back of his head, back and hips. He lost consciousness briefly but came to. He was lethargic and not acting like himself. She immediately notified the Nurse Practitioner (NP) and orders were given to send Resident G to the emergency room for evaluation and treatment. On [DATE] at 12:20 P.M., the mechanical lift sling with the broken strap to fall was observed in the Administrators office. The sling was blue in color with blue binding and pilling at the edges of the entire outer perimeter. There were no frays or tears on the body of the sling. The black ring on the left (leg) bottom strap was torn in half in the middle of the ring. A worn, torn partial label with no observable writing was on the body of the sling. There was no visible label or tags identifying the size of the sling or directions for use. The Administrator indicated the sling was the sling utilized by LPN 2 and CNA 4 to lift Resident G and was a size large. On [DATE] at 12:25 P.M., the Administrator provided a copy of information on the sling, purchased [DATE]. The information included a weight and height sling chart. The chart indicated a size large universal sling was for patients with a weight range from 225 pounds to 325 pounds and height range from 5 feet 5 inches to 6 feet 1 inch. Product details indicated the sling size and fit could vary significantly depending on a patient's weight and girth. These were general guidelines and the physician was to be consulted before sling selection. On [DATE] at 12:37 P.M., CNA 6 was interviewed. She indicated prior to Resident G's fall, sling lifts used in the facility were old and residents had no size assigned to them to be used for mechanical lift transfers. She indicated Resident G was a big man. Staff had to attach the mechanical lift sling straps by the last black ring on each strap to fit his size. She indicated staff checked the slings for use, but did not know who monitored the slings for age and defects. On [DATE] at 2:14 P.M., the Rehabilitation Director was interviewed. She indicated the rehabilitation department provided evaluations for need of mechanical lifts for safe transfers. The department was not responsible for fitting and determining the correct size of sling pad to be used. When asked how staff would know which sized sling pad to use for a resident, she indicated staff should follow the label directions on the sling pad for the appropriate size. She indicated she did not know who monitored the slings for age or defects. In an interview on [DATE] at 10:17 A.M., the Coroner indicated she did not have hospital records to complete a death certificate. She indicated the emergency room indicated Resident G received back, pelvis, neck fractures and succumbed to his injuries. A Safety Guide for Patient Lifts was retrieved, on [DATE], from the Federal Drug Administration website, www.fda.gov. The safety guide indicated to select a patient's sling size, the following should be considered: Assess the patient's size, weight and hip measurement and choose size of sling based on manufacturer recommendation for patient's measurements. Choosing the correct sling size was critical for safe patient transfers. Using the wrong sling or attaching the sling incorrectly could cause an accident resulting in serious injury or death. Prior to use, the sling should be examined for attachment tears, holes, and frayed seams. If the sling shows signs of wear, it should be replaced immediately. A guide to identifying sling deterioration, undated, retrieved from the Proactive website, www.proactivemedical.com indicated straps may appear to be in good condition, but may be compromised under several conditions, including missing, faded, or illegible tags on the sling. A current facility policy, titled Transfers and Mechanical Lifts, was provided by the DON on [DATE] at 2:12 P.M. The procedure indicated the facility would ensure appropriate amounts of varying sizes of slings to accommodate residents and residents would be measured correctly as per manufacturer's instructions on proper sling sizing. Slings found to be damaged, broken or unsafe would be removed from service and replaced. The immediate jeopardy was removed on [DATE], the deficient practice corrected on [DATE] when the facility removed all lift pads from service, assessed residents utilizing lifts for proper fit according to manufacturer's guidelines, replaced all sling with properly sized slings, added sling sizing to care plans and care guidance for CNAs, developed a replacement schedule for slings according to manufacturer's instructions, and reeducated staff on how to identify deterioration of sling pads before use prior to the start of the survey and was therefore Past Noncompliance. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on interview and record review, the facility failed to thoroughly investigate a potential fall for 1 of 3 residents reviewed for accidents (Resident K).Findings include: On 7/24/25 at 1:06 P.M., Resident K's record was reviewed. Diagnoses included diabetes, generalized anxiety disorder, and dementia.An admission Minimum Data Set (MDS) assessment, dated 6/12/25, indicated a Brief Interview Mental Status (BIMS) was 8 indicating the resident had moderately impaired cognition. He required maximal assistance with his activities of daily living (ADL) including transfers, bed mobility, and toileting. He was frequently incontinent of bladder and occasionally incontinent of bowel.Care Plans indicated:-Revised 6/11/25: Resident K was at risk for falls or fall related injuries. He had signs of decreased judgement for safety and hadn't recognized his decline. The goal was for the resident to have reduced risk for fall and fall related injuries. Interventions included: resident was to use a rolling walker for short distances and wheelchair for long distance; staff to encourage and assist to wear non-skid footwear; provide cues as needed; and provide resident with 1 step commands/cues and allow to respond. -Revised 6/16/25: Resident K required assistance with his ADL's and needed encouragement to help with his care. The goal was for his ADL needs to be met daily with staff assistance. Interventions included: provide assistance with personal hygiene; provide assistance with ambulation-used a rolling walker and wheelchair; provide assistance with transfers.Care plans hadn't indicated the amount of assistance the resident required for his ADL's, if Resident K tried to do his own ADL's or walk around the room or to/from bathroom by himself. The fall care plan hadn't indicated he was at risk for falls due to unassisted transfers/ambulation nor were interventions put into place to prevent falls due to unassisted transfers, ambulation, or self-toileting.A progress note, dated 6/5/25 at 7:13 p.m., indicated the resident had arrived to the facility at 4:30 p.m., accompanied by his Power of Attorney (POA) and using a rolling walker. He was alert and verbally responsive. He had a small area of yellow and light purple bruising to his scalp, multiple areas of bruising and skin tear to the left forearm.A Skin Condition Evaluation, dated 6/6/25 at 5:26 p.m., indicated Resident K was admitted with 1 skin tear on his left forearm which measured 1 centimeter (cm) by 1 cm.A Behavioral Diagnostic Evaluation, dated 6/11/25, indicated Resident K had a history of depression, anxiety and dementia with psychosis prior to admission to facility. He had been at another nursing home but referred to this facility for memory care due to greatly declined cognition. He had auditory hallucinations and bizarre/illogical delusions. He was described as struggling with many behaviors since being here. He initially started out on the memory care unit but the noise from the severely demented residents was bothering him and he was threatening to hit the residents who were making noises.Nurse notes indicated:On 6/19/25 at 9:00 a.m., Resident K was walking in his room. Several attempts had been made to assist him with getting cleaning up but he refused. He went to the bathroom on his own and told staff to get out.On 6/30/25 at 1:00 p.m., Resident K was observed sitting on the 2nd bed in his room wearing no shoes or socks and skin injuries observed to his left arm. The nurse assessed the resident who was observed with 5 skin tears to his left arm. He had 3 small skin tears at his wrist, 1 to his forearm and 1 to the upper elbow. Resident K indicated he had not fallen but was unable to describe how the skin tears occurred. Treatments were applied to the skin tears and he was assessed with no further skin injuries observed. Staff initiated neurological checks despite the resident denying he had fallen or hit his head. An Interdisciplinary Team note, dated 7/1/25 at 11:18 a.m., indicated Resident K had a fall on 6/30/25 and received skin tears to his left wrist, left forearm and elbow. He had been observed barefoot. Staff were to encourage use of proper footwear and skin protectors applied.On 7/24/25 at 2:39 P.M., Resident K's POA was interviewed. She indicated the resident was hospitalized on [DATE], allegedly due to severe dehydration, electrolyte imbalances, and wound to his bottom. He was currently receiving hospice services at another facility. She indicated being told, the resident had a fall on 6/30/25 but indicated the resident rarely fell and hadn't known how he had gotten multiple skin tears.On 7/24/25 at 3:15 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. Both were new to the facility and hadn't been employed at the facility when the incident occurred. The DON and ADON reviewed the fall report for Resident K on 6/30/25 and were unable to determine if the resident had an actual fall or if something else had occurred to cause his injuries. The fall report indicated the resident was wheelchair bound. Resident K's MDS had indicated he required maximal assistance with transfers so was unclear how he was observed seated on the other bed in his room with multiple skin tears. The resident had denied falling. The DON and ADON indicated circumstances surrounding the incident should've been thoroughly investigated to determine if the resident had fallen, what environmental factors were involved, and interviews done with staff to rule out another resident's involvement or staff member having witnessed the resident ambulating by himself in the room. On 7/25/25 at 10:30 A.M., the Administrator provided a current copy of the facility policy, titled Fall Prevention which indicated each resident would be assessed for fall risk and receive care and services to minimize the likelihood of falls .A fall was an event where the individual unintentionally came to rest on the ground, floor or other level but not as a result of an overwhelming external force (resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground and can occur anywhere .When any resident experiences a fall, the facility will assess the resident, complete a post fall assessment and incident report, notify the physician and family, review the resident's care plan and update as indicated, document assessments and actions and obtain witness statements in the case of injury.This Citation relates to Complaint 18070993.1-45(a)

Based on interview and record review the facility failed to ensure care plan interventions were implemented, weight losses were reported and addressed timely. This resulted in a significant weight loss of 6.6% in 30 days for 1 of 3 residents reviewed (Resident 37). Findings include: During an observation on 5/4/25 at 11:58 AM, Resident 37 was observed eating lunch independently. He was slow at consuming his meal and tired easily during eating. Resident 37's record was reviewed on 5/5/25 at 1:12 PM. Diagnoses included unspecified dementia, moderate protein-calorie malnutrition, and gastro-esophageal reflux. Resident 37's current Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired. A Nursing Admission Evaluation, dated 4/2/25, indicated Resident 37 had dysphagia and missing teeth or dentures. The evaluation indicated Resident 37 needed assistance with eating. A current care plan titled potential for nutritional risk indicated the resident had a problem of risk for weight loss, with a goal date of 10/30/25. Interventions included notifying the physician of significant weight changes. A current care plan titled needs assistance with activities of daily living indicated the resident had a problem of requiring assistance, with a goal date of 10/30/25. Interventions included providing eating assistance. A review of Resident 37's care Kardex (guidelines for direct care staff to deliver care) indicated assistance was needed for eating activities. A review of Resident 37's weights indicated: On 4/2/25, 180.6 lbs. On 4/9/25, 173 lbs. On 4/16/25, 170 lbs. On 4/23/25, 167 lbs. On 4/30/25, 165 lbs. On 5/1/25, 168 lbs. This is a 6.6% loss in 30 days. No additional weights or reweights were available for review. A review of meal intakes indicated: On 4/8/25, the evening meal was refused. On 4/10/25, the evening meal was refused. On 4/11/25 the evening meal was refused. On 4/12/25, no documentation of the breakfast or lunch meal intake was available for review. On 4/14/25, less than 25% of the breakfast and lunch meals were consumed. On 4/16/25, the breakfast and lunch meals were refused. No documentation of the evening meal was available for review. On 4/18/25, less than 25% of the breakfast meal was consumed. The evening meal was refused. On 4/19/25, no documentation of the evening meal was available for review. On 4/21/25, the breakfast and lunch meals were refused. On 4/23/25, less than 25% of the breakfast meal was consumed. No documentation of the evening meal was available for review. On 4/24/25, less than 25% of the lunch and evening meals were consumed. On 4/25/25, less than 25% of the breakfast and lunch meals were consumed. On 4/26/25, less than 25% of the breakfast meal was consumed. On 4/28/25, less than 25% of the breakfast meal was consumed. No documentation of the evening meal was available for review. On 4/30/25, less than 25% of the lunch meal was consumed. No documentation of the evening meal was available for review. On 5/4/25, less than 25% of the breakfast meal was consumed. On 5/5/25, no documentation of the evening meal was consumed. No further meal intake documentation, record of meal replacement or supplement offering was available for review. Progress notes from 4/2/25 to 4/29/25 did not include any documentation of reweights or reporting weight loss to the physician. During an observation, on 5/7/25 at 10:48 AM, Resident 37 was observed indepndantly eating part of a snack during an activity. Resident 37 did not appear to be interested in consuming the rest of the snack. In an interview, on 5/6/25 at 10:53 AM, Certified Nurse Aide (CNA) 12 indicated CNA staff obtained weights and turned them in to the nurse on the unit. In an interview, on 5/6/25 at 10:54 AM, Qualified Medicine Aide (QMA) 8 indicated 7 residents on the unit were provided with eating assistance and provided their names. He indicated Resident 37 did not receive eating assistance. In an interview, on 5/6/25 at 10:58 AM, Licensed Practical Nurse (LPN) 13 indicated CNAs turned completed weight lists into the nurses who then turned them in to the Nurse Managers. Nurse managers then provided the nurses with reweight lists. She indicated Nurse Managers reported any weight changes to the doctor and families. In an interview, on 5/6/24 at 11:40 AM, the Regional Nurse Consultant (RNC) indicated staff should obtain a reweight when weight variances occur and weight losses of 5% or more should be reported to the physician and family. She indicated a reweight should have been obtained on 4/9/25, 4/16/25 and 4/23/25. She indicated eating assistance should have been provided, meal replacements and supplements should have been offered and recorded. A current policy titled Weight Monitoring, dated 1/2/24 provided by the RNC on 5/6/25 at 11:47 AM indicated weekly weights should be obtained for all newly admitted residents. The policy indicated reweights should be obtained when a weight variance of three pounds or more occurs. Significant weight changes of 5% or more in 30 days should be reported to the physician. 3.1-46(1)

Based on observation, interview and record review the facility failed to store and serve food and drinks to maintain food safety for 78 of 78 residents who consume food and drinks from the kitchen. Findings include: In a continuous observation of the kitchen on [DATE] from 10:13 AM to 11:30 AM, the following was observed: Three medication bottles were found in a open basket, on a counter, with an employee's name on one prescription bottle of Xarelto. The bottle contained tablets. Moisture was observed in 3 of 17 maroon bowls being filled with pudding. 2 of 17 bowls had small specks of white debris inside the bowls. The dishwasher unit had 5 small, black dead bugs and small brown, tan particles on the top surface. A ceiling vent above the freezer had a thick layer of dark gray, fuzzy substance coating the slats. Behind the first freezer, the wall had wavy brown to tan discoloration from the floor to about 1 foot in height. Underneath the shelves in the pantry, 7 round pieces of cereal, brown and white granules were found at the base of 3 out of 4 walls, 2 packets of sugar and 1 packet of salt were found on the floor. Onion peels were found on the floor, small peels and debris were found in the shelving unit. A bottle of lime juice with a use by date of [DATE] was found in the reach- in refrigerator. In the reach -in refrigerator, a pitcher labeled V8 juice, was not sealed and dated with an open date of [DATE]. A jug of chocolate milk had a best by date of [DATE]. An opened, single size milk was found on the top shelf of the refrigerator without a name or date label. In an interview, on [DATE] at 10:45 AM, [NAME] 6 indicated the V8 juice and milk were expired and shouldn't be in the refrigerator. The unlabeled milk should not be in this refrigerator. In an interview, on [DATE] at 11:00 AM, the Dietary Manager indicated staff medication should be locked in staff's lockers. She confirmed 3 bottles of medication including Xarelto, Naproxen, and a combination of acetaminophen, aspirin, and caffeine migraine medication had been unsecured. During an observation, on [DATE] at 11:04 AM, moisture drops were found in between two of 5 large pans. During an observation, on [DATE] at 11:21AM, in the main resident pantry, the following was found: Circular brown stains covered the wooden table top, next to the microwave. Inside the refrigerator, a pitcher of orange juice and red juice was not labled or dated. Milk had a use by date of [DATE]. Lactose free milk had a use by date of [DATE]. A container of French Onion Dip labeled room ,d+[DATE], did not have an opened or use by date. A Pizza [NAME] container with food inside did not have a name or date label. A plasticware container contained a pudding like substance, but did not have a use by date. On the bottom floor of the refrigerator, dried red substance was observed. Inside the freezer, a package of frozen cheese sticks, 3 microwave meals, mozzarella cheese sticks, a package of buns, and a package of pizza rolls did not have a name or date labeled. In a closed shelving unit a carton of popcorn liquid expired on [DATE]. The interior stainless steel of the ice machine had a reddish brown shiny substance across the bottom. A plastic spoon, Milky Way wrapper, and a blue glove were on the floor against the back wall. A linen pillowcase was observed on top the freezer. In an interview, on [DATE] at 11:35 AM, the dietary manager indicated housekeeping staff cleaned the fridge and dietary staff checked for outdates. A current policy, regarding cleaning schedules, dated [DATE], indicated the cleaning schedules would be posted, followed and the Dietary Manager would make regular inspections. A current policy, regarding food storage, dated [DATE], indicated food items were placed into appropriate storage lactions consistent with Food Code Guidelines. Equipment and utensils would be cleaned and sanitized before each use. A current policy, regarding food brought into the kitchen, dated [DATE], indicated food brought into the facility by family or visitors would be labeled and stored with the resident's name and use by date. The nursing or dietary staff would discard food past use by or manufacture expiration dates. A review of current daily cleaning logs, dated [DATE]-[DATE], provided by the Dietary Manager, indicated staff was required to ensure dishes, mugs, bowls, and utensils were cleaned and stored properly. All table countertops and under shelving were cleaned and sanitized. The dish machine was cleaned inside and out. Ensure the dry storage area was organized and floor is mopped. This citation is related to Complaint IN00458229. 3XXX,d+[DATE](i) (3)

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters. Findings include: During an observation, on 5/4/25 at 1:32 PM, 3 of 3 dumpsters were not closed. The first dumpster lid was fully open. The second dumpster had white trash bags propping open the lids. The third dumpster, labeled cardboard, was overstuffed with cardboard propping open both lids. Plastic and trash were found on the ground surrounding the dumpsters and in the tree line to the north. During an observation, on 5/5/25 at 8:50 AM, 3 of 3 dumpsters were not closed. The first dumpster lid was fully open. The second dumpster had white trash bags propping open the lids. The third dumpster, labeled cardboard, was overstuffed with cardboard propping open both lids. Plastic and trash were found on the ground surrounding the dumpsters and in the tree line to the north. In an interview, on 05/08/25 at 09:52 AM, the Dietary Manager indicated, housekeeping, dietary, and nursing staff should make sure dumpster lids are closed and there should be no debris outside the dumpsters. A current policy, dated 12/12/2023, titled Disposal of Garbage and Refuse, indicated dumpsters would be kept closed and free of surrounding litter. 3.1-21(i)(5)

Based on observation, interview and record review the facility failed to ensure toenail care was provided for 1 of 7 residents reviewed (Resident 52). Findings include: During an interview, on 5/6/24 at 11:14 AM, Resident 52 indicated her toenails were very long and she feared they would curl under her toes. She indicated the podiatrist normally cut her toenails but had not for a long time due to his inability to come to the facility when scheduled. She indicated she had discussed her toenail concerns with the Social Service Director. She indicated her excessively long toenails caused walking to be painful. During an observation, on 5/6/25 at 11:24 AM, Resident 52 removed her shoes and socks revealing very long toenails. Her right great toe and the next two toes had thin toenails extending about 1/2 cm beyond the end of her toes with irregular edges. A callous, about 2 cm in diameter, raised about 1/2 cm was present on the ball of her right foot. Her left great toenail and second toenail were observed to be long and very thick. Resident 52's record was reviewed on 5/6/25 at 11:37 AM. Diagnoses included type 2 diabetes without complications and dementia. A review of Resident 52's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 12(mild cognitive impairment). A review of progress notes dated 4/1/25 to 5/6/25 did not contain any documentation of hygiene care refusal. Skin evaluations dated 4/14/25, 4/23/25 and 5/4/25 did not include documentation of long toenails. In an interview, on 5/6/25 at 11:25 AM, the Regional Nurse Consultant (RNC) indicated Resident 52's nails were excessively long and should have been trimmed. She indicated nails were observed during weekly skin checks by nurses, during care and showers by nurse aides. She indicated nurses were able to cut diabetic nails that were not excessively thick, requiring podiatry tools. She indicated the podiatrist had last seen Resident 52 in February and was not able to come to the facility for the visit due in April. In an interview, on 5/6/25 at 11:37 AM, the RNC indicated the podiatrist had last treated Resident 52 on 2/12/25. She indicated the podiatrist was unable to come to the facility on his regularly scheduled visit in April 2025. She indicated Certified Nurse Aides should have identified the long nails during showers and other daily care and reported it to the nurses. She indicated nurses should have identified the long nails during weekly skin assessments and provided any nailcare they were able to provide. Any nailcare they were unable to provide should have been reported to management to arrange a podiatry visit. A current policy titled Activities of Daily Living dated 1/2/24 provided by the RNC on 5/6/25 at 11:47 AM indicated a resident unable to provide any activity of daily living by themselves should be provided the necessary services to maintain good grooming. 3.1-38(a)(3)(E)

Based on observation, interview, and record review the facility failed to ensure staff areas remained secure and smoking materials were secured for 1 of 12 residents reviewed. (Resident 53) Findings include: During an observation, on 5/4/25 at 10:14 AM, Resident 53 indicated he knew almost all the keypad door codes in the building. Resident 53 demonstrated entering the code and gaining access to the conference room, dementia unit, housekeeping closet, shower room and pantry room. Cleaning products were observed in the conference room and housekeeping closet. He verbalized he knew the door codes for in and out access to the smoking area, front doors and end of hallway doors to the outside of the building. During an interview, on 5/4/25 at 10:14 AM, Resident 53 indicated he was supposed to be supervised by staff when smoking and vaping outdoors, but he frequently went by himself. He indicated he vaped in his room at times although he had been told not to. He indicated he stored smoking materials in his safe in his room. He indicated he believed he should be able to vape inside if there was not any nicotine in his vape cartridge. During an interview, on 5/4/25 at 10:29 AM, Qualified Medicine Aide (QMA) 8 indicated Resident 53 knows the codes for most of the keypad entry doors. He indicated whenever the codes had been changed, Resident 53 learned the codes quickly. During an interview, on 5/4/25 at 10:35 AM, Certified Nurse Aide (CNA) 11 indicated Resident 53 knew all the door codes. She indicated staff could not do anything about Resident 53 knowing the codes because he learned the codes right away after they were changed. She indicated all residents in the facility should be supervised when smoking or vaping. During an interview, on 5/4/25 at 10:55 AM, Resident 53 entered the door code to the conference room, held up a Bic lighter indicating the lighter belonged to his roommate. He indicated he had an additional lighter and a lock picking kit locked in his safe in his room. QMA 8, CNA 9, and QMA 10 were present in the interview area. They did not intervene or ask Resident 53 to give them his smoking materials. During an interview, on 5/4/25 at 1:10 PM, Resident 53 indicated the Administrator went around the building and collected lighters and smoking materials from all the smokers when he arrived at work. Resident 53's record was reviewed on 5/4/25 at 1:10 PM. Diagnoses included schizoaffective disorder, antisocial personality disorder, attention deficit hyperactivity disorder, predominantly inattentive type, and anxiety disorder. A review of Resident 53's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). A review of Resident 53's current care plan titled Tobacco Use indicated Resident 53 had a problem of being a current tobacco user, with a goal date of 6/22/25. Interventions included supervising Resident 53 while smoking. A review of Resident 53's current care plan titled, known for non-compliance with smoking policy, indicated the Resident 53 had a problem of being a current tobacco user, with a goal date of 6/22/25. Interventions included notifying the charge nurse when Resident 53 violated the smoking policy. The care plan indicated Resident 53's smoking materials should be kept by facility staff. A review of a document titled Smokers, provided by the Administrator on 5/4/25 at 1:10 PM indicated 12 residents participated in smoking activities. A review of progress notes dated 4/1/25 to 5/7/25 did not contain any documentation of entry into restricted areas, possession of smoking materials or unsupervised smoking or vaping. A progress note dated 5/6/25 at 7:14 PM indicated Resident 53 had been attempting to pick locks in the building and was placed on direct supervision. In an interview, on 5/6/25 at 9:25 AM, the Social Services Director indicated smoking materials were kept locked in the medication room and accessed by the staff member supervising the smokers. The cigarettes were distributed to residents in the smoking area by the staff member who maintains possession of the case of materials throughout the process. She indicated all residents who smoke should be supervised every time they smoke. No resident may smoke or vape unsupervised. In an interview, on 5/7/25 at 8:15 AM, the Administrator indicated Resident 53 had been observed picking a lock and was placed on one-to-one supervision. The Administrator indicated residents should not be able to enter locked facility locations designated for staff only access. In an observation, on 5/7/24 at 8:17 AM, the Administrator presented a video on a cell phone showing Resident 53 using a plastic card, consistent with the size of a credit, debit or identification card, successfully opening the locked door of the pantry room. A current policy titled Smoking, dated 2/14/25, provided by the Administrator on 5/7/25 at 9:19 AM indicated smoking, including the use of electronic cigarettes, was prohibited in designated smoking areas. The policy indicated residents who require supervision while smoking should be supervised by a staff member, family member or volunteer while smoking. The policy indicated the care team maintains a storage system of smoking materials for supervised smoking. This citation is related to Complaint IN00458229. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure the dining room, the 300 hall and one resident room was maintained. Findings include: During an observation, on 05/04/25 at 12:29 PM, the dining room had 4 small areas of the ceiling without paint to match the ceiling. The main doorway corner had a deep gouge approximately 2.5 inches in length by 0.75 inches wide in the drywall, approximately 3 feet from the floor. Drywall was missing in 3 smaller areas down the same corner of the doorway. During an observation, on 5/05/25 at 10:53 AM, heavy dust particles were found on the drop ceiling and metal supports outside room [ROOM NUMBER]. Two groups of three rectangle marks about 1 inch wide were found on the wall between rooms [ROOM NUMBERS], and outside the infection control office. During an observation, on 05/05/25 at 10:14 AM, a 5 foot long trim piece was found on the floor, underneath the headboard of the bedcin room [ROOM NUMBER]. 4 nails, approximately 1-2 inches long were pointing upwards. A review of maintenance logs, on 05/05/25 at 11:45 AM, indicated there were no written work requests for wall or trim damage within the last 6 months. In an interview, on 05/05/25 at 10:34 AM, CNA 2 indicated she would verbally tell maintenance about equipment malfunctions, cracked fire extinguisher covers, or anything that needed fixed. In an interview, on 05/05/25 at 11:23 AM, the Maintenance Director indicated he received verbal or maintenance request forms from staff. The trim piece in room [ROOM NUMBER] needed removed from the room. In an interview, on 5/5/25 at 11:30 AM, the Housekeeping Manager indicated paint repairs should get done the same day as they are reported. In an interview, on 05/08/25 at 9:28 AM, the Administrator indicated the dust on the ceiling and rectangular areas on the walls were something the facility would work on. A current policy, dated 12/12/2023, provided by administration, indicated work orders must be filled out and forwarded to the Maintenance Director. Work orders were to be picked up daily. Emergency requests would be given priority in making necessary repairs. This citation is related to Complaint IN00458229. 3.1-19(e)

Based on observation, interview and record review the facility failed to ensure services were provided for the grooming of facial hair for 1 of 2 residents reviewed (Resident 16). Findings include: On 7/24/24 at 10:34 AM Resident 16 was observed sitting in their wheelchair in the hallway. Resident 16 was observed to have a full mustache of dark hair. Resident 16's record was reviewed on 7/25/24 at 1:01 PM. Diagnoses included dementia, diabetes, stroke, pain in right shoulder, pain in left shoulder, hemiplegia (paralysis) of their left side and hemiparesis (weakness) of their left side. Resident 16's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 10 (moderate cognitive impairment). The MDS indicated Resident 16 required substantial or maximum assistance with personal care such as washing face, combing hair, shaving and applying makeup. Resident 16's Care Plan, dated 11/8/23, indicated the resident needed assistance with activities of daily living (ADLs). The target goal was for the resident to have their needs met daily with assistance from staff through 11/15/24. Interventions included staff assistance with bed mobility, eating, personal hygiene, toilet use, the use of a mechanical lift for transfers, encouraging participation, praising resident efforts, observing and reporting changes in ability to participate in ADLs and screening for the need for a therapy evaluation. Resident 16's Care Plan did not indicate the resident required assistance with grooming of facial hair. Resident 16's Care Plan did not indicate if the resident had a preference about their facial hair being shaved or being left intact. Resident 16's Kardex (care plan summary for providers of direct care) dated current as of 7/29/24 consisted of the following items: 1. Bathing-showers on the evening shift every Wednesday and Saturday 2. Personal Hygiene-staff assistance 3. Oral Care-specify dentures, natural teeth, partials or no teeth Resident 16's Kardex did not indicate the resident required assistance with grooming of facial hair. Resident 16's Kardex did not indicate if the resident had a preference about their facial hair being shaved or being left intact. In an interview on 7/30/24 at 9:43 AM, the Administrator indicated Resident 16 often refused personal care. The Administrator indicated they were unaware the grooming of facial hair had not been included on the resident's Care Plan or Kardex. The Administrator indicated the grooming of facial hair should be offered by the staff- even for female residents. The Administrator agreed including the grooming of facial hair on the Care Plan and the Kardex would remind the staff to offer assistance. In an interview on 7/30/24 at 10:34 AM, the Regional Nurse Consultant and the Director of Nursing (DON) indicated Resident 16 did not have facial hair on 7/30/24. The DON indicated Resident 16 would allow a certain staff member to assist with personal care. The DON indicated Resident 16's refusals of personal care, the resident's preference to have facial hair removed and their preference for a certain staff member should have been on the resident's Care Plan and Kardex. The Regional Nurse Consultant indicated Resident 16's preferences included on the Kardex would be beneficial in making all direct care staff aware of the resident's needs. In an interview on 7/30/24 at 11:20 AM, the Administrator indicated a resident diagnosed with dementia could possibly be unaware of their facial hair. The Administrator indicated facial hair on a woman could be a dignity issue. A current facility policy dated 2001 and revised 3/2018 provided by the Administrator on 7/30/24 at 9:35 AM indicated the facility would provide services according to the resident's MDS assessment for bathing, dressing, grooming and oral care. The policy indicated refusal of personal care by a resident with dementia would be investigated to determine the underlying cause for refusal. 3.1-38(a)(3)

Based on observation, interview and record review, the facility failed to identify triggers to prevent potential re-traumatization for 2 of 11 residents reviewed for mood/behavior (Resident 3 and Resident 16). Findings include: 1. In an observation on 7/24/24 at 10:40 AM, Resident 3 was observed laying in her bed yelling. A staff member arrived, and the resident indicated she wanted to get up. The resident's call light was attached to her bed linens within arm length. In an observation on 7/25/24 at 2:10 PM, Resident 3 was observed laying in her bed yelling out from her room. A staff member arrived, and the resident indicated she needed her brief changed. The resident's call light was attached to her bed linens within arm length. In an observation on 7/26/24 at 12:32 PM, Resident 3 was observed sitting in her wheelchair at the nurses station counter with her lunch in front of her. The resident's arms were shaking, and the Administrator was assisting her. Resident 3's record was reviewed on 07/25/24 at 12:37 pm. Diagnoses included paranoid schizophrenia, schizoaffective disorder, personality disorder, obsessive-compulsive personality disorder, generalized anxiety disorder, severe recurrent major depressive disorder with psychotic episodes, and intellectual disability. Resident 3's current annual Minimum Data Set (MDS) assessment, dated 6/17/24, indicated her Basic Interview for Mental Status (BIMS) score was 11 (moderate cognitive impairment). The MDS indicated the resident experienced 7-11 days in a 2-week period of decreased interest or pleasure in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, feeling bad about herself, she was a failure or had let herself or her family down, and had trouble concentrating on things such as reading the newspaper or watching TV. The MDS indicated the resident experienced 2 - 6 days in a 2-week period of trouble falling or staying asleep or sleeping too much and a poor appetite or overeating. The MDS indicated Resident 3 was on antipsychotics, antidepressants, and antianxiety medications in the last 7 days. Resident 3's Preadmission Screening and Resident Review (PASRR), dated 9/1/22 with an effective date of 8/25/22, indicated she had experienced sexual abuse as a child and was sexually assaulted as a teen. The PASRR indicated she had extreme focus on sexual thoughts, disrobed, rolled around on the ground, thought of ending her life by beating herself up, angry behaviors, chose not to eat, take medications, and/or shower, attempted to leave a group home, and distrust or belief others were trying to harm her, were watching her, or were planning to put her in jail. Resident 3's Initial Social Service History, dated 8/11/23, indicated the resident had some schooling, had some mental disabilities, had been raped and molested as a child over and over, and had been in and out of facilities. Resident 3's Social Service History did not identify the resident's specific identified triggers that could cause Resident 3's re-traumatization of her life experiences. Resident 3's Adverse Childhood Experience (ACE) Questionnaire, dated 8/11/23, indicated the resident answered yes to 10 of 10 questions. This indicated Resident 3 was at high risk to experience toxic stress related to agressive behaviors and sleep diturbances. Resident 3's Psychiatry Progress Notes, dated 7/23/24, indicated the resident was diagnosed with a mental illness at [AGE] years old. The progress note indicated the resident was sexually abused as a child and assaulted as a teen. The progress note indicated the resident was divorced and had two children she had given up for adoption. The progress note indicated the resident experienced severe distrust and focused on frequent sexual thoughts. The progress note indicated the resident had a history of rolling on the floor, had beat herself up, had thoughts of ending her life, and had noncompliance with care with a current complaint of not sleeping well. The progress notes indicated the resident hallucinated; she heard voices singing to her. The progress note indicated the resident had multiple admissions at the State Hospital with Electroconvulsive therapy (ECT) (psychiatric treatment where a generalized seizure is electrically induced to manage refractory mental disorders), and psychiatric hospitals. The most recent admission was due to psychosis and delusions. Resident 3's current Kardex (brief overview of each patient, updated every shift, used by the facility's Certified Nursing Assistant), dated 7/29/24, did not identify Resident 3's specific identified triggers with a potential to cause re-traumatization of her life experiences. A physician's order, dated 8/10/23, indicated Resident 3 could receive psychiatrist services. A physician's order, dated 8/10/23, indicated Resident 3 received Invega 6 milligrams (mg) daily and Invega 3mg at bedtime for depressive type schizoaffective disorder. A physician's order, dated 3/20/24, indicated Resident 3 received risperidone 0.5mg daily for depressive type schizoaffective disorder and major recurrent depressive disorder with psychotic symptoms. A physician's order, dated 3/7/24, indicated Resident 3 received Ativan 1mg two times a day for anxiety. Resident 3's behavior symptoms task monitor indicated the resident displayed the following behaviors 7/1/24 through 7/29/24: Behaviors Number of times -Yelling/Screaming: 38 -Kicking/Hitting: 1 -Wandering: 2 -Abusive Language: 8 -Rejection of Care: 2 Resident 3's current care plan titled Psychosocial Wellbeing Problem, revised 7/08/2024, indicated the resident's life experience included being raped, growing up in a home with emotional and physical abuse, family discord, and witnessing abuse. Resident 3's care plan goal, target date 11/21/24, indicated she would demonstrate the ability to seek out staff support when feeling frustrated or provoked. Interventions included 1) consult with pastoral care, social services and psych services, 2) encourage resident and family/representative to attend quarterly care plan meetings and to be involved in the plan of care, and 3) when conflict arises, remove resident to a calm safe environment and allow her to vent/share feelings. The care plan did not include resident specific identified triggers with a potential to cause re-traumatization of her life experiences. Resident 3's care plan goal, target date 11/21/24, did not include the elimination or reduction of resident specific identified triggers with a potential to cause re-traumatization of her life experience. Resident 3's current care plan titled Behavior Symptoms, revised 7/8/24, indicated the resident experienced behavioral symptoms related to her life experiences of thoughts others talked about her, thoughts others would not listen to her, thoughts others would not give her attention, repetitive noises and movements, being anxious, yelling out, and screaming. Interventions included she would demonstrate the ability to seek out staff/caregiver support when she felt frustrated. The care plan did not include resident specific identified triggers with a potential to cause re-traumatization of her life experiences. Resident 3's care plan goal, target date 11/21/24, did not include the elimination or reduction of resident specific identified triggers with a potential to cause re-traumatization of her life experience. 45794 2. On 7/27/24 at 10:33 AM Resident 16 was observed sitting in their wheelchair in the hallway outside their room. Resident 16 did not make eye contact when spoken to. Resident 16 declined being interviewed. Resident 16's record was reviewed on 7/25 24 at 1:01 PM. Diagnoses included psychotic disorder with delusions, major depressive disorder, dementia, anxiety, visual hallucinations and cerebral infarction (stroke). Resident 16's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 10 (moderste cognitive impairment). The MDS indicated Resident 16 had rejected care. The MDS indicated Resident 16 had dementia, (non-Alzheimer's) anxiety, depression and psychotic disorder. The MDS indicated Resident 16 had episodes of refusing care. Resident 16's Behavior Monitoring and Interventions Report dated 7/1/24 through 7/29/24 indicated the number of times the resident had displayed the following behaviors: 1. Wandering-9 2. Delusions-2 3. Repetitive motions-2 4. Pick at self-2 5. Pushing others-1 6. Disruptive sounds-1 7. Throwing/smearing bodily waste-1 8. Agitation-1 9. Scratching self-1 Resident 16's Care Plan dated 11/25/23 indicated the resident displayed behaviors of visual hallucinations, delusions, yelling, screaming, abusive language and refusal of care. The target goal was Resident 16 would allow support from the staff during the behaviors by 11/15/24. Interventions included medications as ordered, meeting the resident's needs, offering coloring supplies, providing the resident with choices, approaching later and placing the resident at the nurse station. Resident 16's Care Plan did not include attempting to identify resident specific triggers or stressors. Resident 16's Care Plan did not include attempting to identify the resident's specific stressors or triggers with a potential to lead to visual hallucinations, delusions, yelling, screaming, abusive language or refusal of care. Resident 16's Care Plan dated 11/25/23 indicated the resident had a history of trauma, post- traumatic stress disorder, (PTSD) memory problems and sadness as evidenced by sad face, sad affect and statements of sadness. The target goal was for Resident 16 to have positive social interactions with peers by 11/15/24. Interventions included to encourage the resident to share their concerns and wishes and ensure the resident's preferences were communicated to caregivers. Resident 16's Care Plan did not include attempting to identify resident specific triggers or stressors. Resident 16's Care Plan did not include attempting to identify the resident's specific stressors or triggers with potential to cause the resident to make sad statements, have a sad face or have a sad affect. Resident 16's Care Plan dated 11/25/23 indicated the resident had verbalized or displayed the following: feeling down, feeling depressed, feeling hopeless, trouble falling asleep, trouble staying asleep, feeling tired, poor appetite and feeling restless. The target goal was for the resident to seek out staff to vent and to encourage activities with peers through 11/15/24. Interventions included encouraging the resident to express feelings. Resident 16's Care Plan did not include attempting to identify resident specific triggers or stressors. Resident 16's Care Plan did not include specific stressors or triggers with a potential for the resident to feel down, feel depressed, feel hopeless, have trouble falling asleep, have trouble staying asleep, feel tired, have poor appetite or feel restless. Resident 16's Care Plan did not indicate the resident displayed behaviors of wandering, pushing others, throwing or smearing bodily waste, picking at self or scratching self. Resident 16's Kardex (care plan summary for providers of direct care) dated current as of 7/29/24 indicated the resident required assistance with the following: 1. Safety-anti-tippers to wheelchair, mattress to floor, offer of getting up if restlessness is noted and re-education on use of the call light 2. Bathing-showers on the evening shift every Wednesday and Saturday 3. Eating-mechanically altered diet, observe for choking, difficult swallowing, coughing, holding food in their mouth, appearing concerned during meals and refusing to eat 4. Transferring-mechanical lift 5. Resident Care-pressure relieving mattress to bed, pressure relieving cushion to wheelchair 6. Bed Mobility-staff assistance 7. Personal Hygiene-staff assistance 8. Oral Care-specify dentures, natural teeth, partials or no teeth 9. Toileting-assist with toileting Resident 16's Kardex did not indicate the resident had a history of trauma, depression, anxiety, visual hallucinations or delusions. Resident 16's Kardex did not indicate they displayed behaviors of agitation, verbal aggression, refusal of care, delusions or visual hallucinations. Resident 16's Kardex did not indicate specific resident stressors or triggers with a potential to cause re-traumatization, anxiety, agitation, delusions, visual hallucinations or refusal of care. Resident 16's Kardex did not include interventions to minimize the resident's behaviors. Resident 16's Preadmission Screening and Resident Review (PASRR), dated 2/29/24, indicated the resident's diagnoses were psychotic disorder, unspecified depressive disorder, unspecified anxiety disorder and major neurocognitive disorder (dementia) due to multiple etiologies with behavioral disturbance. Resident 5's PASRR indicated their BIMS score was 5 (severe cognitive impairment). A physician order dated 7/23/24 indicated Resident 16's sleep disturbances were to be documented every night due to trouble sleeping. A Psychiatry Progress Note dated 7/23/24 at 6:37 PM indicated Resident 16 had a history of refusal of medications, therapy and personal care. The note indicated Resident 16 was often tearful. Resident 16 had indicated they had been sad for a long time and did not know what caused the sadness. A Behavioral Health Progress Note dated 4/9/24 at 5:47 PM indicated Resident 16 had lived at home with their husband prior to having a fall in the garage. Resident 16 had remained on the garage floor for an undetermined amount of time. Resident 16's husband had a difficult time caring for the resident due to their progression of dementia. Resident 16 had often been paranoid and agitated which resulted in many arguments between the resident and their husband. Resident 16 had served in the Women's Army Corp where they worked with the emergency medical technicians and the military police. In an interview on 7/29/24 at 10:45 AM, the Administrator indicated they were unaware of the need for identification of triggers for trauma survivors. The Administrator indicated Social Services was responsible for mental health Care Plans. In an interview on 7/30/24 at 10:52 AM, the Social Service Director (SSD) indicated they had been employed at the facility for 3 weeks. The SSD indicated they were in the process of reviewing all the facility Care Plans. The SSD indicated each resident should be assessed for the history of trauma upon admission to the facility. A current facility policy dated 1/2/24 provided by the Director of Nursing (DON) on 7/29/24 at 10:30 AM, indicated the facility would identify triggers with a potential to re-traumatize trauma survivors. The policy indicated the facility would identify trigger specific interventions and add the interventions to the resident's Care Plan. For residents who were resistant to sharing their trauma history details, the policy indicated the facility would still make attempts to identify resident specific triggers and formulate Care Plan interventions to minimize the resident's trauma response. A current facility policy dated 1/2/24 provided by the DON on 7/29/24 at 10:30 AM indicated resident specific behavioral Care Plan interventions would be made available on the resident's Kardex.

Based on observation and interview the facility failed to ensure medication carts were secured/locked for 2 of 2 observations. 29 residents resided on the 100 hall. Findings include: During an continuous observation on 11/28/23 at 1:29 PM - 1:32 PM, 2 medication carts on 100 hall were unlocked. The 2 medication carts each had 1 drawer partially open. 2 residents were observed walking past the medication carts. There were also no staff present at the medication carts. During an observation on 11/28/23 at 1:43 PM, 2 medication carts on 100 hall were unlocked. There were no staff present at the medication carts. In an interview on 11/28/23 at 1:32 PM, Qualified Medication Aide (QMA) 2 indicated she was scheduled as the QMA on the 100 hall. QMA 2 indicated she should have locked the medication carts and computers closed prior to walking away from the carts. A resident roster was provided by the Administrator on 11/28/23 at 12:30 PM. The roster indicated 29 residents resided on the 100 hall. A policy, dated 2/2017, titled Medication Storage and Labeling, was provided by the Director of Nursing on 11/28/23 at 2:25 PM. The policy indicated medication carts are secured/locked and only accessible to designated staff. This Citation relates to Complaint IN00421807. 3.1-25(m)

Based on interview and record review the facility failed to ensure medications were giving as ordered for 2 of 5 residents reviewed (Resident B, Resident C). Findings include: 1. In an interview on 8/22/23 at 9:46 AM, Resident B indicated he had not received his medications as ordered, especially in the evenings. Resident B's record was reviewed on 8/22/23 at 11:03 AM. Diagnosis included, epilepsy, glaucoma, multiple sclerosis, hypothyroidism, and Crohn's disease. An annual Minimal Data Set (MDS) assessment, dated 6/23/23 indicated Resident B had a Brief Interview Mental Score (BIMS) of 15/15 (cognitively intact). A Medication Administration Record (MAR) dated August 1, 2023- August 21, 2023 indicated the following: An order, dated 1/16/23, indicated to give hydrocortisone oral tablet 5 mg for hormone replacement (cortisol) after supper. The MAR indicated the medication was not administered on: 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 9/13/21, indicated to instill 1 drop of lubricating plus eye drops 0.5% in both eyes at bedtime. The MAR indicated the medication was not administered on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 5/28/23, indicated to give oxycodone (opioid) -acetaminophen oral 1(7.5-3.25 MG) tablet every 12 hours for pain. The MAR indicated the medication was not administered in the evening on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 6/24/21, indicated to give phenobarbital (anticonvulsant) tablet 64.8 mg 1 tablet 2x daily for seizures. The MAR indicated the medication was not administered in the evening on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. There was no other documentation related to the missed medication in Resident B's chart. 2. In an interview on 8/22/23 at 9:46 AM, Resident C indicated she had not received her medications as ordered. Resident C's record was reviewed on 8/22/23 at 11:02 AM. Diagnosis included, schizoaffective disorder: bipolar type, gastroesophageal reflux disease (GERD), dry eye syndrome, allergic rhinitis, and overactive bladder. A quarterly MDS assessment, dated 7/17/23, indicated Resident C had a BIMS of 12/15 (moderately impaired). A MAR, dated August 1, 2023- August 21, 2023 was reviewed. The MAR indicated the following: An order, dated 6/13/23 indicated to give desmopressin acetate (antidiuretic) tablet at bedtime for overactive bladder. The MAR indicated the medication was not administered on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 4/27/23, indicated to administer lithium carbonate (antimanic) 1 tablet at bedtime for schizoaffective disorder, bipolar type. The MAR indicated the medication was not administered on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 5/4/23, indicated to administer omeprazole 1 capsule for GERD daily. The MAR indicated the medication was not administered on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 5/15/23, indicated to administer flonase allergy relief suspension: 1 spray in both nostrils 2x day for allergies. The MAR indicated the medication was not administered in the evening on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. An order, dated 3/4/23, indicated to instill refresh tears 0.5% solution: 2 drops in both eyes 2x daily for ophthalmic agents. The MAR indicated the medication was not administered on 8/8/23, 8/14/23, 8/19/23 or 8/21/23. There was no other documentation related to the missed medications in Resident C's chart. In an interview on 8/22/23 at 12:20 PM the Director of Nursing (DON) indicated she was unable to find any documentation related to why the medications were not given as ordered. The DON indicated Resident B and Resident C should have received their medications as ordered. A current policy, dated April 2012, titled Guidelines for Charting and Documentation, was provided by the DON on 8/22/23 at 12:43 PM. The policy indicated all medication administered or refused should be documented. This Federal citation relates to Complaints IN00414847 and IN00415402. 3.1-37 (a)

Based on observation, interview, and record review the facility failed to ensure environmental Mintenance for 14 of 82 residents residing in the facility. Findings include: 1. During an observation on 7/17/23 at 9:43 AM, trim along the length of the right side of the bathroom door in room [ROOM NUMBER] was missing. 8 raised metal clips were spaced along the length of the space where trim would normally be placed. Each clip was 2 cm by 6 cm and protruded 3 cm from the wall. 2 residents resided in room [ROOM NUMBER]. In an observation and interview on 7/19/23 at 10:34 AM, the Administrator indicated the protruding clips could cause injury and should have been addressed. He indicated maintenance needs should have been identified during routine room rounds. He indicated the facility did not have a specific policy for room rounds. 2. During a continuous observation beginning on 7/18/23 at 3:10 PM, a door to the maintenance office across the hall from the dining room was propped open with a 5- gallon bucket. A white bottle containing cleaning supplies such as window cleaner and toilet cleaner were on shelves adjacent to the door and visible from the hallway. No staff members were in the office or in the hallway near the office. Residents were in the process of gathering in the dining room for the scheduled bingo activity across the hall. In an observation and interview with the Administrator on 7/18/23 at 3:25 PM, the Administrator indicated the door should not be propped open when not in direct attendance of a staff member due to the presence of potentially harmful chemicals. A list of residents who attended the bingo activity received from the Activity Director on 7/20/23 at 11:59 AM indicated 12 residents were in the dining room during the observations. A current policy dated 7/17 provided by the Director of Nursing indicated examples of hazards included open areas that should be locked when not in use, and access to toxic chemicals. The policy also indicated any element of the resident environment that has the potential to cause injury and is accessible to a vulnerable resident. 3.1-19(f)

Based on observation, interview and record review, the facility failed to ensure dementia care interventions were implemented for 3 of 4 residents reviewed (Resident K, Resident L, and Resident N). Findings include: 1. On 6/28/23 at 1:36 P.M., Resident N's family member was interviewed. The family member indicated she had been notified there had been an incident on 6/24/23 which resulted in the resident getting a large skin tear on her forearm during care. The family member indicated the resident was never combative and was upset that such a large skin tear could occur while trying to assist her into her night clothes. On 6/28/23 at 2:10 P.M., Resident N was observed standing in the middle of her room wearing a very large pair of blue pants. She was frowning, her brows elevated and furrowed. She indicated she had someone else's pants on, the blue ones were not hers. She sat on the bed and tried to take them off as her daughter tried to soothe her and find her a different pair of pants. After a different pair of pants were found and put on, Resident N was all smiles. She was hard of hearing and would put her ear near the speakers mouth so she could hear what was being said. She showed her daughter her left forearm where a clear dressing covered the large area and kept trying to peel the edges of the dressing. On 6/28/23 at 2:49 P.M., Resident N's record was reviewed. Diagnoses included Alzheimer's disease with late onset, major depressive disorder, generalized anxiety order, and disorder of the acoustic nerve (nerve that connects from ear to brain and controls hearing and balance). A quarterly MDS (Minimum Data Set) assessment, dated 5/31/23, indicated the resident had severely impaired cognition. She had new mood indicators of having little interest or pleasure in doing things, feeling down or depressed, trouble falling asleep/sleeping too much, and feeling bad about herself (indicated moderate depression). She had no behaviors but had disorganized thinking. The resident required supervision and walked without assistance in her room and hallway. She required limited assistance with dressing and extensive assistance of 1 with toileting and personal hygiene. Care plans indicated the following: -5/3/21, the resident had cognitive impairment due to Alzheimer's disease. Interventions included to be alert to her non-verbal cues, problems or unmet needs and intervene as needed. -5/3/21, exhibits signs and symptoms of anxiety with a goal of her demonstrating effective coping skills. Interventions included to listen to her needs and adjust the plan as appropriate and if combative or resistive, postpone care/activity and allow her to regain her composure and re-approach. -3/1/22, the resident had behavior symptoms and physical aggression such as slapping people out of confusion with a goal of the resident's needs being met. Interventions included approaching her in a calm and friendly manner and explaining to her what was going to be done prior to initiating a task. Review of behavior reports indicated Resident N had no behaviors during the month of June 2023 other than 1 episode of wandering. A change in condition report, dated 6/24/23 at 9:50 p.m., indicated the resident had a skin tear. A new order was to keep the area covered with a dressing. A Telehealth note, dated 6/25/23, indicated the resident had a skin tear after being combative with a CNA (Certified Nurse Aide) while being changed. Her left arm had a large skin tear and the resident kept picking at the dressing. She was completely unaware of the injury. On 6/28/23 at 10:37 A.M., CNA 10, was interviewed. She was assigned on the hall to care for Resident N. She indicated she had never witnessed the resident be combative with anyone including staff. The resident was always happy, gave hugs and kisses, and kept to herself. CNA 10 indicated the resident did much of her own care for herself; took herself to the bathroom and dressed herself. Occasionally, she would need assistance following bowel incontinence. On 6/29/23 at 2:02 P.M., CNA 15 was interviewed. The CNA had been caring for Resident N when she got a skin tear. The CNA indicated she hadn't been very familiar with the resident and was trying to help out the CNA assigned to that group. She asked the resident if she could help her change her pants as they were soiled and the resident said no however, there was stool all over her pants and on the bed linens. She thought the resident had changed her mind as she stood up from the bed and started to pull down her pants. When the CNA tried to help her, the resident pushed, screamed and slapped the CNA. CNA 15 indicated she held onto the residents arm to keep her from slapping and allowed her to remove the soiled pants. When questioned, CNA 15 hadn't known the resident could be combative, how many staff were supposed to care for her, or what care was to be provided and what care the resident could perform herself. She had no care sheet, care plan, or CNA assignment sheet that explained the care to be given. 2. On 6/28/23, the following observations and interviews were completed on the secured memory care unit where Resident K resided. -9:45 A.M., during an initial tour of the secured memory care unit, several male residents were observed ambulating throughout the hallway and other resident's rooms. An unidentified male resident, sat in a wheelchair near the door and was trying to speak with anyone that came near him. He had a grimace on his face and tears in his eyes and raised his voice at times, as he tried to communicate his frustration.In the dining room, 2 activity staff were observed trying to assist residents to sit at the table for an activity. Once seated, some of the resident's would get back up and were redirected to sit down and participate in the activity. 2 CNA's (Certified Nurse Aides) and a nurse were observed trying to provide personal care and medications to residents. They were continually up and down the hallways and into rooms trying to provide care while intervening with wandering residents going into others rooms. Resident K was seated in the dining room and participated in the balloon toss activity. -11:59 A.M., residents were observed in the dining room as staff passed out lunch trays. Resident K was seated at a different table eating his lunch. Doors to the resident's rooms were closed. Staff went into each resident room, delivering trays and assisting resident's out of the rooms that were not their's. A male resident was escorted out of another resident's room. After walking a few steps down the hallway, CNA 2 observed the resident had a soiled sock and removed it from his hand. -3:15 P.M., 5 residents on the memory care unit were observed wandering up and down the hallway while others sat in the dining room. 2 CNA's were seated at the nurse's station but would get up often to redirect residents away from others or intervene with resident's displaying behaviors. 1 female resident was lying on the floor near the desk. Staff were encouraging her to get off the dirty floor. A male and female resident were overheard in the dining room, arguing and raising their voices and cursing. Staff quickly intervened and removed the female resident from the dining room. Staff present were interviewed about dementia care provided on the unit. CNA 3 indicated they always worked on the memory care unit and spent most of their time, intervening in resident conflicts or redirecting them. Most of the residents on the unit wandered, had behaviors, and would only engage in activities for very short periods of time. When questioned, CNA 3 and Nurse 5 indicated resident behaviors were documented on the computer but there were no individualized interventions to implement for resident behaviors other than distract and re-direct as the dementia of residents on the unit was so advanced. The Memory Care Unit Coordinator indicated staff tried to keep residents busy but their attention span was extremely short. When questioned about behaviors and assessment of residents prior to being placed on the unit, she indicated she'd had no involvement in who was admitted , what behaviors the residents may have and how it would affect other residents residing on the unit. On 6/28/23 at 11:50 A.M., Resident K's record was reviewed. Diagnoses included dementia with agitation, anxiety disorder, and psychotic disorder with delusions. He resided on the secured memory care unit. Care plans were: -6/8/23, the resident had cognitive impairment due to dementia. The goal was for him to interact with others daily for mental stimulation with an intervention of allowing the resident extra time to respond. -6/15/23, the resident exhibited behaviors due to dementia and anxiety. The goal was for him to seek out staff/caregiver support when feeling frustrated or provoked. Interventions were non-specific and included providing medications as ordered, if combative or resistive, postpone care/activity, re-approach, and document behaviors per behavior management program. An admission note, dated 6/6/23 at 1:33 P.M., indicated the resident was alert and oriented to himself with clear speech. He required extensive assistance of 1 staff member to walk but his gait was unsteady. He was not easily redirected and hadn't followed verbal instructions regarding safety. Progress notes indicated the following: -6/7/23 at 5:46 p.m., Resident K wandered in and out of other resident's rooms, incontinent of bowel and bladder. He was uncooperative with care at times and difficult to redirect. There was no indication of behavioral interventions attempted. -6/8/23 at 6:46 p.m., Resident K roamed into other resident's rooms. He walked by himself with a steady gait. He was confused to place, time, and person and was combative with care. There was no indication of behavioral interventions attempted. -6/12/23 at 8:52 p.m., the resident was observed to strip naked several times while walking down the hallway and wandering into other residents rooms. He was threatening, verbally aggressive with staff and threw a dirty brief in staff's face. He was unable to be redirected or dressed. He was monitored until the behavior ended and was assisted to bed. -6/13/23 at 6:54 p.m., the resident was involved in an altercation with another resident. He complained of a headache and was given Tylenol. There was no indication of behavioral interventions attempted. A Behavior Report for June 2023, indicated Resident K had the following behaviors: -1 episode of frequent crying. -9 episodes of repetitive movements. -9 episodes of yelling/screaming. -1 episode of kicking/hitting. -8 episodes of pushing. -10 episodes of grabbing. -4 episodes of pinching/scratching/spitting. -30 episodes of wandering. -19 episodes of abusive language. -15 episodes of threatening behavior. -5 episodes of sexually inappropriate behavior. -7 episodes of rejecting care. A counselors progress note, dated 6/27/23, indicated the resident was was no longer able to be maintained at home due to advancing dementia. Since admission, staff reported he was anxious, irritable, had sexually inappropriate behaviors towards staff and other residents, disrobed in the hallway and once threw a dirty brief at staff while being assisted to toilet. He was described as irritable, anxious, agitated, resisting care, delusional and sundowning. He had severely impaired cognition. The plan was to provide him with individual therapy and psychiatric treatment services. 3. On 6/28/23 at 12:06 P.M., Resident L's record was reviewed. Diagnoses included Schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder, psychotic disorder with delusions, and dementia with behavioral disturbance. The resident had a long psychiatric history and was hospitalized in February 2023 for physical aggression towards residents and staff which was triggered by another resident who wandered into her room. A quarterly MDS (Minimum Data Set) assessment, dated 6/12/23, indicated the resident had moderately impaired cognition. She had several mood indicators of moderate depression and disorganized thinking. She had delusions and rejected care over 1-3 days of the assessment. Care plans were: -11/9/22: The resident exhibited physical aggression toward other residents. The goal was to demonstrate the ability to seek out staff when feeling frustrated or provoked. Interventions included: provide resident with personal space and place a STOP sign on the resident's door. -3/28/22: The resident had an acute confusional episode and delusions due to schizoaffective disorder. The goal, with a target date of 7/3/23, was for the acute episode to be resolved. Interventions included: address environmental factors such as recent change in environment, environmental noise or commotion. A psychologist progress note, dated 5/30/23, indicated the resident was visited. During the visit, the resident told the therapist she was hearing voices and seeing things that she knew were not real and wanted to go to the psychiatric hospital. She indicated she wanted out of the facility and hadn't understood why she had to stay. She believed everyone was against her and if she wasn't able to leave, she would go to war. She refused a shot, had increased paranoia, and believed staff were trying to kill her with shots. A Behavior Report for June 2023, indicated Resident L had the following behaviors: -11 episodes of repetitive movements. -24 episodes of yelling/screaming. -1 episode of kicking/hitting. -5 episodes of pushing. -4 episodes of grabbing. -14 episodes of wandering. -21 episodes of abusive language. -16 episodes of threatening behavior. -2 episodes of sexually inappropriate behavior. -6 episodes of rejecting care. A social service note, dated 6/12/23 at 8:04 a.m., indicated the resident had increased agitation, refused her medications and was banging on the door saying she was ready to leave and go to jail. She yelled at staff and accused everyone of stealing her money. She was re-directed with snacks and a pop and agreed to take her medications. A progress note, dated 6/13/23 at 7:01 p.m., indicated the resident was involved in an altercation with another resident and was placed on 1:1 supervision until further IDT (Interdisciplinary Team) review. An IDT note, dated 6/16/23 at 2:46 p.m., indicated a review of the resident's past 180 days of behaviors indicated a trend regarding intrusive wanderers that entered her room. A progress note, dated 6/26/23 at 4:02 p.m., indicated the resident came out of her room, angry, because another resident had wandered into her open door and she started banging onto the door. A progress note, dated 6/28/23 at 8:27 a.m., indicated the resident was discharged and transported to a sister facility for continued care. On 6/28/23 at 3:20 P.M., CNA 3 and Nurse 5 were interviewed about how intrusive wandering residents were kept out of others rooms and they indicated room doors would be kept closed. When questioned, neither indicated interventions to be used if a resident hadn't wanted their door closed but wanted other residents to stay out of their room. Nurse 5 indicated it was a memory care unit and wandering residents was to be expected. She indicated use of a STOP sign or strap across the door wouldn't stop wandering residents because their dementia was too far advanced. CNA 3 and Nurse 5 indicated they would distract or re-direct to try and keep residents from wandering into others rooms. Neither CNA 3 nor Nurse 5 were aware of any specific, person centered interventions for behaviors for residents that resided on the unit. On 6/29/23 at 10:28 A.M., the Social Service Director (SSD) was interviewed. She indicated, currently, there were no specific, person-centered, dementia care plans for residents who resided on the secured memory care unit or who had a diagnosis of dementia. The facility did not have a dementia program in place but were in the process of implementing one. She indicated that she and the Memory Care Unit Coordinator were each receiving separate training from consultants on dementia care and were working on putting the pieces together to incorporate behaviors, dementia, and programming. On 6/29/23 at 11:00 A.M., the SSD provided a current copy of a policy titled Dementia Care which stated the following: It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being .1. The facility will assess, develop, and implement care plans through an interdisciplinary team approach that includes the resident, their family, and/or resident representative, to the extent possible. 2. The care plan goals will be achievable .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia progression .4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary This Federal tag relates to Complaints IN00410783, IN00411611, and IN00411878. 3.1-37

Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by staff for 2 of 4 residents reviewed. The deficient practice was corrected on 1/5/2023 when the facility completed mesures to remove the deficient practice. (Resident B, Resident E). Findings Include: 1. A record review was completed for Resident B on 1/19/2023 at 11:04 AM. Diagnoses included, unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and depression. An admission, Minimum Data Set assessment (MDS), dated [DATE], indicated Resident B had a Brief Interview Mental Status (BIMS) score of 00/15 (severely impaired). 2. A record review was completed for Resident E on 1/19/2023 at 11:05 AM. Diagnosis included dementia. A quarterly MDS assessment, dated 12/6/2022, indicated Resident E had a BIMS score of 13/15 (cognitively intact). An investigation file was provided by the Administrator on 1/19/2023 at 9:58 AM. The investigation file included a plan of action, dated 1/5/2023. The plan of action indicated a Certified Nursing Assistant (CNA) allegedly was verbally abusive to a resident on 1/4/2023. The file also included staff statements, as follows: Qualified Nursing Assistant (QMA) 3's statement, dated 1/4/2023, indicated she had assisted Resident E in the shower room when CNA 2 entered the shower room toilet area with Resident B. QMA 3 assisted Resident E out of the shower room and overheard Resident B repeating the word salad. CNA 2 told Resident B to stand twice and then the third time told Resident B to stand the f* up. CNA 2 continued to sternly repeat commands turn, sit, then sit again. QMA 3 then heard CNA 2 say this shift's f* retarded. QMA 3 then stepped in and told CNA 2 not to speak and handle the residents like that. QMA 3 indicated CNA 2 responded and who do you think you are? QMA 3 responded an employee who takes care of these residents almost every day. QMA 3 then notified management. The Assistant Director of Nursing (ADON)'s statement, dated 1/4/2023, indicated the ADON was notified by a CNA of CNA 2 talking and using explicit verbal wording when talking with a resident. The ADON and two other managers assessed the situation. CNA 2 was still using explicit verbal language while in the presence of the managers. The ADON and another manager talked with Resident E. Resident E indicated they overheard the conversation with the explicit language. Licensed Practical Nurse (LPN) 4's statement, dated 1/4/2023, indicated QMA 3 went to managers immediately. QMA 3 reported CNA 2 was being verbally abusive to a resident. CNA 2 also had cursed at staff. LPN 4 indicated herself, MDS Coordinator 5 and the ADON arrived on the hall, asked CNA 2 what happened and CNA 2 continued to curse in front of Resident E. MDS Coordinator 5's statement, dated 1/4/2023, indicated QMA 3 reported she was in the shower room with Resident E when CNA 2 entered the shower room with Resident B and assisted with their toileting. QMA 3 overheard CNA 2 say sit down, sit the f* down, this is retarded. QMA 3 indicated she intervened and told CNA 2 don't talk to the residents like that. QMA 3 indicated CNA 2 responded who the f* are you? QMA 3 indicated she responded a CNA who cares. QMA 3 then indicated she notifed management. MDS Coordinator 5 indicated she, and 2 other nurse managers went to the shower room to speak with CNA 2. MDS Coordinator 5 indicated CNA 2 was immediately defensive and continued to curse in front of the resident. CNA 2 indicated she made the statement to QMA 3. MDS Coordinator 5 indicated she and the ADON spoke with Resident E who was present and Resident E stated it was horrible, she cursed and yelled, saying f* and sit down. In an interview on 1/19/2023 at 10:43 AM, QMA 3 indicated on 1/4/2023, she had taken Resident E to the shower room and CNA 2 assisted Resident B into the room, but in the toileting area. QMA 3 indicated she heard CNA 2 tell Resident B to sit down then said sit the f* down. QMA 3 indicated she told CNA 2 not to talk to the resident like that and reminded CNA 2 to slow down especially when assisting residents with dementia. CNA 2 responded to QMA 3 as who the f* do you think you are? QMA 3 indicated Resident B was safe on the toilet at the time. QMA 3 indicated she notified management immediately. In an interview on 1/19/2023 at 10:54 AM, LPN 4 indicated on 1/4/2023, a staff member had notified her, the ADON and other management staff that a staff member was verbally abusive to a resident. LPN 4 indicated she and other management staff immediately arrived to the hall, CNA 2 was very rude and unprofessional at the time. LPN 4 indicated CNA 2 was told to leave, the resident was assessed, and the Director of Nursing and Administrator were notified. In an interview on 1/19/2023 at 10:33 AM, CNA 6 indicated verbal abuse included when a resident was put down by staff, staff used inappropriate language, yelled, screamed or name called towards and/or around residents. A current policy, last revised 3/2022, titled Abuse Prevention Program, was provided by the Administrator on 1/19/2023 at 10:20 AM. The policy indicated committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents verbal abuse: is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. The facility corrected the deficient practice prior to the beginning of the current survey, on 1/5/2023, after completing review of all residents, care plans, progress notes; staff education; monitoring; and clinical competency validations. This Federal citation is related to Complaint IN00398620. 3.1-27(b)

Based on observation, interview and record review, the facility failed to ensure a Registered Nurse was present in the building for at least 8 hours per day for 2 of 12 days reviewed. This deficient practice had the potential to affect 81 of 81 residents residing in the facility. Findings include: During a record review on 9/21/22 at 11:24 A.M., staffing schedules for the nursing department were reviewed. No Registered Nurses were listed on the schedule for Saturday, 9/17/22 and Sunday, 9/18/22. During an interview with the Administrator on 9/21/22 at 12:49 P.M., the Administrator indicated a Registered Nurse was scheduled to work on Saturday, 9/17/22 and Sunday, 9/18/22 and did not report to work. The Administrator indicated the shift was replaced with a Licensed Practical Nurse, and no Registered Nurses were working in the building on 9/17/22 and 9/18/22. In an interview with Nurse Consultant 7 on 9/21/22 at 2:11 P.M., she indicated she was not aware of a company policy on Registered Nurse Coverage. 3.1-17(b)(3)

Based on observation, interview, and record review the facility failed to protect residents in the secured unit from abuse related to a resident with physically and sexually aggressive behaviors. This resulted in physical and sexual abuse for in 5 of 5 residents reviewed for abuse. (Resident B, Resident C, Resident D, Resident E and Resident F) The immediate jeopardy began on 10-5-21 when the facility failed to put interventions and supervision in place to prevent abuse. The Executive Director, Director of Nursing Services, and Clinical Nursing Consultant were notified of the immediate jeopardy at 12:30 P.M. on 2-24-22. The immediate jeopardy was removed on 2-25-22 but noncompliance remained at the lower scope and severity level of pattern no actual harm with potential for minimal harm. Findings include: 1. Resident B's record review began on 2-23-22 at 10:15 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's most current quarterly MDS (Minimum Data Set) dated 1-5-22 indicated the resident was not able to be assessed for a BIMS ( brief interview for mental status) score due to memory. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 9-27-21 for [MEDICATION(S)] tablet 0.5 milligrams (mg). The order indicated to give 1 tablet 3 times a day for anxiety. On 10-1-21 for Southern Care hospice. On 10-7-21 for [MEDICATION(S)] tablet 50 mg. The order indicated to give 50 mg by mouth at bedtime for [CONDITION(S)]. On 10-12-21 for [MEDICATION(S)] tablet 100 mg. The order indicated to give 100 mg by mouth one time a day for major depressive disorder. On 12-1-21 for [MEDICATION(S)] tablet delayed released 125 mg. The order indicated to give 250 mg by mouth 3 times a day for anticonvulsant. On 12-10-21 for [MEDICATION(S)] tablet 1 mg. The order indicated to give 1 tablet by mouth every 6 hours as needed for as needed for anxiety and agitation On 2-22-22 for [MEDICATION(S)] tablet 2 mg. The order indicated to give 2 mg by mouth every 12 hours as needed for aggressive behavior until 2-27-22. A review of Resident B's care plan dated 10-6-21 indicated Resident B often exhibited behavior symptoms of unprovoked physical aggression to peers and or staff at times. The goal had a revision date of 1-13-22. The goal indicated Resident B would not have more than 1 of episodes physical aggression to peers monthly. Each intervention had a initiated date on 10-6-21. There was no documentation interventions had been updated. There was not a care plan to address sexual aggression. A review of a behavior management assessment dated [DATE] indicated Resident B had advanced dementia. The assessment indicated the resident continued with aggressive behavior, wandering, pacing, [CONDITION(S)], signs and symptoms of agitation. A sleep disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No other interventions were initiated. A review of the behavior management assessment dated on 12-9-21 indicated Resident B continued to be combative with care, had physical and verbal aggression with care, intrusive wandering, had exit seeking behavior, urinated in inappropriate places, and took items that were unsafe from staff at times. The Interdisciplinary team (IDT) recommend an evaluation by an NP since the resident was on hospice. A review of progress notes on 10-5-21 at 8:54 P.M. indicated the Resident B was moving things in the dining room, had verbal and physical aggression with staff, but was becoming calmer. There were no notes to indicate Resident B had a peer to peer altercation. A review of progress note dated 11-8-21, indicated the POA requested Resident B have lorezapam 1 mg on shower days to decrease his aggression. The NP was notified and new order was received. A review of progress notes dated 12-2-21 at 8:43 P.M. indicated Resident B was aggressive, grabbing private areas of Resident C. There was no documentation the resident was redirected or any intervention the staff had attempted to protect Resident C. A review of an NP note dated 12-3-21, indicated Resident B continued to have significant increased agitation. The NP noted they had increased the resident's divaloprex dose on 12-1-21. The note indicated the dose increase did not seem to be impacting the resident. Resident B was not overly cooperative with the visit, he posed a safety risk for himself, other residents and staff. The note indicated Resident B had significant sundowner's related to Alzheimer's. A review of the progress notes dated 1-2-22 at 8:24 P.M. indicated Resident B was observed entering Resident D's room. The note indicated there was a resident to resident altercation, but did not describe the nature of the altercation. The note indicated there were no injuries. There was no documentation the resident was redirected or any intervention the staff had attempted to protect Resident D. A review of progress notes dated 2-4-22 at 4:40 P.M. indicated the family and MD were aware of altercation with peer. There was no indication of the nature of the altercation. The note indicated the resident was placed on increased staff supervision and IDT monitoring. There was no description of what increased supervision or IDT monitoring consisted of. A review of the record did not indicate supervision or monitoring had been documented. In an observation on 2-22-22 at 2:48 P. M., Resident B was observed to enter the room closest to the Nurse's station. A random staff member got up from behind the nurses station and went into the residents room, but could not redirect Resident B from the resident's room. The staff member obtained assistance from another random staff member, and the resident was able to be redirected out of the room. Resident B was then left to wander in the hall without close supervision. There were no activities to engage the resident. In an interview, LPN 3 on 2-23-22 at 1:25 PM, indicated Resident B was very aggressive, abusive, and hard to re-direct. She indicated when the staff sees Resident B engaging with another resident, they were to re-direct him and distract him from what he was doing. She was not able to state how the staff were to distract the resident. In an interview, the Social Services Director (SSD) on 2-23-22 at 1:46 PM, indicated there was a gap from December 2020 to now, for psychiatric services. The psychiatric NP had to drop him since he was put on hospice. Hospice should have taken over those services, but she did not see any behavior notes from hospice. Usually, the NP would come once a week but COVID changed the availability of services. Resident B was a very aggressive person. 2. In a review of an Indiana State incident report dated 10-5-21 at 8:12 PM, the facility reported Resident B was observed to have physical contact with Resident E without physical injury. An undated witness statement indicated Resident E was sitting in his wheelchair eating snacks when Resident B, being unprovoked, hit him in the head with a closed fist. With help from another staff member the staff were able to separate Resident B and Resident E, however Resident B continued to another resident but was redirected from hitting the resident by staff intervention. A review of Resident E's progress note dated on 10-6-21 at 8:32 PM, indicated the resident was in a peer to peer altercation. A head to toe assessment was performed with no skin issues noted. There were not notes to indicate the nature of the altercation or if any further evaluations for latent bruising, neurological checks, or psychosocial distress had been performed. Resident E's record was reviewed on 2-23-22 at 10:45 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A most current annual MDS dated [DATE] indicated Resident E had a BIMS score of 14 out of 15. This indicated Resident E had moderate cognitive impairment. The assessment indicated the resident required extensive assistance of 1 staff member for hygiene and mobility, and was confined to a wheelchair, making it difficult for Resident E to defend himself from others. A record review of Resident E's care plan dated 7-10-20 indicated Resident E was at risk for potential negative interactions/altercations with peer and staff. Resident E had decreased safety awareness and decreased awareness of appropriate social/personal boundaries. Resident E often yelled out, made repetitive statements, and inappropriate comments. The goal indicated Resident E would have no complications from any negative interactions with other residents. There were no interventions to monitor for effects of the incident on 10-5-21. 3. In a review of an Indiana State incident report dated 12-2-21, the facility reported on 12-2-21 at 5:30 P.M., Resident B was agitated and made physical contact with Resident C. There was no description of the nature of the incident. An undated witness statement indicated Resident B was observed to walk over to Resident C and grab her by her private area. Staff tried removing Resident B from Resident C but Resident B kept returning to her. There was no documentation of further staff redirection or removal from the area to prevent further contact. A record review on 2-23-22 at 11:25 A.M. indicated Resident C's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current quarterly MDS dated [DATE] indicated the resident had a BIMS score of 9 out of 15. This indicated Resident C had moderate cognitive impairment and unable to consent to sexual advances. A review of Resident C's progress notes dated 12-2-21, did not indicate a note regarding any physical contact with another resident 12-2-21. There were no progress notes to indicate staff had completed any further evaluations, for latent bruising, skin assessments, psychosocial distress, or head to toe assessments. A record review of Resident C's care plan, indicated there were no care plans or interventions to monitor Resident C for any distress from the physical contact on 12-2-21. A review of Resident C's record did not indicate resident C had given consent to be touched in the private area nor had the facility assessed the resident for psychosocial wellbeing after 12-2-21. 4. In a review of an Indiana State incident report dated 1-3-22, the facility reported on 1-2-22 at 5:15 P.M., Resident B was observed to go into Resident D's room and kick at her without physical contact. A facility incident report dated 1-2-22 indicated Resident D walked into her room and saw Resident B in her bed. Resident D told Resident B to leave and he said no, and kicked at her. Resident D indicated that she became afraid, and thought that Resident B might rape her so she called 911 and screamed. A review of Resident D's record on 2-23-22 at 12:23 PM indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 1-2-22 indicated the resident had an altercation with another resident on the unit. The note did not indicate the nature of the altercation, but indicated there were no injuries and the resident denied discomfort. A review of the most current MDS dated indicated the resident had a BIMS score of 13 of 15. This indicated the resident had mild cognitive impairment. A review of Resident D's care plans indicated there were no care plans regarding false allegations related to her diagnoses. 5. In a review of an Indiana State incident report dated 2-4-22 the facility reported on 2-4-22 at 4:15 PM, the facility reported staff heard Resident F yell and entered room. Staff observed Resident F laying in bed with Resident B standing over Resident F holding him down. A review of Resident F's record on 2-23-22 at 1:00 PM, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current quarterly MDS 1-14-22 dated indicated the resident had a BIMS score of 9 of 15. This indicated Resident F was moderately cognitively impaired. A review of progress notes dated 2-4-22 at 4:30 P.M. indicated Resident F was screaming get out while in his room. Resident B was observed by staff to be holding Resident F down in his bed. Resident B was redirected out of the room. A head to toe assessment was completed with no injuries. Resident F denied pain and had no signs or symptoms of psychosocial distress. A current facility policy, Abuse Prevention Program, dated 3-2021, was provided by the Director of Nursing on 2-24-22 at 3:30 PM. The policy indicated . Our facility is committed to protecting our residents from abuse by anyone including, but are not necessarily limited to: facility staff, other residents .assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues .Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents .our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, residents representatives, sponsors, other residents, friends or other individuals The immediate jeopardy that began on 10-5-21 was removed on 2-25-22 when the facility assessed residents for abuse, trained staff to recognize and prevent abuse, identify underlying causes of abuse, and put interventions into place to address abusive behaviors., but remained at the lower scope and severity of pattern no actual harm, but potential for minimal harm because monitoring had not been completed. This Federal citation is related to Complaint IN 427, and IN 964 3.1-27(a)(b)

Based on observation, interview and record review, the facility failed to provide behavioral services for a resident with physical and sexual aggressive behaviors. (Resident B) This resulted in a failure to protect 4 of 4 residents from unwanted physical and sexual contact. (Resident C, Resident D, Resident E and Resident F) The immediate jeopardy began on 10-5-21 when the facility failed to put interventions and supervision in place to address aggressive behavior. The Executive Director, Director of Nursing Services, and Clinical Nursing Consultant were notified of the immediate jeopardy at 12:30 P.M. on 2-24-22. The immediate jeopardy was removed on 2-25-22 but noncompliance remained at the lower scope and severity level of pattern no actual harm with potential for minimal harm. Findings include: Resident B's record was reviewed on 2-23-22 at 10:15 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's most current quarterly MDS dated [DATE] indicated the resident was not able to be assessed for a BIMS ( brief interview for mental status) score due to memory. A review of Resident B's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An order dated on 9-27-21 for [MEDICATION(S)] tablet 0.5 milligrams (mg). The order indicated to give 1 tablet 3 times a day for anxiety. An order dated on 10-1-21 for hospice. An order dated on 10-7-21 for [MEDICATION(S)] tablet 50 mg. The order indicated to give 50 mg by mouth at bedtime for [CONDITION(S)]. An order dated on 10-12-21 for [MEDICATION(S)] tablet 100 mg. The order indicated to give 100 mg by mouth one time a day for major depressive disorder. An order dated on 12-1-21 for [MEDICATION(S)] tablet delayed released 125 mg. The order indicated to give 250 mg by mouth 3 times a day for anticonvulsant. An order dated on 12-10-21 for [MEDICATION(S)] tablet 1 mg. The order indicated to give 1 tablet by mouth every 6 hours as needed for as needed for anxiety and agitation. An order dated on 2-22-22 for [MEDICATION(S)] tablet 2 mg. The order indicated to give 2 mg by mouth every 12 hours as needed for aggressive until 2-27-22. A review of Resident B's care plan initiated on 10-6-21 indicated Resident B often exhibited behavior symptoms of unprovoked physical aggression to peers and staff at times. The goal had a revision date on 1-13-22, indicated Resident B would not have more than 1 of episodes physical aggression to peers monthly. Each interventions had an initiated date on 10-6-21. There was no documentation to indicate interventions had been updated to address any behavioral episode. There were no new care plan to address the sexual aggression. A review of a behavior management assessment dated [DATE] indicated Resident B had advanced dementia. The assessment indicated the resident continued with aggressive behavior, wandering, pacing, [CONDITION(S)], signs and symptoms of agitation. A sleep disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No other interventions were initiated. A review of progress note dated 11-8-21, indicated the POA requested Resident B have lorezapam 1 mg on shower days to decrease his aggression. The NP was notified and new order was received. A review of the behavior management assessment dated on 12-9-21 indicated Resident B continued to be combative with care, had physical and verbal aggression with care, intrusive wandering, had exit seeking behavior, urinated in inappropriate places, and took items that were unsafe from staff at times. The Interdisciplinary team (IDT) recommend an evaluation by an NP since the resident was on hospice. 1. A review of progress notes on 10-5-21 at 8:54 P.M. indicated the Resident B was moving things in the dining room, had verbal and physical aggression with staff, but was becoming calmer. There were no notes to indicate Resident B had a peer to peer altercation. A of an Indiana State incident report dated 10-5-21 at 8:12 PM, indicated Resident B was observed to have physical contact with Resident E without physical injury. An undated witness statement indicated Resident E was sitting in his wheelchair eating snacks, when Resident B, unprovoked, hit him in the head with a closed fist. With help from another staff member they were able to separate Resident B and Resident E, however, Resident B continued to another resident. The staff was able to stop Resident B from hitting another resident. 2. A review of progress notes dated 12-2-21 at 8:43 P.M. indicated Resident B was aggressive, grabbing private areas of Resident C. There was no documentation the resident was redirected or any intervention the staff had attempted to protect Resident C. A review of Indiana State incident report dated on 12-2-21 at 5:30 PM, reported Resident B was agitated and made physical contact with Resident C. There was no description of the nature of the incident. An undated witness statement indicated Resident B was observed to walk over to Resident C and grab her by her private area. Staff tried removing Resident B from Resident C but Resident B kept returning to her. There was no documentation of further staff redirection or removal from the area to prevent further contact. A review of an NP note dated 12-3-21, indicated Resident B continued to have significant increased agitation. The NP noted they had increased the resident's divaloprex dose on 12-1-21. The note indicated the dose increase did not seem to be impacting the resident. The note indicated Resident B was not overly cooperative with the visit, he posed a safety risk for himself, other residents and staff. The note indicated Resident B had significant sundowner's related to Alzheimer's disease. 3. A review of the progress notes dated 1-2-22 at 8:24 P.M. indicated Resident B was observed entering Resident D's room. The note indicated there was a resident to resident altercation, but did not describe the nature of the altercation. The note indicated there were no injuries. There was no documentation the resident was redirected or any intervention the staff had attempted to protect Resident D. A review of Indiana State incident report dated 1-3-22, indicated Resident B was observed to go into Resident D's room and kick at her without physical contact. A facility incident report dated 1-2-22 indicated Resident D walked into her room and saw Resident B in her bed. Resident D told Resident B to leave, he said no and kicked at her. Resident D indicated she became afraid and thought Resident B might rape her, so she called 911 and screamed. 4. A review of progress notes dated 2-4-22 at 4:40 P.M. indicated the family and MD were made aware of an altercation with a peer. There was no indication of the nature of the altercation. The note indicated the resident was placed on increased staff supervision and IDT monitoring. There was no description of what increased supervision or IDT monitoring consisted of. A review of the record did not indicate supervision or monitoring had been documented. A review of an Indiana State incident report. Indicated on 2-4-22 at 4:15 PM, indicated the staff heard Resident F yell and entered the room. Staff observed Resident F laying in bed with Resident B standing over Resident F holding him down. In an observation on 2-22-22 at 2:48 P. M., Resident B was observed to enter the room closest to the Nurse's station. A random staff member got up from behind the nurses station and went into the residents room, but could not redirect Resident B from the resident's room. The staff member obtained assistance from another random staff member, and the resident was able to be redirected out of the room. Resident B was then left to wander in the hall without close supervision. There were no activities to engage the resident. A record review of Resident B's behavior management assessment dated on 10-29-21 indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Sleep disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident B's behavior management assessment dated on 12-9-21. Resident continues to be combative with care, physical and verbal aggression with care, intrusive wandering, exit seeking, urinating in inappropriate places, taking items that are unsafe from staff at times. Interdisciplinary team (IDT) recommend evaluation by NP as resident is on hospice. A review of Resident B's Behavior symptoms report indicated he had physical aggression on the following dates: 10-10-21 at 8:28 PM. 10-13-21 at 1:49 PM 10-13-21 at 7:34 PM. 10-14-21 at 9:23 AM. 10-16-21 at 10:08 AM. 10-20-21 at 1:34 PM. 10-22-21 at 12:43 PM. 10-23-21 at 1:59 PM. 10-23-21 at 7:19 PM. 10-29-21 at 1:05 PM. 10-30-21 at 5:59 AM. 10-30-21 at 1:59 PM. 10-30-21 at 3:07 PM. 10-31-21 at 8:25 PM. 11-2-21 at 1:10 PM. 11-3-21 at 12:37 PM. 11-5-21 at 9:46 AM. 11-6-21 at 11:14 AM. 11-7-21 at 9:48 AM. 11-8-21 at 7:20 AM. 11-9-21 at 9:23 AM. 11-9-21 at 8:17 PM. 11-11-21 at 11:59 AM. 11-11-21 at 7:00 PM. 11-12-21 at 7:00 AM. 11-13-21 at 9:44 AM. 11-14-21 at 9:33 AM. 11-16-21 at 2:25 AM. 11-16-21 at 1:11 PM. 11-17-21 at 2:15 AM. 11-17-21 at 8:59 PM. 11-18-21 at 2:22 PM. 11-18-21 at 1:36 PM. 11-18-21 at 8:35 PM. 11-19-21 at 7:47 AM. 11-20-21 at 5:40 AM. 11-20-21 at 11:56 AM. 11-21-21 at 9:53 AM. 11-22-21 at 8:17 PM. 11-23-21 at 7:10 AM. 11-24-21 at 7:21 AM. 11-26-21 at 7:38 AM. 11-26-21 at 4:32 PM. 11-27-21 at 4:02 PM. 11-28-21 at 3:15 PM. 11-30-21 at 2:09 AM. 11-30-21 at 8:59 PM. 12-1-21 at 3:15 PM. Behavioral documentation from 12-2-21 through 12-23-21 was not provided. 12-24-21 at 2:46 AM. 12-24-21 at 8:23 PM. 12-25-21 at 5:43 AM. 12-25-21 at 1:07 PM. 12-25-21 at 8:12 PM. 12-26-21 at 5:56 AM. 12-26-21 at 8:59 PM. 12-27-21 at 9:40 AM. 12-27-21 at 8:49 PM. 12-28-21 at 3:45 PM. 12-29-21 at 5:59 AM. 12-29-21 at 5:09 PM. 12-30-21 at 4:16 PM. 12-31-21 at 3:58 AM. 12-31-21 at 3:40 PM. 1-1-22 at 3:45 PM. 1-2-22 at 12:28 AM. 1-2-22 at 9:35 AM. 1-2-22 at 8:54 PM. 1-3-22 at 3:51 PM. 1-4-22 at 9:39 AM. 1-4-22 at 3:36 PM. 1-6-22 at 3:17 PM. 1-7-22 at 2:49 AM 1-7-22 at 8:25 PM. 1-8-22 at 3:54 AM. 1-8-22 at 1:59 PM. 1-8-22 at 8:53 PM. 1-9-22 at 10:25 AM. 1-9-22 at 8:55 PM. Behavioral documentation from 1-10-22 through 2-23-22 was not provided. There was no documentation behaviors had been trended for patterns and no behavioral interventions documented for each of the above times of physical aggression. In an interview, Nurse 3 on 2-23-22 at 1:25 PM, indicated Resident B was very aggressive, abusive, and hard to re-direct. She indicated when staff sees him engaging with another resident, they were to re-direct him and distract him from what he was doing. She was not able to state how the staff were to distract the resident. In an interview, the Social Services Director (SSD) on 2-23-22 at 1:46 PM, indicated there was a gap from December 2021 to now, for psychiatric services. The psychiatric NP had to drop him since he was put on hospice. Hospice should have taken over those services, but she did not see any behavior notes from hospice. Usually, the NP would come once a week but COVID changed the availability of services. Resident B was a very aggressive person. In an interview, CNA 3 on 2-24-22 at 11:35 AM, indicated they were doing one on one monitoring with Resident B. She indicated she was keeping her distance because he was agitated and exit seeking. Staff would try to calm the resident with snacks, or drinks. Resident B was observed to be pacing fast down the hallway and entered the dinning room where other residents are watching a movie. No staff redirected or approached the resident. In an interview, the Director of Nursing on 2-24-22 at 11:50 AM, indicated she had called hospice to get their notes regarding Resident B, but no notes had been given to them. She indicated the facility had given all the documentation they had regarding Resident B. A current facility policy, Mood and Behavior Management, dated 7-20, was provided by the Director of Nursing on 2-23-22 at 4:05 PM. The policy indicated . It is the policy of [NAME] Care to provide interventions for all residents with behavioral and/or mood indicators that may be problematic or distressing. Residents are provided a supportive environment that is aimed at prevention, relief, and/or accommodation of their behavior and/or mood in addition to interventions that are specific to the resident's individualized needs The immediate jeopardy that began on 10-5-21 was removed on 2-25-22 when the facility assessed residents for aggressive behavior, trained staff to implement individualized behavioral interventions, identify underlying causes of aggressive behavior, and put interventions into place to address aggressive behaviors., but remained at the lower scope and severity of pattern no actual harm, but potential for minimal harm because monitoring had not been completed. This Federal Citation is related to Complaint IN 427 and IN 964. 3.1-37 3.1-43

Based on observation, interview and record review, the facility failed to ensure 11 of 85 residents residing in the facility received their clothing back from the laundry in a timely manner. This resulted in residents missing therapy, being embarrassed and ashamed of how they looked or smelled. (Resident 4, Resident 16, Resident 17, Resident 23, Resident 28, Resident 35, Resident 39, Resident 40, Resident 52, Resident 61, and Resident 74) 1. Resident 61 was interviewed on 7/15/21 at 8:31 AM. During the interview Resident 61 indicated his family provided him with 10 pairs of pants and he did not have any of them now. Resident 61 indicated his missing clothing made him angry and he wanted to slap the [expletive] out of someone for stealing from him. Resident 61 indicated it made him very very angry that his clothing was missing. Resident 61 indicated that his missing clothing impeded his therapy progress because they would not take him to therapy with clothing smelling of urine and he did not have clean pants. Resident 61 did not have pants on during the interview and had a blanket covering his upper legs. He indicated he felt ashamed. 2. Resident 52 was interviewed on 7/11/21 at 12:23 PM. During the interview Resident 52 indicated she had missing clothes and it took a long time to get laundry back. Resident 52 indicated the facility was aware of her missing clothes. During the interview resident 52 started crying and indicated she just wanted her laundry back. 3. Resident 17 was interviewed on 7/12/21 at 10:47 AM. During the interview Resident 17 indicated she had missing clothes and it took forever for laundry to be returned to her. Resident 17 indicted she never saw some of her laundry again after it was taken for washing. Resident 17 indicated she has let staff know about it, but nothing has happened. Resident 17 was interviewed on 7/16/21 at 10:32 AM. During the interview Resident 17 indicated she was frustrated to the point of crying that she was missing clothes. 4. During an observation on 7/11/21 11:43 AM, Resident 40 was standing in the doorway of her room facing the hallway. Resident 40 was wearing a hospital gown. The hospital gown was thread bare. The resident's skin and the outline of her body were observed through it. 5. Resident 28 was interviewed on 7/11/21 at 12:25 PM. During the interview Resident 28 indicated she had many missing laundry items. She indicated she was very very frustrated about her missing laundry and it made her very angry sometimes. Resident 28 indicated she had told staff about the missing laundry and had talked to the Social Service Director about it but nothing had happened. 6. On 7/12/21 at 12:48 P.M., Resident 35 was observed sitting in his room covered with a blanket. On 7/12/21 at 2:44 P.M., in an interviewed Resident 35's significant other indicated the resident had 15 shirts and 15 jogging pants missing. They reported to a nurse all the time and was told staff had looked for the missing clothing. Resident 35's Representative indicated only 1 person worked in the laundry. They indicated the resident had no pants to wear, so he would not go out of his room. 7. Resident 74 was interviewed on 7/14/21 at 2:44 PM. During the interview Resident 74 indicated she thought someone had taken her clothes and her missing clothes made her feel that she was not important and depressed. She indicated she was not getting clothes back and when she did it took a long time. 8. On 7/15/21 at 9:38 A.M., interviewed Resident 16 indicated he had to mark his name in his clothing and was frustrated his clothing items were still missing. 9. On 7/15/21 at 9:56 A.M., interviewed Resident 4 indicated a month ago had observed staff as they had gone through his drawers and removed his clothing. The resident indicated not all of his clothing had been returned and he felt angry about the missing clothing, because he had nothing to wear. 10. Resident 23 was interviewed on 7/16/21 at 1:55 PM. During the interview Resident 23 indicated his missing laundry made him feel not good. He indicated he only had one pair of pants to wear at the moment and it took a long time to get anything back., so right now he was smelly. 11. In an interview on 7/14/21 at 1:25 P.M., Resident 39 indicated she had asked staff to put her name is a pair of capris pants that had never returned from the laundry. The resident indicated her feelings were hurt because the pants had never returned. The Director of Nursing was interviewed on 7/16/21 at 10:49 AM. During the interview the DON indicated there had been laundry issues since she started in March. They had been trying to address the laundry issues, but the laundry had been an ongoing issue and was still an issue. She indicated although there was no policy addressing resident dignity, the residents should be treated with dignity and respect at all times. The Administrator was interviewed on 7/16/21 at 11:02 AM. During the interview the Administrator indicated laundry had been an issue since he started in November 2020. The Administrator indicated it reached its peak in April, but it had gotten better. On 7/14/21 at 1:25 P.M., the Resident Council Meeting with the Indiana Department Of Health was conducted with 9 residents present. The residents indicated the following: 6 of 9 residents had problems with laundry since January 2021. 6 of 6 residents had missing laundry and had not received any compensation for their missing laundry. 6 of 6 residents had laundry that had not been returned to them for a long time and they had to wear the same clothing on multiple days and had received other resident's laundry. 6/6 residents had worn hospital gowns because they had no night clothes and 1 resident had refused to wear a hospital gown because it made him feel ashamed. A review of the Grievance log indicated the following: February 2021, there was one complaint regarding missing clothing. March 2021, there were no complaints regarding missing clothing. April 2021, the 4 grievances included: on 4/5, the laundry was backed up. On 4/7, the resident's clothes were missing. On 4/15, the resident's clothes were missing. On 4/23, clothing was missing and the room smelled of urine. May 2021, on 5/12 the resident's clothing was missing and the clothing they had smelled of urine. June 2021, on 6/24 there was missing clothing. On 6/25 there was missing clothing. July 2021, on 7/2 there was missing clothing. On 7/6 there was missing clothing. This deficiency is related to Complaint IN 808 and IN 105. 3.1-9(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices for COVID-19 were followed during the pandemic to prevent the spread of [MEDICAL CONDITION] when transmission-based precautions were not implemented for residents with symptoms of COVID-19 and/or who tested positive for COVID-19, for 10 of 10 residents reviewed for infection control (Resident B, Resident C, Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, Resident M, and Resident O). Residents were not effectively placed in 14 day quarantine upon admission, with residents leaving their room during this time and other residents with dementia on the same wing wandering the hall, potentially affecting the 20 residents residing on the secured unit of the facility. The Immediate Jeopardy began on 9/08/20 when Resident B and Resident C were exhibiting symptoms of COVID-19, and neither resident was placed into transmission-based precautions nor tested for COVID-19 until facility-wide testing on 9/15/20. Resident D and Resident E were also not placed into transmission-based precautions after exhibiting symptoms of COVID-19 infection. All four residents tested positive for COVID-19. The Administrator, Director of Nursing, and Regional Nurse Consultant were notified of the Immediate Jeopardy at 5:45 p.m. on 9/22/20. The Immediate Jeopardy was removed on 9/24/20 but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 9/22/20 at 10:00 A.M., the Administrator and DON (Director of Nursing) were interviewed. During the interview, they indicated routine staff COVID-19 testing, completed on 9/11/20, yielded 3 positive employee results which were reported on 9/14/20. The 3 staff members were placed on leave and all residents currently in the facility were tested for COVID-19 on 9/15/20 as part of their outbreak investigation. Four residents were found to have positive COVID-19 test results; three reported on 9/18/20 and one reported on 9/19/20. Resident B, Resident C, and Resident D were transferred to their sister facility for COVID care on 9/18/20. Resident E was transferred the evening of 9/19/20 following her reported positive COVID test. They indicated new admissions or re-admissions were placed in quarantine, in a private room, for 14 days following admission to the facility. These rooms were located on the secured unit. On 9/22/20 at 11:07 A.M., the secured wing of the facility was observed. Residents with dementia resided in the front half of the wing (9 residents), and residents who were in 14 day quarantine resided in rooms in the back half of the wing (11 residents). There was no barrier noted between the front and back halves of the wing. There were three residents observed wandering throughout the wing. They were not wearing masks. The designated quarantine rooms at the back half of the wing were double occupancy rooms, some of which had two residents residing in these rooms. Each of these rooms had a sign on the door indicating occupants in the room were under contact and droplet transmission-based precautions; however, some of the residents were out of their rooms. 1. On 9/22/20 at 12:30 P.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. He resided on the secured unit and had chronic behaviors of pacing and wandering. On 9/7/20 at 9:27 a.m., a weights and vitals summary form, indicated Resident B's temperature was 99.5 degrees Fahrenheit (F). A Nurse Progress note, dated 9/8/20 at 7:20 p.m., indicated the resident had been in bed the entire shift. He had a non-productive cough, appeared lethargic and tired, and his skin color blushed. At 8:34 p.m., he had a large, watery, foul smelling stool. At 9:17 p.m., he had a temperature of 100.5 degrees Fahrenheit and was given Tylenol 325 mg-1 tablet by mouth. There was no documentation that the physician had been notified or that transmission based precautions were put into place. A MAR (Medication Administration Record) for September 2020, indicated a respiratory status assessment on 9/9/20 revealed Resident B had diminished lung sounds on the night shift. He had a temperature of 100.0 degrees on day shift, a temperature of 100.0 degrees on evening shift, and a temperature of 99.8 on the night shift. There was no documentation that the physician had been notified or transmission based precautions put into place. An NP (Nurse Practitioner) Progress note, dated 9/10/20 at 9:02 p.m., indicated the resident was seen for fever and fatigue. He'd had a temperature; maximum of 100.9 per nursing. He had a moist, productive cough and his lung sounds were diminished and course throughout all lung fields. Orders were given to obtain a chest x-ray and lab tests - a complete blood count, metabolic profile, ammonia level and urinalysis in the morning. The MAR indicated [REDACTED]. There were no further nurse notes found on 9/10/20 through 9/16/20. A chest x-ray report, dated 9/10/20, indicated no pneumonia. Social Service notes, dated 9/16/20 at 9:05 a.m. and 9/18/20 at 8:55 a.m., indicated the resident's behaviors of pacing and wandering continued and re-direction was used successfully. A NP Progress note, dated 9/17/20 at 2:55 p.m., indicated the resident was seen for a routine visit. Resident B seemed to be doing much better and he was noted to be ambulating in the hall much more and had been afebrile (without fever). His lung sounds were diminished and course throughout the lung fields. There was no documentation regarding the chest x-ray in this note. A Respiratory Pathogen Panel lab form, with a collection date of 9/15/20 at 9:15 a.m., was for a COVID-19 panel. The form indicated the collection date of the sample was 9/15/20, it was processed on 9/17/20, and positive results reported to the facility on [DATE]. There was no further documentation in Resident B's record following the reported positive COVID-19 test result. 2. On 9/22/20 at 1:00 P.M., Resident C's record was reviewed. [DIAGNOSES REDACTED]. Resident C shared a room with Resident B on the secured unit. He ambulated throughout the secured unit. A weights and vitals summary form indicated Resident C's temperature was elevated on 9/7/20 at 3:46 p.m. at 99.5 degrees Fahrenheit (F). The form indicated he had temperature elevations on the following days and times: 9/8 at 11:11 p.m. - temperature of 99.0 degrees F; 9/9 at 7:51 p.m. - temperature of 99.0 degrees F; 9/10 at 12:51 a.m. and 1:31 a.m. - temperatures of 99.0 degrees F, and again at 10:23 a.m. - temperature of 99.9 degrees F. A MAR for September 2020, indicated respiratory status assessments completed on 9/8 and 9/9/20, indicated the resident had diminished lung sounds. A NP progress note, dated 9/8/20 at 3:00 p.m., indicated Resident C had been seen for increased blood pressures. There was no documentation to indicate the NP had been notified of the resident's elevated temperature. A MD note, dated 9/9/20, did not include documentation related to the resident's elevated temperatures. A NP progress note, dated 9/10/20 at 4:23 p.m., was for a 90 day routine visit. There was no documentation to indicate the NP had been notified of the resident's elevated temperature. A Nurse progress note, dated 9/13/20 at 5:24 p.m., indicated the resident had been found on the floor next to his bed. He complained of nausea and an order for [REDACTED]. No further documentation was found regarding the resident's condition on 9/14, 9/15, or 9/16/20. An NP progress note, dated 9/17/20 at 1:45 p.m., indicated the resident was seen for a fever of 99.5 degrees F. Resident C complained of feeling tired but otherwise denied problems/concerns. Facility wide COVID testing was pending at this time. The plan was to rule out COVID and obtain labs in the morning. A Respiratory Pathogen Panel lab form, with a collection date of 9/15/20 at 12:15 p.m., was for a COVID-19 panel. The form indicated the collection date of the sample was 9/15/20, it was processed on 9/17/20, and positive results reported to the facility on [DATE]. A Social Service note, dated 9/18/20 at 5:34 p.m., indicated Resident C's family was notified that the resident was being transferred to a sister facility for COVID care. 3. On 9/22/20 at 1:44 P.M., Resident D's record was reviewed. [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE] following hospitalization at an acute care center. Resident D resided on the secured unit and shared a room with Resident F. Residents D and F's room was next to Residents B and C's room. A NP progress note, dated 8/7/20 at 7:32 a.m., indicated the resident was seen for admission. He was noted with increased confusion and agitation. He did not know where he was or why he was here and he wanted to leave. A Social Service progress note, dated 8/7/20 at 1:27 p.m., indicated the resident was welcomed to the facility. He was pleasantly confused but was able to verbalize he was looking forward to getting back home. He walked independently. Nurse progress notes indicated the following: 8/09/20 at 7:10 p.m., resident had been very confused and aggressive. He had been in other residents' rooms and out in the main hall looking for the exit door. 8/10/20 at 5:46 a.m., resident had been wandering in the hall and getting into other resident's room. 8/13/20 at 7:00 p.m., resident was very agitated and was walking the hallway, back and forth. 8/15/20 at 8:44 p.m., resident was progressively agitated. He was standing and pacing back and forth watching the doors. There was no documentation found to indicate the resident had been in, or attempts made to, quarantine for 14 days following admission to the facility. A Nurse progress note indicated on 9/5/20 at 12:38 p.m., the resident had attempted to hit one resident and grab another resident. He was sent to the ER and returned to the facility following an evaluation. There was no documentation to indicate he had been placed into quarantine following the ER visit. On 9/6/20 at 12:50 p.m., a Nurse progress note indicated Resident D wasn't too agitated today but had a brief fight with Resident C this afternoon. A NP progress note, dated 9/10/20 at 4:13 p.m., indicated the resident was seen for a 30 day visit. He was doing well at the time of the visit and per staff, had been much less agitated. There were no nurse progress notes or assessments found from 9/10/20 through 9/17/20. A Respiratory Pathogen Panel lab form, with a collection date of 9/15/20 at 10:15 a.m., was for a COVID-19 panel. The form indicated the collection date of the sample was 9/15/20, it was processed on 9/17/20, and positive results reported to the facility on [DATE]. A weights and vitals summary form indicated on 9/18/20 at 9:23 p.m., the resident had a temperature of 99.7 degrees F. A Social Service note, dated 9/18/20 at 3:03 p.m., indicated Resident D's family was notified of the resident's positive COVID-19 test and that he would be transferred to their sister facility for care. A Nurse note, dated 9/18/20 at 5:39 p.m., indicated while staff were preparing to transfer the resident to their sister facility, he'd had a change in condition. The family was notified of the resident's decreased blood pressure, increased pulse, low grade temperature and oxygen saturations. Family was asked if they wanted the resident sent to the ER or transferred to the sister facility where he would be kept comfortable. In keeping with the known resident wishes, the family wanted him sent to the other facility and kept comfortable. On 9/24/29 at 11:50 A.M., the Administrator indicated Resident D had passed away at their sister facility. 4. On 9/22/20 at 2:00 P.M., Resident E's record was reviewed. [DIAGNOSES REDACTED]. Resident E resided on the 100 hall, which was a separate wing from the secured unit. A NP progress note, dated 9/14/20 at 10:51 a.m., indicated the resident was seen for leg pain. During the visit, she was assessed to have clear but diminished lung sounds. On 9/17/20 at 1:55 p.m., an NP progress note indicated the resident was seen for fever and malaise. She had a temperature of 101.0 degrees F. She had general malaise, increased fatigue, loss of taste, dry cough and nausea without emesis. She had a COVID test pending. The plan was to rule out COVID-19 and obtain lab tests in the morning. There was no documentation found to indicate Resident E was placed into transmission based precautions despite having COVID-19 symptoms and a pending COVID test. A Nurse progress note, dated 9/19/20 at 1:54 p.m., indicated the CNA (Certified Nurse Assistant) had been assisting the resident to get out of bed when she was unable to stand and was lowered to the floor. She was assisted up off the floor with the Hoyer lift and 3 staff members and placed in her recliner chair. At 3:05 p.m., the resident was very anxious and had been calling out all day. Her oxygen saturations were lower than 90% but rose to 94% on 2 liters of oxygen. She complained of being congested, weak, having a non-productive cough, and thick mucus and phlegm in her airways which she couldn't cough up. At 3:10 p.m., the nurse was notified by the DON that the resident's COVID-19 test had returned positive and that the resident would be moved to their sister facility for care. A Respiratory Pathogen Panel lab form, with a collection date of 9/15/20 at 10:15 a.m., was for a COVID-19 panel. The form indicated the collection date of the sample was 9/15/20, it was processed on 9/18/20, and positive results reported to the facility on [DATE]. 5. On 9/23/20 at 1:20 P.M., Resident F's record was reviewed. [DIAGNOSES REDACTED]. Resident F shared a room with Resident D on the secured unit. He wandered and paced throughout the secured unit. An NP progress note, dated 9/17/20 at 12:56 p.m., indicated Resident F was seen for diarrhea the past 2 days. The plan was to rule out COVID and a COVID test was pending. Staff were to obtain labs in the morning. A Respiratory Pathogen Panel lab form, with a collection date of 9/15/20, was for a COVID-19 panel. The form indicated the collection date of the sample was 9/15/20, it was processed on 9/17/20, and negative results reported to the facility on [DATE]. There was no documentation found to indicate the resident had been placed in transmission based precautions despite having COVID symptoms and exposure to his roommate that had tested positive. On 9/23/20 at 12:46 P.M., Resident F was observed in a different room with a new roommate. He was not in transmission based precautions. There was a strong odor of stool noted in the doorway of his room. BM (bowel movement) records, provided on 9/23/20, indicated the resident continued to have loose, incontinent stools. On 9/23/20 at 3:11 P.M., the DON was questioned about Resident F's placement with a new roommate and lack of transmission based precautions despite his exposure and symptoms. She indicated she hadn't been aware of this and would look into it. On 9/24/20 at 11:40 A.M., Resident F remained in his room with his new roommate and was not placed in transmission based precautions. 6. On 9/24/20 at 12:03 P.M., Resident G's record was reviewed. [DIAGNOSES REDACTED]. He resided on the 100 hall. The Administrator reported Resident G had been having symptoms of COVID and was administered a rapid COVID test last evening which had been positive. He was transferred to their sister facility late afternoon on 9/23/20. A weights and vitals summary form indicated on 9/20/20 at 10:44 a.m. and 12:11 p.m., Resident G's temperature was 100.0 degrees F. On 9/20/20 at 5:05 p.m., his temperature was 100.1 and on 9/21/20 at 4:29 p.m., it registered at 99.0 degrees F. On 9/20/20 at 12:39 P.M., a Nurse progress note indicated the resident complained of not feeling well. He had an elevated temperature which had been checked twice. He complained of having a productive cough with phlegm that was white and yellow in color. He also complained of some shortness of breath but this is his normal every week response. The NP was notified but no new orders had been received yet. An NP progress note, dated 9/21/20 at 10:21 a.m., indicated the resident was seen for a cough. He was noted to have an increased productive cough with yellow sputum, SOB (Shortness of Breath) with exertion, and a temperature of 100.0 degrees F over the weekend. The resident stated he was feeling a little better and was eating and drinking. He admitted to some malaise. He was COVID negative last week. His breath sounds were course in all lung fields. The plan was to get a chest x-ray and obtain labs in the morning. On 9/23/20 at 9:03 a.m., a Social Service note indicated a visit had been attempted with Resident G but he hadn't been feeling well. On 9/23/20 at 1:48 p.m., a Nurse note indicated the resident had complaints of SOB, generalized weakness, and had a temperature of 99.0 degrees F. His chest x-ray results had come back negative for pneumonia. He was COVID tested per rapid test and was found to be positive. He was to be discharged to their sister facility for COVID care. The resident resided in a private room however, there was no documentation to indicate he had been placed into transmission based precautions with the appropriate PPE (Personal Protective Equipment) worn when caring for the resident. 7. On 9/24/20 at 12:23 P.M., Resident J's record was reviewed. [DIAGNOSES REDACTED]. Resident J resided on the 300 hall and had a roommate. During the initial tour of the facility on 9/22/20 between 10:45-11:15 a.m., Resident J was observed in her room with her roommate with the door open on the 300 hall. There were no transmission based precaution signs seen on the door nor was there any PPE in the hallway next to the room for staff to don before entering the room. An NP progress note, dated 9/21/20 at 10:46 a.m., indicated the resident was seen for a cough and fatigue. She indicated she'd had an increased cough, fatigue and nausea. Her cough was harsh but non-productive. She complained of body aches and SOB with exertion. Her lung sounds were course throughout. The plan was to obtain a chest x-ray and labs in the morning. The resident was not placed in TBP, despite having COVID symptoms, until 9/23/20 at 9:52 a.m. when a Social Service note indicated the resident was informed she would need to move to an isolation room due to having symptoms of COVID. Resident J remained in her room with her roommate from 9/21/20-9/23/20 when she was moved to an isolation room. She and her roommate, who became symptomatic with malaise and abnormal taste on 9/23/20, were both placed in the same room and on TBP on the isolation unit on 9/23/20. 8. During the intial tour of the facility on 9/22/20 between 10:45-11:15 a.m., Resident O was observed in her room with her roommate, Resident H, with the door open on the 100 hall. There were no transmission based precaution signs seen on the door nor was there any PPE in the hallway next to the room for staff to don before entering the room. On 9/25/20 at 12:15 P.M., Resident O's record was reviewed. [DIAGNOSES REDACTED]. Resident O resided on the 100 hall. She shared a room with Resident H whom had been diagnosed with [REDACTED]. Both resident's resided in a room next to Resident E. An NP progress note, dated 9/21/20 at 11:15 a.m., indicated the resident was seen for cough and fatigue. Resident O had been noted to have an increased non-productive cough and increased fatigue, and had eaten poorly at breakfast. Her breath sounds were course on exam. The plan was to obtain a chest x-ray and labs in the morning. Resident O was not placed into transmission based precautions despite COVID symptoms. There was no further documentation found to indicate the chest x-ray had been completed. A Nurse progress note, dated 9/23/20 at 12:50 p.m., indicated the resident was without fever and had no SOB; lung sounds were clear. The resident continued with a non-productive cough. 9. On 9/24/20 at 12:17 P.M., Resident H's record was reviewed. [DIAGNOSES REDACTED]. She resided on the 100 hall and shared a room with Resident O which was next to Resident E's room. A Social Service note, dated 9/21/20 at 4:03 p.m., indicated a visit had been conducted with the resident out of her room. A Nurse progress note, dated 9/23/20 at 12:46 p.m., indicated the resident had no fever or SOB. Her lung sounds were clear. She had been resting quietly in bed. On 9/24/20 at 7:55 a.m., a Nurse progress note indicated the resident was found to have a temperature of 102.0 degrees F. Orders were received to place the resident in TBP and obtain labs. An NP progress note, dated 9/24/20 at 3:03 p.m., indicated the resident had been found to have a fever of 102 which was responsive to administration of [MEDICATION NAME]. The resident had a COVID test pending. Her breath sounds were diminished in all fields. The plan was to place the resident in isolation and obtain labs. Resident H's roommate, Resident O, had symptoms of COVID when seen by the NP on 9/21/20 at 11:15 a.m. Resident O was not placed on TBP and continued to share the room with Resident H. Resident H had been out of her room and visiting with the Social Service staff member on 9/21/20 at 4:03 p.m., after her roommate was identified as having symptoms of COVID. 10. On 9/25/20 at 11:30 a.m., Resident M's record was reviewed. [DIAGNOSES REDACTED]. Resident M resided in a private room on the 100 hall. She was alert and oriented and propelled herself in her wheelchair. She was observed every day of the survey in the 100 and 300 hallways visiting other residents. She wore a mask but occasionally, would be observed with the mask below her nose. On 9/19/20 at 6:29 a.m. and 10:15 a.m., Resident M was administered cough medicine for a cough. On 9/20/20 at 1:44 p.m., a Nurse progress note indicated the resident complained of not feeling good. She stated she was burning up. Her temperature was normal but she had an occasional congested cough with thick mucous. She had no SOB and her upper lung lobes were clear. An NP progress note, dated 9/21/20 at 10:42 a.m., indicated the resident was seen for a cough. She had been having an increased cough over the weekend. She had no fever but did have labored breathing with exertion. She was having a cough with yellow phlegm and had increased fatigue. Her lung sounds were diminished. The plan was to obtain a chest x-ray. Resident M was not placed into transmission based precautions despite COVID symptoms. There was no further documentation found to indicate the chest x-ray had been completed. A Nurse progress note, dated 9/23/20 at 10:15 a.m., indicated the resident was without fever and had no SOB. Her lung sounds were clear. She was up and active in her chair. On 9/22/20 at 2:10 P.M., the Administrator, DON, MDS nurse, and Regional Nurse Consultant were interviewed. During the interview, they were questioned about Resident B and Resident C's COVID symptoms that were documented on 9/7/20 which included a temperature elevation. The Administrator referred to an outdated CDC (Centers for Disease Control) poster that listed 100.4 degrees F as being an elevated temperature which was what they used in determining if resident's had symptoms of COVID infection. She and the DON both, indicated Resident B and Resident C had other symptoms of COVID which were listed as symptoms on the outdated CDC poster. They were unable to answer questions regarding Resident D's admission and lack of quarantine following admission to the facility as they were not employed in the facility at that time and there were no other staff to ask. The DON indicated Resident E had stayed in her room following her reported positive COVID test on 9/19/20; however, she was unable to state whether the resident had been in transmission based precautions (TBP) prior to discharge to their sister facility. When questioned about admission to the facility and quarantine for the first 14 days, the Administrator indicated she had just put the SSD (Social Service Director) in charge of keeping track of this. The SSD would place residents in TBP upon admission and track when their 14 days were up and facilitate transfer to their permanent room. On 9/23/20 at 3:07 P.M., the Administrator provided a current copy of the facility's policy, titled COVID-19 Resident Policy which stated the following: Purpose of Policy: To provide early detection and effective triage and isolation of potentially infectious residents to prevent unnecessary exposures among residents, healthcare personnel and visitors at the the facility. *Policy subject to current CDC guidelines and updates Review of CDC guidance, Preparing for COVID-19 in Nursing Homes, dated as updated 6/25/20, included the following: Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. Actively monitor all residents upon admission and at least daily for fever (T?100.0 degrees F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0 degrees F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. Review of CDC guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, Considerations for the Public Health Response to COVID-19 in Nursing Homes, dated as updated 4/30/20, included the following: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. Resident with new-onset suspected or confirmed COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible,should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Counsel all residents to restrict themselves to their room to the extent possible. HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. Maintain all interventions while assessing for new clinical cases (symptomatic residents): Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions. If testing is available, asymptomatic residents and HCP who were exposed to the resident with COVID-19 (e.g., on the same unit) should be considered for testing. The immediate jeopardy that began on 9/8/20 was removed on 9/24/20 when the facility assessed all residents for symptoms of COVID, placed those with symptoms in Transmission Based Precautions, completed contact tracing for residents with known positive COVID tests, and began educating staff on transmission based precautions for admitted , readmitted , and symptomatic residents; and contact tracing of residents and staff. The noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still conducting outbreak testing and all employees had not been inserviced on how to properly conduct contact tracing. 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure a resident was not left unattended in a room as a measure to prevent a fall for 1 of 3 residents reviewed for accidents (Resident B). This resulted in severe facial bruising and a large blood filled hematoma on her forehead. Findings include: 1. The clinical record of Resident B was reviewed on 11/19/15 at 9:45 a.m. The record indicated the resident's [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B was severely cognitively impaired. Resident B was totally dependent for transfers with 2 person assist. During an observation and interview with LPN #1 on 11/19/15 at 9:30 a.m., Resident B was observed sitting in her wheelchair in her room. LPN #1 indicated there were no bed or chair alarms in place. Resident B was observed to have a large, blood filled, hematoma above her left eye on her forehead. She was also observed to have various stages of bruising on under both eyes. During an interview on 11/19/15 at 10:00 a.m., LPN #2 indicated she was unable to find a care plan related to alarms, but knew Resident B had alarms for both the bed and wheelchair. She indicated she documented that she had checked the alarms were in working order. Review of a nursing note dated 11/6/15, provided by the SSD (Social Service Designee) on 11/20/15 at 8:30 a.m., indicated the following: Resident fell forward from wheelchair while in her room. She hit her head and face on floor. 5 x 6 cm (centimeter) elevated bruise/abrasion on L (left) forehead. 1 x 1 cm (centimeter) abrasion to bridge of nose. 1 cm (centimeter) superficial laceration under L (left) eye. NP (nurse practitioner), spouse, and DON (Director of Nursing) notified. N.O. (new order) to hold ASA (aspirin) x 2 days, and neuro checks initiated. Spouse does not want her sent to hospital at this time. Review of the Fall Investigation dated 11/6/15 at 4:20 p.m., indicated Resident was transferred by lift from bed to wheelchair. Sitting in w/c (wheelchair) in room, fell from wheelchair. The investigation indicated there was not a bed alarm or personal chair alarm on at the time of the fall. Review of a physician's orders [REDACTED]. Review of a physician's progress note dated 11/9/15, indicated fall forward out of wc (wheelchair), noticed leaning forward by visitor et (and) fell face forward, hitting forehead, visitor notified nurse. Review of symptoms included, but were not limited to, left eye black with edema, abrasion to forehead, bruising, abrasion on nose between eyes and bleeding with fall from face. The physical examination by the Nurse Practitioner dated 11/9/15, indicated Approx (approximately) 5 x 6 cm (centimeter) round abrasion, dried red dng (drainage) noted c (with) some scabbing, 1 cm abrasion @ (at) bridge of nose, scabbing over, red, purple bruising noted L (left) eye c (with) edema et (and) some @ (at) R (right) eye c (with) bruising L (left) forehead, tiny resolving abrasion .5 cm (centimeter) under L (left) eye, 0 (zero) drainage. Review of the November 2015 Treatment Administration Record (TAR), indicated bed and/or chair alarms are tested every shift by applying and releasing pressure to alarm pad to ensure in working order. Staff documented each shift the bed and chair alarms were in working order from 11/1 through 11/19/15. During an interview on 11/19/15 at 3:00 p.m., LPN #3 indicated she was the nurse on duty when Resident B fell . She indicated the resident was just transferred from her bed to her wheelchair and she had gone next door to transfer another resident when the daughter of the roommate yelled for help. She indicated she was not aware Resident B could not be left unattended in her room while she was up in her wheelchair. She also indicated she was signing off the alarms were in working order. During an interview on 11/19/15 at 3:35 p.m., CNA #4 indicated he was on duty at the time of the fall. He indicated Resident B's face swelled up immediately and he applied ice to the resident's face even through dinner. He indicated he was unaware Resident B was not to be left her in room alone when she was up in her wheelchair. During an interview on 11/19/15 at 4:30 p.m., Director of Nursing (DON) indicated it was not a facility policy if a resident was a fall risk that they could not be left in their rooms alone. She indicated it was not on the CNA assignment sheet the resident could not be left alone in her room, but the CNA's have access to all care plans. She indicated she could not answer why the nurses were charting the bed and chair alarms were being checked when they were not in place. She indicated the alarms were a nursing measure and they did not need an order to place the alarms. Review of a Fall Prevention Care Plan, initiated 5/15 and updated 10/15, indicated, (Name of resident) is at risk for falls r/t (related to) Dementia, A-fib, pacemaker and weakness and unsteady gait. Her primary mode of locomotion is her w/c (wheelchair); but she is unable to propel self independently. The intervention included, but were not limited to, Do not leave alone in wheelchair in her room. A Communication Care Plan, initiated 5/1/15 and updated 10/15, indicated, (Name of resident) has a [DIAGNOSES REDACTED].but for the most part, relies on staff to anticipate and meet her needs She does not use her call light appropriately and is unable to understand it's usage due to her cognitive loss. During an observation on 11/20/15 at 9:40 a.m., Resident B had both a bed alarm and chair alarm in her room. Resident B was not in her room at the time of the observation. Review of the current policy titled Fall Prevention provided by the Administrator on 11/19/15 at 12:40 p.m., indicated the following: .Purpose: To identify residents who are at risk for falls and a plan for a fall prevention program. Procedure: .C. If the resident is identified to be at risk for fall, initiate a fall prevention care plan. .H. Fall prevention interventions are added to the nursing assignment group sheets and plan of care. .J. The Charge Nurses monitor through the 24-hour report as needed and monthly through the narrative progress to care plan goals. This Federal tag relates to Complaint IN 954. 3.1-45(a)(2)