Every finding on record at Morristown Manor

Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document whether self-administration of medications was clinically appropriate for 1 of 8 residents observed during medication administrations. (Resident 52) Findings include: The clinical record for Resident 52 was reviewed on 5/21/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident was cognitively intact. A physician's order, dated 1/7/25, indicated the resident was to receive 400 milligrams (mg) of magnesium oxide twice a day. A physician's order, dated 11/5/21, indicated the resident was to receive 240 mg of diltiazem (blood pressure medication) once a day. A physician's order, dated 4/13/22, indicated the resident was to receive a calcium supplement once a day. A physician's order, dated 9/13/24, indicated the resident was to receive carboxymethylcellulose sodium eye drops once a day. A physician's order, dated 5/6/25, indicated the resident was to receive 12.5 mg of metoprolol (blood pressure medication) twice a day. The staff was to obtain resident's heart rate and ordered to hold the medication if her heart rate was less than 60 beats per minute. An observation was conducted of a medication administration for Resident 52 with Qualified Medication Aide (QMA) 2 on 5/21/25 at 9:10 a.m. QMA 2 was observed preparing Resident 52's medications at the medication cart. She had pulled the following tablets: 400 mg of magnesium, 12.5 mg of metoprolol, oyster shell calcium supplement, and 240 mg of diltiazem. She then went to the resident's room to administer the medications. QMA 2 was observed obtaining the resident's heart rate and administering the resident's eye drops. The resident's cup of medications was placed on the bedside table. After, QMA 2 walked to the doorway prior to the resident picking up the medication cup of pill medications. The resident was not observed taking the pill medications. An interview was conducted with QMA 2 on 5/21/25 at 9:35 a.m. She indicated Resident 52 was able to take her medications without supervision. An interview was conducted with the Director of Nursing (DON) on 5/22/25 at 9:22 a.m. She indicated Resident 52 had not been assessed to determine if she could safely administer her medications herself. A bedside medication and self-administration of medications policy was provided by the DON on 5/22/25 at 9:44 a.m. It indicated, .Each resident who desires to self-administer medication will be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. Procedure. 1. Each resident is offered the opportunity to self-administer his/her medications during the routine assessment by the facility's interdisciplinary team (IDT). 2 .If the resident desires to self-administer medication, an assessment is conducted by the IDT of the resident's cognitive, physical and visual ability to carry out this responsibility .3. Cognitive ability should be the initial assessment to determine if a resident is capable of self-medicating. It is recommended that the Mini-Mental Status Examination or similar screening tool be used. Once cognitive status is established, the resident requires a skills assessment. 4. The IDT determines the residents ability to self-administer medications by means of a skill assessment as follows: a) The resident's medications are obtained from the pharmacy by usual means. b) The resident is instructed in the use of the package, purpose of the medication, reading of the label and scheduling of medication doses. c) The resident is then requested to read the label on each package and indicate at what time the medication should be taken, and any other special instructions for use. d) The resident is asked to demonstrate the removal of the medication from the package 3.1-11(a)

Based on observation and interview, the facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for environment. (Resident 11) Findings include: On 5/20/25 11:18 a.m., an observation of Resident 11's room revealed as the resident sat in her wheelchair, her call light was not within reach as it laid across her bed. During an observation of Resident 11 in her room on 5/21/25 10:37 a.m., the resident's call light was between the wall and the resident's bed, not within reach, as she sat in her wheelchair. During an interview on 5/21/25 10:39 a.m., the Social Services Director (SSD) indicated Resident 11's call light should be within her reach. On 5/22/25 at 3:44 p.m., the Director of Nursing (DON) indicated the facility did not have a policy specific to the use of call lights. 3.1-3(v)(1)

Based on interview and record review, the facility failed to timely update a care plan with new interventions for behavior management for 1 of 3 residents reviewed for dementia care (Resident 69). Findings include: The clinical record for Resident 69 was reviewed on 5/21/25 at 10:36 a.m. The diagnoses included, but were not limited to, dementia with mood disturbance and paranoid mood disorder. A care plan, with a start date of 9/6/24 and last revised 5/6/25, indicated she had physically abusive behavioral symptoms and violent behaviors such as grabbing another resident's shirt and arm, and hitting staff during care. The goal was for her not to be physically abusive to other residents, visitors, and/or staff. The interventions, which were initiated on 9/6/24, included but were not limited to, administering medications as ordered by the physicians, avoid over-stimulation, convey an attitude of acceptance towards her, and divert her behavior by offering an activity. A Quarterly Minimum Data Set (MDS) assessment, completed 3/10/25, indicated she was moderately cognitively impaired and had displayed verbal behaviors toward others and wandering behaviors for one to three days during the assessment period. A progress note, dated 3/9/25 at 7:50 p.m., indicated Resident 69 seemed mad at the staff and was making comments towards staff as if they had said something to her and argued with staff. Resident 69 had indicated she was leaving and attempted to leave the building through the dining room door. A staff member had been able to redirect her to her room. A social service progress note, dated 3/10/25 at 6:22 a.m., indicated Resident 69 had exhibited cursing, screaming, exit seeking, and false beliefs on 3/9/25. Staff attempted to redirect, provide one on one attention, offered food and fluids, provided a calm environment, and ensured Resident 69's safety. Staff had attempted meaningful activities and a back rub. The interventions were not effective. The Intradisciplinary Team (IDT) had met and reviewed behaviors. Staff were to continue to redirect Resident 69 as needed, offer reassurance and validation, and provide walks for Resident 69 if needed. The behavior care plan had not been updated to reflect the attempt to exit the facility or new interventions to address the behavior. A social service progress note, dated 3/12/25 at 6:17 a.m., indicated, on 3/12/25 at 2:05 a.m., Resident 69 was wandering about the unit. The staff had tried to redirect but it was not effective. The IDT team had met and reviewed the behavior. Staff were to redirect Resident 69 as needed and the resident was placed on fifteen-minute checks. The behavior care plan had not been updated with the new intervention of fifteen-minute checks. A progress note, dated 3/20/25 at 4:57 p.m., indicated Resident 69 had displayed increased aggressive behaviors and exit seeking. The Nurse Practitioner (NP) was informed and a new order for medication changes had been received. A social service progress note, dated 3/21/25 at 6:06 a.m., indicated Resident 69 had been wandering on 3/20/25 at 3:42 p.m. Staff had redirected with food and fluids, and the intervention was effective. On 3/20/25 at 4:30 p.m., Resident 69 began pacing and threatening staff. Resident 69 had displayed false beliefs and misperceptions and threatened to hit staff. Staff had attempted redirection, and it was not effective. The IDT team had met and reviewed behaviors. Staff would continue to redirect Resident 69 as needed. Resident 69's Depakote (anti-convulsant medication used to stabilize mood) was increased. A progress note, dated 4/10/25 at 1:13 p.m., indicated the Psychiatric NP and Proactive NP had been made aware of the urinalysis results and possible room move to the secured unit. A social services progress note, dated 4/11/25 at 2:36 p.m., indicated the nursing staff had spoken with Resident 69's daughter about moving Resident 69 to the secured dementia unit. Verbal consent had been received to move Resident 69. A progress note, dated 4/11/25 at 3:22 p.m., indicated Resident 69 has been relocated to the secured dementia unit. The behavior care plan had not been updated with the new intervention of relocating Resident 69 to the secured dementia unit. During an interview on 5/22/25 at 1:54 p.m., Social Service Director 1 indicated staff had tried many non-pharmalogical interventions with Resident 69 such as walking with her, back rubs, validating her feelings, and offering snacks. During an interview on 5/22/25 at 1:54 p.m., the Director of Nursing indicated Resident 69 had displayed exit seeking behavior and had begun wandering more. There had been a change in Resident 69's cognition, and she had become very focused on leaving the building. She was not always able to communicate her wants or feelings and could become agitated very quickly with little warning. There had been labs done and many attempts to redirect and calm Resident 69. There was another resident in the facility who seemed to exacerbate Resident 69's behavior. The facility had somewhat generalized care plans and Resident 69's care plans could be more individualized. During an interview on 5/22/25 at 3:13 p.m., the Director of Nursing indicated the facility did not have a specific care plan policy but followed the Resident Assessment Instrument Manual. On 5/22/25 at 8:42 a.m., the Director of Nursing provided the Behavioral Health Management Program Policy, dated January 2024, which indicated .[Name of Facility Corporation] believes in a person-centered care approach and tailors all considerations for the individual affected, including physical and psychosocial aspects of wellbeing when it comes to managing maladies that manifest behavioral disturbances . 3.1-35(b)(1)

Based on interview and record review, the facility failed to monitor the use of a non-invasive ventilator (NIV) for 1 of 1 resident reviewed for respiratory care. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 5/21/25 11:10 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and hypoxemia (low levels of oxygen in the blood). A Quarterly Minimum Data Set (MDS) assessment, completed 2/11/25, indicated Resident 11 was cognitively intact. A care plan, initiated on 11/18/2020, indicated Resident 11 had a diagnosis of sleep apnea and was at risk for respiratory difficulties or distress. The goal was for the resident to have no related complications through the next review related to sleep apnea diagnosis. Interventions included, but were not limited to, apply the NIV machine as ordered and to list settings, monitor oxygen saturation levels and apply oxygen as ordered, and contact physician as needed. A physician's order, dated 4/14/25, indicated the NIV to be applied at bedtime and instructed the use of specific settings of the machine. Staff were to monitor and document respiratory rate, minute volume, exhaled tidal volume, and resident tolerance. A review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARs) was conducted on 5/21/25 11:21 a.m. The MARs and TARs did not contain documentation of monitoring with the use of the NIV, as ordered. An interview was conducted, on 5/21/25 at 2:10 p.m., with the Director of Nursing (DON). She indicated the order set was put in on the respiratory flowsheet, which was unseen by nursing. Therefore, there was no documentation of the treatment recorded. On 5/22/25 at 3:31 p.m. the DON provided the Non-Invasive Ventilation Policy, last revised 12/2022, which indicated .Respiratory and/or nursing personnel trained to perform and care for the Non-Invasive Ventilation dependent resident will perform equipment setup, monitoring, and troubleshooting as per physician order .24. Document procedure in resident's medical record (date and time, concerns and action taken, resident's tolerance of procedure, respiratory assessment (breath sounds, oxygen saturation, pulse rate and respiratory rate) and type of Non-Invasive ventilation . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by utilizing hand hygiene during medication administrations for 3 of 8 residents observed during medication administrations. (Resident 50, Resident 52, and Resident 85) Findings include: 1. The clinical record for Resident 50 was reviewed on 5/21/25 at 8:40 a.m. The diagnoses included, but were not limited to, vascular dementia. An observation was conducted of a medication administration for Resident 50 with Qualified Medication Aide (QMA) 2 on 5/21/25 at 8:40 a.m. QMA 2 was observed preparing the resident's medications at the medication cart. She had pulled all pill medications from the drawers and utilized scissors to cut the storage packaging of the pill medications. She then dropped the pill medications in a medication cup. During that time, she had donned gloves to touch a pill medication. After doffing her gloves, she crushed the pill medications; grabbed a spoon from a plastic storage bag and mixed the pill medications in pudding. She then administered the medications to the resident in the dining room. During the preparation of the pill medications, QMA 2 was observed touching scissors, storage bag of unwrapped spoons, drawers of the medication cart, and computer mouse. There was no observation of QMA 2 utilizing hand hygiene prior to donning and doffing gloves or prior to the administration of the medication to the resident. 2. The clinical record for Resident 52 was reviewed on 5/21/25 at 9:00 a.m. The diagnoses included, but were not limited to, hypertension. An observation was conducted of a medication administration for Resident 52 with QMA 2 on 5/21/25 at 9:10 a.m. QMA 2 was observed preparing Resident 52's medications at the medication cart. During that time, she touched the computer mouse, pill packets, a pill medication, scissors, medication drawers, and a storage bag of unwrapped spoons. She then went to the resident's room to administer the medications. QMA 2 was observed donning on gloves, administering eye drops, and touching the resident's face. She then doffed her gloves and left the room. There was no observation of hand hygiene prior to leaving the medication cart and donning her gloves. 3. The clinical record for Resident 85 was reviewed on 5/21/25 at 9:26 a.m. The diagnoses included, but were not limited to, vascular dementia. An observation was conducted of a medication administration for Resident 85 with QMA 2 on 5/21/25 at 9:26 a.m. QMA 2 was observed preparing the pill medications at the medication cart. She pulled all medications including a medication patch. During that time, she was observed touching pill packets, the computer mouse, medication drawers, pen, and medication patch. After, she entered the resident's room. QMA 2 was observed donning gloves and applied a new medication patch on the resident's back. After the administration of the pill medications and medication patch, she left the room. There was no observation of hand hygiene prior to administration of the medication patch and donning gloves. An interview was conducted with QMA 2 on 5/21/25 at 9:35 a.m. She indicated she utilized hand hygiene prior to pulling the medications and after the administration to the resident. She should have utilized hand hygiene prior to donning gloves. An interview was conducted with the Infection Preventionist on 5/22/25 at 10:17 a.m. She indicated the staff should utilize hand hygiene before the preparation of the medications and prior to leaving the medication cart to administer the medication to the resident. A medication administration policy was provided by the Director of Nursing on 5/22/25 at 9:03 a.m. It indicated, .5. Bring medication cart to an area adjacent to resident room .7. Wash hands before medication pass .8. Remove medication from drawer, read label when taking from drawer and before putting in medication cup or pouring liquids .19. Cart was locked .Gel hands 21. Knock on resident's door before entering residents room . 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure proper medication administration procedures were followed by preparing medications for more that one resident at a time during medication administration for 2 of 2 medications carts reviewed for the prepping of medications for multiple residents. (Facility) Findings include: An observation of the Pine and Juniper units medication carts was conducted on 4/18/24 at 7 p.m. The following was observed: 1. The Pine unit's medication cart was reviewed with QMA (Qualified Medication Assistant) 2. QMA 2 unlocked the medication cart and in the top drawer there two medication cups with medications in them. QMA 2 indicated, one of the medication cups contained medications for Resident Q but when she went to administer the resident her medications she was not available to take her medications. QMA 2 also indicated, the other medication cup with medications inside it were for Resident R. When asked how many residents at a time can they prepare medications ahead of time for she indicated, none. QMA 2 then identified the medications inside each cup for the respective residents. a. Resident Q's medication cup contained the following medications: Tramadol (pain medication), gabatentin (nerve pain medication), acetaminophen, atorvastatin (cholesterol- reducing medication), Lasix (diuretic), melatonin (sleep aid), pramipexole (Parkinsons and/or restless leg medication) and Xarelto (anti-coagulant). b. Resident R's medication cup contained the following medications: Aptiom (seizure medication), Lasix, oyster shell calcium (supplement), lamotrigine (mood stabilizer). 2. Immediately following the Pine unit's medication cart, the Juniper unit's medication cart was reviewed with LPN (Licensed Practical Nurse) 3. LPN 3 unlocked the medication cart and in the top drawer were 5 medication cups containing medications for multiple residents. LPN 3 then identified who the prepared medications belonged to and what medications were in each cup as follows: a. Resident S's medication cup contained: buspirone (anti-anxiety medication), diltiazem (blood pressure medication), Trazadone, Xanax (anti-anxiety medication) b. Resident T's medication cup contained: depakote (anti-seizure, bipolar medication), and senna (laxative) c. Resident U's medication cup contained: atorvastatin, buspirone, carvedilol (blood pressure medication), Lasix, melatonin, oyster shell calcium, and acetaminophen d. Resident V's medication cup contained: buspirone, coreg (blood pressure medication), Cymbalta (antidepressant/nerve pain medication) and Norco (pain medication) e. Resident X's medication cup contained: buspirone and tramadol A QMA Responsibilities policy was received on 4/19/24 at 12:01 p.m. from DON (Director of Nursing). It indicated, Other considerations and Reminders .NO presetting of medication The facility did not have an Administration of Medication policy per DON but instead followed the Licensed Nurse Med Pass Clinical Skills Validation. This Federal tag relates to Complaint IN00431737. 3.1-25(b)(5)

Based on observation, interview, and record review, the facility failed to ensure controlled medications stored in the facility's locked medication storage drawer in the medication refrigerator inside the main medication room were labeled with an opened date and a label which at a minimum includes the medication name (generic and/or brand), prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration for 2 of 4 resident's medications reviewed for medication storage. (Resident C and P) Findings include: A medication storage observation of the facility's main nursing station medication room was conducted on 4/18/24 at 7:23 p.m. with DON (Director of Nursing). With the medication room was a medication refrigerator which contained a locked metal box which held controlled medications. Inside the locked controlled medication drawer the following was observed: 1. An opened box containing a multi-dose bottle of lorazepam (anti-anxiety medication) which had also been previously opened. On the medication box was a handwritten name in black marker. DON indicated the name written on the box was the last name of Resident C. Neither the box nor the opened bottle of medication inside the box had a pharmacy label affixed with the resident's full name, the prescribed dose, or the route of administration. 2. An opened box containing an opened multi-dose bottle of lorazepam liquid. On the medication box was Resident P's name handwritten in black marker. Neither the box nor the opened bottle of medication inside the box had a pharmacy label affixed with the resident's full name, the prescribed dose, or the route of administration. An interview with DON conducted at the same time as the observation indicated, the medications mentioned above were obtained from the facility's medication management machine and not from the pharmacy. A Medication Labeling policy received on 4/19/24 at 9:59 a.m. from DON indicated, All labeling of prescriptions filled by [pharmacy's name] will be the responsibility of the dispensing pharmacist and will be consistent with State and Federal requirements. Labeling of prescription for outside pharmacies will also be according to State and Federal regulations. Labeling of over the counter drugs NOT dispensed by [pharmacy's name] are the responsibility of the outside pharmacy or the facility Medications Administered by Authorized Staff .shall be labeled as follows . a. Name of Drug b. Route of administration, if other than oral c. The strength and volume . d. The control number and expiration date e. Identification of the manufacturer, [NAME] or pharmacy f. Prescription number g. Special storage conditions . 2. Multiple dose drug distribution systems that dispense single unit packages require the label to contain the following a. Identification of the pharmacy b. Resident's name c. Date of dispensing d. Non-proprietary and/or proprietary name of the drug e. Strength expressed in the metric system whenever possible . 3.1-25(j) 3.1-25(k)

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident for 1 of 4 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 3/22/24 at 10:40 a.m. Resident D's diagnoses included, but not limited to, dementia and mood (affective) disorder (marked disruption in emotions; extreme highs/severe lows). An interview with Resident D conducted on 3/22/24 at 10:40 a.m. indicated she was going to be discharged from the facility on April 1, 2024. When asked why she was going to be discharged , she indicated she had been abusive to another resident. An interview with SSD (Social Services Director) conducted on 3/26/24 at 3:55 p.m. indicated Resident D was being discharged to another facility once her granddaughter had chosen one that is closer to her. When asked if Resident D's discharge was related to abuse, SSD indicated yes and Resident D had body slammed another resident to the floor then tried to deny that she knew anything about how the other resident came to be resting on the floor. An Indiana State Department of Health reportable incident report was received on 3/27/24 at 1:56 p.m. The report indicated, Resident D and Resident P, who both resided on the memory care unit, had a resident-to-resident altercation on 11/7/23. The Brief Description of Incident indicated, 11/7/23 [Resident P's first name] claimed [Resident D's first name] pushed her but there were no witnesses. It was in a common area, so we were able to access a camera and verify the incident. The type of injury added indicated, [Resident P's first name] has a knot to the back of her head and a skin tear. The immediate actions included: separation of the two residents; Resident D was placed on one-on-one supervision; pain and skin assessments were completed; social services was to provide 72 hours of psychosocial support; and families, doctors and the administrator were notified. Resident D was sent to a psychiatric facility for evaluation and treatment. The follow-up dated 11/13/23 indicated, no signs/symptoms of distress were noted for Resident P and Resident D had gone to a psychiatric facility. The investigation file for the resident-to-resident altercation between Resident D and P was received on 3/27/24 10:10 a.m. from CS (Clinical Specialist). Within the file, was a typed statement which indicated, There was not witness to the actual incident. The resident [sic, Resident P's full name] was found on the floor and she stated she was pushed. The camera footage was pulled and the entire incident was viewed. [sic, name of Resident P] was attempting to sit at the empty seat at the dining room table. [sic, Resident D's name] grabbed the chair not allowing [sic, Resident P's name] to sit down. Then [sic, Resident D's name] stood up, threw a metal drinking cut at [sic, Resident P] hitting her in the abdomen area. Then [sic, Resident D's name] came around the side of the table and forcefully shoved [sic, Resident P] onto the floor. [sic, Resident D] picked up her cup and quickly sat back down in her spot at the table. The staff within approx.[sic, approximately] 30 seconds who were in the pantry of the dining area came to [sic, Resident P] who was on the floor to assess and care for her. The video footage was viewed by the DON [sic, Director of Nursing], SSD [sic, Social Services Director], and the clinical specialist. 11/7/23 A nursing note in Resident D's clinical record dated 11/7/23 at 12:27 p.m. indicated Resident was seen on the video footage shoving another resident. Resident P indicated she was shoved onto the floor by Resident D. Resident D stated, she didn't do anything. A nursing note in Resident P's clinical record dated 11/7/23 at 2:34 p.m. indicated Resident P was shoved down in the dining room and sustained a skin tear to her right hand and a hematoma to the back of her head. A Social Services note dated, 11/7/2023 at 3:17 p.m. indicated social services had spoken to Resident D who indicated, she had pushed Resident P because she did not want that lady to sit with her at the table. When Resident D was told she would be going to a psychiatric facility, she replied, I don't give a f***, send me the f*** anywhere. A nursing note dated, 11/8/2023 at 10:01 a.m. indicated, IDT [sic, Interdisciplinary Team] met and reviewed recent aggressive behaviors from 11/07/2023. resident [sic, Resident D] was not triggered or instigated by any other residents. behaviors[sic] were very aggressive that resulted in injuries to other resident. Resident[sic, Resident D] was removed from situation and immediately placed on 1 on 1 supervision until resident left for [sic, name of psychiatric facility] for in patient psych stay. no [sic] further behaviors once 1 on 1 initiated. resident [sic] did leave this am [sic, a.m.] for hospital. A Social Services note dated, 1/29/2024 at 12:08 p.m. in Resident D's clinical record indicated, a care plan meeting with Resident D, Resident D's family, SSD (Social Services Director), IP (Infection Preventionist) and ED (Executive Director) had occurred, and they discussed Resident D's behaviors and stated, we are not able met her needs here at this facility. [sic, Resident D] is physically and verbally aggressive towards others, hiding knifes [sic] and scissors in her bra and under her bed. An Abuse, Neglect, and Misappropriation Prohibition and Prevention policy was received on 3/22/24 at 3:38 p.m. from ED. The policy indicated, it is the policy of the facility to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse .Reporting to the Administrator .Our facility will not condone resident abuse by anyone, including .other residents .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Physical abuse is defined as hitting, slapping, pinching, kicking, etc . 3.1-27(a)(1)

Based on interview and record review, the facility failed to timely report a reportable incident for 2 of 4 residents reviewed for abuse. (Resident 94 and Resident E) Findings include: 1. The clinical record for Resident 94 was reviewed on 3/25/24 at 10:30 a.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The resident was admitted on [DATE]. The 2/9/24 Admission Minimum Data Set (MDS) Assessment for Resident 94 indicated she was severely impaired. 2. The clinical record for Resident E was reviewed on 3/22/24 at 3:11 p.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The 1/8/24 Quarterly Minimum Data Set (MDS) Assessment for Resident E indicated he was severely impaired. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:00 a.m. It indicated .Incident date: 2/27/24 Incident Time: 3:01 p.m Brief Description of Incident .[Resident 94] touched [Resident E] on the outside of his pants in his lap area . An event for Resident 94 dated 2/26/24 indicated the resident on 2/26/24 at 10:00 a.m., had touched male resident in private area. A Social Services note for Resident E dated 2/26/24 at 2:41 p.m., indicated Visited with [Resident E] and asked if anything happened this morning. He said he couldn't remember. I asked if a female resident touched his private area. [Resident E] stated [NAME] (sic). I asked if that bothered him, he said no it was fine with me. A Social Services note dated 2/26/24 at 2:54 p.m., indicated spoke with [Resident 94] today regarding this morning incident. [Resident 94] did not recall doing that. I explained to her that she cannot go up to another resident and touch them. She replied okay. An interview was conducted with the Executive Director on 3/26/24 at 3:46 p.m. He indicated when the incident between Resident E and Resident 94 was first reported to him; it was not presented to him as something he thought at that time needed to be reported. After realizing the incident did need to be reported; he reported on 2/27/24. An abuse policy was provided by the Executive Director on 3/22/24 at 3:38 p.m. It indicated .It is the policy of [NAME] & Associates, Inc. and its member Communities to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and misappropriation of their property .Policy Interpretation and Implementation .C. Reporting to State Agencies .1. Allegations of abuse and any neglect, mistreatment or injury of unknown source that results in serious injury will be reported immediately to the State licensing/certification agency through that agency's approved method of incident reporting .2. Allegations of mistreatment, neglect, or injury of unknown source that do not result in serious injury will be reported within a reasonable amount of time not to exceed 24 hours to the State licensing/certification agency through the approved method of reporting . 3.1-28(c)

Based on interview and record review, the facility failed to thoroughly investigate a reportable incident for 2 of 4 residents reviewed for abuse. (Resident E and Resident 94) Findings include: 1. The clinical record for Resident 94 was reviewed on 3/25/24 at 10:30 a.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The resident was admitted on [DATE]. The 2/9/24 Admission Minimum Data Set (MDS) Assessment for Resident 94 indicated she was severely impaired. 2. The clinical record for Resident E was reviewed on 3/22/24 at 3:11 p.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The 1/8/24 Quarterly Minimum Data Set (MDS) Assessment for Resident E indicated he was severely impaired. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:00 a.m. It indicated .Incident date: 2/27/24 Incident Time: 3:01 p.m Brief Description of Incident .[Resident 94] touched [Resident E] on the outside of his pants in his lap area . An investigation involving Resident 94 and Resident E was provided by the Clinical Specialist on 3/27/24 at 10:30 a.m. The investigation included but was not limited to: a written statement by Certified Nursing Assistant (CNA) 5. It indicated the following: To Whom This May Concern: I walked out of a Resident's room, and there was [Resident 94], in the hallway in front of the nurse's station holding another resident's private area. I quickly asked her to stop, saying you can not do that, and I asked the nurse to help because she's (sic) wouldn't let go so the nurse grabbed her, and I grabbed him, and took him to his room immediately!!! . The investigation did not include any additional statements from the staff that were present during the incident between Resident 94 and Resident E. An interview was conducted with CNA 5 on 3/27/24 at 11:55 a.m. She indicated Resident E was clothed and standing in the hallway. Resident 94 had ambulated up to Resident E and grabbed his genitalia through his clothing. CNA 5 had intervened to separate the residents, but Resident 94 would not let go of Resident E's private area. She hollered for assistance from Registered Nurse (RN) 10. RN 10 had assisted with separating the residents. Resident E did not voice any pain during that time. An interview was conducted with the Clinical Specialist on 3/27/24 at 1:33 p.m. She indicated the investigation between Resident 94 and Resident E provided was complete. An interview was conducted with RN 10 on 3/28/24 at 9:29 a.m. She indicated she was at the nurse's station and Resident 94 and Resident E were in the hallway. CNA 5 had hollered for her assistance. She had assisted CNA 5 with the separating of the two residents, but when she approached them Resident 94 was not touching Resident E's private area at that time. She had provided assistance with removing Resident E away from Resident 94 by taking him to his room. She then performed an assessment on Resident E and did not observe any injuries to him. RN 10 indicated she could not recall being asked for a written statement about the incident. She works PRN (as needed) and did not return to the facility for approximately a week after the incident. An abuse policy was provided by the Executive Director on 3/22/24 at 3:38 p.m. It indicated .It is the policy of [NAME] & Associates, Inc. and its member Communities to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and misappropriation of their property .Policy Interpretation and Implementation .V. Abuse Investigations. 1. Should an incident or suspected incident of resident abuse, neglect, injury of an unknown source or misappropriation of resident property be reported, the Administrator or designee ensure the immediately protection and safety of the involved resident(s) and then will appoint a member of management to investigate the alleged incident while retaining ultimate responsibility for ensuring a timely and thorough investigation. 2. The Administrator or designee will provide to the person in charge of the investigation a complete copy of any supporting documents relative to the alleged incident. 3. The individual conducting the investigation will, at a minimum .g. Interview staff (on all shifts) who have had contact with the resident before, during, and immediately after the period of the alleged incident . 3.1-28(d)

Based on interview and record review, the facility failed to accurately complete the cognitive assessment portion of the MDS (Minimum Data Set) Assessment for 3 of 5 residents reviewed for Resident Assessment (Resident 28, 54, and 78). Findings include: 1a. The clinical record for Resident 28 was reviewed on 3/27/24 at 1:30 p.m. The Resident's diagnosis included, but was not limited to, dementia. A Quarterly MDS Assessment, completed 1/29/24, indicated that Resident 28 was usually able to make herself understood and was able to understand others. The BIMS (Brief Interview for Mental Status) of the MDS was not completed. 1b. The clinical record for Resident 54 was reviewed on 3/27/24 at 1:40 p.m. The Resident's diagnosis included, but was not limited to, dementia. A Quarterly MDS Assessment, completed 1/29/24, indicated that Resident 54 was usually able to make herself understood and was able to understand others. The BIMS (Brief Interview for Mental Status) of the MDS was not completed. 1c. The clinical record for Resident 78 was reviewed on 3/27/24 at 1:50 p.m. The Resident's diagnosis included, but was not limited to, dementia. A Significant Change of Status MDS Assessment, completed 2/29/24, indicated he was usually able to make himself understood and was usually able to understand others. The BIMS (Brief Interview for Mental Status) of the MDS was not completed. During an interview on 3/27/24 at 2:40 p.m., the SSD (Social Services Director) indicated that Residents 28, 54, and 78 were capable of answering questions for the BIMS Assessment, and that the assessments should have been completed for them. During an interview on 3/27/25 at 2:51 p.m., the MDSC (Minimum Data Set Coordinator) indicated the BIMS Assessment should have been completed on the MDS for Residents 28, 54, and 78. The facility used the RAI (Resident Assessment Instrument) as the policy for completing the MDS Assessments.

Based on interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to monitor the urine characteristics of a resident being evaluated for a urinary tract infection for 2 of 3 residents reviewed for urinary catheter. (Resident H and Resident L). Findings include: 1. The clinical record for Resident H was reviewed on 3/26/24 at 10:06 a.m. Resident H's diagnoses included, but not limited to, urinary tract infection, acute pyelonephritis (infection of the kidneys), extended spectrum beta lactamase resistance (ESBL, a multi-drug resistant organism), and neuromuscular dysfunction of the bladder (lack of bladder control). A nursing note dated 1/14/2024 at 11:39 p.m. indicated Resident H had an anchored catheter for urinary drainage. The urine was very foul smelling and dark. His urine was tested in-house with a urine analyzer and had numerous abnormal values. Resident H's urine was to be sent to the lab in the morning for a urinalysis with culture and sensitivity. A physician's note dated 1/15/24 indicated, Resident H was seen in follow up rounds to review/discuss recent urinalysis with culture and sensitivity lab/diagnostic testing from 1/15/24 due to malodorous urine. The results noted the urine was positive for leukocytes, nitrites and bacteria while the culture was still pending. A new order for Keflex (an antibiotic) 500 mg (milligrams) twice a day for 7 days was to be started and possibly adjusted once the culture came back. A physician's note dated, 1/18/2024 indicated, Resident H's urine culture showed mixed flora which indicated, a contaminated sample and the lab recommended a repeat sample. The antibiotic did not meet McGreer's criteria but was continued as his urine was reported as cloudy with large sediment and a foul odor. Resident H was also noted to have had increased behaviors recently. No repeat urinalysis with culture and sensitivity labs were to be completed at that time as Resident H was currently on oral antibiotics, and this could have resulted in a false negative urine culture. A physician's order dated 9/28/23 indicated, to provide urinary catheter care every day and night shift. Resident H's care plan dated 4/3/23 and last revised on 2/17/24 indicated; he had an indwelling urinary catheter related to a neuromuscular dysfunction of bladder. Interventions included, but not limited to, provide catheter care every shift and as needed (start date 5/17/23). An interview with CS (Clinical Specialist) conducted on 3/26/24 at 4:14 p.m. indicated, a review of Resident H's MAR (medication administration report) and TAR (treatment administration report) for January and February 2024 did not contain verification documentation that indwelling urinary catheter care had been performed every shift from 1/15/24 to 2/5/24. A Bed Bath/Perineal procedure was provided by CS on 3/27/24 at 10:19 a.m. CS indicated, the facility does not have an indwelling urinary catheter care policy. The Bed Bath/Perineal care procedure indicated, Catheter care: 22. If resident has catheter, check for leakage, secretions or irritation. Gently wipe four inches of catheter from meatus out .Perineal Care .For Males .Pull back foreskin if male is uncircumcised. Wash and rinse the tip of penis using circular motion beginning with urethra. Continue washing down the penis to the scrotum and inner thighs. Rinse off soap and dry. Return foreskin over the tip of the penis. 40287 2. The clinical record for Resident L was reviewed on 3/22/24 at 10:52 a.m. The Resident's diagnosis included, but were not limited to, cerebral infarct (stroke) and dysuria (painful urination). She was admitted to the facility on [DATE]. An Admission Assessment, dated 3/11/24, indicated Resident L was occasionally incontinent at night and had no symptoms of burning, frequency, pain with urination, or urgency. She wore incontinent pads or briefs to assist with controlling incontinence. A care plan, initiated 3/12/24, indicated Resident L had urinary incontinence. She required staff to assist with toileting and toilet hygiene. The goal was for her not to develop skin breakdown related to incontinence. The interventions included, but were not limited to, assist with toileting and personal hygiene as needed, provide incontinent care after each episode, and weekly skin assessments. A BIMS (Brief Interview for Mental Status) Assessment, completed 3/19/24, indicated she was cognitively intact. A Nurse Practitioner Progress Note, dated 3/20/24, indicated that Resident L had complaints of dysuria on exam. A UA C&S (Urinary Analysis with Culture and Sensitivity) was ordered. During an interview on 3/22/24 at 10:52 a.m., Resident L indicated she thought she was getting a urinary tract infection. She had told the facility, and they were testing her. It took a long time for the staff to take her to the bathroom and she was having urinary accidents. A Nursing Progress Note, dated 3/22/2024, indicated urine was collected for UA C&S and sent to the lab. A Nursing Progress Note, dated 3/25/2024, indicated that the urine sample previously sent to the lab was reported as possibly contaminated. The Nurse Practitioner had been made aware. During an interview on 3/26/24 at 3:19 p.m., Resident L indicated she was beginning to have burning with urination and that it seems to run every 15 minutes. During an interview on 3/26/24 at 3:57 p.m., the Director of Nursing indicated the Nurse Practitioner had been informed of possible contamination of the previous urine sample and had ordered to repeat the UA. A Nursing Progress Note, dated 3/27/2024, indicated that urine had been obtained and sent to the lab that morning. A urine culture was pending at that time and the nurse practitioner was aware. During an interview on 3/27/24 at 11:11 a.m., the Director of Nursing indicated a urine sample that had been sent to the lab that morning had been collected by using an in and out catheter. The Nursing Progress notes did not contain any assessment of Resident L's urine color, characteristics, any odor present in the urine, or how the urinary sample was obtained. On 3/28/24 at 12:16 p.m., the Clinical Specialist provided the current Catheterizing the Urinary Bladder with an In and Out Straight Catheter Skills Validation which read .Document .Document the procedure: Documentation should include a detail of the procedure, the resident's tolerance of the procedure, the color, character and amount of the urine noted in the drainage bag . This citation relates to Complaint IN00425957. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to provide adequate supervision for an ambulatory cognitively impaired resident that resided on the memory care unit for 3 of 4 residents reviewed for abuse. (Resident 15 and Resident 94, and Resident E) Findings include: 1a. The clinical record for Resident E was reviewed on 3/22/24 at 3:11 p.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The 1/8/24 Quarterly Minimum Data Set (MDS) Assessment for Resident E indicated he was severely cognitively impaired. 1b. The clinical record for Resident 94 was reviewed on 3/25/24 at 10:30 a.m. The diagnoses for the resident included, but were not limited to, dementia with psychotic disturbance and hallucinations. The resident was admitted on [DATE]. The 2/9/24 Admission Minimum Data Set (MDS) Assessment for Resident 94 indicated she was severely cognitively impaired. A care plan for Resident 94 dated 2/7/24 indicated .[Resident 94] has a diagnosis of dementia with behaviors and at times exhibits the following signs and symptoms attempting to hit staff, yelling out. [Resident 94] also has a current dx [diagnosis] of hallucinations and is at risk of experiencing certain behaviors regarding .Approach .New or worsening behaviors will be monitored and new interventions will be considered in order to promote the highest level of quality of life for this resident .Allow for hoarding or wandering in a controlled environment with acceptable limits . A care plan dated 2/27/24 indicated .Resident touching another resident inappropriately. Increased interest in touching self, masturbation .Approach .Give resident privacy in own room when desires to masturbate or touch self .Resident on 15 min [minutes] check until deemed necessary to remove per IDT [Interdisciplinary Team.] . A care plan dated 3/6/24 indicated Entering another residents room and taking their belongings .Approach .Goal. Resident will not go into other residents rooms and take their belongings .Approach. Encourage resident to join in scheduled activities to keep her busy .See [Psych Provider] as needed .Stop sign placed on other residents door, 15 min checks to continue until deemed appropriate to remove by IDT .Try self directed activities to help keep resident busy, walk with resident in hallway . A care plan dated 3/6/24 indicated .Resident is at risk for psychosocial distress from physical contact from another resident .Approach .Monitor for any signs of distress, withdraw, change in mood A care plan for Resident 94 dated 3/14/24 indicated Behavioral symptoms. Resident is at risk wandering, exit seeking, history of elopement from home, expresses the need to go home or leave, , and/or expresses anger or frustration about being in the community. wander guard to L [left] ankle. Resident cuts off wanderguard at times .Approach .3/14/24 Increase staff monitoring as needed .Redirect resident if wandering in unsupervised areas .When resident begins to wander, provide comfort measures for basic needs . A physician order dated 2/6/24 indicated Resident 94 was to receive 10 milligrams of memantine daily for a diagnosis of dementia with psychotic disturbances that included hallucinations. A physician order dated 2/6/24 indicated the resident was to receive 2 milligrams of diazepam in the morning daily for combative behavior. The medication was discontinued on 2/7/24. A physician order dated 2/6/24 indicated the resident was to receive 2 milligrams of diazepam at bedtime daily for combative behavior. A nursing progress note for Resident 94 dated 2/6/24 indicated Unable to complete admission PPD [Purified Protein Derivative] testing at this time. Patient is being extremely combative, yelling, swinging arms/attempting to strike nursing staff, screaming and unable to redirect. Will continue w/ [with] plan of care. A Social Services note for Resident 94 dated 2/7/24 indicated Nursing staff did report that on the evening of 2/6/24, resident was combative with nursing staff during admission process/care; attempting to hit nursing staff, verbal aggression. Staff also report that on the morning of 2/7/24, resident was yelling out/screaming at others during care. Staff will continue to reassure resident of her safety during care, and will continue to cue and assist resident as necessary. A physician note dated 2/7/24 indicated .behaviors in hospital requiring prn [as needed] zyprexa. Consult psych if needed. Cont [continue] memantine, diazepam reports of anxiety and behaviors. Add hydroxyzine 25 mg [milligrams] bid [twice a day] prn x 14 days. May need to increase diazepam dosage . A physician order dated 2/8/24 indicated the resident was to receive 25 milligrams of hydroxyzine twice a day as needed. A physician note dated 2/9/24 indicated Resident 94 was confused, but mood was stable. A nursing progress note for Resident 94 dated 2/23/24 indicated Resident wandering throughout the entire morning. She had to be redirected from 3 other resident rooms. In the last room she was found unclothed in another residents bed and had ripped her brief off. She does not take direction well and is not able to understand what you're asking d/t [due to] dementia. Will continue to redirect. An event for Resident 94 dated 2/26/24 indicated the resident on 2/26/24 at 10:00 a.m., had touched male resident in private area. Interventions that were put in place after the incident was one on one interaction, reassurance from staff, 15-minute monitor checks, and psych provider was notified. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:00 a.m. It indicated .Incident date: 2/27/24 Incident Time: 3:01 p.m Brief Description of Incident .[Resident 94] touched [Resident E] on the outside of his pants in his lap area .Follow up: 3/5/24 [Resident 94] was seen by psych and new med [medication] added to help with behavior. 15-minute checks continue for [Resident 94]. Interdisciplinary team will evaluate circumstances to decide when they can be discontinued. Neither resident is showing any s/s [signs and symptoms] of psychosocial distress from incident. An investigation involving Resident 94 and Resident E was provided by the Clinical Specialist on 3/27/24 at 10:30 a.m. The investigation included but was not limited to: a written statement by Certified Nursing Assistant (CNA) 5. It indicated the following: To Whom This May Concern: I walked out of a Resident's room, and there was [Resident 94], in the hallway in front of the nurse's station holding another resident's private area. I quickly asked her to stop, saying you cannot do that, and I asked the nurse to help because she's (sic) wouldn't let go so the nurse grabbed her, and I grabbed him, and took him to his room immediately!!! . An interview was conducted with CNA 5 on 3/27/24 at 11:55 a.m. She indicated she was the staff present during the incident on 2/26/24 between Resident E and Resident 94. Resident E was clothed and standing in the hallway. Resident 94 had ambulated up to Resident E and grabbed his genitalia through his clothing. CNA 5 had intervened to separate the residents, but Resident 94 would not let go of Resident E's private area. She hollered for assistance from Registered Nurse (RN) 10. RN 10 had assisted with separating the residents. Resident E did not voice any pain during that time. Resident 94 was then placed on every 15-minute checks. An interview was conducted with RN 10 on 3/28/24 at 9:29 a.m. She indicated she was at the nurse's station and Resident 94 and Resident E were in the hallway. CNA 5 had hollered for her assistance. She had assisted CNA 5 with the separating of the two residents, but when she approached them Resident 94 was not touching Resident E's private area at that time. She had provided assistance with removing Resident E away from Resident 94 by taking him to his room. She then performed an assessment on Resident E and did not observe any injuries to him. A Post Behavioral/Emotional IDT Form dated 2/26/24 indicated .resident went to common area and touch a male resident in his private area .New interventions that will be added to prevent a reoccurrence; make sure resident does not sit next to male resident in common area . A 2/28/24 Behavior IDT follow up for Resident 94 indicated resident was on 15-minute monitoring checks and psych provider ordered 10 milligrams of Paxil (antidepressant) daily. A physician order dated 2/28/24 indicated the resident was to receive 10 milligrams of Paxil daily. A Social Services note dated 3/6/24 at 7:49 a.m., indicated On 3-5-24 at 11:12 p.m., [Resident 94] was having trouble sleeping, up walking and going in/out of other residents rooms taking their personal belongings. Staff did try the following redirection, one-on-one, toileted, provided a calm environment, given food/fluids, was not effective. IDT team reviewed behaviors. Staff will continue to redirect resident as needed. 1c. The clinical record for Resident 15 was reviewed on 3/25/24 at 1:11 p.m. The diagnosis for the resident included, but was not limited to, dementia. The 1/29/24 Admissions Minimum Data Set (MDS) Assessment for Resident 15 indicated she was severely cognitively impaired. A nursing progress note dated 3/6/24 at 8:13 a.m., indicated Res [resident] 94 in [Resident 15]'s room trying to take res in room belongings. Res [94] was struck in the back with a closed fist before staff could intervene. Res was not injured by this contact. Res skin was assessed and found to have no redness or bruising to area Res does not seem to have any memory of this incident and continues to try and go into others rooms and take things out of rooms that are not hers. Res redirected several times without effectiveness. A reportable incident that was reported to the Indiana Department of Health was provided by the Clinical Specialist on 3/25/24 at 9:01 a.m. It indicated .Incident date: 3/6/24 Incident Time: 9:01 a.m Brief Description of Incident .[Resident 94] wandered into [Resident 15]'s room and before staff could reach [Resident 94] and redirect her [Resident 15] touched her back with her hand .Immediate Action taken .Residents were immediately separated. Skin and pain assessment has been initiated .Stop sign was placed at [Resident 15]'s door .Follow up .[Resident 94] was seen by psych [provider] and new order added to care. 15 - minute checks continue with [Resident 94] IDT team met and reviewed behaviors. Staff will continue to redirect as needed. They will try and engage her in self-directed activities along with scheduled activities. An investigation involving Resident 94 and Resident 15 was provided by the Clinical Specialist on 3/27/24 at 10:30 a.m. The investigation included but was not limited to: a written statement by License Practical Nurse (LPN) 2. It indicated, 3/6/24 at 8:05 a.m. Res [94] was in [Resident 15's room] and had taken some belongings from res [15]. Res in [Resident 15's room] was distressed about [Resident 94] in her room. Res [94] had belongings in her hand. Retrieved res belongings and got her to head to the door. As were coming through the door [Resident 15] hit her in the back. Removed res [94] from [Resident 15's room] & assessed for injury. Res in [Resident 15's room] went back to her chair and was upset about her being in her room . A Social Services progress note dated 3/7/24 at 7:37 a.m., indicated On 3-6-24 at 8:00 a.m., [Resident 94] was rummaging through other residents's belongings. Staff did try the following redirection, one-on-one, offered food/fluids was not effective. On 3-6-24 at 9:47 p.m., [Resident 94] was having trouble sleeping, wondering into other residents rooms, taking their belongings, waking them up and yelling at them about her husband. Staff did try the following redirection, one-on-one, food/fluids, toileted, returned to her room, position change, was not effective. On 3-7-24 at 2:56 a.m., [Resident 94] was having trouble sleeping and wandering. Staff did try the following redirection, one-on-one, toileted, returned to her room, position change, was not effective. IDT team met and reviewed behaviors. Staff will continue to redirect resident as needed. Resident just had a recent increase in her Paxil. A physician order dated 3/6/24 indicated Resident 94 was to be increased to 20 milligrams of Paxil daily. An observation behavior note for Resident 94 dated 3/8/24 indicated .follow up behavior and resident altercation/contact .Root cause: Resident with altercation with other female resident and also previously touched male resident in hallway in his lap area on outside of his pants/increased pleasing self-masturbation. Current status: resident conts [continues] to wander however no aggression or physical contact with others. Resident has had no psychosocial distress from physical contact to back when she roamed into other residents room to take her items. Intervention(s): Paxil was increased by psych earlier this week, and it does seem to be helping. Psych evaluated resident this week. This resident is on 15 min checks, and a stop sign is on the door for the female resident whos room she entered and that is effective at this time. Staff gives redirection as needed and engages in appropriate activities . A psych visit note dated 3/8/24 indicated .The patient reports no difficulty with sleeping at night. Staff notes she is having trouble with some difficulty with being up wandering at times. If she continues to have difficulty we will add melatonin She denies difficulty with anxiety and no symptoms are observed. She is more restless than anxious, probably due to her confusion .She is having difficulty with behaviors, including stealing belongings from peers and going in their room. She also has had some sexual behaviors. She was started on Paxil for these, and her dose was increased recently .Staff are obtaining UA on her today. Her recent one was negative for UTI [Urinary Tract Infection]. The patient's cognition is significantly declined. She is currently receiving memantine for cognition decline, which we will probably discontinue once her behavior issues are stabilized Follow up 1 month . An observation behavior note for Resident 94 dated 3/15/24 indicated follow up behaviors .Root cause: resident with behaviors, wandering into others rooms, taking belongings, recently having hypersexual behaviors, such as masturbating. Current status: residents sexual behaviors have decreased, no touching others, conts to roam in to others rooms, and is taking down stop signs. They are not effective. Intervention(s): psych is following resident, and [Medical Provider]. U/A [Urinalysis] ordered. Paxil was started and also increased which has helped resident some . A Social Services note for Resident 94 dated 3/18/24 indicated On 3/15/24 at 9:16 p.m., [Resident 94] was repetitive asking questions. Staff did try to redirect, was not effective. On 3/16/24 at 1:00 a.m., [Resident 94] was having trouble sleeping and going into other residents rooms while they were sleeping. She would uncover them and tell them it was time to get up. She also pulled their clothing out of the closet and put them on top of them. Staff did try the following redirection, offered food/fluids, toileted and returned to her room, was not effective. On 3/17/24 at 7:31 p.m., [Resident 94] was wondering about the unit. Staff did try the following redirection, backrub and provided calm environment, was not effective. IDT team met and reviewed behaviors. Staff will continue to redirect resident as needed through out her daily routine. They will also try to have her do self directed activities and join in scheduled activities. A medical provider note dated 3/19/24 indicated .Resident with pacing and restlessness at night .Start low dose melatonin 3 mg q hs [every night. A physician order dated 3/20/24 indicated the resident was to receive 3 milligrams of melatonin daily at bedtime. A behavior follow up note dated 3/22/24 indicated Root cause: resident with ongoing behaviors. sexual behaviors have decreased some, not touching others. Conts to wander into other areas. Current status: stable. Conts to wander into others space, non pharm [nonpharmacological] interventions attempted. Staff attempting to engage in activities and keep resident busy. Staff reported to NP [Nurse Practitioner] resident not sleeping well. Intervention(s): Melatonin started, cont ss [social services] follow up, psych, and NP to follow .no further IDT monitoring needed at this time . Resident's 94 staff monitoring documents were provided by the Clinical Specialist on 3/26/24 at 12:55 p.m. The monitoring documents indicated Resident 94 was on staff 15-minute monitoring checks on 2/26/24, 2/27/24, 2/28/24, 2/29/24, 3/1/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/7/24, 3/8/24, 3/9/24 and 3/10/24. An observation was made of Resident 94 on 3/25/24 at 10:55 a.m. During a scheduled activity on the memory care unit, Resident 94 was observed wandering. The resident had wandered into Residents' 68 and 79's room. The residents that reside in the room were not present in the room at that time. Resident 94 was observed going to one of the resident's bed and messing up blankets; rummaging through the closet, and the bathroom. There was no observation of staff redirecting the resident at that time. The resident then left the room and ambulated to the nurse's station. Resident 94 indicated at that time; she needed her, dirty white clothes. During an interview with CNA 5 on 3/27/24 at 11:55 a.m., she indicated Resident 94 wanders in and out of residents' rooms, and it upsets other residents. A stop sign was placed on Resident 15's door after the incident occurred on 3/6/24, with Resident 15. Resident 15 gets upset when Resident 94 takes her belongings. Resident 94 goes into other residents' rooms; messes up their covers and belongings. The stop signs do not help. The resident removes the stops signs. The resident does like her room to be set at a warmer temperature. She will occupy her time in her room at times if the temperature in her room was set to her liking. During an interview with RN 10 on 3/28/24 at 9:29 a.m., she indicated Resident 94 does wander in and out of other residents' rooms. They utilize stop signs on the doors to detour her from entering. An interview was conducted with LPN 2 on 3/28/24 at 11:06 a.m. She indicated she was the staff person present during the incident on 3/6/24 with Resident 94 and Resident 15. She was assisting a resident; assuring that resident was not going to fall and had observed Resident 15 getting aggravated with Resident 94 in her room taking her belongings. She heard Resident 15 yelling get out! Then, LPN 2 entered the room to intervene and redirect. LPN 2 was able to get Resident 94 to head to the doorway of the room. During that time, Resident 15 hit Resident 94 in the back prior to getting Resident 94 to exit the room. LPN 2 indicated stops signs do not stop Resident 94 from entering other residents' rooms. She removes them. Does not help at all; nothing works. She wanders everywhere. A Behavioral Health Management Program was provided by the Director of Nursing on 3/28/24 at 11:50 a.m. It indicated, Behavior policy .[NAME] communities provide services to our residents with specific diseases and disorders. Some of our residents have medical disabilities that can lead to disruptive behaviors and these behaviors have the potential to create a negative effect on the resident, other residents, visitors, and the staff. It is [NAME]'s policy that each community will have a behavior program that: identifies, monitors, manages, and disseminates (whenever possible) all behavioral events by utilizing the least invasive approach based on the individual resident affected. Our goal is to provide the highest level of functioning and well being for each resident we serve. [NAME] believes in a person-centered care approach and tailors all considerations for the individual affected, including physical and psychosocial aspects of well being when it comes to managing maladies that manifest behavioral disturbances . 3.1-37(a)

Based on interview and record review, the facility failed to ensure transmission-based precautions (TBP) were initiated timely for a resident with COVID-19 for 1 of 3 residents reviewed for TBP. (Resident 255) Findings include: The clinical record for Resident 255 was reviewed on 3/25/24 at 1:55 p.m. The diagnoses included, but were not limited to, COVID-19, cough, and hypertension. A progress note, dated 3/16/24 at 12:54 p.m., indicated Resident 255 admitted to the facility from the hospital and admitted with COVID-19. A physician order, dated 3/18/24, indicated the following, .droplet/contact isolation, with no roommate. All meals, activities, therapy and services must be provided in room with isolation precautions followed There was no indication in the progress notes or the physician orders that the resident was in TBP until 3/18/24. A policy titled COVID-19 Policy and Procedure, dated 8/6/23, was provided by Clinical Specialist on 3/26/24 at 12:55 p.m. The policy indicated the following, .Additional PPE [personal protective equipment] and Other Precautions .A. Face Shield/Goggles, N95 Respirator, and a Gown must be worn by healthcare personnel (HCP) who provide essential direct care within 6 feet of the resident when .1. Caring for a Resident in a Red Zone 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure annual influenza immunization was administered per physician orders for 1 of 5 residents reviewed for immunizations. (Resident 82) Findings include: The clinical record for Resident 82 was reviewed on 3/25/24 at 1:50 p.m. The diagnoses included, but were not limited to, heart failure, diabetes mellitus, and weakness. An immunization consent form, undated, indicated consent was given to administer the influenza vaccine. A physician order, dated 11/3/23, was noted for Fluzone Quad 2023-2024 (flu vaccine) intramuscular injection. The electronic medication administration record (EMAR), dated November of 2023, indicated the dose of Fluzone Quad was not signed off, as administered, on 11/3/23. An interview conducted with the Infection Preventionist (IP), on 3/26/24 at 4:50 p.m., indicated she reached out to the physician and obtained an order to administer the influenza vaccine since it was still within the window to receive the annual influenza vaccine. A policy titled Influenza Immunization Policy - Residents, revised 9/23/20, was provided by the Executive Director on 3/22/24 at 1:30 p.m. The policy indicated the following, .All residents will be offered an influenza vaccination as appropriate when residing in a [name of Corporation] Community. Annually [name of Corporation] will offer the influenza vaccination beginning on October 1 unless the vaccinations have not yet been received in stock by [name of pharmacy] and continue through the influenza season .This policy is created with the intention to follow current CDC [Centers for Disease Control and Prevention] recommendations for influenza vaccination A document from the Centers for Disease Control and Prevention (CDC) titled Key Facts About Flu Vaccines, last reviewed March 22, 2024, indicated the following, .When should I get vaccinated .For most people who need only one dose of influenza vaccine for the season, September and October are generally good times to be vaccinated against influenza. Ideally, everyone should be vaccinated by the end of October

Based on interview and record review, the facility failed to accurately reflect the resident's fall status, related to the Minimum Data Set (MDS) assessment, for 1 of 3 residents reviewed for falls. (Resident E) Findings include: The clinical record of Resident E was reviewed on 8-30-23 at 12:09 p.m. His diagnoses included, but were not limited to, dementia, history of falls, muscle weakness, congestive heart failure and atrial fibrillation (irregular heart rhythm). He resided on a secured dementia care unit. A review of his most recent MDS assessment, a quarterly assessment, dated 8-5-23, indicated he had no falls since the most recent prior MDS assessment, a significant change assessment on 6-20-23. A review of Resident E's progress notes from 7-30-23 to 8-30-23 identified 3 falls that should have been identified for the look back period of 6-20-23 to 8-5-23, with 2 falls on 7-30-23 and 1 fall on 8-2-23. In an interview with the MDS Coordinator on 8-30-23 at 2:05 p.m., she indicated she would need to review Resident E's falls for the appropriate time period. In a second interview on 8-30-23 at 2:10 p.m., with the MDS Coordinator, she indicated she had counted a total of 5 falls for the time period, with 2 or more falls without injury and 2 or more falls with non-major injury. Looks like one of the company's traveling MDS people completed the 8-5-23 MDS assessment. Any number of reasons it could have been put in incorrectly. She stipulated the facility does not have a particular policy or procedure for MDS assessments, but uses the most current Resident Assessment Instrument (RAI) manual. The Centers for Medicare and Medicaid Services' Long Term Care Facilities Resident Assessment Instrument 3.0, version 1.16, October, 2018 manual, section J-1800 indicated, Falls are a leading cause of morbidity and mortality among nursing home residents. Falls result in serious injury, especially hip fractures. Fear of falling can limit an individual ' s activity and negatively impact quality of life .Identification of residents who are at high risk of falling is a top priority for care planning. A previous fall is the most important predictor of risk for future falls. Falls may be an indicator of functional decline and development of other serious conditions such as delirium, adverse drug reactions, dehydration, and infections. External risk factors include medication side effects, use of appliances and restraints, and environmental conditions. A fall should stimulate evaluation of the resident ' s need for rehabilitation, ambulation aids, modification of the physical environment, or additional monitoring (e.g., toileting, to avoid incontinence). Coding for the documentation of falls, section J-1900, should reflect any falls that have occurred since the previous assessment period. Coding for the number of falls and any injuries should reflect any injuries received as a result of the fall, specific to the terms of no falls, injury or major injury. Definitions of those injuries are as follows: Injury (except Major includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. Major Injury includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. Coding for the number of falls utilizes the codes of none (0), one (1) or two or more (2). This Federal tag relates to Complaint IN00415226. 3.1-31(a) 3.1-31(c)(3) 3.1-31(c)(4)

Based on interview and record review, the facility failed to immediately notify a resident's physician of an x-ray result timely which indicated, the resident had sustained an elbow fracture from a fall that occurred days prior resulting in delayed treatment and a significant change in the resident's condition for 1 of 2 residents reviewed for accidents. (Resident 56) Findings include: The clinical record for Resident 56 was reviewed on 1/20/23 at 11:57 a.m. Resident 56's diagnoses included, but not limited to, irritable bowel syndrome, congestive heart failure, weakness, and chronic obstructive pulmonary disease. A nursing note dated 10/8/2022 at 5:18 p.m. indicated, she had received a phone call from Resident 56's roommate indicating, Resident 56 had gotten up out of bed, walked herself to the bathroom, slipped and fell . Upon arriving at the resident's room, Resident 56 was sitting on her bottom and when asked if she hit her head, she stated no. Resident 56 had a laceration noted to bilateral elbows and she complained of pain to her left elbow where the laceration was noted. Resident was reminded that she needs to use her call light for assistance when she needs to get up. Resident was taken to assist dining room for dinner. A nursing note dated 10/9/2022 at 3:18 a.m. indicated, Resident 56's neurological checks continued, no further injuries were noted, all range of motion to all extremities without difficulty, and resident denied pain from fall but stated, I always hurt somewhere. A nursing note dated 10/10/2022 at 2:32 p.m. was recorded as a Late Entry on 10/10/22 at 2:32 p.m. indicated, Resident 56 was lethargic that morning, refused to take her medications, and did not eat breakfast. Resident 56 screams out in pain when touching the left arm. Resident's Nurse Practitioner (NP) gave a new order for a STAT (sic, without delay.) x- ray of her left shoulder and arm. A physician's order dated 10/10/22 indicated, to obtain a two-view x-ray of left shoulder and arm STAT. A radiology report dated 10/10/22 at 8:51 p.m. EDT (sic, eastern standard time) was received on 1/19/23 at 2:24 p.m. from DON (Director of Nursing). The report indicated; Resident 56 had a nondisplaced left ulna olecranon (elbow) fracture with soft tissue swelling over the fracture. A nursing note dated 10/12/22 at 9:30 a.m. indicated, Resident 56 was being sent to the local emergency room related to a fractured elbow. At the time of the transfer to the hospital's emergency room , Resident 56's fall occurred 4 days prior, and the x-ray had been resulted for approximately 36 hours. An interview with DON conducted on 1/20/23 at 10:52 a.m. indicated, the person who retrieved Resident 56's x-ray results from 10/10/22 placed the results in NP 6's folder instead of immediately calling the on-call physician or NP 6. NP 6 found Resident 56's x-ray result on 10/12/22 when she reviewed the contents of her folder. DON indicated, the expectation was whomever took the x-ray result off the fax machine, should have read the report, called the results to the on-call physician or the NP, and not simply place the report in a folder. She further indicated, whenever there is a fall, pain assessments should be done and charted, and the fall event should have a narrative fall assessment. An interview with Resident 56's NP 6 conducted on 1/20/23 at 11:42 a.m. indicated, the on-call service had been informed of the fall on 10/8/22. NP 6 indicated, she had come into the facility on the 12th and found the x-ray result in her folder. There was nothing documented on it whatsoever. I can tell from the report that the x-ray was sent to the facility on the 10th at 8:11 p.m. She stated, someone should have been notified of the result. The facility could have called me personally on Tuesday . NP 6 indicated, the facility had a lot of agency staff working there at that time and they can't stick it in a folder and not address it. NP 6 indicated, had she been made aware of the result sooner, Resident 56 would have received treatment quicker. Resident 56's Annual MDS (minimum data set) dated 9/1/22 indicated, prior to the fall on 10/8/22, she required limited assistance of one person for bed mobility, transfers, toileting, and personal hygiene; supervision with set up for eating; physical help in part of one person for bathing; could walk in room and on the unit with limited assistance of one person. Resident 56's quarterly MDS dated [DATE], after the fall on 10/8/22, indicated she required, extensive assistance of two persons for bed mobility, transfers, toileting, and personal hygiene; extensive assistance of one person for eating; and was totally dependent on one person for bathing. Resident 56's care plan dated 7/28/22 indicated, she was risk for decreased walking self-performance related to unsteadiness on feet. Interventions included, but not limited to, apply gait belt and provide rolling walker prior to walking, monitor for signs/symptoms of pain, shortness of breath, and fatigue, and refer to therapy as needed. 3.1-5(a)(1) 3.1-5(a)(2) 3.1-5(a)(3) 3.1-5(a)(4)

Based on observation, interview and record review, the facility failed to ensure staff were present while a resident with a history of losing his balance and falling was toileting, resulting in the resident falling and obtaining a clavicle (collar bone) fracture; review a resident's fall during a collective Interdisciplinary Team meeting; and evaluate a resident's reported fall, per policy, for 1 of 3 residents reviewed for falls, 1 of 1 resident reviewed for notification of change, and 1 of 2 residents reviewed for pain. (Residents L, 42, and 76) Findings include: 1. The clinical record for Resident 42 was reviewed on 1/18/23 at 12:30 p.m. The diagnosis for the resident included, but was not limited to, left and right above the knee amputation. The 12/4/22 Annual Minimum Data Set (MDS) Assessment for Resident 42 indicated he was cognitively intact. The functional status the resident was needing for toileting and transfers were extensive assistance of 2 staff persons. The fall care plan for Resident 42 dated 2/24/21 indicated Resident [42] at risk for falling and fall related injuries related to history of falls with fracture, unsteadiness on feet, opioid use, antidepressant use. Short term goal. Will minimize risk for injuries Approach start date 8/31/22: Staff to not leave while resident sitting on toilet . An Event dated 12/9/22 for Resident 42 indicated resident had an unwitnessed fall in his room. He indicated he was sitting in his wheelchair and attempted to scoot himself back into the wheelchair. He lost his balance and fell on to the floor. The resident did not obtain any injuries. An IDT (Interdisciplinary Team) note dated 12/9/22 indicated IDT met and reviewed recent fall from early this morning. resident had been refusing to go to bed, so resident was sitting up in wheelchair watching his laptop, he went to scoot himself back into his wheelchair and lost his balance and fell forward. no injuries noted. Spoke with therapy and OT [occupational therapy] to eval for w/c [wheelchair] positioning d/t [due to] recent amputation. Care plan reviewed and updated. A nursing progress note written by License Practical Nurse (LPN) 1 dated 12/22/22 indicated Heard yelling from [Resident 42]'s room ., ran in to find res [resident] on floor on R [right] side with active red blood from rectum with blood clots noted and gross amt blood in toilet from stool .order rec'd [received] to send to ER [emergency room ] for eval [evaluation] and tx [treatment] . A hospital discharge summary dated 12/23/22 indicated Resident 42 was admitted on [DATE]. He had a recent left above knee amputation 3-4 weeks ago. Resident 42 indicated he was reaching for some toilet paper when he lost his balance and fell off the toilet. The report indicated he had a clavicle fracture from the fall. Resident 42's clinical record did not include a fall event nor an IDT review for the resident's fall that had occurred on 12/22/22. An observation was made of Resident 42 on 1/23/23 at 10:22 a.m. The resident was observed in his bed with a sling on his left arm. He indicated in December; he had fallen off the toilet and had broken his collar bone. Two staff members had assisted him onto the toilet then left the bathroom. After he finished, he reached to grab some toilet paper and fell off the toilet. The two staff members were not present in the resident's bathroom or room at the time of the fall. An interview was conducted with LPN 1 on 1/23/23 at 10:28 a.m. She indicated she had heard Resident 42 yelling from his room. He was found in the bathroom with no staff presence lying on his stomach leaning on his right side. She had assessed him at that time. She had also noticed the resident had blood clots on the floor. She believed after he fell , he rolled himself on his right side. She notified the medical provider and received an order to send the resident to the hospital. The resident had a fracture to his left clavicle and possibly a bleeding hemorrhoid due to being on an anticoagulant from his amputation. Resident 42 was always transferred with 2 staff members. The staff members that day had stepped out of the room to gather supplies and left him unattended. He usually is just fine being left alone. An interview was conducted with the Nurse Consultant on 1/23/23 at 3:23 p.m. She indicated there should have been an IDT review, but there was no fall event assessment opened after Resident 42's fall on 12/22/22. After a fall occurs, the staff will open a fall event then it will trigger an IDT review. 40287 2. The clinical record for Resident 76 was reviewed on 1/17/23 at 3:00 p.m. The Resident's diagnoses included, but were not limited to, urinary tract infection and dementia. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/22, indicated she had severely impaired cognition and required extensive assistance of 1 staff member for transfers. A Post Fall Assessment Event Report, dated 12/24/22, indicated that Resident 76 had fallen will sitting in a chair in the dining room. She had not sustained an injury. An IDT progress note, dated 12/25/22 at 1:09 a.m., indicated the IDT (Interdisciplinary Team) had med and reviewed the recent witnessed fall from 12/24/22. During an interview on 1/17/23 at 3:09 p.m., Family Member 18 indicated that Resident 76 had a fall on Christmas eve. During an interview on 1/24/23 at 11:10 a.m., the IP (Infection Preventionist) indicated that she had written the IDT progress note on 12/25/22 at 1:09 a.m. Resident 76's fall had been reviewed by the IP and the Director of Nursing Services prior to the IDT note being written. The IDT team had not been present at the time of the review. 30344 3. The clinical record for Resident L was reviewed on 1/19/23 at 10:56 a.m. His diagnoses included, but were not limited to, anxiety. He was admitted to the facility on [DATE] for aftercare following a joint replacement surgery revision and discharged from the facility on 11/2/22. The 9/23/22 hospital discharge summary, signed 9/26/22 at 9:01 a.m., indicated he was admitted to the hospital on 9/20/23 with a diagnosis of infected right total hip arthroplasty. He underwent a resection hip arthroplasty with insertion of antibiotic-impregnated cement spacer .The patient will follow up for a two-week follow-up visit for wound inspection and general recovery. The facility's physician's orders indicated for him to be seen 5 times per week for up to 4 weeks to address therapeutic exercise, therapeutic activities, neuromuscular re-education, and gait training in order to improve safe functional mobility, starting 9/27/22 through 10/27/22. The orders indicated his activity level was partial weight bearing with assist times one per his orthopedic nurse practitioner, effective 10/3/22 to 11/2/22. An interview was conducted with Resident L on 1/20/23 at 9:41 a.m. He indicated towards the end of his stay, he fell while at the facility and reinjured his right hip. He saw his orthopedic surgeon following the fall for an x-ray and was told it looked like his hip joint moved a quarter inch, but nothing was broken. The 10/24/22 Physical Therapy note, co-signed by PT (Physical Therapist) 16, read, Pt [Patient] states that he experience [sic] a fall on 10/22 while performing HEP [home exercise program] given to him by physician. Pt has printed copy and has provided copy to Therapy and Nrsg. [Nursing.] Pt states he was performing L [left] hip Add in standing with FWW [Four Wheeled Walker] for support @ BS [bedside] when he felt pain and a 'pop' in R [right] hip and he fell to floor. Pt reports he was able to get himself back in bed and then informed nrsg. Nrsg reports pt complained of pain after performing exs [exercises] and x-ray was ordered. Pt also had his brother and father transport him to [name of hospital] for R hip x-rays on 10/23. X-rays results unknown at this time. Pt states that he was by physician not to participate in therapy x [times] 1 week. Nrsg attempting to clarify. Pt education to perform standing hip abduction LLE [lower left extremity] as this is contraindicated based on current WB [weight bearing] orders. An interview was conducted with PT 16 on 1/20/23 at 12:45 p.m. He indicated to his knowledge; Resident L's orthopedic physician sent him back with a home exercise program. Resident L was attempting to do the exercises on his own in his room. The program was a preprinted one, one not specialized to Resident L specifically. PT 16 reviewed the HEP after finding out about the 10/22/22 fall, as Resident L did not share it with them prior. One of the exercises included was full weight bearing on each leg, but Resident L was only 50% weight bearing at the time. PT 16 spoke to nursing about it. PT 16 had never heard of this type of situation before. Residents may have outside appointments, but they never give home exercise programs. Normally, residents would give a copy to nursing and if there was something important for therapy to know, he would get it. If PT 16 had known about this HEP program given to Resident L, he would have suggested holding off on the exercises to get clarification, because the HEP contradicted the weight bearing orders and it was not safe for him to do these exercises by himself. The HEP was sent to Resident L's email. If Resident L had asked therapy, they could have provided some guidance. He was uncertain if the facility knew about the appointment that day. The 10/22/22, 12:21 p.m. nurse's note, recorded as a late entry on 10/23/22 at 12:22 p.m. by LPN (Licensed Practical Nurse) 1, indicated he complained of increased pain and inability to bear weight on his right leg. An order for a right hip x-ray was placed. The note did not reference a fall. The 10/22/22, 2:55 p.m. nurse's note, written by LPN 1, indicated he complained of intense pain and weakness after doing recommended exercises from his orthopedic surgeon at last visit. An order was placed for an x-ray of the right hip. The note did not reference a fall. The 10/23/22, 12:23 p.m. nurse's note, written by LPN 1, read, [Name of company performing x-ray] here to do xray, was told xray could not be shared with his surgeon and so now he is demanding to go to [name of hospital] for xray that his surgeon can interpret. Explained that we can fax his xray to his physician, but he would not relent. Father here to take him to ER [emergency room ] for evaluation per res [resident] request. Res signed self out LOA [leave of absence] for this. An interview was conducted with LPN 1 on 1/20/23 at 10:53 a.m. She indicated Resident L mentioned therapy having him do something and he was sore, so she suggested getting an x-ray. He informed her therapy wanted him to do exercises on his own as well and he got up to go to bathroom on his own and when he went to stand up, he had intense pain, and felt a pop, but he didn't tell me anything about falling. He may have fallen at some point while at the facility, but I don't remember it being tied to that. When a resident had an unwitnessed fall, their process was to do neurological checks, do one on one monitoring, if necessary, do vitals every 15 minutes for the first hour, then every hour for 4 hours, then every shift. As far as documentation, they would complete an event in the electronic health record for each fall. There were no events/post fall assessments in Resident L's clinical record relating to his reported 10/22/22 fall. The facility's Safety Events--Post Fall Assessment from their electronic health record system included the following information: position of the resident immediately following the fall; what resident was doing prior to the fall; resident's location after the fall; environmental factors that may have contributed to the fall; whether the resident was using an assistive device at the time of the fall; what the resident said happened: whether the fall was witnessed; the physical assessment of the resident; and interventions initiated. An interview was conducted with UM (Unit Manager) 2 on 1/20/23 at 11:08 p.m. She indicated she did not recall Resident L falling while at the facility. She remembered him coming back from an orthopedic visit saying he was non-weight bearing, but not providing any paperwork. Resident L would tell nursing the notes were on his phone and couldn't give it to them. The 10/31/22 orthopedic note read, He states that he has been bearing some weight on that side and it is not more painful than before, but we discussed that out of an abundance of caution I would like to make him non weightbearing to prevent any displacement if there is a fracture. On 1/20/23 at 2:32 p.m., the NC (Nurse Consultant) provided page 3 of a home exercise program. An interview was conducted with the NC at this time. The page had a picture of a person standing, holding onto the back of a chair, with their left leg on the ground, and their right leg lifted outward to the side. It read, Stand facing your kitchen counter or straight back chair with hands counter for balance and bring your operated leg out to the side you may need to work up to holding for a count of 10 . The NC indicated UM 2 gave her the above referenced page from her email, as it was not scanned into his clinical record. An interview was conducted with the Nurse Consultant on 1/23/23 at 3:23 p.m. She after a fall occurs, the staff were to open a fall event which would also trigger an IDT review. A fall policy was provided by the Nurse Consultant on 1/23/23 at 2:30 p.m. It indicated .Purpose. The purpose of this policy is to provide [NAME] communities with best practices and evidence based approaches to prevent falls and protect residents who are at risk for falling. Policy .The components of this fall program include: 1. Fall risk assessment; 2. Fall event assessment; 3. Strategies of prevention; 4. Strategies of intervention; 5. Interdisciplinary guidance; 6. Care planning; and 7. staff education. As such, the Community must take reasonable steps to ensure it implements, best practices and evidence-based approaches to prevent falls and protect residents who are at risk for falling. Due to the risks associated with falls for older adults living in long-term care facilities, compliance with this policy is essential. Procedure. This section describes the process for the prevention of falls and accurate documentation when there is a fall. Accurate documentation of fall risks and falls provides a clinical picture of a resident and is utilized in developing their plan of care. It is the responsibility of the interdisciplinary team to document falls prevention, when a fall occurs, and interventions to avoid future falls. General Overview of fall program. Step one: Fall risk assessment .Step two: Fall Event Assessment. The fall event assessment will be completed by the charge nurse if a patient experiences a fall. This data will be utilized by the community to thoroughly investigate the root cause for each fall and ensure effective interventions are put into place to prevent additional falls. Step three: Strategies of Prevention . Step four: Strategies of Intervention .Step five: Interdisciplinary Guidelines. If a fall occurs, the interdisciplinary team (IDT) will meet collectively and examine the fall using the following criteria: i. Review the post fall assessment completed by the charge nurse; ii. GEMBA the actual place, the real place where the current process is in action (University of Indianapolis and the Indiana Department of Health, 2014). An IDT member/designee will physically visit the place of the fall to verify the post fall assessment and investigate for any additional information that could be useful in preventing a reoccurrence; iii. A root cause analysis will be performed utilizing the 5 whys [NAME] process; iv. A member/designee of the IDT will assist the team and update the care plan and the nurse aide assessment sheets to ensure accuracy of fall preventions; v. The therapy-nursing IDT communication form will be opened; vi, The community will be encouraged to record fall history that can be used in the QAPI [Quality Assurance & Performance Improvement] and QA [Quality Assurance] meetings; and vii. A narrative IDT note will include: a. Root cause explanation with new intervention strategy to prevent reoccurrence b. Associate communication update c. Therapy/nursing communication completion d. Care plan updated e. Physician and family notification Step six: Care planning .Step seven: Staff Education . This Federal Tag relates to Complaint IN00393035. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to perform a self-administration of medication assessment prior to allowing a resident to self-administer medications for 1 resident randomly observed for self-administration of medications (Resident 104). Findings include: The clinical record for Resident 104 was reviewed on 1/20/23 at 9:22 a.m. The Resident's diagnosis included, but were not limited to, chronic congestive heart failure. On 1/20/23 at 9:22 a.m., LPN (Licensed Practical Nurse) 1 was observed standing at the medication cart in the hallway outside of the unit dining room. Dietary Aide 17 approached the medication cart and informed LPN 1 that Resident 104's medications were sitting on his breakfast tray in the dining room. LPN 1 locked her medication cart and went to the dining room table where Resident 104 had been setting. She picked up a plastic medication cup which contained several pills and brought it back to the medications cart. During an interview on 1/20/23 at 9:23 a.m., LPN 1 indicated that she had given Resident 104 his medications while he was sitting at the table. He had brought them to his mouth, and she had thought that he had swallowed them. He must not have taken them, or he possible spit them back into the cup. During an interview on 1/20/23 at 3:14 p.m., the Nurse Consultant indicated Resident 104 did not have a self-medication assessment. On 1/20/23 at 3:14 p.m., the Nurse Consultant provided the current Licensed Nurse Med Pass Clinical Skills Validation which read .24. Remained with the resident to ensure that the medication was swallowed . 3.1-11(a)

Based on interview and record review, the facility failed to protect a resident's right to be free from abuse related to a resident getting intentionally pushed out of her room by her roommate and threatening them with clinched fists (Resident 53 and 73) and intentionally pushing another resident into their walker (Resident 53 and 14) for 2 of 2 residents reviewed for abuse. Findings include: The clinical record for Resident 53 was reviewed on 1/23/23 at 9:52 a.m. Resident 53's diagnoses included, but not limited to, cognitive social or emotional deficit following cerebral infarction (stroke), vascular dementia with behavioral disturbance, generalized anxiety disorder, and delusional disorder. Resident 53's quarterly MDS (minimum data set) dated 8/12/22 indicated, she had moderate cognitive impairment. Resident 53's quarterly MDS dated [DATE] indicated, she had no behaviors. 1. An event note dated 10/29/22 indicated, Resident 53 had aggressively pushed her roommate, Resident 73, while in her wheelchair, out of their room and into the hallway, then shook her fist in Resident 73's face, and Resident 73 screamed. A nursing note dated 10/29/22 at 6:58 p.m. indicated, Resident 53 was moved to another room. A nursing note dated 10/31/2022 at 3:30 p.m. indicated, new orders were received to send Resident 53 to a psychiatric facility related to aggressive behaviors towards Resident 73. A nursing note dated 10/29/2022 at 4:36 p.m. and recorded as a Late Entry on 10/31/2022 at 3:41 p.m. indicated, Resident [sic, Resident 53] was physically aggressive towards roommate [sic, Resident 73] by pushing roommate out of room aggressively while roommate was in her wheelchair[sic] out into hallway then roommate screamed out and this resident shook her fist in roommates face.[sic] resident did not make contact with fist. Resident walked away from roommate . A nursing note from Resident 73's electronic health record (EHR) dated, 10/29/2022 at 4:49 p.m. indicated, QMA [sic, qualified medication assistant] reported to writer that resident stated her roommate pushed her out of her room by her w/c[sic, wheelchair]. Resident stated her finger did get pinched when her w/c[sic] moved. Head to toe shows only a small bruise on 4th finger of her right hand .Resident stated roommate threatens her to beat her up in the middle of the night. Resident stated once that she drew her fist at her and the nurse came in just in time to stop it. ED[sic, Executive Director] and DON [sic, Director of nursing] notified of incident . A Social services note from Resident 73's EHR dated 11/2/2022 at 4:09 p.m. indicated, Resident 73 had been fine since her roommate was no longer in the same room as her. Both Resident 73 and her family had voiced that they did not want Resident 53 to be roommates. An incident report was received on 1/23/23 from ED (Executive Director) at 12:51 p.m. The incident report indicated; the incident date was 11/1/22 at 11:30 a.m. The brief description of incident stated, 11/2/22 (sic, Resident 73's first name) stated to staff that (sic, Resident 53's first name) her roommate at the time pushed her into the hallway while she was seated in her wheelchair. Type of injury added was a small bruise noted on Resident 73's 4th finger of her right hand and was possibly pinched by the wheelchair moving forward. The follow up dated 11/9/22 indicated, Resident 53 and 73 will no longer be roommates. An interview with Resident 73 was conducted on 1/23/23 at 11:00 a.m. She indicated, Resident 53 had Alzheimer's and would get more confused during the night. She stated, when she and Resident 53 were roommates, Resident 53 would turn off the lights and yell at her to stop wasting electricity. She indicated the evenings were most unpleasant and that she had faced her double fists more times than I could count. She stated, since Resident 53 moved out of her room, she tries not to come in direct contact with her but, there have been a few times she wandered into her room in the middle of the night and was trying to get in bed with her new roommate. She indicated, the staff came in and had to redirect her out of the room. Resident 73 stated, I don't want her to terrify my roommate. Resident 73's annual MDS dated [DATE] indicated, she was cognitively intact. 2. An incident report dated 12/27/22 was received on 1/23/23 from ED (Executive Director) at 12:51 p.m. It indicated, on 12/27/22 Resident 14 stated, Resident 53 came into her room, so she grabbed her arm to redirect her when Resident 53 pushed back and caused Resident 14 to move backwards up against her door. No injury was noted. The immediate action taken was a pain and skin assessment was completed on Resident 14. Preventive measure stated, an investigation had been initiated into the interaction between Resident 14 and Resident 53 and a sign had been placed on Resident 53's door to identify it as hers. The follow up dated 1/3/23 indicated, Resident 14 wasn't showing any signs of distress from the incident and interviews conducted with staff didn't coincide with Resident 14's version of the incident. Resident 53 was unable to recall the incident and staff will continue to redirect Resident 53 as needed. A Social services note dated 12/27/2022 at 3:57 p.m. indicated, social services had spoken with Resident 14 that afternoon and asked her if she was still feeling unsafe. Resident 14 replied yes as long as she was still next door to her. Resident 14 stated, she was going to put her chair in front of door as long as Resident 53 was next door to her. A nursing note dated 12/27/2022 at 4:54 p.m. indicated, Resident 14's skin was assessed that morning and no bruising or skin issues were noted. Resident 14 had pointed to her right buttock/hip area and stated, right there, but I haven't bruised yet, but I will later. An interview with Resident 14 was conducted on 1/23/23 at 11:16 a.m. Resident 14 indicated, Resident 53 wanders at nighttime. On 12/26/22, Resident 53 had wandered into Resident 14's room so Resident 14 took Resident 53 by her arm and had guided her back out of her room. She stated, about an hour later, Resident 53 was back in her room near the doorway, so she approached her went to guide her out of her room when Resident 53 shoved me back and she had hit her hip on the walker which was behind her. Resident 14 stated, that area didn't have a bruise but I hurt for days. Resident 14 indicated, when referencing Resident 53 during the nighttime hours that she's like a crazy person at nighttime. She continued by stating, she was afraid of having her live next door to her. She admitted there were a few nights she had put her chair against the door because she was afraid of her. Resident 14's annual MDS dated [DATE] indicated, she was cognitively intact. The investigation file related to Resident 53 and 14's incident contained a handwritten sheet with the names of staff who worked the evening/night shift on 10/26/22 into 10/27/22. The handwritten note next to an agency CNA's name (certified nursing assistant 25) indicated, [sic, Resident 53's name] came in + [sic, and] started yelling @ [sic, at] her +[sic] felt fearful +[sic] was putting a chair to block her door .going into rooms, turning off lights, An interview with ED (Executive Director) was conducted on 1/23/23 at 12:11 p.m. ED indicated, he didn't believe the incident between Resident 53 and 73 was abuse related to Resident 53 pushing on resident 73's wheelchair and not her person. He further indicated, he did not report the incident between Resident 53 and 73 timely related to him being on vacation. An Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy was received on 1/17/23 at 2:03 p.m. from ED. The policy indicated, Our abuse prevention/intervention program includes, but is not limited to, the following . j. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues; . r. Reporting any allegation of abuse or neglect to the State licensing/certification agency .immediately with a brief description of the alleged occurrence. s. Thoroughly investigating each allegation regardless of source or credibility of information . Reporting to the Administrator .5 .Abuse is the 'willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .b. Verbal abuse is defined as any use of oral, written or gestured language . d. Physical abuse is defined as hitting, slapping, pinching, kicking .7. When an incident of resident abuse is suspected or determined, such incident must be reported to the Administrator, or designee, regardless of the time lapse since the incident occurred. 3.1-27(a)(1) 3.1-27(b)