Every finding on record at Rensselaer Care Center

Based on observation, record review and interview, the facility failed to ensure a sanitary kitchen was maintained related to proper chemical level in the dishwasher for 1 of 1 kitchen. (Main Kitchen) This had the potential to affect the 89 residents who received food from the kitchen.Finding includes:On 4/29/26 at 9:59 a.m., the Initial Kitchen tour was completed with the Dietary Manager (DM). The DM indicated the dishwasher was a chemical dishwasher and the chemical solution was tested every shift. She obtained a test strip and checked the chemical solution following the wash cycle. The test strip registered 0 parts per million (PPM). The DM indicated the chemical reading should be 100 PPM. She obtained a different bottle of test strips and again checked the chemical solution following the wash cycle. The test strip color remained unchanged and had not registered any PPM reading. The DM indicated she was not sure why the test strips had not registered any chemical level. She would call the dishwasher service company.The Low Temperature Dish Machine Log, dated 4/2026, indicated on 4/29/26 at breakfast the rinse temperature was 120 degrees Fahrenheit and the chemical level was 100 PPM.A current facility policy titled Ware Washing-Dish Machine/Manual Process, indicated .Low Temp Dish Machine.2. The temperature and parts per million [PPM] of the sanitizer [50-100 PPM] will be recorded on the Low Temperature Dish Machine Log a minimum of three times per day.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to provide education of the benefits and risks of the COVID-19 vaccine and failed to offer the COVID-19 vaccine to the employees of the facility, which had the potential to affect all the residents who reside in the facility.Finding includes:During an interview on 4/30/26 at 2:43 p.m., the Minimum Data Set Assessment (MDS) Nurse indicated COVID-19 education and vaccination had not been offered to her.During an interview on 5/1/26 at 1:59 p.m., the Nurse Consultant indicated the COVID-19 education and vaccine had not been offered to the staff.During an interview on 5/6/26 at 9:50 a.m., the Administration indicated there were 99 staff members including therapy who were employed by the facility.A facility COVID-19 policy, dated 11/25/25, indicated the facility would provide education regarding the benefits and potential side effects associated with the COVID-19 vaccine and offer the vaccine unless it was medically contraindicated, or the the staff were already immunized.

Based on observation, record review and interview, the facility failed to ensure medications and treatments were stored properly related to an expiration date torn off a medication, multi-use vial of medication undated, biological medication not destroyed timely and unlabled biologicals for 1 of 2 Medication Rooms and 2 of 3 Medication and Treatment Carts observed.Findings include:1. During an observation of the East Wing Medication cart on 4/30/26 at 11:14 a.m., there was an opened bottle of nitroglycerin (chest pain) 0.4 milligrams with Resident 28's name. The expiration date on the bottle was torn off by the tape on the lid. The date opened was 11/16/24. RN 2 indicated the bottle of nitroglycerin would be removed and re-ordered. 2. During an observation of the Skilled Medication Room on 4/30/26 at 11:28 a.m., there was an opened container of Cetaphil Cream stored on the shelf. RN 1 indicated the name on the label was no longer a resident at the facility. There was an opened bottle of miconizide nitrate 2% (anti-fungal powder) stored on the shelf with no name or label. RN 1 indicated he was unsure to whom the powder belonged.There was an opened and partially used vial of Tuberculin (TB test) solution stored in the refrigerator with no opened date on the vial. RN 1 indicated he would destroy the vial.There was an opened and used tube of antibiotic ointment stored without a plastic bag and without a label in the treatment cart. RN 1 indicated he was unsure to whom the ointment belonged.A facility medication storage policy, dated 6/30/25, and received from the Infection Control Nurse as current, indicated medications and biologicals were to have an expiration date on the label and were to be stored separately from other medications. Staff were to record the date opened on the medication container. Any multi-dose vial injectable medication was to be dated when opened and discarded within 28 days, unless manufacturer specifies a different date for the opened vial. The facility was to destroy and reorder medications and biological's with worn, incomplete, or missing labels.410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)410 IAC 16.2-3.1-25(o)410 IAC 16.2-3.1.25(r)

Based on record review and interview, the facility failed to ensure a resident with a colostomy (opening in the colon that lets stools pass from the body) received appropriate treatment and services related to a lack of documentation of completed colostomy bag changes and stoma care for 1 of 1 resident reviewed for ostomies. (Resident 1)Finding includes:During an interview on 4/30/26 at 11:26 a.m., Resident 1 indicated she had a colostomy and a urinary catheter that the staff had to help her with managing.Resident 1's record was reviewed on 5/1/26 at 12:05 p.m. Diagnoses included, but were not limited to, paraplegia (paralysis on lower half of body) and colostomy status.The Quarterly Minimum Data Set assessment, dated 4/15/26, indicated the resident was cognitively intact and had an indwelling catheter and an ostomy.A Care Plan, revised on 4/22/26, indicated the resident had a colostomy. Interventions included, but were not limited to, ostomy care as needed.The May 2026 Physician's Order Summary had no orders for a colostomy or the care to be provided for the colostomy.During an interview on 5/6/26 at 10:30 a.m., the Director of Nursing had no further information to provide.A facility policy titled, Colostomy and Ileostomy Care, indicated, .The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(3)

Based on observation, record review, and interview, the facility failed to ensure urinary catheter care was completed and the catheter was kept off the floor for 2 of 2 residents reviewed for catheters. (Residents 1 and 32)Findings include:1. During an observation and interview on 4/30/26 at 9:17 a.m., Resident 1 was observed sitting up in her bed. She indicated she had a urinary catheter and an ostomy (an opening in the abdomen to allow for waste/stool drainage). She did not receive routine peri-care/catheter care. At the time, the catheter collection bag was attached to the side of the bed and was resting directly on the floor as the bed was in a low position. The catheter bag was not contained in a basin.On 5/1/26 at 9:57 a.m., Resident 1 was observed sitting in the recliner chair in her room. The catheter collection bag was sitting on the floor next to the recliner. The catheter bag was not contained in a basin.On 5/4/26 at 11:49 a.m., Resident 1 was observed sitting in the recliner chair in her room. The catheter collection bag was sitting on the floor next to the recliner. The catheter bag was not contained in a basin.Resident 1's record was reviewed on 5/1/26 at 12:05 p.m. Diagnoses included, but were not limited to, paraplegia (paralysis on lower half of body) and cognitive communication deficit.The Quarterly Minimum Data Set assessment, dated 4/15/26, indicated the resident was cognitively intact and had an indwelling catheter.A Care Plan, revised on 2/4/26, indicated the resident had an indwelling catheter. Interventions included, but were not limited to, position catheter bag and tubing below level of bladder, change catheter as needed.A Care Plan, revised on 4/22/26, indicated the resident had her catheter bag in a basin on the floor to facilitate drainage per the resident's preference. Interventions included, but were not limited to, catheter care per orders, and make sure basin is next to the bed.A Physician's Order, dated 4/10/26, indicated indwelling catheter to straight drainage, size 20 French with 30 cc bulb; change for infection, obstruction, or when the closed system is compromised every 24 hours as needed.There were no orders or documentation in the resident's record to indicate catheter care was provided.During an interview on 5/4/26 at 11:53 a.m., LPN 9 indicated she had hung the catheter bag on the side of the recliner, but the bag must have slipped down.During an interview on 5/6/26 at 10:31 a.m., the Director of Nursing was notified of the concern and had no further information to provide. 2. On 4/29/26 at 10:09 a.m., Resident 32 was observed sleeping in bed. He had a urinary catheter collection bag connected to the side of the bed and the bed was in a low position. The catheter collection bag was resting directly on the floor. It was not contained in a basin.On 5/1/26 at 10:03 a.m., Resident 32 was observed sleeping in bed. He had a catheter collection bag connected to the side of the bed and the bed was in a low position. The catheter collection bag was sitting on the floor. It was not contained in a basin.Resident 32's record was reviewed on 5/4/26 at 9:22 a.m. Diagnoses included, but were not limited to, obstructive and reflux uropathy (blockage in the urinary tract that stops urine from flowing) and hydronephrosis with ureteral stricture (urine flow blockage causing backpressure and kidney swelling).The Quarterly Minimum Data Set assessment, dated 3/1/26, indicated the resident was severely cognitively impaired and he had an indwelling urinary catheter.A Care Plan, revised on 3/3/26, indicated the resident had an indwelling urinary catheter. Interventions included, but were not limited to, catheter care every shift and position the catheter bag and tubing below the level of the bladder.The May 2026 Physician's Order Summary indicated the resident had an indwelling catheter to straight drainage with a 16 French catheter and 10 cc bulb, change catheter bag as needed, and catheter care every shift.During an interview on 5/6/26 at 10:31 a.m., the Director of Nursing was notified of the concern and had no further information to provide.A facility policy titled, Indwelling Urinary Catheter Foley Management, and noted as current, indicated, .2. Maintain unobstructed urine low.b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.7. Routine hygiene is appropriate.410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure safety was maintained related to a lack of a smoking safety assessment for 1 of 5 residents reviewed for accidents. (Resident 74)Finding includes:On 4/29/26 at 12:51 p.m. Resident 74 was observed going out to the courtyard with his daughter to smoke. The resident's daughter remained with him while he was smoking. At 1:04 p.m., Activities staff was observed taking residents out to the courtyard to smoke where they joined Resident 74. She remained outside with the residents while they were smoking.Resident 74's record was reviewed on 5/1/26 at 10:34 a.m. Diagnoses included, but were not limited to, nicotine dependence.A Care Plan, dated 2/4/25, indicated the resident was a smoker and could go out to smoke at the designated smoking times or with family. The interventions indicated a smoking evaluation would be completed quarterly.The most recent Smoking Safety Evaluation was completed on 11/6/24 and indicated the resident demonstrated the ability to safely smoke with supervision.During an interview on 5/1/26 at 10:15 a.m., the Nurse Consultant indicated Social Services had just completed a smoking evaluation on 4/30/26. There were no other evaluations completed since 11/6/24. A current facility policy titled Smoking Facility, indicated .Resident Smoking Determination. 1. Residents who currently smoke will have a smoking assessment completed upon admission, readmission, with significant change, and quarterly by a licensed nurse .410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on record review and interview, the facility failed to ensure residents received the necessary care and services related to medications not given as ordered and interventions and medications not provided for a resident with constipation for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for hospitalization. (Residents 16 and 6)Findings include:1. Resident 16's record was reviewed on 5/4/26 at 8:27 a.m. The diagnoses included, but were not limited to, hypertension, hypothyroidism, and excessive weight loss. a. A Physician's Order, dated 5/13/25, indicated megestrol acetate (stimulates the appetite), 40 milligrams (mg) per milliliter (ml), 10 ml was to be administered twice a day. The April 2026 Medication Administration Record (MAR) indicated the a.m. dose of megestrol acetate had not been administered on 4/18/26. b. A Physician's Order, dated 6/2/25, indicated metoprolol tartrate (anti-hypertensive), 25 mg twice daily. Do not give the medication if the systolic blood pressure is less than 110 or diastolic blood pressure less than 50. The February 2026 MAR indicated the blood pressure (BP) on 2/27/26 was 109/77 and the morning dose of metoprolol tartrate was administered. The March 2026 MAR, indicated the metoprolol tartrate was administered when the blood pressure was outside the parameters on the following dates:On 3/1/26 the p.m. BP was 107/66.On 3/5/26 the a.m. BP was 106/63.On 3/14/26 the a.m. BP was 100/66.On 3/15/26 the a.m. BP was 100/68 and the p.m. BP was 108/70.On 3/23/26 the p.m. BP was 108/72.On 3/24/26 the a.m. BP was 104/70.On 3/31/26 the p.m. BP was 108/67. The April 2026 MAR, indicated the metoprolol tartrate was administered when the blood pressure was outside the parameters on the following dates:4/1/26 the a.m. BP was 106/68.4/2/26 the a.m. BP was 108/68.4/15/26 the a.m. BP was 100/68.4/16/26 the a.m. BP was 100/68 The April 2026 MAR also indicated the metoprolol tartrate had not been administered at the p.m. dose on 4/5/26, the a.m. and p.m. dose on 4/18/26, and the p.m. dose on 4/26/26. c. A Physician's Order, dated 6/2/25, indicated levothyroxine (hypothyroidism) 25 micrograms, one tablet was to be administered daily. The May 2026 MAR indicated the medication had not been administered at 5:00 a.m. on 5/3/26. During an interview on 5/4/26 at 2:09 p.m., the Nurse Consultant indicated the medications were not given as ordered. A facility medication administration policy, dated 9/9/25 and received as current from the Nurse Consultant, indicated medications were to be administered per the physician orders. 2. The closed record for Resident 6 was reviewed on 4/30/26 at 3:19 p.m. Diagnoses included, but were not limited to, malignant neoplasm of the uterus and constipation. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 12/1/25, indicated the resident was cognitively intact. The Bowel and Bladder Elimination Task documentation, dated 11/26/25 through 12/1/25, indicated the resident had not had any bowel movements. A Nurse Practitioner Note, dated 11/28/25, indicated the resident had complained of constipation and indicated she had not had a bowel movement for a while. The Nurse Practitioner indicated she would add additional medication for constipation. The assessment and plan indicated an order for bisacodyl (a laxative medication) rectal suppository 1 unit rectally every 24 hours as needed for constipation. A Physician's Order, dated 11/28/25, indicated bisacodyl rectal suppository, insert one unit rectally every 24 hours as needed for constipation. The Medication Administration Record (MAR), dated 11/2025 and 12/2025, indicated the bisacodyl suppository had not been administered. A Nurse Practitioner Note, dated 12/1/25, indicated the resident had continued complaints of constipation and staff reported resident had not had any bowel movement since arrival to the facility. An abdominal X-ray was ordered. Abdominal x-ray results, dated 12/1/25, indicated ileus (paralyzed bowel) versus obstructive bowel gas pattern. CT (computed tomography, a medical imaging test that uses X-rays and a computer to create detailed cross-sectional images of the body) may be indicated. A Progress Note, dated 12/1/25 at 8:39 p.m., indicated the Nurse Practitioner had been notified of the abdominal X-ray results and the resident was sent to the emergency room for evaluation. A Progress Note, dated 12/2/25 at 12:21 a.m., indicated the hospital was called for an update on the resident. The resident had a CT scan completed, was diagnosed with a bowel obstruction, and would be transferred to another hospital. During an interview on 5/1/26 at 1:45 p.m., the Nurse Consultant indicated the resident had been sent to the local hospital for evaluation. There they completed a CT of the abdomen, which indicated a bowel obstruction but with the lead point being a mass probably related to her uterine cancer. A current facility policy titled Bowel Protocol, indicated .2. The facility in coordination with the resident's attending practitioner will implement standing orders to address a lack of bowel movement. a. These orders may vary within the facility for each attending practitioner. b. These orders may vary depending on the individual needs of a resident. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications quarterly per the care plan for 1 of 1 resident reviewed for self-administration of medication. (Resident 1)Finding includes:During an observation and interview on 4/30/26 at 9:23 a.m., Resident 1 was observed sitting up in her bed. There was a tube of nystatin (anti-fungal cream) on the bedside table with a medication label on it. The resident indicated she applied the cream herself and she knew how to use the cream appropriately.On 5/1/26 at 9:57 a.m., the nystatin cream was observed on the bedside table in Resident 1's room.Resident 1's record was reviewed on 5/1/26 at 12:05 p.m. Diagnoses included, but were not limited to, paraplegia (paralysis on lower half of body) and cognitive communication deficit.The Quarterly Minimum Data Set assessment, dated 4/15/26, indicated the resident was cognitively intact. The resident had limited range of motion on both sides of upper and lower extremities.A Medication Self-Administer Review, dated 11/27/24, indicated the resident was able to self-administer the following medications unsupervised: vitamin D, K1, and K2 by mouth one capsule daily, ultimate multivitamin by mouth one capsule daily, triple complex magnesium by mouth two capsules daily, calcium magnesium zinc and vitamin D3 by mouth three tablets daily, magnesium glycinate 500 milligrams by mouth one tablet daily, and calm forte (sleep aid) 2 tablets by mouth at bedtime.There was no other self-administration assessment completed after 11/27/24.A Care Plan, dated 1/2/25, indicated the resident was able to administer medications to herself. Interventions included, but were not limited to, assess resident for self-administration of medications quarterly.A Physician's Order, dated 4/10/26, indicated nystatin external cream 100,000 unit/gram apply to groin twice daily for 14 days and apply to groin topically every 8 hours as needed.A Physician's Order, dated 4/10/26, indicated the resident could self-administer medications brought to her by the nursing staff. It was her request for the nurse to leave pills in a cup at bedside.During an interview on 5/6/26 at 10:30 a.m., the Director of Nursing indicated there were no other self-administration assessments completed. A facility policy titled, Self-Administration of Medication, and noted as current, indicated, .3. The assessment will contain at a minimum the following: a. The medications are appropriate and safe for self-administration.7. A reassessment by the interdisciplinary team is conducted quarterly and with any significant change in the condition of the resident to assure that safe self-administration of medications is still feasible.410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on record review and interview, the facility failed to ensure a resident's blood pressure was monitored for an as needed (prn) blood pressure medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 5)Finding includes:Resident 5's record was reviewed on 5/6/26 at 11:45 a.m. Diagnoses included, but were not limited to, heart failure and stage 3 chronic kidney disease. A Physician's Order, dated 11/16/25, indicated to give midodrine HCL tablet 10 milligrams (mg) three times daily for hypotension (low blood pressure), hold if systolic blood pressure (SBP, top number) is greater than 120. The order was discontinued on 3/23/26.A Physician's Order, dated 3/23/26, indicated to give midodrine HCL tablet 10 mg every eight hours as needed if SBP is less than 120. The March 2026 Medication Administration Record (MAR) indicated midodrine had not been administered after 3/23/26. The April and May 2026 MAR indicated the midodrine had never been administered. There were no blood pressures recorded in the MAR or in the vital signs section of the medical record since 3/23/26. During an interview on 5/6/26 at 1:58 p.m., the Director of Nursing indicated there were no blood pressures recorded since 3/23/26 for the prn midodrine. She was unsure why the blood pressures had not been checked when the new order was initiated.410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(6)

Based on record review and interview, the facility failed to ensure care plans were implemented and in place for pain and hypotension for 2 of 20 resident's care plans reviewed. (Resident 5 and 7)Findings include: 1. Resident 5's record was reviewed on 5/6/26 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, stage 3 chronic kidney disease and heart failure. A Physician's Order, dated 11/16/25, indicated to give midodrine HCL tablet 10 milligrams (mgs) three times daily for hypotension (low blood pressure), hold if systolic blood pressure is greater than 120. The order was discontinued on 3/23/26.A Physician's Order, dated 3/23/26, indicated to give midodrine HCL tablet 10 mgs, every eight hours as needed if SBP is less than 120. There was no care plan related to hypotension, During an interview on 5/6/26 at 1:58 p.m., the Director of Nursing indicated there should be a care plan for hypotension. 2. Resident 7's record was reviewed on 5/1/26 at 11:25 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, peripheral autonomic neuropathy and peripheral vascular disease. The admission Minimum Data Set (MDS) assessment, dated 3/30/26, indicated the resident was cognitively intact and had pain that occasionally interfered with day to day activities and received interventions for pain. A Physician's Order, dated 3/26/25, indicated to give tramadol (pain medication) 50 milligrams (mgs) every six hours as needed for pain. The Medication Administration Record indicated the resident took the tramadol 1-3 times daily. A Physician's Order, dated 3/26/26, indicated to give gabapentin (for neuropathy) 300 mgs, three times daily. There was no pain care plan in the resident's record. During an interview on 5/1/26 at 2:02 p.m., the MDS nurse indicated there should be a pain care plan and she must have forgotten to initiate it. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on record review and interview, the facility failed to ensure pain medication and non-pharmacological interventions were administered as ordered for 1 of 3 residents reviewed for pain management. (Resident 33)Finding includes:During an interview on 4/30/26 at 9:58 a.m., Resident 33 indicated she had a lot of pain with her right arm and shoulder. The facility staff had recently changed her pain medicine schedule. She was having a hard time getting the staff to administer the medications as she needed them and she did not want to have to keep track of how often and what time medications were requested.Resident 33's record was reviewed on 5/1/26 at 3:08 p.m. Diagnoses included, but were not limited to, osteoarthritis, low back, left and right arm pain, and intervertebral disc degeneration.The Annual Minimum Data Set assessment, dated 4/17/26, indicated the resident was cognitively intact. The resident received scheduled and as needed pain medications and non-pharmacological interventions for pain.A Care Plan, revised on 4/30/26, indicated the resident had pain in her neck due to osteoarthritis. Interventions included, but were not limited to, medications and neck pack as ordered.A Physician's Order, dated 11/1/24, indicated Nurse to apply warm neck wrap to resident's neck daily for 20 minutes. Check the skin to neck before and after application.The April 2026 Treatment Administration Record indicated the neck wrap was not marked as administered on 4/7, 4/12, 4/18, 4/22, 4/26, and 4/28/26.A Physician's Order, dated 4/9/26, indicated hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg), one tablet by mouth every 8 hours as needed, crush and mix it into pudding.The April 2026 Medication Administration Record indicated the resident received the hydrocodone-acetaminophen oral tablet on 4/25/26 at 8:00 p.m. and again at 9:30 p.m.A Physician's Order, dated 4/14/26, indicated tramadol oral tablet 50 mg by mouth four times a day, crush and mix in pudding. The April 2026 Medication Administration Record indicated the resident's tramadol was not marked as administered on 4/15/26 at 12:00 p.m. and 6:00 p.m., 4/16/26 at 6:00 a.m., 4/18 at 6:00 a.m. and 12:00 p.m., and 4/26/26 at 6:00 a.m. During an interview on 5/6/26 at 2:11 p.m., the Director of Nursing indicated she had no further information to provide.A facility policy titled, Administration of Medications, indicated, .2. Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration.c. Right Dose. Check the MAR and the doctor's order before medicating.e. Right Time and Frequency. Check the order for when it would be given and when was the last time it was given.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to ensure interventions were attempted prior to administering PRN (as needed) anti-anxiety medications and receiving an order for a routine anti-anxiety medication, for 1 of 3 residents reviewed for resident to resident abuse. (Resident F)Finding includes:Resident F's record was reviewed on 3/5/26 at 1:50 p.m. The diagnoses included, but were not limited to, Alzheimer's disease.A Physician's Order, dated 12/4/25 and discontinued on 12/17/25, indicated lorazepam (anti-anxiety) 0.5 milligrams (mg) every 24 hours as needed for anxiety/agitation for 14 days.The Medication Administration Record (MAR), dated 12/2025, indicated the resident received the prn lorazempam on the following dates:12/6/25 at 8:42 a.m. - A Nurse's Progress Note, dated 12/6/25 at 6:20 p.m., indicated the lorazepam had been given on 12/6/25 in the morning due to increased yelling and behaviors. The medication helped for a short period then he started yelling out at staff. There was no indication other interventions were attempted prior to the medication administration.12/7/25 at 10:13 a.m. - There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.12/8/25 at 7:42 a.m. - A Nurse's Progress Note, dated 12/8/25 at 12:18 p.m., indicated he was yelling in the dining room, received the prn dose of lorazepam, and was responding well. There was no indication other interventions were attempted prior to the medication administration.12/11/25 at 8:10 a.m. - There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.12/13/25 at 7:42 a.m. - A Nurse's Progress Note, dated 12/13/25 at 10:13 a.m., indicated the lorazepam was administered for agitation, yelling at other residents, and making inappropriate comments in the dining room and common area. There was no indication other interventions were attempted prior to the medication administration.12/15/25 at 8:34 a.m. - There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.A Physician's Order, dated 12/17/25 and discontinued on 12/30/25, indicated lorazepam 0.5 mg every 24 hours as needed of anxiety and/or agitation for 14 days.The Medication Administration Record (MAR), dated 12/2025, indicated the resident received the prn lorazempam on the following dates:12/18/25 at 8:10 a.m. - A Behavior Progress Note, dated 12/18/25 at 9:40 a.m. indicated he was yelling at the staff and other residents in the dining room. The lorazepam was administered. Approximately 45 minutes after the medication was administered he became aggressive with the staff. There was no indication other interventions were attempted prior to the medication administration.12/25/25 at 8:50 a.m., 12/26/25 at 12:18 p.m., 12/27/25 at 12:20 p.m., 12/28/25 at 5:09 p.m., 12/29/25 at 1:03 p.m., and 12/30/25 at 11:05 a.m. - There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.A Physician's Order, dated 12/30/25 and discontinued on 1/7/26, indicated lorazepam 0.5 mg every 12 hours as needed for anxiety, for 14 days.The MAR, dated 12/2025, indicated the lorazepam had been administered on 12/31/25 at 11:17 a.m. There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.The MAR, dated 1/2026, indicated the lorazepam had been administered on 1/1/26 at 5:57 p.m., 1/6/26 at 8:49 a.m., and 1/7/26 at 8:09 a.m. There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.A Physician's Order, dated 1/7/26 and discontinued on 1/22/26, indicated lorazepam 0.5 mg, give in the morning before breakfast and evening before the supper meal prn.The MAR, dated 1/2026, indicated the lorazepam had been administered on 1/8/26 at 5:46 a.m. and 6:00 p.m., 1/9/26 at 5:15 p.m., 1/10/26 at 7:39 a.m. and 5:46 p.m., 1/11/26 at 7:33 a.m. and 5:07 p.m., 1/13/26 at 5:05 a.m., 1/14/26 at 4:59 p.m., 1/19/26 at 6:18 p.m., 1/20/26 at 5:27 p.m. There was no documentation on the MAR, Behavior Sheets, nor Progress Notes what behaviors the resident was exhibiting. There was no indication other interventions were attempted prior to the medication administration.A Care Plan, dated 1/6/26, indicated physical aggressiveness was present and has had physical altercation with other residents and poor impulse control. The interventions included medications would be administered as ordered. The resident's needs would be assessed and anticipated, physical and verbal cues would be used to alleviate anxiety, and the behaviors and attempted interventions would be documented.A Quarterly Minimum Data Set assessment, dated 1/29/26, indicated a severely impaired cognitive status, no behaviors, and received an anti-depression medication.A Psychiatric Nurse Practitioner's (NP) Progress Note, dated 2/3/26 at 11 p.m., indicated on the clinical update on 2/4/26, the resident was seen in his room, was irritable and swearing. His roommate has voiced concerns of the resident swearing and threatening him. The staff had noticed an increase in behaviors since the as needed lorazepam order had expired. He had been receiving the lorazepam in the morning prior to breakfast and in the evening prior to dinner. Discussed behaviors with the Director of Nursing and Social Service Director and will order a scheduled lorazepam twice a day to help with the irritability.A Physician's Order, dated 2/5/26, indicated lorazepam 0.5 mg was to be given routinely twice a d day related to generalized anxiety disorder.There was no documentation in the Progress Notes or MAR that indicated the resident was having behaviors from 1/21/26 to 2/5/26.The Behavior Monitoring and Interventions Record indicated behaviors of cursing at others, anger toward others, throwing food, and agitation on 2/2/26 at 1:30 p.m. The intervention of removing the resident resident from the situation and offering food/drink improved the behaviors. There was no change in the behaviors when a calm environment was provided and attempts to reapproach.The Behavior Monitoring and Intervention Record indicated behaviors of grabbing and hitting at others on 2/4/26 at 8:31 a.m. The interventions of redirection and reapproach were not effective.The Behavior Monitoring and Intervention Record indicated a behavior or cursing at other was present on 2/5/26 at 8:50 a.m. The intervention of redirection and removing from the situation were not effective.During an interview on 3/6/26 at 10:03 a.m., the Director of Nursing indicated there had been no interventions documented prior to the administration of the lorazepam prior to 2/2/26.During an interview on 3/6/26 at 1:30 p.m., the Administrator indicated she was unable to locate a facility policy for the administration of prn medication. A Behavioral Health policy, dated 9/2/25, and received from the Administrator as current, indicated pharmacological interventions were to only be used when non-pharmacological interventions are ineffective or when clinically indicated.This citation relates to Intake 2788391.410 IAC (Indiana Administrative Code) 16.2-3.1-3(w)

Based on record review and interview, the facility failed to ensure a resident who required assistance for activities of daily living (ADL's), received bathing/showers at least twice a week, for 1 of 3 residents who require extensive to dependent assistance for ADL's. (Resident J)Finding includes:Resident J's record was reviewed on 3/6/26 at 10:29 a.m. The diagnoses included, but were not limited to, stroke. A Care Plan, revised on 10/2/25, indicated assistance from staff was needed with ADL's. A Quarterly Minimum Data Set assessment, dated 2/7/26, indicated maximum assistance was required for bathing and had a moderately impaired cognitive status.The Bathing Task indicated showers were to be completed on Wednesday and Saturday evening. There were no shower forms or tasks signed that indicated bathing occurred on December 17, 2025; January 7, 17, and 21, 2026; and February 4, 18, and 25, 2026.During an interview on 3/6/26 at 11:28 a.m., the Wound Nurse indicated no further shower forms were found that indicated the resident received bathing on the above days.This citation relates to Intake 2733197.410 IAC's (Indiana Administrative Codes) 16.2-3.1-38(a)(3) and 16.2-3.1(b)(2)

Based on record review and interview, the facility failed to implement the abuse policy and procedure for abuse training yearly for 2 of 5 staff members who have been employed at the facility for over four months. (LPN 1 and CNA 2)Finding includes:Employee records were reviewed on 3/6/26 at 2:15 p.m.LPN 1's start date at the facility was 4/12/24 and CNA 2's start date was 7/11/24. LPN 1 and CNA 2 had not completed abuse training and resident rights training since their start dates in 2024.During an interview on 3/6/26 at 2:30 p.m., the Business Office Manager indicated LPN 1 and CNA 2 had no abuse or resident rights training in 2025.During an interview on 3/6/25, the Corporate Regional Manager indicated the training was to be completed yearly.A facility policy, dated 5/6/25 and received from the Administrator as current, indicated the facility would maintain an effective training program for all staff, which included at a minimum training on abuse and abuse prevention. This citation relates to Intake 2788391.410 IAC (Indiana Administrative Code) 16.2-3.1-14(k)(1)

Based on observation, record review, and interview, the facility failed to serve, store, and prepare food under sanitary conditions, related to opened food stored more than 72 hours, dirt/debris/food on the floors of the walk in cooler, dried storage area, and food preparation area, dirty shelves, food stored without opening dates and in dirty containers, dented cans, opened bags of cereal not re-sealed, and a staff member with uncovered open areas on his arm, for 1 of 1 kitchen.(Main Kitchen) This had the potential to affect 85 of 86 residents who reside in the facility.Findings include: The following was observed in the kitchen on 7/14/25 at 5:40 a.m. through 6:20 a.m.: 1.Dietary Aide 4 was emptying out several containers of food into the trash bin. He indicated he was, dumping food because the food needed thrown out. He indicated cooked/opened food can be stored for three days and everyone who worked in the kitchen was responsible for making sure the food was removed after the three days. He indicated there was no Dietary Manager and the [NAME] was in charge.There was a plastic container of cooked chicken breast with the date of 6/29/25 and a pan of potato salad dated 7/1/25 that Dietary Aide 4 was getting ready to discard.2. Walk in cooler:a. The floor was dirty with dirt, debris, food, and dishes and there was a dark black substance in the corner by the door.b. The shelving was dirty with a dark black substance on every shelf.c. There were 30 pitchers of orange juice, fruit juice, tea, and lemonade not dated. There were two large plastic containers of of juices not dated.d. There were two boxes of liquid eggs, one box of pasteurized eggs, two boxes of ham and a box of turkey breast stored on the floor.e. There was a plastic container of tomato soup that was dated 7/9/25.f. There was a plastic container of pears that was dated 7/9/25.g. There was a plastic container of spinach that was dated 7/1/25.h. There were four opened blocks of cheese wrapped in plastic wrap with no date.i. There was an opened container of chicken base, sweet tangy BBQ sauce, sweet and sour sauce, and mustard without a date when they were opened.j. There was a container of Caesar Salad Dressing, dated 7/8/25 with spilled dressing on the outside of the container and around the outside lid.k. There was pickle relish spilled on the tray with ice tea pitchers and on the top storage shelf.l. There was a box of turkey breast stored on the top storage shelf over a bag of lettuce.m. There was a dead fly on the mustard container.n. There was an open non-dated plastic bag with two hot dogs in the bag, stored in a pan on a shelf.2. Food preparation and serving area:a. There was dried food on the base of the Robo-[NAME] (used to puree food). b. There were four drawers which stored cooking utensils that were dirty with debris' and there was a build-up of crumbs and grease on the drawersc. There were two drawers which stored cleaning clothes with dried food, debri and a build-up of crumbs and grease on the drawers.d. The stove had dried spills of food and grease drippings on the doors of the oven.e. There was dried food and dried spilled liquid on top of the prep table. [NAME] 3 indicated the evening shift should have cleaned the kitchen after supper.f. The floor under the prep and serving table was dirty with debri, dried food, and liquids.g. There was dried food on the food rack that stored the cereal in bowls already filled for breakfast.h. There was drippings of liquid and dried food on the plastic protector of the steam table.i. There were two of four food carts with dried food and liquid on the outside and inside of the carts.j. The kitchen floor was dirty with debri,food, and spilled liquids.k. There was a brown dried substance on the side hand washing sink.l. There three of four, three tiered carts that were dirty and stained and had coffee pots and carafe's stored on the carts.m. There was dried food on the inside of the microwave.n. The ice scoop was stored uncovered next to the ice machine.o. The ice machine had a build up of a white substance on the inside ledge where the door comes down.p. There was dried food on the pan covers and the shelf of the steam table.q. There were dried meat particles on the meat slicer and dried food substances on the base of the meat slicer. 3. Freezera. There were nine boxes of food stored on the floor.b. There was one box on the floor that contained an open bag of corn on the cob and there was a box of pork sausage stored on top of the opened bag of corn. 4. Dry storage:a. There were salt and sugar packets and packets of crackers on the floor.b. There was spilled sugar granules on the floor.c. The floor was dirty with debris and garbaged. The plastic sugar container on the shelf was left partially opened.e. The plastic containers for the flour and brown sugar were stored on the floor.f. There was a dented can of pineapple and fruit cocktail stored on in the can holders.g. There were seven of eight bags of opened cereal not closed securely on the shelf.h. There was a box of orange juice mix and chocolate pudding mix stored on the floor. 5. Dietary Aide 5 had uncovered and opened scrapes on his arm. He stated he scraped it on some wood and no one had told him they needed to be covered.Dietary Aide 4 indicated at the time of the observations, the Administrator was in charge of the kitchen. He tries to clean the walk in cooler weekly and it was everyone's responsibility to put orders away when they come in. He indicated the food was to be stored on the shelves or a crate and not the floor.During an interview on 7/14/25 at 5:54 a.m., [NAME] 3 indicated cooked and opened food were kept for three days. She acknowledged the observations of the walk in cooler and indicated the boxes were not to be stored on the floor and the turkey breast was not to be stored above the other food on the top shelf.The kitchen was re-toured with the Director of Nursing (DON) on 7/14/25 at 6:20 a.m. and she acknowledged all of the above observations.A facility food safety policy, dated 5/1/25, and received as current from the DON, indicated food was to be stored and prepared in accordance with professional standards for food service safety. Food is stored at a minimum of six inches off the floor, prepackaged food is placed in a leak proof container that is labeled with the name of the contents and date it was placed in the container. A use by date is noted on the label. Dented cans are returned to the vendor but stored in a designated area away from other food. Raw meats are stored on shelves below the fruits and vegetables or other ready to eat food. Leftovers are dated properly and discarded after 72 hours. All dried storage are to be stored six inches off the floor. Opened packages of food are to be resealed tightly. The shelves are to be kept clean.This citation relates to Complaints 1805787 and 1805788.3.1-21(a)(2)

Based on record review and interview, the facility failed to ensure grievances voiced by the residents were resolved or attempted to be resolved in a timely manner and failed to follow up on the resolution to ensure the grievances were resolved, for 8 of 11 residents interviewed for grievances. (Resident H, K, L, M, N,O, P, Q, and E)Findings include: 1.The Grievance forms were reviewed on 7/15/25 at 8 a.m. and indicated:A Grievance form, dated 4/8/25, Resident K had not received the morning medications until 11:35 a.m. and had to ask four times for the medication. The investigation indicated the residents' Medication Administration Records (MARs) were audited and the medications were received during the administration window. The DON explained to the resident the medications were given during the administration window and the Agency Nurse was slower with the medication administration than the facilities nurses. The response from the resident, indicated the resident was still frustrated though accepting.A Grievance form, dated 4/8/25, indicated Resident N indicated she had not received her morning medications. The investigation indicated the resident was interviewed and the MAR was audited. The medications were given within the administration window. The finding indicated the Agency Nurse was slower than the facility nurse and the resident was, angry that the medications were late. An explanation was given to the resident about the four hour window and the resident was pleased with the outcome.The Resident Council Meeting Notes were reviewed, after approval of the Resident Council President, on 7/14/25 at 8:21 a.m. The meeting, dated 5/13/25, indicated concerns were voiced about medications were administered late, meals were served late and the residents were not receiving the food they requested. The notes indicated a Grievance form was filled out.A Grievance form, dated 5/13/25, indicated during the Resident Council Meeting, the residents indicated the lunch and dinner meals were coming 30 minutes to an hour late daily and the meals were served were not what they were requesting. The investigation indicated the Cooks were interviewed and the the carts from the kitchen were observed for how long it took for the nursing staff to pass the meal trays. The nursing staff had not started passing the trays on the East and South Unit for 12 minutes and the [NAME] on evenings had not started preparing the food trays on time. The Nursing staff were educated to pass the meal trays when they arrive on the unit. The Grievance form did not address the residents not receiving the food they requested. There was no response from the residents to the plan of action documented.An Inservice Education Report, dated 5/20/25 and received from the DON, indicated the topic was medication administration. The content of the inservice was left blank. The Resident Council Meeting Notes, dated 6/10/25, indicated the meals and the medication were still not received on time. The notes indicated a Grievance form was filled out.A Grievance form, dated 6/10/25, indicated in the Resident Council Meeting the residents had a concern about the late meals. The lunch meal was 15-20 minutes late daily and the dinner meal was 30-40 minutes late. The aides were late coming into the Dining Room to pass out the meal. The investigation indicated the Administrator had spoken with the Dietary Department and educated them to do their best to serve the meals on time. There was no documentation about the Concerned Party's response to the action plan or the outcome of the action plan.During an interview on 7/14/25 at 8:21 a.m., the Director of Nursing (DON), indicated the medications were not late and there was a four hour window (7:00 a.m. to 11:00 a.m. 3:00 p.m. to 6:00 p.m. and 7:00 p.m. to 11:00 p.m.) for the medication administration. The facility's Nursing Staff know which residents want their medications earlier and moved around. Not all of the Agency Nurses do this and they start on one hall and go down the hall for each resident. She indicated she was going to ask a facility nurse to write out a routine on who wanted their medications earlier but the nurse was vacation. She indicated either herself or the Social Service Director would follow up with the residents to determine if their concern had improved. She indicated there nothing documented for the follow-up of the grievances. During an interview on 7/14/25 at 9:41 a.m., Resident H, the Resident Council President, indicated when certain Agency Nursing Staff work, the medications were administered late. There were days when he never received his morning medications until 12:00 p.m. He indicated he was told there was a four hour window for the medication administration, though there were days when the medications were still received late. He indicated other residents have had concerns with this also. He also indicated the meals were served late also and he has not always received the food he has requested. He indicated the concerns were reported in the Resident Council Meetings and to staff members and he was unaware what the facility has put into place for a correction plan. He indicated he was told he was not allowed to ask what has been put into place to correct the concerns or the outcome of the concerns. No one has followed up with him to ensure anything had improved. During monthly Resident Council Meetings they ask if there has been improvement and that was the only time they asked.The Resident Council President invited the Surveyor to come to the Resident Council Meeting, on 7/14/25 at 10 a.m There were eight residents who attended the meeting and approved this invitation. The residents indicated the meals were still late in the Dining Room and the residents who ate in their rooms received their trays even later. They indicated the medications were still not administered timely. Residents H, K, L, M, N, O, P, and Q, indicated there were no follow-up on their concerns about the late medications and meals. They indicated there had been no improvement with the medication administration and the meal service.During an interview on 7/14/25 at 11:15 a.m., the DON reviewed the grievances from the past Resident Council Meetings and indicated there were not grievances about the medications given to her. She indicated there had been an inservice in May on the medication administration pass. There had been no documentation to ensure there had been improvement with the medication administration. She indicated there had been no follow up to the dietary concerns.2. A Grievance, dated 6/24/25, indicated Resident E voiced a concern about the treatment for her pressure ulcers had not been completed on 6/22/25 on the evening shift. The day shift nurse, who worked on 6/23/25 had acknowledged the treatment had not been completed on the evening shift on 6/22/25. The investigation indicated the Treatment Administration Record had been reviewed and the treatment had not been signed out as completed on 6/22/25. The actions taken to resolve the concern indicated the the times of the treatments had been changed. The resident was pleased with the time change and would let the facility know if there were further concerns.During an interview on 7/15/25 at 11:13 a.m. with Resident E and a family member, the resident indicated there had been multiple days when her treatments had not been completed. The treatment had not been completed on the evening shift on 7/14/25 and was reported to the nurse on the night shift, who completed the treatment. She indicated this concern with others have been reported to the management and she does not feel the management followed up on her concerns. She does not feel there has been improvement with the plan of action put into place after her grievance was reported and no one has followed up with her to ask her if there had been improvement. She indicated she had not been receiving the meal she has requested and that it does no good to report this, as the kitchen, does not listen.Review of the facility's grievance policy, dated 6/15/22, and received by the DON as current, indicated the person voicing the grievance had a right to receive a written decision regarding the grievance. All concerns were to be reported to the Supervisor on duty. The Administrator, DON, and/or other personnel were to be notified as needed by the supervisor. Following up with the resident and family would be completed to communicate the resolution or explanation and to ensure the issue was handled to the resident's and family's satisfaction. The Administrator or Designee wa responsible to ensure all grievances were reviewed and addressed timely. To ensure the individual feels that some type of resolution had been communicated, achieved and maintained.This citation relates to Complaint 1805785.3.1-7(a)(1)3.1-7(b)

Based on record review and interview, the facility failed to ensure residents were provided choices and the choices were honored for meals, for 9 of 11 residents interviewed. (Residents H, K, L, M, N, O, P, Q, and E)Findings include:1.The Resident Council Meeting Notes were reviewed on 7/14/25 at 8:21 a.m. The meeting notes, dated 5/13/25, indicated residents were not receiving what they requested for meals. The notes indicated a Grievance form was filled out.A Grievance form, dated 5/13/25, indicated during the Resident Council Meeting, the residents were not receiving the meals they requested. The Grievance form had not addressed the issue about the residents not receiving the meals they requested.During an interview on 7/14/25 at 9:41 a.m., Resident H, the Resident Council President, indicated sometimes the meal menus were not posted and the residents were instructed to give dietary a two hour notice for wanting something that was not on the menu. If the the menu was not posted, they did not know what is being served. The CNA's were supposed to come around in the evening and ask the residents what they would like to eat the following day so the residents could order what they wanted. The CNA's did not do that any more and the residents were served whatever was on the menu.The Resident Council President invited the Surveyor to come to the Resident Council Meeting on 7/14/25 at 10 a.m There were eight residents who attended the meeting and approved this invitation. Residents H, K, L, M, N, O, P, and Q, indicated the menus were not posted timely to decide what they would like to eat. The CNA's were no longer taking the meal orders the night before.During an interview on 7/14/25 at 2 p.m., the Administrator indicated the CNA's were suppose to sit with the residents and help them fill out their menu for the next day and that had not been getting completed. 2. During an interview on 7/15/25 at 11:13 a.m. with Resident E and a family member, the resident indicated she was a diabetic and she is served too many carbohydrates. She did not like scrambled eggs and has told the staff this but she still received scrambled eggs every morning. She indicated it does no good to talk to the kitchen staff, they don't listen.Resident E's record was reviewed on 7/15/25 at 2:04 p.m. The diagnoses included, but were not limited to, paraplegia, diabetes mellitus, and stage four (full thickness skin loss) pressure ulcers. A Physician's Order, dated 11/15/24, indicated a regular diet was ordered, prefers fried eggs and 1 piece of toast for breakfast, requested pork not be served, and double proteins.A Care Plan, revised 2/3/25, indicated a nutritional problem was present. The interventions indicated the diet would be provided as ordered, the Registered Dietician would evaluate and make diet changes as needed.A Quarterly Minimum Data Set assessment, dated 6/20/25, indicated an intact cognitive status, no behaviors, set up help is needed for meals, a significant weight loss while not on a prescribed diet (determined the mechanical lift scale was broken), and was not ordered a therapeutic diet.The Dietary Card, received as current from [NAME] 3, indicated a preference of a fried egg for breakfast and double proteins.During an interview on 7/15/25 at 2:07 p.m., the Director of Nursing indicated the dislike for scrambled eggs was not included on the Dietary Card.A facility food preference policy, dated 4/29/25 and received from the Administrator as current, indicated allergies, dislikes, and special requests, as deemed appropriate, are addressed prior to the meal service to ensure an appropriate alternate(s) are served prior to the meal being received by the resident. This citation relates to Complaint 1805785.3.1-20(a)

Based on observation, record review and interview, the facility failed to serve 1 of 2 meals observed at an appetizing temperature, related to a supper meal served with temperatures of the food under 135 degrees. This had the potential to affect 71 residents who are on a regular diet with regular textured foods.Finding includes:A Grievance form, dated 7/10/25, indicated Resident J voiced a concern about cold food. The response to the grievance indicated the resident stated the concern was resolved on 7/14/25.On 7/15/25 at 5:00 p.m., the Administrator was notified a test tray for the supper meal was needed.The supper included BBQ chicken, greens and mashed potatoes. The test tray was received on 7/15/25 at 6:00 p.m., the temperature of the BBQ chicken was 133.6 F, the mashed potatoes was 126.2 F, and the spinach was 90.3 F. The chicken and the mashed potatoes were warm to taste and the spinach was cold to taste.During an interview on 7/15/25 at 6:00 p.m., Dietary Aide 7 indicated the steam table had been shut off for about two minutes prior to the sample tray being received.The Administrator was informed at the time of the sample tray testing of the food temperatures. No further information was received.The food temperature policy, dated 4/28/25, indicated the hot foods were to be held at a minimum of 135 degrees.This citation relates to Complaints 1805785 and 1805787.3.1-21(a)(2)

Based on record review and interview, the facility failed to ensure treatments for pressure ulcers were completed as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident E)Finding includes: During an interview on 7/15/25 at 11:13 a.m. with Resident E and a family member, the resident indicated there had been multiple days when her treatments had not been completed. The treatment had not been completed on the evening shift on 7/14/25 and was reported to the nurse on the night shift, who completed the treatment.Resident E's record was reviewed on 7/15/25 at 2:04 p.m. The diagnoses included, but were not limited to, paraplegia, diabetes mellitus, and stage four (full thickness skin loss) pressure ulcers. A Care Plan, revised on 1/1/25, indicated upon admission there were two stage four pressure ulcers located on the sacrum and right ischium. The interventions indicated the pressure ulcer treatment would be completed as ordered.A Quarterly Minimum Data Set assessment, dated 6/20/25, indicated an intact cognitive status, no behaviors, impairment of both lower extremities, required maximum assistance with bed mobility, had two stage four pressure ulcers on admission, and received pressure ulcer care.A Physician's Order, dated 4/9/25 and discontinued on 7/10/25, indicated zinc oxide external paste 40% was to be applied to the right ischium periwound every day shift. The TAR (Treatment Administration Record), dated 7/2025, indicated the treatment had not been completed on 7/6/25 on the day shift.A Physician's Order, dated 4/16/25 and discontinued on 7/10/25, indicated the right ischium was to be washed with wound wash then place collagen (wound treatment) to the wound wound bed and cover with hydroferablue (foam wound cover). Zinc oxide was to be applied to the periwound then cover the wound with a foam dressing daily and as needed. The TAR, dated 7/2025, indicated the treatment had not been completed on the day shift (no time scheduled).A Physician's Order, dated 4/16/25 and discontinued on 7/10/25, indicated Betamethasone Valerate External ointment 0.1% (help to relieve discomfort caused by skin conditions) was to be applied to the sacral periwound every day shift. The TAR, dated 7/2025, indicated the treatment had not been completed on the day shift on 7/6/25.A Physician's order, dated 6/11/25 and discontinued on 7/10/25, indicated an order to wash the pressure ulcer on the sacrum with wound wash then place collagen to the upper wound bed and calcium alginate (wound treatment) to the lower wound bed and cover with hydroferablue. The TAR, dated 6/25/25, indicated the treatment had not been completed at 8:00 p.m. on 6/22/25 and 6/27/25. The TAR, dated 7/2025, indicated the treatment had not been completed on 7/4/25 at 8:00 p.m. and 7/6/25 at 8:00 a.m.A Physician's Order, dated 7/10/25, indicated BNZ (bacitracin, nystatin, zinc) cream was to be applied to the sacrum periwound twice a day with the dressing changes. The TAR, dated 7/2025 indicated the treatment had not been completed on 7/11/25 at 8:00 a.m.A Physician's Order, dated 7/10/25, indicated the treatment to the sacrum was to be completed twice a day and as needed. The sacral wound was to cleaned with wound wash, collagen was to be placed on the upper wound bed and calcium alginate to the lower wound bed and then covered with hydroferablue. BNZ was to be applied to the periwound and the wound was to be covered with a super absorbent dressing. The TAR, dated 7/2025 indicated the treatment had not been completed on 7/11/25 at 8:00 p.m.The Director of Nursing (DON) was informed of the missed treatments on 7/15/25 at 2:03 p.m. No further information was provided.A facility pressure ulcer policy, dated 6/11/25 and received from the Corporate RN Consultant as current, indicated a resident with pressure ulcers would receive necessary treatment and services to promote healing. A facility wound care policy, dated 6/12/25 and received from the Corporate RN Consultant as current, indicated after a physician's order is received for the wound care, the physician's order would be followed.This citation relates to Complaint 1805786.3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a respiratory treatment was monitored for 1 of 3 residents reviewed for oxygen. (Resident B)Finding includes:During random observations on 7/15/25 at 9:49 a.m., Resident B was observed lying in bed on his right side. There was a nebulizer treatment running but Resident B was not wearing oxygen or a oxygen mask (used for nebulizer treatment). Lying next to the resident's legs was the nebulizer mask which was disconnected from the medication cup. Agency LPN 1 was notified and assisted the resident on putting his nebulizer mask back on. Once the mask was back in place, Agency LPN 1 left the room. At 9:54 a.m., the Agency LPN 1 was observed passing medication to another resident until 9:59 p.m. At 10:01 a.m., Agency LPN 1 returned to Resident B's room to remove the nebulizer treatment. The resident was not wearing the nebulizer mask, it was lying next to him on the bed. The treatment was completed and oxygenation levels were checked. During an interview at the time, Agency LPN 1 indicated she usually sets a timer for fifteen minutes and goes back in to remove the treatment when her alarm goes off. She indicated the resident was confused at times and impulsive at times and would pull his nasal cannula and nebulizer mask off frequently. She had a video monitor sitting on her treatment cart and she would monitor the resident periodically.The record for Resident B was reviewed on 7/14/25 at 9:00 a.m. Diagnoses included, but were not limited to, COPD, dementia, displaced fracture of acetabulum (concave surface of the pelvis), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body).The 6/30/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was severely impaired for decision making. The resident required substantial to maximum assistance with toileting, bathing, and dressing. The resident used oxygen and had hospice care.A Care Plan, dated 6/10/25, indicated the resident required oxygen therapy.Physician's Orders, dated 6/10/25, indicated to administer 3 milligram/3 milliliter Ipratropium-Albuterol Inhalation Solution (nebulizer treatment) four times a day through inhalation.During an interview on 7/15/25 at 10:43 a.m., the Director of Nursing indicated she understood the respiratory concern and had no additional information to provide.The current Small Volume Nebulizer Therapy policy provided by the Director of Nursing on 7/15/25 at 11:04 a.m., indicated standard of practice was followed by the Lippincott procedure and included a facility approved addendum to the Lippincott procedure. The addendum indicated, .remain with the patient and continue the treatment until the nebulizer begins to sputter.This citation relates to complaint 1805785 and 1805786.3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to ensure ground meat was provided in accordance with the physician orders and failed to ensure specialized dietary instructions were provided to nursing staff for 6 of 6 residents on a memory care unit reviewed for a mechanically altered with ground meat diet. (Residents B, G, H, J, K, and L) This deficient practice resulted in a cognitively impaired resident with a history of food stuffing, ingesting the regular meat, the resident's airway becoming blocked, and the resident expired. (Resident B). The immediate jeopardy began on [DATE] when a cognitively impaired resident on the memory care unit with a history of stuffing food into her mouth and swallowing without chewing, was found unresponsive with sausage in her mouth and airway after the evening meal. The resident had an order for a diet with ground meat for meals. There were no dietary cards nor ground meat provided for the evening meal on [DATE]. The staff working provided the resident with polish sausage cut into pieces. The resident was found unresponsive after the evening meal with a large amount of unchewed sausage in her mouth and airway. The Heimlich Remover and CPR (Cardiopulmonary resuscitation) were completed resulting in more sausage being found in the resident's mouth. The resident was unable to be revived, even after EMS (Emergency Medical Services) arrived and took over care, and was pronounced deceased by EMS. The cause of death provided by the Coroner was aspiration of food. The Executive Director (ED) was notified of the immediate jeopardy at 11:02 a.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding include: 1. An Indiana Department of Health (IDOH) Incident Report, dated [DATE], indicated at 6:25 p.m., Resident B was observed lying on her bed by Agency CNA 1. The CNA notified Agency LPN 2 and Agency LPN 2 assessed the resident. The resident was unresponsive, and the Agency LPN 2 observed food in the resident's mouth. Agency LPN 2 completed a finger sweep of the resident's mouth and removed visible food. CPR was then initiated, and EMS was notified. EMS arrived at the facility at 6:40 p.m. and took over the care. The resident was pronounced deceased at 7:08 p.m. by the EMS and the Coroner was notified and arrived at the facility at 7:15 p.m. The report did not include sufficient documentation to determine who initiated CPR, who notified EMS, and who or when the Coroner was notified. Resident B's record was reviewed on [DATE] at 10:45 a.m. The diagnoses included, but were not limited to, dementia and psychotic disorder with delusions. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B had severely impaired cognitive status, had physical, verbal, and other types of behaviors ,d+[DATE] days per week. She had no impairment of the upper and lower extremities. She required supervision while eating, was independent with bed mobility and transfers, and required supervision with ambulation. She was not on a special diet, received an antipsychotic medication, and an anti-anxiety medication. A Physician's Order, dated [DATE], indicated a regular mechanical soft diet with ground meat. A care plan for repetitive requests during mealtime, dated [DATE], indicated Resident B put excess amounts of food in her mouth and did not take the time to chew or swallow safely. The plan included, but was not limited to, interventions of limiting meals to two helpings, offer food/drink and redirect as needed, offer one food item at a time, and provide supervision. A mechanically altered diet with ground meat interventions had not been added to the care plan. During an interview on [DATE] at 2:11 p.m., CNA 4 indicated on [DATE], the meal was delivered to the memory care unit in metal containers and the CNAs had to serve the food to the residents. The Dietary Staff never sent the dietary cards or the ground meat for the evening meal. CNA 4 asked Agency LPN 3 to call the kitchen, but he was not sure if she did. When this had happened before, they were told to cut the meat up into little pieces. The Polish sausage was served to Resident B. CNA 4 cut the Polish sausage into dime size pieces and served the meal to Resident B. During an interview on [DATE] at 10:00 a.m., the Dietary Manager (DM) indicated the meals were served homestyle. The meal was sent to the memory care unit in covered metal pans for nursing staff to serve on plates, and dietary staff were expected to send properly prepared food and each resident's meal ticket with specialized instructions with the meal. The DM indicated nursing staff were expected to follow the specialized dietary instructions on the meal tickets; however, the dietary staff forgot to send the ground meat and the meal tickets to the unit on [DATE]. The DM indicated the Cook on duty [DATE], reported the nursing staff had not alerted the dietary staff that the ground meat and the meal tickets with specialized instructions were not received. The DM indicated cutting the sausage into small bites was not equivalent to the specialized texture of ground meat. During an interview on [DATE] at 8:10 a.m., Agency LPN 2 indicated she was receiving report from Agency LPN 3 when Agency CNA 1 notified them of Resident B's status. She immediately went to the resident's room. The resident was lying on her back and she saw Polish sausage chunks unchewed on the outside of the resident's mouth. The chunks looked like they would be as if the sausage was cut in sections, though was unable to approximate the size. The resident was unresponsive. Agency LPN 2 gave instructions for Agency CNA 1 to get the crash cart and to call EMS. Agency LPN 2 performed a finger sweep of the resident's mouth and proceeded to initiate the Heimlich Maneuver and more sausage chunks came out of the mouth. She had not seen any more, so she began CPR and another large amount of sausage came out of her mouth. CPR was stopped and the Heimlich Maneuver and another finger sweep was completed and there was no more food observed in the mouth or throat, and started CPR again. EMS arrived and took over the resident's care. Agency LPN 2 indicated the meals were always done when she came in to work. She was aware the resident would hold food in her mouth and would try to take fluids and food off of the medication cart. 2. On [DATE] at 11:00 a.m. a list was provided by the DON that indicated there were five residents on the memory care unit who had physician orders for mechanical soft diets with ground meat. a. Resident G's record was reviewed on [DATE] at 1:33 p.m. The diagnoses included, but were not limited to dementia and dysphasia. A quarterly MDS assessment, dated [DATE], indicated a severely impaired cognitive status and supervision was required for eating. A Care Plan, dated [DATE], indicated a diagnosis of dysphasia and a mechanically altered diet was required. A Physician's Order, dated [DATE], indicated a mechanically altered diet was to be served. b. Resident H's record was reviewed on [DATE] at 1:50 p.m. The diagnoses included, but were not limited to dementia, Parkinson's disease, and dysphagia. A quarterly MDS assessment, dated [DATE], indicated a severely impaired cognitive status supervision was required for eating. A Care Plan, dated [DATE], indicated a diagnosis of dysphasia and a mechanically altered diet was required. A Physician's Order, dated [DATE] indicated a mechanically altered diet was to be served. c. Resident J's record was reviewed on [DATE] at 2:06 p.m. The diagnoses included, but were not limited to dementia and dysphasia. A quarterly MDS assessment, dated [DATE], indicated a severely impaired cognitive status and supervision with eating was required. A Care Plan, dated [DATE], indicated a risk for weight fluctuations. The interventions included to serve a diet as ordered by the physician. There were no care plans for the dysphasia diagnosis and mechanically altered diet. A Physician's Order, dated [DATE], indicated a mechanically altered diet was to be served. d. Resident K's record was reviewed on [DATE] at 2:29 p.m. The diagnoses included, but were not limited to dementia. A quarterly MDS assessment, dated [DATE], indicated a severe impairment for decision making and required moderate assistance with eating. A Care Plan, dated [DATE], indicated a risk for weight fluctuations. The interventions included to serve a diet as ordered by the physician. There was no care plan for the mechanically altered diet. A Physician's Order, dated [DATE], indicated a mechanically altered diet was to be served 3. During a meal observation on the dementia care unit, on [DATE] at 5:01 p.m., Activity Aide/CNA 5 was observed to serve breaded shrimp to Resident L. The breaded shrimp was observed to not be mechanically altered. Activity Aide/CAN 5 cut the breaded shrimp into small pieces and assisted the resident with her meal. Resident L's record was reviewed on [DATE] at 2:54 p.m. The diagnoses included, but were not limited to, dementia. An annual MDS assessment, dated [DATE], indicated a severe impairment for decision making and supervision was required for eating. A Care Plan, dated [DATE], indicated assistance was required for eating. The interventions indicated a diet as ordered by the physician would be served. There was no care plan for the mechanically altered diet. A Physician's Order, dated [DATE], indicated a mechanically altered diet was to be served due to difficulty chewing. During an interview, on [DATE] at 6 p.m., the Regional Vice-President provided a dietary spreadsheet and indicated it was for the current menu cycle. The spreadsheet indicated the alternate meat to be served for a mechanically altered ground meat diet during the evening meal, on [DATE], was ground breaded shrimp. The facility mechanically altered diet policy, dated [DATE] and received from the Executive Director as current, indicated the diet consisted of easy to chew and easy to swallow foods. The meats were to be served as ground and moist and foods that were in large chunks and were too hard to chew would be avoided. A facility meal service policy, dated [DATE], and received from the Director of Nursing as current, indicated the resident would be identified to verify accuracy of the diet being served. The meal was to be verified to ensure it matched the correct diet that was prescribed for the resident. The immediate jeopardy that began on [DATE] was removed [DATE] when the facility assessed all residents for their current diet orders, audits to residents' care plans and dietary tray cards were completed, and any discrepancies were corrected. Nursing staff were in-serviced regarding checking resident tray cards when setting up resident trays and removing trays when residents were done eating. Dietary staff were in-serviced on preparing diet consistencies and sending tray cards to the units. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Complaint IN00432816. 3XXX,d+[DATE](a)(3)

Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent a cognitively-impaired resident on the Memory Care Unit with a history of food stuffing from ingesting and aspirating a large amount of unchewed food, for 1 of 3 residents reviewed for dining room supervision. This deficient practice resulted in the death of Resident B. The immediate jeopardy began on [DATE] when a cognitively impaired resident on the memory care unit with a history of stuffing food into her mouth and swallowing without chewing, was found unresponsive with sausage in her mouth and airway after the dinner meal. The resident had a care plan to be supervised during meals. The staff working did not supervise the resident and failed to ensure the entire dining room was within view of staff during the meal to ensure the resident did not stuff food into her mouth from other residents' plates that were left on the tables. The resident was found unresponsive after the evening meal with a large amount of unchewed sausage in her mouth and airway. The Heimlich Remover and CPR (Cardio Pulmonary Resuscitation) were completed, resulting in more sausage being found in the resident's mouth. The resident was unable to be revived, even after EMS (Emergency Medical Services) arrived and took over care, and was pronounced deceased by EMS. The cause of death provided by the Coroner was aspiration of food. The Executive Director (ED) was notified of the immediate jeopardy at 11:02 a.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: An Indiana Department of Health (IDOH), Incident Report, dated [DATE], indicated at 6:25 p.m., Resident B was observed lying on her bed by Agency CNA 1. The CNA notified Agency LPN 2 and Agency LPN 2 assessed the resident. The resident was unresponsive, and the Agency LPN 2 observed food in the resident's mouth. Agency LPN 2 completed a finger sweep of the resident's mouth and removed visible food. CPR was then initiated, and EMS was notified. EMS arrived at the facility at 6:40 p.m. and took over the care. The resident was pronounced deceased at 7:08 p.m. by the EMS and the Coroner was notified and arrived at the facility at 7:15 p.m. The report did not include sufficient documentation to determine who initiated CPR, who notified EMS, and who or when the Coroner was notified. The facility follow-up investigation on the IDOH Incident Report, dated [DATE], indicated the following interviews were completed by the facility: Agency CNA 1 indicated she was in the Dining Room serving food and Resident B was wandering in and out of the Dining Room during the evening meal. At approximately 6:25 p.m., she began rounds to check on the residents and found Resident B lying in bed. She called the resident's name three times and completed a sternal rub and there was no response and reported this to the Nurse immediately. Agency LPN 3 indicated she had been giving report to Agency LPN 2, when Agency CNA 1 reported the resident was unresponsive. She went with Agency LPN 2 and immediately assessed the resident. Agency LPN 2 completed a finger sweep of the resident's mouth and initiated CPR. Agency LPN 3 assisted with suctioning and more food was removed from the resident's mouth. When EMS arrived they took over. Agency LPN 2 indicated Agency CNA 1 came to the desk while she was receiving report from Agency LPN 3 and informed them the resident was unresponsive. Both Nurses responded immediately. She had assessed the resident and observed polish sausage in the resident's mouth. She completed a finger sweep and removed all visible food. She had attempted to do a thrust on the resident's chest and was able to visibly see more sausage, which she removed from the resident's mouth. CPR was initiated beginning with chest compressions. EMS took over the care when they arrived and pronounced the expiration of the resident at 7:08 p.m. CNA 4 indicated Resident B received her evening meal between 5:20 and 5:30 p.m. Resident B only ate some of her mashed potatoes, then left the dining room. Resident B then walked back into the Dining Room and he observed her trying to take food off of other residents' plates who had finished and had left food on their plate. He attempted to redirect Resident B and asked her to sit down and finish her meal. Resident B walked out of the dining room at approximately 5:45 p.m. and that was the last time he saw her. He then cleaned all the tables and took the dishes to the kitchen. Activity Aide 5 indicated she had been feeding another resident in the Dining Room and saw Resident B only for a split second and then the resident left the Dining room. During staff interviews on [DATE] at 9:36 a.m., CNA 6, LPN 7, and CNA 8 were at the Nurses' Station. CNA 6 indicated the resident ambulated independently. CNA 6 and LPN 7 indicated Resident B would take anyone's food if no one was watching and cram the food in her mouth. LPN 7 indicated the resident was quiet and sneaky with food. CNA 6 indicated if they saw her taking food, they were to re-direct her back to her own food. Staff would stay with her and cue her to slow down and swallow before taking the next bite. She typically would put the food directly into her mouth and did not carry the food with her. CNA 6 indicated at the time of the incident, the food was served homestyle, so the food was brought down on an open cart and they served the food. CNA 8 indicated the plates could not be removed from the table until after everyone was done eating. Resident B's record was reviewed on [DATE] at 10:45 a.m. The diagnoses included, but were not limited to, dementia and psychotic disorder with delusions. The Nurses' Progress Notes indicated: On [DATE] at 9:54 a.m., Resident B would fill her mouth with all the food items given to her without chewing the food. She would not accept redirection and continued to rapidly fill her mouth with as much food as it would hold. She then drank fluids to wash the food down. On [DATE] at 4 p.m., Resident B continued to put all food items in her mouth at the same time and continued to wash the food down with fluids without chewing. Foods were given one item at a time for resident safety. On [DATE] at 4:26 a.m., Resident B ate another resident's food and drank their water. She was redirected and responded aggressively to the staff. On [DATE] at 5:30 p.m., Resident B continued to shove food into her mouth in large quantities without chewing then attempted to wash the food down with a drink. She was unable to be redirected. Items were given one at a time with same results. On [DATE] at 7:48, Resident B was taking food from other trays. Staff attempted to redirect and were unsuccessful. On [DATE] at 8 a.m. Resident B was pacing in the Dining Room and taking food off of other resident's plates. Staff attempted to redirect. She would then take food off of the food cart. After multiple attempts to redirect she sat down and ate her own meal. The Physician and Family were notified. On [DATE] at 2:43 p.m., Resident B was observed taking food from other residents' plates. On [DATE] at 2:24 p.m., Resident B consumed her food rapidly by placing large amounts of food in her mouth at one time. She had attempted to take food off of other residents' plates. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B had a severely impaired cognitive status, had physical, verbal, and other types of behaviors ,d+[DATE] days per week. She had no impairment of the upper and lower extremities. She required supervision while eating, was independent with bed mobility and transfers, and required supervision with ambulation. She was not on a special diet, received an antipsychotic medication and an anti-anxiety medication. A Care Plan for repetitive requests during mealtime, dated [DATE], indicated Resident B put excess amounts of food in her mouth and did not take the time to chew or swallow safely. The plan interventions included, but were not limited to, limiting meals to two helpings, offer food/drink and redirect as needed, offer one food item at a time, and provide supervision. There were no interventions for the behavior added to the care plan after [DATE]. The comprehensive plan of care did not include documentation to indicate Resident B took food from the plates of other residents. A Nurse's Progress Note, dated [DATE] at 5:24 p.m., indicated Resident B continued to place large amounts of food in her mouth and drank fluids to swallow. A Physician's Order, dated [DATE], indicated the resident wanted cardiopulmonary resuscitation (CPR) completed if needed, and an order, dated [DATE], indicated the resident was to have a regular diet with ground meat. The Nurses' Progress Notes, indicated: On [DATE] at 4:18 p.m., Resident B attempted to take other resident's food during the meal. She placed a large amount of food in her mouth and swallowed without chewing. On [DATE] at 7 p.m., writer (Agency LPN 2) was receiving report from the off-going Nurse (Agency LPN 3) at 6:25 p.m. when CNA (Agency CNA 1) called writer to the resident's room. Resident B had hot dog bites in her throat and she was absent of vital signs (temperature, pulse, respirations, blood pressure) and pale in color. The off-going Nurse was instructed to call EMS and the crash cart was obtained. Polish sausage was scooped out of the resident's mouth and the Heimlich Maneuver was initiated while the resident laid in bed and the resident's head was turned to the side. More Polish sausage pieces came out at that time. Writer continued to pull more Polish sausage from the resident's mouth. EMS arrived and relieved the Nurse (Agency LPN 2). During an observation on [DATE] at 11:37 a.m., there were 17 residents, 2 CNAs, 1 LPN and 1 Activity Aide in the Memory Care Dining Room to assist the residents with the noon meal. During an interview on [DATE] at 2:11 p.m., CNA 4 indicated, when the incident occurred, there were two CNAs (CNA 4 and Agency CNA 1) and an Activity Aide/CNA (Activity Aide 5) in the Dining Room. The meals were brought back in metal containers and the CNAs had to serve the food to the residents. CNA 4 started serving the meal about 5:15 p.m. - 5:20 p.m. Resident B's food was first to be served because she was trying to grab the food out of the containers. The Dietary Staff never sent down the dietary cards or the ground meat. CNA 4 asked the nurse (Agency LPN 3) to call the kitchen, but he was not sure if she did. When this had happened before, they were told to cut the meat up into little pieces. The Polish sausage was served to Resident B, the sausage was cut into dime size pieces. Resident B sat down and only ate her mashed potatoes. She did not eat the sausage. She kept getting up. CNA 4 indicated he was unable to re-direct her. He had been attempting to serve the other residents in the Dining Room. Resident B walked out of the dining room, she had only eaten her potatoes. She had not eaten her sausage or vegetable. Every resident received sausage that evening except one. Resident B was wandering in and out of the Dining Room and the staff could not get her to sit down. CNA 4 indicated he never saw her grab any food, though he was sitting with his back to the entry doors into the Dining Room. He indicated when she walked out of the Dining Room, there was nothing in her hands and she always would puff her cheeks out, so he could not tell if she was holding food in her mouth. Resident B had not been chewing. When all the residents were through eating, the plates were picked up and scraped into the garbage can. He then took the items to the kitchen, and clocked out on break around 6:04 p.m. He indicated the resident would hoard food in her room and she never ate any of her own sausage. During an interview on [DATE] at 2:30 p.m., Agency CNA 1 indicated the residents were being served supper in the Dining room. She indicated CNA 4 had cut the resident's sausage into small bites. The staff were trying to get Resident B to stay in the Dining Room to eat. Activity Aide 5 was passing drinks out to everyone. Agency CNA 1 then indicated she had sat down to assist two residents with their meals. From where she was sitting, she did not have a clear view of both entry doors. She observed Resident B come in and out of the Dining Room twice. She never saw the resident take food off of another tray. The last time she saw Resident B in the Dining room was about 5:45 p.m. She never saw Resident B with Polish sausage in her mouth and she never ate her own serving of the sausage. During an interview on [DATE] at 2:52 p.m., Activity Aide 5 indicated she assisted with passing out the meals and then sat down to feed a resident. She saw Resident B just standing there and then she was gone. She did not have full view of the entry doors. During an interview on [DATE] at 8:10 a.m., Agency LPN 2 indicated she was receiving report from Agency LPN 3 when the CNA notified her of Resident B's status. She immediately went to the resident's room. The resident was lying on her back and she saw Polish sausage chunks unchewed on the outside of the resident's mouth. The chunks looked like they would be as if the sausage was cut in sections, though she was unable to approximate the size. The resident was unresponsive. She gave instructions for the CNA to get the crash cart and to call EMS. She performed a finger sweep of the resident's mouth and proceeded to initiate the Heimlich Maneuver and more sausage chunks came out of the mouth. She had not seen any more, so she began CPR and another large amount of sausage came out of her mouth. CPR was stopped and she again completed the Heimlich Maneuver and another finger sweep and had not seen any more food in the mouth or throat and started CPR again. EMS arrived and took over the resident's care. She indicated the meals were always done when she came in to work. She was aware the resident would hold food in her mouth and would try to take fluids and food off of the medication cart. During an interview on [DATE] at 9:40 a.m. Agency LPN 3 indicated, during the evening meal, she was passing medications in the Dining room. It was hard to get the residents to sit down. There were 2 CNAs and an Activity Aide. The residents were served their meal and the residents who needed help were being assisted by the CNAs and Activity Aide. She then went back to the Nurses' Desk and indicated she could see the Dining Room from the desk. She stated she could see the residents but not the tables when she looked through the window to the Dining Room from the desk. She had not seen Resident B go in and out of the Dining Room, though that didn't mean the resident wasn't in there, as this was her third time at the facility, and she was trying to get to know the residents. She indicated the staff had reported the resident ate fast and wandered in and out of the room. Agency LPN 3 indicated, on [DATE], she administered Resident B's medications between 9 and 10 a.m. and she still had eggs in her mouth from breakfast that was served around 8 a.m. Agency LPN 3 indicated she asked the staff then about the resident and was told she would hold food in her mouth all the time. During an interview on [DATE] at 10:00 a.m., the Dietary Manager (DM) indicated the meals were served homestyle. The meal was sent to the memory care unit in covered metal pans for nursing staff to serve on plates, and dietary staff were expected to send properly prepared food and each resident's meal ticket with specialized instructions with the meal. The DM indicated nursing staff were expected to follow the specialized dietary instructions on the meal tickets; however, the dietary staff forgot to send the ground meat and the meal tickets to the unit on [DATE]. The DM indicated the Cook on duty [DATE], reported the nursing staff had not alerted the dietary staff that the ground meat and the meal tickets with specialized instructions were not received. The DM indicated cutting the sausage into small bites was not equivalent to the specialized texture of ground meat. During an interview on [DATE] at 10:15 a.m., the Director of Nursing (DON) indicated there was no care plan that indicated Resident B took food off of the other resident's plates. She indicated there were always staff in the Dining Room to supervise the residents. During an interview with the County Coroner on [DATE] at 11:41 a.m., he indicated the cause of death was due to aspiration of food, dementia, hypertension, and diabetes mellitus. During an interview on [DATE] at 1:41 p.m., the DON indicated there was no protocol or policy for a certain staff member to monitor Resident B. All of the staff in the Dining Room were to monitor and supervise the residents. The protocol of not picking up the finished plates had been the procedure for a long time and the Memory Care Unit started homestyle dining in early March of 2024. She educated the staff when this started and she reminded them to not pick up the plates until everyone was finished eating so that the meal time would be more homelike. The DON acknowledged there had not been new interventions added for the behaviors of the resident stuffing her mouth with food and that there was no care plan for the resident taking food off other residents' plates. A facility policy for meal service, dated [DATE] and received from the DON as current, indicated the resident was to be positioned appropriately for meals. The residents were to be monitored in case additional assistance was needed. The tray was to be removed when the resident was finished eating. The immediate jeopardy that began on [DATE] was removed [DATE] when the facility assessed all residents for the need of additional supervision and if at-risk interventions were implemented. Residents in need of additional supervision were reviewed for appropriate care and interventions, and care plans updated. Nursing staff were inserviced regarding supervision and safety during meals. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Complaint IN00432816. 3XXX,d+[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure a resident received adequate assistance and assistive devices to prevent accidents, related to a dependent resident who was unable to stand being lowered to the floor during a transfer from a shower chair to a Broda chair (high back/reclining chair) without the use of a gait belt or mechanical lift. The resident was then assisted off the floor and into the Broda chair before notifying the Nurse of the fall to complete an assessment. The fall resulted in a closed [MEDICAL CONDITION] of the left femur and increased pain for 1 of 4 residents reviewed for falls. (Resident B) Finding includes: During an observation on 04/26/18 at 9:34 a.m., Resident B was sitting in a Broda chair. There was a mechanical lift pad underneath the resident. At the time of the observation, LPN 1 indicated the resident had fractured her femur due to a transfer in the shower room when her knees buckled and she was lowered to the floor. During an observation on 04/26/18 at 1:45 p.m., CNA 2 and CNA 3 used a mechanical lift to transfer the resident from the Broda chair to the bed. She had facial grimaces during the transfer. CNA 2 and CNA 3 indicated she was a two person assistance with transfers with the use of a gait belt before the fall and could bear a little weight, but after the fall she was now a mechanical lift for transfers and she now had increased pain with movement. Resident B's record reviewed on 04/26/18 at 3:21 p.m. The [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 2/12/18 , indicated the cognition status was not assessed, decision making skills were severely impaired, required extensive assistance of two persons for bed mobility, transfers, and dressing, was dependent of one for bathing, and had no falls. Nurses' Progress Notes, indicated: - 04/07/18 at 4:36 p.m., Late entry for 04/04/18 at 3:45 p.m. - a CNA informed LPN 8 that the resident's knees buckled during a transfer and the resident had to be lowered to her knees. A third CNA came and assisted with transferring the resident back into the Broda chair. The CNAs brought the resident to the Nurse and informed her of lowering the resident to the floor. She was assessed (in the Broda chair) the resident with no pain or discomfort, left knee noted with red area, no rotation to bilateral legs and hips equal in Broda. - 04/10/18 at 6:25 a.m., late entry for 04/05/18 at 4:05 a.m. - LPN 9 heard a scream from the resident's room, CNA 4 was in the room providing care. The resident was grabbing her left leg. CNA 4 explained she was informed in report the resident had a fall earlier in the day. LPN 9 had not been informed of the fall. The left thigh was [MEDICAL CONDITION] and approximately three inches above the knee was indented. There was no redness or bruising and the left leg appeared to be shorter than the right with external rotation. LPN 9 and CNA 4 placed log rolled towels on each side of the left leg. - 04/05/18 at 9:55 a.m., Late entry for 04/05/18 at 8:45 a.m. -The resident was grimacing and did not want to get out of bed. Left lower leg was indented at the lateral thigh and shortened in length compared to the right lower extremity. - 04/05/18 at 11:30 a.m. - The resident was transferred to the emergency room . - 04/05/18 at 8:20 p.m. - The resident returned from the emergency room with a [DIAGNOSES REDACTED]. - 04/06/18 at 10:45 p.m. - Grimaces and moans during care and repositioning. - 04/07/18 at 2:13 a.m. - No visual or verbal sign of pain, until repositioning or turning to change, she moans a little. - 04/07/18 at 12:35 p.m. - Wincing with care. - 04/08/18 at 12:44 a.m. - Showing signs and symptoms of pain. The emergency room Physician's Progress Note, dated 04/05/18 at 12:47 p.m., indicated a [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 2/12/18, indicated the resident was a high risk for falls., A care plan, dated 10/06/15, indicated at risk for falls due to poor safety awareness and balance, and use of mechanical lift for transfers. Interventions included assist with mobility. There were no interventions to indicate a gait belt was to be used and on 04/05/18 the intervention of hoyer lift for transfers was added. A care plan, dated 10/06/15, indicated severe cognitive impairment, dependent on staff to provide activities of living care. Interventions included, (11/21/14) may use hoyer lift with transfers. The Investigation indicated the following statements from staff: - 04/05/18 - CNA 5: CNA 7 and CNA 5 were transferring the resident after her shower was given, the resident's knees buckled and they could not support her and she was lowered to the floor to her knees. CNA 6 came and assisted with getting the resident off the floor and into the chair. - 04/05/18 - CNA 6: She was walking down the hall and saw the shower room call light on, and assisted CNA 5 and CNA 7 transfer the resident back into the chair. - 04/09/18 - CNA 7: CNA 5 was in the shower room giving the resident a shower, the shower room call light was activated, the resident was in the shower chair dressed. CNA 5 and CNA 7 stood her up, the pants fell down to her ankles. CNA 7 attempted to grab the pants, and the resident's knees buckled. Attempts were made to hold the resident off the floor, the resident ended up on the floor with her feet underneath her. The CNAs could not lift the resident up, so the call light was activated and CNA 6 came in to help get the resident off the floor and into the chair. - 04/09/18 - LPN 8: The CNA brought the resident in the Broda chair to the Nurses' Station and informed her she was lowered to her knees in the shower room and it took three CNAs to get her back into the Broda chair. The resident was sitting in the Broda chair with legs straight in front. The left knee had a red area and no other issues were observed. There was no leg rotation in the Broda chair and no sign or symptoms of pain. The Investigation, dated 04/09/18, indicated the staff were educated on gait belt use and informing the nurse at the time of the incident and not to move the resident after an incident. During an interview on 4/27/18 at 10:50 a.m., the Assistant Director of Nursing (ADON) /Interim DON, indicated the Business Office Assistant came and got her around 8:45 a.m. on 04/05/18, and asked her to assess the resident. The mechanical lift was initiated after the fall and the facility policy was to use a gait belt with anyone who required two assistants for transfers, but the gait belt had not been used. The CNAs should not have moved the resident until the nurse assessed the resident after the fall. An undated facility policy, titled, Types of Transfers, received on 04/27/18 at 8:32 a.m. from the Corporate RN, indicated, .Place the gait belt around the resident .If the resident is incapacitated or excessively heavy, a mechanical lift may be the choice for safe transfers .gait belt is considered safe and a 'must' to be used when you transfer any resident needing assistance . A facility policy, dated 10/04, titled, Lifting Techniques - General Information, received from the Corporate RN as current, indicated, .Report all accidents no matter how insignificant they may appear . This Federal tag relates to Complaint IN 350. 3.1-45(a)(2)

Based on observation, record review, and interview the facility failed to ensure a dependent resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in range of motion related to splints not applied as ordered for 1 of 1 sampled residents reviewed for limited range of motion. This resulted in a decline in range of motion and worsening contracture of the resident's left hand. (Resident 65) Finding includes: On 12/28/17 at 10:32 a.m. Resident 65 was observed lying in bed with her eyes closed. Her hands were resting on her abdomen, her left and right hands were in a closed fist, and there were no splint devices observed in place. On 1/3/18 at 3:00 p.m. the resident was observed lying in bed with her eyes closed. Her hands were resting on her abdomen, her left hand was in a closed fist, her right hand was in a closed fist with her index finger was pointing outward, and there were no splint devices observed in place. Resident 65's record was reviewed on 12/29/17 at 11:56 a.m. [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 8/14/17, indicated the resident was cognitively impaired, dependent of staff for Activities of Daily Living (ADLs), and had a functional deficit in range of motion of impairment on both sides, upper and lower extremities. Interview with the West Unit Manager on 1/2/18 at 4:15 p.m., indicated the resident was last seen by therapy in 2016 and was not sure if the resident currently had any splint devices. Interview with the Rehab Services Manager on 1/3/18 at 2:21 p.m., indicated therapy had last worked with the resident for splinting in February 2016. At the time of discharge from therapy on 2/10/16 they recommended bilateral upper extremity splints for four hours at a time and had discussed splint schedule with nursing staff. She indicated the resident was picked up again for therapy today. The Occupational Therapy Plan of Treatment, dated 2/11/16, indicated the resident had bilateral hand, finger, and wrist contractures. The discharge summary indicated the resident tolerated bilateral upper extremity splints 4 hours at a time twice a day, no follow up services were needed, and nursing staff was to resume splint program. The 2/2016 Physician order [REDACTED]. Interview with the Medical Records Nurse and the Rehab Services Manager on 1/3/18 at 3:19 p.m. indicated in September of 2016, the resident had a few skin tears from the splints and the splints were put on hold until they were modified and the skin tears healed. The splints were then supposed to be resumed. In November of 2016, the resident obtained a right forearm skin tear and the right hand splint was put on hold while the skin tear treatment was in place. The splint was supposed to be resumed following the treatment of [REDACTED]. Continued interview with the Rehab Services Manager on 1/3/18 at 3:29 p.m., indicated therapy had re-evaluated the resident today and picked her up for therapy. The resident's left hand contracture had declined and the resident's right hand contracture was unchanged from 2/2016. The therapy plan of treatment, dated 1/3/18, indicated the resident's right upper extremity ROM was unchanged from 2/2016 with good fit of previous splint. The left upper extremity finger joints were fixed at 90 degrees flexion with < (less than) 15 degrees ROM. The left upper extremity splint was unable to be put in place due to finger tightness. 3.1-42(a)(2)

A. Based on record review and interview, the facility failed to ensure a resident with a fracture received treatment timely, which caused the resident pain, for 1 of 2 residents reviewed with fractures in a total sample of 18. (Resident #L) B. Based on record review and interview, the facility failed to ensure residents received the necessary care and services related to assessments of a [MEDICAL TREATMENT] shunt (access for [MEDICAL TREATMENT]) for 1 of 1 resident who received [MEDICAL TREATMENT] and assessment/follow up of a resident with a low blood sugar for 1 of 10 residents with diabetes mellitus in a total sample of 18. (Resident #D and #G) Findings include: A. 1. Resident #L's closed record was reviewed on 8/22/12 at 3:10 p.m. Resident #L's [DIAGNOSES REDACTED]. A significant change MDS (minimum data set) assessment, dated 3/9/12, indicated the resident had severe cognitive impairment and required extensive assistance of two staff members for bed mobility, transfers, and toilet use. A nurses' note, dated 4/17/12 at 12 p.m., indicated "MD here to see (sic). N.O. (new order) received et (and) noted...." A physician progress notes [REDACTED]. The nurses' notes indicated: 4/17/12 at 9 p.m., "...R knee notes c (with) trace [MEDICAL CONDITION]. Elevated knee for comfort..." 4/18/12 at 2:30 p.m., "(Physician name) called @ (at) 1:15 p.m. and message left for nurse concerning R knee [MEDICAL CONDITION] and pain. Resident grimaces when leg elevated...Passed onto next shift to follow-up since no return call from (physician's name) office..." 4/18/12 at 4:15 p.m., New orders recd (received) per (physician name) for x-ray of R knee d/t (due to) Dx (diagnoses) of pain & [MEDICAL CONDITION] to area..." 4/18/12 at 8:30 p.m., "(name of x-ray company) here x-ray of knee done- area remains swollen...elevated on pillow while in bed- tyl (Tylenol) given earlier for Dx of pain c (with) positive results..." 4/19/12 at 6 p.m., "Rt (right) knee cont (continues) c [MEDICAL CONDITION] Rt knee elevated in bed..." 4/20/12 at 8:30 a.m., "Res (Resident) c facial grimacing during A.M. (morning) care et also grabbing Rt knee. Rt knee continues c [MEDICAL CONDITION] (Physician's name) office et notified..." 4/20/12 at 11:50 a.m., "Rec;d N.O. for...x-ray of Rt knee c (name of x-ray company)..." 4/20/12 at 1 p.m., "Called (name of x-ray company) to schedule x-ray of Rt knee. Stated that an x-ray was done on 4/18/12. Asked to fax results." 4/20/12 1:10 p.m., "Rec'd results of Rt knee x-ray. Faxed et called (Physician's name) c results of Rt knee x-ray. N.O. to schedule consult c orthopedic doctor at (name of hospital) et have therapy apply long knee brace to leg...Called (hospital name) scheduling to schedule apt (appointment) c orthopedic, stated that she will call back c date et time..." The X-ray report, dated 4/18/12, indicated "...SIGNIFICANT FINDINGS RIGHT KNEE: Two view right knee demonstrates malpositioning on the total right knee prosthesis with respect to the distal femoral...The possible presence of a fracture at this site cannot be excluded........IMPRESSION....... Malpositioning of the total knee prosthesis with respect to the distal femoral. (knee)..This may be due to a fracture..." A physician's orders [REDACTED]. The resident's MAR (Medication Administration Record), dated 4/12, indicated the resident had received Tylenol for pain on 4/17/12 at 7 a.m. and 4/20/12 at 8:00 a.m. for right knee pain. The MAR lacked documentation of any pain medication administered to the resident on 4/18/12. During an interview on 8/23/12 at 11:15 a.m., LPN #6 indicated she had taken care of resident #L on 4/18/12. She indicated she had documented the note on 4/18/12 at 2:30 p.m. She indicated she had administered Tylenol to the resident when the resident was grimacing in pain, but she had not documented the Tylenol administration on the MAR. A nurses' note, dated 4/21/12 at 10 a.m., indicated "...rec'd order to send to (name of hospital) ER (emergency room ) for Eval (evaluation) et tx (treatment)..." This was three days after the x-ray was ordered. A right knee x-ray, dated 4/21/12, indicated "...Discussion: The study is frontal, lateral and both oblique views. There is...fracture just above the femoral prosthesis. The fracture is offset by at least 50% with the knee lateral to the femoral shaft...IMPRESSION: Distal femoral shaft fracture with displacement." During an interview on 8/22/12 at 3:25 p.m., the ADoN (Assistant Director of Nurses), indicated they should have gotten the x-ray results back before 4/20/12 when it had been done on 4/18/12. She indicated the resident should have gotten pain medication and treatment before the 20th when they got the results of the x-ray. She indicated the resident was sent to the hospital on the 21st. B1. Resident #G's record was reviewed on 08/23/12 at 9:20 a.m. The resident's [DIAGNOSES REDACTED]. The Physician's Recapitulation orders, dated 08/12 indicated an order dated 01/04/12 for [MEDICATION NAME] (medication given for low blood sugar) 1 milligram (mg) as needed for glucose less than 60 after administration of orange juice if unable to elevate above 70. The Medication Administration Record (MAR), dated 08/12, indicated the [MEDICATION NAME] had been administered on 08/03/12. The MAR and medical record lacked documentation of the blood sugar result and an assessment prior and after administering the [MEDICATION NAME]. During an interview on 08/23/12 at 10:45 a.m., the Assistant Director of Nursing (ADoN) indicated the nurse should have written the information on the back of the MAR. B2. Resident #D's record was reviewed on 08/20/12 at 2:45 p.m. The resident's [DIAGNOSES REDACTED]. The Physician's Recapitulation Orders, dated 08/12, indicated an order 07/06/12 for [MEDICAL TREATMENT] three times a week. The Nurses Notes, Pre/Post [MEDICAL TREATMENT] Checklist, and the MARs lacked documentation to indicate the shunt had been assessed every shift or after the resident had [MEDICAL TREATMENT]. During an interview on 08/20/12 at 3:30 p.m., the Core Unit Manager indicated the shunt is only checked on Monday, Wednesday, and Friday after [MEDICAL TREATMENT]. She indicated the the Pre/Post [MEDICAL TREATMENT] checklist forms were not getting filled out. During an interview on 08/21/12 at 1:25 p.m., the DoN (Director of Nursing) indicated she had reviewed the facility's policy and wrote orders to assess the shunt site every shift. The facility policy, dated 12/11/01, titled "Shunt/Fistula Sample Acute Care Plan", received from the DoN as current, indicated, "...Assess shunt site pressure dressing post [MEDICAL TREATMENT] every 80 minutes...Check thrill and bruit (vibration) every shift...Assess shunt site for s/s (signs and symptoms) of infection q (every) shift...." 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the Administrator was notified immediately of allegations of abuse and failed to investigate and report the allegation of abuse to the Indiana State Department of Health (ISDH), in a timely manner, which resulted in the residents on the unit not being protected from potential further abuse for 2 of 24 residents (Residents #B and #C) who resided on the Special Care Unit and 1 of 15 residents (Resident #H) who resided on the Skilled Unit. This had the potential to affect all 24 residents who reside on the Special Care Unit and 15 residents who reside on the Skilled Unit. The immediate jeopardy began on 11/17/11 when the facility failed to notify the Administrator immediately of the allegation, failed to protect the residents on the Special Care Unit from potential further abuse, and failed to investigate and report the allegation of abuse. The Administrator was notified of the immediate jeopardy on 11/21/11 at 2:10 p.m. The immediate jeopardy was removed on 11/23/11, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. A confidential interview on 11/21/11 indicated Resident #B had said a resident male comes in to the room and, "gropes" Resident #C . The confidential interview indicated the hospital called the facility on 11/17/11 and reported the allegation to the nurse on Resident #B's unit. A hospital emergency room (ER) report, dated 11/17/11, indicated Resident #B (Resident #C's roommate) was in the ER due to a loss of consciousness. An ER note, dated 11/17/11 at 11:30 a.m., indicated, "PT (patient) states there is a large, tall gentleman who sneaked into my room at night and fondeled (sic) my neighbor. (Physician's Name) notified." An ER note, dated 11/17/11 at 12:22 p.m., indicated, "Report given to (Nurses Name). RCC (Rensselaer Care Center)..." During an interview on 11/21/11 at 11:30 a.m., LPN #2 indicated after she received report from the ER nurse and was told about the allegation, she reported the allegation to her Unit Manager. During an interview on 11/21/11 at 11:40 a.m., The SCU (Special Care Unit) Manager indicated LPN #2 had reported the allegation to her and she then informed the Administrator and the Director of Nursing (DoN) and notified the physician on call. She indicated she had not charted the allegation in the resident's record because she was not sure she should. During an interview on 11/21/11 at 12:05 p.m., LPN #2 indicated she had received report from the ER nurse at the hospital and the nurse had told her the resident had said there was a tall dark guy who comes in her room and goes over to her roommate and does something under the cover. LPN #2 indicated the ER nurse said the resident pointed toward the private area. LPN #2 indicated there was a tall, male resident on the unit (Resident #D) who wanders into other residents' rooms. LPN #2 indicated Resident #C was Resident #B's roommate. During an interview on 11/21/11 at 12 p.m., the Administrator indicated it was reported to him that someone went into the resident's room at night and checks her private part. He indicated he did not feel it was an allegation of abuse because it was truthful statement, because they do go in and check the resident for incontinency during the night. During an interview on 11/21/11 at 12:40 p.m., the Administrator indicated he had been told about a dark man going into the room but not about the private areas. He indicated he was told the tall dark man was from the hospital. He indicated he is now hearing conflicting statements, and that from what he heard today, he would do an investigation and report the allegation. During an interview on 11/21/11 at 2:50 p.m., the SCU Unit Manager indicated she had reported what the ER nurse had said, that it was a tall dark man and that he touched the resident's private areas. She indicated she told the Social Service Director, and the Social Service Director told the Administrator. She indicated the policy states to notify the Administrator of all allegations. During an interview on 11/21/11 at 2:50 p.m., the ADoN indicated she was told it was some large man that went into the resident's room. She stated, "that is all I can remember." She indicated she thought it was someone from the hospital. A Witness Statement Form, dated 11/21/11 at 12:50 p.m., and signed by LPN#2, indicated, "...a nurse from (hospital name) ER called report to writer on res (resident)...reported that res...told her that a tall dark man comes in her room et goes over to roommate et touches her roommates the nurse said she...made a hand gesture insinuating touching in the peri area...Writer reported it to the Unit Manager." A Witness Statement Form, dated 11/21/11 at 1:50 p.m., and signed by the Social Service Director, indicated, "writer notified on 11/17/11 by Special Care Unit Manager that charge nurse...was informed by nurse at (hospital name) that (resident name) reported a tall dark man had entered res room at night. ED (Executive Director) (Administrator) notified immediately on 11/17/11. On 11/21/11 writer & ED notified by Unit Manager that res. alleged her roommate was touched in peri-area. I was not aware of peri-area allegation until 11/21/11." The investigation, dated 11/21/11, and received from the Administrator, indicated a male CNA had been notified to call the facility and would be placed on suspension until the investigation has been completed. The form indicated the resident had not alleged the male CNA, but he is the only male employee that works midnights on special care and the last day the employee had worked was on 11/08/11. A Witness Statement Form, dated 11/21/11 at 2 p.m., and signed by the SCU Unit Manager, indicated, "...(Resident name) made an allegation that there was a tall dark man that came into their room at night & touched her roomates (sic) private parts...I was told this by the nurse on SCU & I reported this to the ADoN & Social Services." Resident #D was observed on 11/21/11 at 2:45 p.m. wandering independently around the hallway in the SCU. A) Resident #D's record was reviewed on 11/21/11 at 11:25 a.m. Resident #D's [DIAGNOSES REDACTED]. Resident D's nurses' notes indicated: 10/16/11 at 11:03 a.m., "...urinated on floor of co-resd (resident) room..." 10/17/11 at 5 a.m., "Res (Resident) up @ (at) 1:00 a.m. ambulating in hallway..." 10/18/11 8 p.m., "15 min (minute) safety checks continue- res ambulating in halls of SCU most of shift..." 10/20/11 at 9:30 p.m., "...Res continues to exit seek and wander in and out of other res rooms uninvited. Res not easily redirected and is uncooperative @ times." 10/21/11 at 9:45 p.m., "...Res also wanders in and out of other res rooms taking objects..." 10/24/11 at 8:15 p.m., "...15 min checks (indicated by a check mark) continue...ambulates frequently & goes into other res rooms..." 10/27/11 at 9:30 p.m. "...wanders in and out of other res's rooms..." 10/31/11 at 6:45 p.m., "...res ambulates independently throughout unit often wanders into co-res rooms uninvited..." 11/3/11 at 9:45 p.m., "...Res continues to exit seek, wander in/out of other res rooms taking things, and is combative and uncooperative w/ staff..." 11/3/11 2 a.m., "...ambulates independently..." 11/6/11 at 3:50 a.m., "...res continues to remove personal items out of others rooms..." 11/6/11 at 11 p.m., "...res vomited in another res room..." 11/9/11 at 9:50 p.m., "...res continues to ambulate around unit...taking other resident's belonging, and being non-cooperative w/ staff..." 11/10/11 at 5:55 a.m., "...res ambulates independently throughout unit..." 11/10/11 at 10 p.m., "...Res continues to exit seek, take things that don't belong to him..." 11/14/11 at 9:00 p.m., "...Res had also urinated in another resident's trash can in their room." 11/15/11 at 5:30 a.m., "...15 min checks (indicated by a check mark) continue...res OOB (out of bed) most of shift wandering in halls , going into co-res rooms..." 11/15/11 at 7:30 p.m., "...Needs frequent redirection c staying out of other res rooms/belongings..." Resident D's care plans, indicated: A care plan, dated 10/21/11, "...I wander the units...I will often wander unit and go into co-res rooms...." A care plan, dated 11/1/11, "....I void in inappropriate places...trash cans other resident's room..." B) Resident #B's record was reviewed on 11/21/11 at 2:20 p.m. The resident's [DIAGNOSES REDACTED]. Resident #B's Admission/5 day Minimum Data Set Assessment (MDS), dated [DATE] indicated the resident had impaired cognition. Resident #B's Risk worksheet for Abuse, Neglect & Exploitation, dated 11/06/11, indicated the resident was at risk for abuse due to a [DIAGNOSES REDACTED]. C) Resident #C's record was reviewed on 11/21/11 at 2:40 p.m. The resident's [DIAGNOSES REDACTED]. The resident's Quarterly MDS assessment, dated 10/25/11, indicated the resident had a short-term memory problem and was moderately impaired for decision making. The resident's Risk worksheet for Abuse, Neglect & Exploitation, dated 04/22/11, indicated the resident was at risk for abuse due to a [DIAGNOSES REDACTED]. 2. Resident #H's record was reviewed on 11/22/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Admission/5-day Minimum Data Set (MDS) assessment, dated 10/28/11, indicated a cognitive pattern score of 15 (cognition intact), and required extensive assistance of two or more for bed mobility, transfers, and toilet use. A Facility Incident Reporting Form, incident date 11/20/11, and received at the ISDH on 11/21/11, indicated, "(resident name) reported to her nursing assistant that the (sic) she was being treated mean by the day girl (CNA name). She nudges her to use the bathroom instead of the bedside commode, and she is afraid she will fall..." The Witness Statement Forms indicated: 11/20/11 at 5:35 p.m., written and signed by CNA #3, indicated, " Saturday the 19th, (CNA #3 and CNA #4 names) were putting (resident name) to bed from the wheel chair (sic) and when she stood up she wouldn't stand very well, so I had a hold of the gait belt and so did (CNA #4) and (resident name) was standing kinda still in front of the wheel chair (sic) and (CNA #4 name) said stand up or your gonna fall. Kept saying that and then...(CNA #4) let it go (gait belt) and I eased the (resident name) into the wheel chair (sic)." 11/20/11 at 5:35 p.m., written and signed by CNA #5, indicated, "When getting report from (CNA #4) the last two times I've worked...(CNA#4) says we need to make (resident name) walk to the bathroom even if she refuses to. She says that you use the gait belt and stand her up then give her a little push and let go till she start (sic) moving her feet..." 11/22/11 at 3:10 p.m., written and signed by LPN #6, date of incident 11/19/11, time of incident 6-2, "I was not informed of any allegations of abuse with (resident name), from family, resident or staff at any time during my shifts." The Skilled Unit nursing schedules, dated 11/01/11 through 11/22/11, received from the ADoN (Assistant Director of Nursing), indicated CNA #5 had last worked on the Skilled unit on 11/18/11 and 11/20/11. During an interview on 11/22/11 at 2:05 p.m., CNA #5 indicated she had concerns with CNA #4 telling the resident she had to walk even though the resident had refused. She indicated on 11/20/11, when CNA #4 said to give her (resident) a little push, CNA #4 then let go of the resident. CNA #5 indicated she had not told anyone about the incident. She indicated she should have reported CNA #4 was making the resident walk to the bathroom and that she said to give the resident a little push. During an interview on 11/22/11 at 2:30 p.m., CNA #3 indicated CNA #4 kept telling the resident she was going to fall and then CNA #4 let go of the gait belt. She indicated she had told CNA #4 the resident needed to use the bedside commode and CNA #4 said no, she is going to use the bathroom. She indicated when CNA #4 let go of the resident's gait belt, the resident fell back and CNA #3 eased the resident into the wheelchair. CNA #3 indicated she did not report the incident to anyone. She indicated she should have reported the incident on 11/19/11. During an interview on 11/22/11 at 1:43 p.m., the DoN indicated she had not been told about the allegation until 11/20/11. The immediate jeopardy that began on 11/17/11 was removed on 11/23/11 when the facility initiated an investigation of the allegation of abuse, notified the resident's families and physicians, and implemented interventions to prevent potential abuse from occurring. The facility revised the abuse policy to include immediately notifying the Administrator if abuse is seen, heard, and/or suspected. The facility had staff assigned for continuous monitoring of the Special Care Unit to ensure resident safety. All interviewable residents in the facility were interviewed to ensure no outstanding allegations of abuse exist. 140 of 147 staff members were inserviced on the revised abuse policy. 23 employees interviewed were able to explain the revised procedure if they see, hear, and/or suspect abuse. The Administrator was inserviced by the Corporate Regional Vice President, to include the need to immediately investigate all allegations of abuse. Staff will be questioned by the facility for knowledge of the revised abuse policy. Audits were completed by the facility through interviewing alert and oriented residents about care issues and staff were interviewed for their knowledge of the revised abuse policy. The facility will continue to audit staff daily on all shifts for the first week and then monthly with the results of the audit to be forwarded to the performance improvement committee. The resident concerns/grievance log and resident council minutes will be reviewed to ensure immediate investigations of all concerns have been initiated. The audits will be completed weekly by the Administrator and monthly by the Regional/Divisional staff and then forwarded to the performance improvement committee. Noncompliance remained at the lower scope and severity level of pattern no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility has not inserviced all staff, and they will continue to audit staff and residents to ensure the facility abuse policy is followed. This Federal tag relates to Complaint IN 610. 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on observation, record review and interview, the facility failed to follow their abuse prevention policy and procedure by failing to ensure the Administrator was notified immediately of allegations of abuse and failed to investigate and report the allegation of abuse to the Indiana State Department of Health (ISDH), in a timely manner, which resulted in the residents on the unit not being protected from potential further abuse for 2 of 24 residents (Residents #B and #C) who resided on the Special Care Unit and 1 of 15 residents (Resident #H) who resided on the Skilled Unit. This had the potential to affect all 24 residents who reside on the Special Care Unit and 15 residents who reside on the Skilled Unit. The immediate jeopardy began on 11/17/11 when the facility failed to notify the Administrator immediately of the allegation, failed to protect the residents on the Special Care Unit from potential further abuse, and failed to investigate and report the allegation of abuse. The Administrator was notified of the immediate jeopardy on 11/21/11 at 2:10 p.m. The immediate jeopardy was removed on 11/23/11, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. A confidential interview on 11/21/11 indicated Resident #B had said a resident male comes in to the room and, "gropes" Resident #C . The confidential interview indicated the hospital called the facility on 11/17/11 and reported the allegation to the nurse on Resident #B's unit. A hospital emergency room (ER) report, dated 11/17/11, indicated Resident #B (Resident #C's roommate) was in the ER due to a loss of consciousness. An ER note, dated 11/17/11 at 11:30 a.m., indicated, "PT (patient) states there is a large, tall gentleman who sneaked into my room at night and fondeled (sic) my neighbor. (Physician's Name) notified." An ER note, dated 11/17/11 at 12:22 p.m., indicated, "Report given to (Nurses Name). RCC (Rensselaer Care Center)..." During an interview on 11/21/11 at 11:30 a.m., LPN #2 indicated after she received report from the ER nurse and was told about the allegation, she reported the allegation to her Unit Manager. During an interview on 11/21/11 at 11:40 a.m., The SCU (Special Care Unit) Manager indicated LPN #2 had reported the allegation to her and she then informed the Administrator and the Director of Nursing (DoN) and notified the physician on call. She indicated she had not charted the allegation in the resident's record because she was not sure she should. During an interview on 11/21/11 at 12:05 p.m., LPN #2 indicated she had received report from the ER nurse at the hospital and the nurse had told her the resident had said there was a tall dark guy who comes in her room and goes over to her roommate and does something under the cover. LPN #2 indicated the ER nurse said the resident pointed toward the private area. LPN #2 indicated there was a tall, male resident on the unit (Resident #D) who wanders into other residents' rooms. LPN #2 indicated Resident #C was Resident #B's roommate. During an interview on 11/21/11 at 12 p.m., the Administrator indicated it was reported to him that someone went into the resident's room at night and checks her private part. He indicated he did not feel it was an allegation of abuse because it was truthful statement, because they do go in and check the resident for incontinency during the night. During an interview on 11/21/11 at 12:40 p.m., the Administrator indicated he had been told about a dark man going into the room but not about the private areas. He indicated he was told the tall dark man was from the hospital. He indicated he is now hearing conflicting statements, and that from what he heard today, he would do an investigation and report the allegation. During an interview on 11/21/11 at 2:50 p.m., the SCU Unit Manager indicated she had reported what the ER nurse had said, that it was a tall dark man and that he touched the resident's private areas. She indicated she told the Social Service Director, and the Social Service Director told the Administrator. She indicated the policy states to notify the Administrator of all allegations. During an interview on 11/21/11 at 2:50 p.m., the ADoN indicated she was told it was some large man that went into the resident's room. She stated, "that is all I can remember." She indicated she thought it was someone from the hospital. A Witness Statement Form, dated 11/21/11 at 12:50 p.m., and signed by LPN#2, indicated, "...a nurse from (hospital name) ER called report to writer on res (resident)...reported that res...told her that a tall dark man comes in her room et goes over to roommate et touches her roommates the nurse said she...made a hand gesture insinuating touching in the peri area...Writer reported it to the Unit Manager." A Witness Statement Form, dated 11/21/11 at 1:50 p.m., and signed by the Social Service Director, indicated, "writer notified on 11/17/11 by Special Care Unit Manager that charge nurse...was informed by nurse at (hospital name) that (resident name) reported a tall dark man had entered res room at night. ED (Executive Director) (Administrator) notified immediately on 11/17/11. On 11/21/11 writer & ED notified by Unit Manager that res. alleged her roommate was touched in peri-area. I was not aware of peri-area allegation until 11/21/11." The investigation, dated 11/21/11, and received from the Administrator, indicated a male CNA had been notified to call the facility and would be placed on suspension until the investigation has been completed. The form indicated the resident had not alleged the male CNA, but he is the only male employee that works midnights on special care and the last day the employee had worked was on 11/08/11. A Witness Statement Form, dated 11/21/11 at 2 p.m., and signed by the SCU Unit Manager, indicated, "...(Resident name) made an allegation that there was a tall dark man that came into their room at night & touched her roomates (sic) private parts...I was told this by the nurse on SCU & I reported this to the ADoN & Social Services." Resident #D was observed on 11/21/11 at 2:45 p.m. wandering independently around the hallway in the SCU. A) Resident #D's record was reviewed on 11/21/11 at 11:25 a.m. Resident #D's [DIAGNOSES REDACTED]. Resident D's nurses' notes indicated: 10/16/11 at 11:03 a.m., "...urinated on floor of co-resd (resident) room..." 10/17/11 at 5 a.m., "Res (Resident) up @ (at) 1:00 a.m. ambulating in hallway..." 10/18/11 8 p.m., "15 min (minute) safety checks continue- res ambulating in halls of SCU most of shift..." 10/20/11 at 9:30 p.m., "...Res continues to exit seek and wander in and out of other res rooms uninvited. Res not easily redirected and is uncooperative @ times." 10/21/11 at 9:45 p.m., "...Res also wanders in and out of other res rooms taking objects..." 10/24/11 at 8:15 p.m., "...15 min checks (indicated by a check mark) continue...ambulates frequently & goes into other res rooms..." 10/27/11 at 9:30 p.m. "...wanders in and out of other res's rooms..." 10/31/11 at 6:45 p.m., "...res ambulates independently throughout unit often wanders into co-res rooms uninvited..." 11/3/11 at 9:45 p.m., "...Res continues to exit seek, wander in/out of other res rooms taking things, and is combative and uncooperative w/ staff..." 11/3/11 2 a.m., "...ambulates independently..." 11/6/11 at 3:50 a.m., "...res continues to remove personal items out of others rooms..." 11/6/11 at 11 p.m., "...res vomited in another res room..." 11/9/11 at 9:50 p.m., "...res continues to ambulate around unit...taking other resident's belonging, and being non-cooperative w/ staff..." 11/10/11 at 5:55 a.m., "...res ambulates independently throughout unit..." 11/10/11 at 10 p.m., "...Res continues to exit seek, take things that don't belong to him..." 11/14/11 at 9:00 p.m., "...Res had also urinated in another resident's trash can in their room." 11/15/11 at 5:30 a.m., "...15 min checks (indicated by a check mark) continue...res OOB (out of bed) most of shift wandering in halls , going into co-res rooms..." 11/15/11 at 7:30 p.m., "...Needs frequent redirection c staying out of other res rooms/belongings..." Resident D's care plans, indicated: A care plan, dated 10/21/11, "...I wander the units...I will often wander unit and go into co-res rooms...." A care plan, dated 11/1/11, "....I void in inappropriate places...trash cans other resident's room..." B) Resident #B's record was reviewed on 11/21/11 at 2:20 p.m. The resident's [DIAGNOSES REDACTED]. Resident #B's Admission/5 day Minimum Data Set Assessment (MDS), dated [DATE] indicated the resident had impaired cognition. Resident #B's Risk worksheet for Abuse, Neglect & Exploitation, dated 11/06/11, indicated the resident was at risk for abuse due to a [DIAGNOSES REDACTED]. C) Resident #C's record was reviewed on 11/21/11 at 2:40 p.m. The resident's [DIAGNOSES REDACTED]. The resident's Quarterly MDS assessment, dated 10/25/11, indicated the resident had a short-term memory problem and was moderately impaired for decision making. The resident's Risk worksheet for Abuse, Neglect & Exploitation, dated 04/22/11, indicated the resident was at risk for abuse due to a [DIAGNOSES REDACTED]. 2. Resident #H's record was reviewed on 11/22/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Admission/5-day Minimum Data Set (MDS) assessment, dated 10/28/11, indicated a cognitive pattern score of 15 (cognition intact), and required extensive assistance of two or more for bed mobility, transfers, and toilet use. A Facility Incident Reporting Form, incident date 11/20/11, and received at the ISDH on 11/21/11, indicated, "(resident name) reported to her nursing assistant that the (sic) she was being treated mean by the day girl (CNA name). She nudges her to use the bathroom instead of the bedside commode, and she is afraid she will fall..." The Witness Statement Forms indicated: 11/20/11 at 5:35 p.m., written and signed by CNA #3, indicated, " Saturday the 19th, (CNA #3 and CNA #4 names) were putting (resident name) to bed from the wheel chair (sic) and when she stood up she wouldn't stand very well, so I had a hold of the gait belt and so did (CNA #4) and (resident name) was standing kinda still in front of the wheel chair (sic) and (CNA #4 name) said stand up or your gonna fall. Kept saying that and then...(CNA #4) let it go (gait belt) and I eased the (resident name) into the wheel chair (sic)." 11/20/11 at 5:35 p.m., written and signed by CNA #5, indicated, "When getting report from (CNA #4) the last two times I've worked...(CNA#4) says we need to make (resident name) walk to the bathroom even if she refuses to. She says that you use the gait belt and stand her up then give her a little push and let go till she start (sic) moving her feet..." 11/22/11 at 3:10 p.m., written and signed by LPN #6, date of incident 11/19/11, time of incident 6-2, "I was not informed of any allegations of abuse with (resident name), from family, resident or staff at any time during my shifts." The Skilled Unit nursing schedules, dated 11/01/11 through 11/22/11, received from the ADoN (Assistant Director of Nursing), indicated CNA #5 had last worked on the Skilled unit on 11/18/11 and 11/20/11. During an interview on 11/22/11 at 2:05 p.m., CNA #5 indicated she had concerns with CNA #4 telling the resident she had to walk even though the resident had refused. She indicated on 11/20/11, when CNA #4 said to give her (resident) a little push, CNA #4 then let go of the resident. CNA #5 indicated she had not told anyone about the incident. She indicated she should have reported CNA #4 was making the resident walk to the bathroom and that she said to give the resident a little push. During an interview on 11/22/11 at 2:30 p.m., CNA #3 indicated CNA #4 kept telling the resident she was going to fall and then CNA #4 let go of the gait belt. She indicated she had told CNA #4 the resident needed to use the bedside commode and CNA #4 said no, she is going to use the bathroom. She indicated when CNA #4 let go of the resident's gait belt, the resident fell back and CNA #3 eased the resident into the wheelchair. CNA #3 indicated she did not report the incident to anyone. She indicated she should have reported the incident on 11/19/11. During an interview on 11/22/11 at 1:43 p.m., the DoN indicated she had not been told about the allegation until 11/20/11. The facility policy, dated 02/09, received as current from the Administrator and titled, "Protection of residents:reducing the threat of Abuse & Neglect", indicated, "...Reporting Alleged Abuse...3. All alleged...violations...will be promptly reported to the administrator and/or director of nursing...9. The administrator, director of nursing...will complete an investigation of the incident...no later than five (5) working days after the reported occurrence...12. Federal requirements mandate the facilities must ensure all allegations of abuse are reported immediately to their state survey agency...The immediate reports should be submitted as soon as possible, but non later than 24 hours of a facility learning of the allegation...If the accused individual is an employee, they will be placed on suspension pending results of the investigation while the incident is being investigated. if the accused individual is not an employee, the person will be denied unsupervised access to the resident..." The immediate jeopardy that began on 11/17/11 was removed on 11/23/11 when the facility initiated an investigation of the allegation of abuse, notified the resident's families and physicians, and implemented interventions to prevent potential abuse from occurring. The facility revised the abuse policy to include immediately notifying the Administrator if abuse is seen, heard, and/or suspected. The facility had staff assigned for continuous monitoring of the Special Care Unit to ensure resident safety. All interviewable residents in the facility were interviewed to ensure no outstanding allegations of abuse exist. 140 of 147 staff members were inserviced on the revised abuse policy. 23 employees interviewed were able to explain the revised procedure if they see, hear, and/or suspect abuse. The Administrator was inserviced by the Corporate Regional Vice President, to include the need to immediately investigate all allegations of abuse. Staff will be questioned by the facility for knowledge of the revised abuse policy. Audits were completed by the facility through interviewing alert and oriented residents about care issues and staff were interviewed for their knowledge of the revised abuse policy. The facility will continue to audit staff daily on all shifts for the first week and then monthly with the results of the audit to be forwarded to the performance improvement committee. The resident concerns/grievance log and resident council minutes will be reviewed to ensure immediate investigations of all concerns have been initiated. The audits will be completed weekly by the Administrator and monthly by the Regional/Divisional staff and then forwarded to the performance improvement committee. Noncompliance remained at the lower scope and severity level of pattern no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility has not inserviced all staff, and they will continue to audit staff and residents to ensure the facility abuse policy is followed. This Federal tag relates to Complaint IN 610. 3.1-28(a)

Based on observation, record review, and interview, the facility failed to ensure a resident's care was not neglected related to not assisting residents to the bathroom as needed in a timely manner and call lights being turned off and the residents' needs not being met, which resulted in incontinence and tearfulness of a resident (Resident #H). This affected 1 of 9 residents who required assistance with toileting in a sample of 11 (Resident #H), 1 of 8 residents in a supplemental sample of 8 (Resident #R), and 2 of 3 families of residents confidentially interviewed. Findings include: 1) During an interview on 11/21/11 at 9:15 a.m., Resident #H indicated she has to wait long periods of time to get help to the bathroom. She indicated she has been incontinent because she has had to wait so long for help. During the interview, the resident became tearful and upset when talking about having to wait for help to use the bathroom and having some incontinence of urine. During an observation on 11/21/11, at 12:07 p.m., the SDC (Staff Development Coordinator) was passing the noon meal trays. Resident #H's call light was activated and the SDC answered the call the light, and Resident #H indicated she needed to use the bathroom. The SDC informed Resident #H she would go and get some help. The SDC then went back to passing the food trays to the residents on the unit then returned to the Nurses' Desk checking a resident's record. During an observation on 11/21/11 at 12:16 p.m., the SDC was still at the Nurses' Desk. No one had went in to help Resident #H to the bathroom. The SDC then left the unit without getting assistance to help the resident to the bathroom. During an interview on 11/21/11 at 12:20 p.m., Resident #H's family member indicated the resident had asked to go to the bathroom, but no one had come to help her. During an interview on 11/21/11 at 12:25 p.m., Resident #H had indicated she still needed to go to the bathroom and she was feeling very uncomfortable. The call light was reactivated and LPN #7 answered the call light and told the resident she would go and get some help to assist her to the bathroom. During an observation on 11/21/11 at 12:30 p.m., CNA #8 and QMA #9 entered Resident #H's room to assist the resident onto the bedside commode. During an interview on 11/21/11 at 12:45 p.m., the SDC indicated resident #H had wanted assistance to the bathroom when she had answered the resident's call light. The SDC indicated she went and told the CNAs on the unit, the resident needed to use the bathroom. During an interview on 11/21/11 at 12:48 p.m., QMA #9 (working the unit) indicated she was first aware the resident needed to go to the bathroom when LPN #7 came and told her. During an interview on 11/21/11 at 12:50 p.m., CNA #8 (working the unit) indicated she was unaware Resident #H needed to use the bathroom until LPN #7 came and told her. Resident #H's record was reviewed on 11/22/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Admission/5-day Minimum Data Set (MDS) assessment, dated 10/28/11, indicated a cognitive pattern score of 15 (cognition intact), and required extensive assistance of two or more for bed mobility, transfers, and toilet use. The MDS assessment indicated the resident was frequently incontinent. 2) During an interview on 11/21/11 at 11:55 a.m., Resident #R indicated they wait sometimes an hour for his call light to be answered and to be assisted to the bathroom. Resident #R indicated this happens frequently at meal times. Resident #R was identified as alert, oriented, and interviewable by RN #10 during the initial tour on 11/17/11 at 12:20 p.m. Resident #R's record was reviewed on 11/23/11 at 8 a.m. The resident's [DIAGNOSES REDACTED]. The CNA care card indicated the resident required 2 persons to transfer the resident. 3) During a confidential family interview on 11/20/11, a family member indicated during meals all the staff are off the floor, and they will not assist their family member to the bathroom until all the residents are back from the dining room. The family member indicated when their family member rings her call light, the staff will come in to answer it, turn it off and tell their family member they will be back, then it is about 15-20 minutes before anyone will come back into the room. 4) During another confidential family interview on 11/21/11, a family member indicated sometimes their family member waits 15-30 minutes to get help to the bathroom. They indicated the staff will answer the call light, they tell the resident they will go get help, but then the resident waits a long time for the staff to return. The family member indicated this happens a lot, especially during the meal times. 5) During another confidential family interview on 11/21/11, a family member indicated their family member sometimes has to wait an hour to an hour and a half for assistance to the bathroom. The family member indicated they have been told the resident has to wait until the dining room is cleared out before they can assist the resident to the bathroom. This Federal tag relates to Complaint IN 610. 3.1-27(a)(3) 3.1-28(a)

Based on observation, interview, and record review, the facility failed to provide care for residents to enhance the resident's dignity, related to not assisting the residents to the bathroom timely, which resulted in one resident (Resident #H) being incontinent at times and becoming tearful when discussing not being assisted to the bathroom timely as needed, for 1 of 9 residents who required assistance with toileting in a sample of 11 (Resident #H), 1 of 8 residents in a supplemental sample of 8 (Resident #R), and 2 of 3 families of residents confidentially interviewed. Findings include: 1) During an interview on 11/21/11 at 9:15 a.m., Resident #H indicated she has to wait long periods of time to get help to the bathroom. She indicated she has been incontinent because she has had to wait so long for help. During the interview, the resident became tearful and upset when talking about having to wait for help to use the bathroom and having some incontinence of urine. During an observation on 11/21/11, at 12:07 p.m., the SDC (Staff Development Coordinator) was passing the noon meal trays. Resident #H's call light was activated and the SDC answered the call the light, and Resident #H indicated she needed to use the bathroom. The SDC informed Resident #H she would go and get some help. The SDC then went back to passing the food trays to the residents on the unit then returned to the Nurses' Desk checking a resident's record. During an observation on 11/21/11 at 12:16 p.m., the SDC was still at the Nurses' Desk. No one had went in to help Resident #H to the bathroom. The SDC then left the unit without getting assistance to help the resident to the bathroom. During an interview on 11/21/11 at 12:20 p.m., Resident #H's family member indicated the resident had asked to go to the bathroom, but no one had come to help her. During an interview on 11/21/11 at 12:25 p.m., Resident #H had indicated she still needed to go to the bathroom and she was feeling very uncomfortable. The call light was reactivated and LPN #7 answered the call light and told the resident she would go and get some help to assist her to the bathroom. During an observation on 11/21/11 at 12:30 p.m., CNA #8 and QMA #9 entered Resident #H's room to assist the resident onto the bedside commode. During an interview on 11/21/11 at 12:45 p.m., the SDC indicated resident #H had wanted assistance to the bathroom when she had answered the resident's call light. The SDC indicated she went and told the CNAs on the unit, the resident needed to use the bathroom. During an interview on 11/21/11 at 12:48 p.m., QMA #9 (working the unit) indicated she was first aware the resident needed to go to the bathroom when LPN #7 came and told her. During an interview on 11/21/11 at 12:50 p.m., CNA #8 (working the unit) indicated she was unaware Resident #H needed to use the bathroom until LPN #7 came and told her. Resident #H's record was reviewed on 11/22/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Admission/5-day Minimum Data Set (MDS) assessment, dated 10/28/11, indicated a cognitive pattern score of 15 (cognition intact), and required extensive assistance of two or more for bed mobility, transfers, and toilet use. The MDS assessment indicated the resident was frequently incontinent. 2) During an interview on 11/21/11 at 11:55 a.m., Resident #R indicated they wait sometimes an hour for his call light to be answered and to be assisted to the bathroom. Resident #R indicated this happens frequently at meal times. Resident #R was identified as alert, oriented, and interviewable by RN #10 during the initial tour on 11/17/11 at 12:20 p.m. Resident #R's record was reviewed on 11/23/11 at 8 a.m. The resident's [DIAGNOSES REDACTED]. The CNA care card indicated the resident required 2 persons to transfer the resident. 3) During a confidential family interview on 11/20/11, a family member indicated during meals all the staff are off the floor, and they will not assist their family member to the bathroom until all the residents are back from the dining room. The family member indicated when their family member rings her call light, the staff will come in to answer it, turn it off and tell their family member they will be back, then it is about 15-20 minutes before anyone will come back into the room. 4) During another confidential family interview on 11/21/11, a family member indicated sometimes their family member waits 15-30 minutes to get help to the bathroom. They indicated the staff will answer the call light, they tell the resident they will go get help, but then the resident waits a long time for the staff to return. The family member indicated this happens a lot, especially during the meal times. 5) During another confidential family interview on 11/21/11, a family member indicated their family member sometimes has to wait an hour to an hour and a half for assistance to the bathroom. The family member indicated they have been told the resident has to wait until the dining room is cleared out before they can assist the resident to the bathroom. A facility policy, dated 11/90, and received as current from the ADoN, titled, "Call Light, Use of", indicated, "...2. Answer all call lights promptly whether or not you are assigned to the resident...6. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room. 7. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room...." This Federal tag relates to Complaint IN 610. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure residents receive necessary services to maintain good personal hygiene related to call lights not responded to timely or turned off and residents' needs were not met, which resulted in Resident #H to be incontinent and tearful, for 1 of 9 residents who required assistance with toileting in a sample of 11 (Resident #H), 1 of 8 residents in a supplemental sample of 8 (Resident #R), and 2 of 3 families of residents confidentially interviewed. Findings include: 1) During an interview on 11/21/11 at 9:15 a.m., Resident #H indicated she has to wait long periods of time to get help to the bathroom. She indicated she has been incontinent because she has had to wait so long for help. During the interview, the resident became tearful and upset when talking about having to wait for help to use the bathroom and having some incontinence of urine. During an observation on 11/21/11, at 12:07 p.m., the SDC (Staff Development Coordinator) was passing the noon meal trays. Resident #H's call light was activated and the SDC answered the call the light, and Resident #H indicated she needed to use the bathroom. The SDC informed Resident #H she would go and get some help. The SDC then went back to passing the food trays to the residents on the unit then returned to the Nurses' Desk checking a resident's record. During an observation on 11/21/11 at 12:16 p.m., the SDC was still at the Nurses' Desk. No one had went in to help Resident #H to the bathroom. The SDC then left the unit without getting assistance to help the resident to the bathroom. During an interview on 11/21/11 at 12:20 p.m., Resident #H's family member indicated the resident had asked to go to the bathroom, but no one had come to help her. During an interview on 11/21/11 at 12:25 p.m., Resident #H had indicated she still needed to go to the bathroom and she was feeling very uncomfortable. The call light was reactivated and LPN #7 answered the call light and told the resident she would go and get some help to assist her to the bathroom. During an observation on 11/21/11 at 12:30 p.m., CNA #8 and QMA #9 entered Resident #H's room to assist the resident onto the bedside commode. During an interview on 11/21/11 at 12:45 p.m., the SDC indicated resident #H had wanted assistance to the bathroom when she had answered the resident's call light. The SDC indicated she went and told the CNAs on the unit, the resident needed to use the bathroom. During an interview on 11/21/11 at 12:48 p.m., QMA #9 (working the unit) indicated she was first aware the resident needed to go to the bathroom when LPN #7 came and told her. During an interview on 11/21/11 at 12:50 p.m., CNA #8 (working the unit) indicated she was unaware Resident #H needed to use the bathroom until LPN #7 came and told her. Resident #H's record was reviewed on 11/22/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Admission/5-day Minimum Data Set (MDS) assessment, dated 10/28/11, indicated a cognitive pattern score of 15 (cognition intact), and required extensive assistance of two or more for bed mobility, transfers, and toilet use. The MDS assessment indicated the resident was frequently incontinent. 2) During an interview on 11/21/11 at 11:55 a.m., Resident #R indicated they wait sometimes an hour for his call light to be answered and to be assisted to the bathroom. Resident #R indicated this happens frequently at meal times. Resident #R was identified as alert, oriented, and interviewable by RN #10 during the initial tour on 11/17/11 at 12:20 p.m. Resident #R's record was reviewed on 11/23/11 at 8 a.m. The resident's [DIAGNOSES REDACTED]. The CNA care card indicated the resident required 2 persons to transfer the resident. 3) During a confidential family interview on 11/20/11, a family member indicated during meals all the staff are off the floor, and they will not assist their family member to the bathroom until all the residents are back from the dining room. The family member indicated when their family member rings her call light, the staff will come in to answer it, turn it off and tell their family member they will be back, then it is about 15-20 minutes before anyone will come back into the room. 4) During another confidential family interview on 11/21/11, a family member indicated sometimes their family member waits 15-30 minutes to get help to the bathroom. They indicated the staff will answer the call light, they tell the resident they will go get help, but then the resident waits a long time for the staff to return. The family member indicated this happens a lot, especially during the meal times. 5) During another confidential family interview on 11/21/11, a family member indicated their family member sometimes has to wait an hour to an hour and a half for assistance to the bathroom. The family member indicated they have been told the resident has to wait until the dining room is cleared out before they can assist the resident to the bathroom. A facility policy, dated 11/90, and received as current from the ADoN, titled, "Call Light, Use of", indicated, "...2. Answer all call lights promptly whether or not you are assigned to the resident...6. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room. 7. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room...." This Federal tag relates to Complaint IN 610. 3.1-38(a)(2)(C)

Based on record review and interview, the facility failed to ensure the residents received adequate supervision and assistance to prevent accidents, related to transferring a resident with a mechanical lift (Hoyer) with assistance of only one staff member, which resulted in the resident falling from the sling, hitting her head, and received staples to the back of her head (Resident #J), failed to ensure safety alarms were on, secure and functioning (Resident #K and #S) and failed to ensure the safety of a confused resident who gained access to a pot of hot coffee in a locked nutritional pantry (Resident #D), for 3 of 11 residents reviewed for accident and hazards in a sample of 11 (Residents #D, #J, and #K) and 1 resident in a supplemental sample of 8 (Resident #S). Findings include: 1. During the initial tour of the facility on 11/17/11 at 11:55 a.m. with the Assistant Director of Nursing (ADoN), the ADoN indicated resident #J had fallen from the mechanical lift and received a laceration of the head. The ADoN indicated a CNA had transferred the resident with the Hoyer without having help from another staff member. Resident #J's record was reviewed on 11/22/11 at 8:40 a.m. The resident's [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 10/25/11, indicated the resident had short and long term memory problems, and required extensive assistance of two or more staff for bed mobility and toilet use. The MDS assessment indicated transfers from surface to surface occurred only once or twice and required assistance of two or more staff members, and the resident's range of motion was impaired on both sides of the body. The CNA Care Guide, dated 11/21/11, indicated the resident required two people to assist with transfers with the Hoyer. A physician's orders [REDACTED]. A care plan, dated 11/08/11, indicated the resident was a risk for falls due to poor trunk control. The interventions included to transfer with two assistants and the Hoyer lift. A, "Facility Incident Reporting Form", dated 11/08/11, indicated, "...Employee was transfering (sic) a resident out of bed with a Hoyer lift when the resident slipped off the pad. Resident went down to floor and hit head on hoyer bar..." A hospital emergency room report, dated 11/08/11, indicated the resident received six staples to the back of her head. An employee termination form, dated 11/09/11, indicated the CNA had been terminated for transferring the resident with the Hoyer lift and only one staff member assisting. A professional resource, titled, "Indiana State Department of Health Division of Long Term Care Nurse Aide Training Program July 1998", Topic 22: Transferring, indicated, "...4. A mechanical lift...have at least one co-worker assist when using a mechanical lift..." 2. Resident #S's record was reviewed on 11/29/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Quarterly MDS assessment, dated 08/09/11, indicated the resident required extensive assistance by two or more staff for bed mobility and had one prior fall without injury since the last assessment had been done. A care plan, dated 12/20/10 and revised 11/28/11, indicated the resident was a risk for falls. The interventions included, (07/10/11) clip alarm while in bed for resident safety. The resident's CNA care guide, dated 11/29/11, indicated the resident required two plus assistance for toileting and was totally dependent for transfers. A Nurses' Note, dated 11/25/11 at 5:45 a.m., indicated, "writer walking down the hall, noticed from hallway that res (resident) was sitting on floor on landing strip on (L) (left) side of bed, clip alarm was on res et (and) alarm box in res bed was not sounding..." A Nurses' Note, dated 11/25/11 at 8:30 a.m., indicated the resident had been changed for incontinence about 30 minutes prior to being found on floor. During an interview on 11/29/11 at 10:10 a.m., LPN #15 indicated the residents who are on an air mattress need to have the clip alarm box securely attached to the bed or the alarm box will slide with the resident. She indicated the alarm box was not attached to the bed, and was laying on the bed when the resident fell from the bed and the alarm had not activated. She indicated the alarm could have been knocked off, but at the time of the fall, the alarm box was not secure. During an interview on 11/29/11 at 11:15 a.m., the Director of Nursing indicated she worked 11/25/11 during the night. She indicated she had just checked and changed the resident and turned her prior to the fall. 3. Resident K's record was reviewed on 11/22/11 at 8:45 a.m. Resident K's [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 10/12/11, indicated the resident was cognitively impaired and required assistance of one to two staff for transfers and ambulation. A fall risk assessment, dated 10/12/11, indicated the resident had a total score of 20. The form indicated a score of 10 or higher is at risk for falls. A care plan, dated 3/11/11 and updated 7/24/11, indicated "I have unsteady gait/balance at times...I am at risk for falls. 7/24/11 I had an unattended fall while self transferring....Approaches...Sensory pad alarm to bed 7/24/11..." The resident's nurses' notes, dated 11/2/11 at 6:10 a.m., indicated "Sound heard from Nurse's Station upon investigation resd (resident) observed on floor c (with) walker flipped over. Resd laying supine...Bed pressure alarm on but not functioning. Alarm immediately replaced...no injuries noted..." Review of the resident's CNA care guide, dated 11/29/11, indicated the resident had a sensory alarm to her bed. The resident's physician's orders [REDACTED]. The resident's treatment administration record, dated 11/11, lacked documentation of the bed alarm or of checking to ensure functioning. During an interview on 11/29/11 at 8:55 a.m., LPN #11 indicated the resident had a bed alarm. She indicated there was usually an order for [REDACTED]. She indicated the resident did not have an order and it was not on the resident's TAR to check to ensure the alarm was functioning. She indicated the alarm should have been functioning when the resident fell on [DATE]. 4. Resident D's record was reviewed on 11/21/11 at 11:25 a.m. Resident D's [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 10/13/11, indicated resident D was cognitively impaired, and had exhibited physical behavioral symptoms one to three days and had put others at significant risk for physical injury. A care plan, dated 10/21/11 and updated 11/15/11, indicated "I have dx (diagnosis) of dementia and I can become agitated at times r/t (related to) my dementia and confusion. I can become easily frustrated and become uncooperative and combative towards staff..." A nurses' note, dated 10/17/11 at 9:30 p.m., indicated "Res (resident) alert walking around halls of SCU (Special Care Unit). Remains on 15 min (minute) checks (indicated by a check mark) for behaviors ...Somehow, res was able to figure out how to get into the SCU's locked kitchenette. Res was found by staff walking out of DR (dining room) and into hallway w\ (with) a hot pot of coffee. Three staff members were required to get the hot pot of coffee out of res hands. No one was injured, however, res was very uncooperative and combative towards staff during this time..." A social service progress note, dated 10/18/11, indicated "on 10/14/11 res was exit seeking and was uncooperative c (with) staff & combative toward staff. Res continues to urinate in inappropriate places...Res was able to get into kitchenette and had a pot of coffee. Staff was able to remove it, but he remained very uncooperative & combative towards staff. Res continues on 15 min checks." The resident's care plans, dated 10/10/11 and updated 11/15/11, lacked documentation to indicate any interventions had been put into place to prevent the resident from entering the locked kitchenette. During an interview on 11/22/11 at 8:42 a.m., the Maintenance Director indicated the last time the code on the door to the special care unit's kitchenette had been changed was at least a year ago. During an interview on 11/22/11 at 9:50 a.m., the SCU Manager indicated the resident had gotten into the kitchenette but it had not happened again since then. She indicated the staff were monitoring him and he was on 15 minute checks. She indicated the resident went everywhere and walks constantly. During an interview on 11/22/11 at 10 a.m., the SCU Manager indicated she was unable to find where they had done anything to keep the resident out of the kitchenette. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure there was sufficient staff to provide assistance with eating in a timely manner to prevent the resident's food from becoming cold for 6 residents who received rooms trays on the skilled unit and 14 residents who received room trays on the core unit for 2 of 3 units in the facility. The facility also failed to provide care as indicated on the CNA Care Guide, and toilet residents in a timely manner, which resulted in a resident having incontinent episodes, for 1 of 9 residents who required assistance with toileting in a sample of 11 (Resident #H) and 2 residents in a supplemental sample of 8 (Resident #R and #S), and 2 of 3 residents whose families were confidentially interviewed. Findings include: 1) During an interview on 11/21/11 at 9:15 a.m., Resident #H indicated she has to wait long periods of time to get help to the bathroom. She indicated she has been incontinent because she has had to wait so long for help. During the interview, the resident became tearful and upset when talking about having to wait for help to use the bathroom and having some incontinence of urine. During an observation on 11/21/11, at 12:07 p.m., the SDC (Staff Development Coordinator) was passing the noon meal trays. Resident #H's call light was activated and the SDC answered the call the light, and Resident #H indicated she needed to use the bathroom. The SDC informed Resident #H she would go and get some help. The SDC then went back to passing the food trays to the residents on the unit then returned to the Nurses' Desk checking a resident's record. During an observation on 11/21/11 at 12:16 p.m., the SDC was still at the Nurses' Desk. No one had went in to help Resident #H to the bathroom. The SDC then left the unit without getting assistance to help the resident to the bathroom. During an interview on 11/21/11 at 12:20 p.m., Resident #H's family member indicated the resident had asked to go to the bathroom, but no one had come to help her. During an interview on 11/21/11 at 12:25 p.m., Resident #H had indicated she still needed to go to the bathroom and she was feeling very uncomfortable. The call light was reactivated and LPN #7 answered the call light and told the resident she would go and get some help to assist her to the bathroom. During an observation on 11/21/11 at 12:30 p.m., CNA #8 and QMA #9 entered Resident #H's room to assist the resident onto the bedside commode. During an interview on 11/21/11 at 12:45 p.m., the SDC indicated resident #H had wanted assistance to the bathroom when she had answered the resident's call light. The SDC indicated she went and told the CNAs on the unit, the resident needed to use the bathroom. During an interview on 11/21/11 at 12:48 p.m., QMA #9 (working the unit) indicated she was first aware the resident needed to go to the bathroom when LPN #7 came and told her. During an interview on 11/21/11 at 12:50 p.m., CNA #8 (working the unit) indicated she was unaware Resident #H needed to use the bathroom until LPN #7 came and told her. Resident #H's record was reviewed on 11/22/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Admission/5-day Minimum Data Set (MDS) assessment, dated 10/28/11, indicated a cognitive pattern score of 15 (cognition intact), and required extensive assistance of two or more for bed mobility, transfers, and toilet use. The MDS assessment indicated the resident was frequently incontinent. 2) During an interview on 11/21/11 at 11:55 a.m., Resident #R indicated they wait sometimes an hour for his call light to be answered and to be assisted to the bathroom. Resident #R indicated this happens frequently at meal times. Resident #R was identified as alert, oriented, and interviewable by RN #10 during the initial tour on 11/17/11 at 12:20 p.m. Resident #R's record was reviewed on 11/23/11 at 8 a.m. The resident's [DIAGNOSES REDACTED]. The CNA care card indicated the resident required 2 persons to transfer the resident. 3) During a confidential family interview on 11/20/11, a family member indicated during meals all the staff are off the floor, and they will not assist their family member to the bathroom until all the residents are back from the dining room. The family member indicated when their family member rings her call light, the staff will come in to answer it, turn it off and tell their family member they will be back, then it is about 15-20 minutes before anyone will come back into the room. 4) During another confidential family interview on 11/21/11, a family member indicated sometimes their family member waits 15-30 minutes to get help to the bathroom. They indicated the staff will answer the call light, they tell the resident they will go get help, but then the resident waits a long time for the staff to return. The family member indicated this happens a lot, especially during the meal times. 5) During another confidential family interview on 11/21/11, a family member indicated their family member sometimes has to wait an hour to an hour and a half for assistance to the bathroom. The family member indicated they have been told the resident has to wait until the dining room is cleared out before they can assist the resident to the bathroom. 6) During a confidential interview on 11/21/11, they indicated there was not enough staff to serve the resident's meals. They indicated the resident's trays had to sit up to an hour and a half before they were served. They indicated there was only one staff member left on the hall to feed the residents and if someone had to use the bathroom who needed more than one person to assist them they had to wait until someone came back from the dining room when the meal was over or until they could find someone to assist them. They indicated the residents were incontinent more now because of not having enough staff to toilet the residents. They indicated the residents were not being laid down after meals because there was not enough time to get everyone laid down. 7) The noon meal food cart, which contained room trays for the core unit, was observed on 11/21/11 at 12:10 p.m., sitting on the south hall. CNA #13 was observed taking the food cart from the south hall to the west hall on 11/21/11 at 12:14 p.m. CNA #13 indicated she had already served south hall and the food trays which were left to be served were on the east and west halls. LPN #10 and RN #14 were observed serving room trays on the west hall on 11/21/11 at 12:15 p.m. On 11/21/11 at 12:24 p.m., there were still 2 trays observed in the food cart on the west unit. During a confidential staff interview on 11/21/11, they indicated there was not enough staff to get the residents fed timely. They indicated there were three residents who had to be fed and one resident takes an hour to feed. They indicated the resident who takes an hour has to wait until the other two residents were fed before they could even begin to feed her. They indicated the food was usually not to warm by the time the trays were passed. The last tray was observed to be served on the west hall on 11/21/11 at 12:30 p.m. The test tray temperatures were taken with the Dietary Manager on 11/21/11 at 12:30 p.m.: the fish was 93.7 degrees, spinach was 97.7 degrees, potatoes were 94 degrees and the milk was 52.7 degrees. The fish and spinach were cold to the taste. The potatoes were cold and rubbery and the milk was barely cold. During an interview on 11/21/11 at 12:37 p.m.,, the Dietary Manager indicated the cart came out of the kitchen at 11:55 a.m. The kitchen "Food Temperature Log" for the noon meal on 11/21/11, indicated the fish had been 211 degrees, spinach was 181 degrees and the potatoes were 181 degrees, and the milk was 37 degrees when they were served in the kitchen. 8) During an interview on 11/23/11 at 10:18 a.m., the DoN (Director of Nurses) indicated there were two food carts delivered on the halls. She indicated if the staff were not ready to feed the resident, their tray would go back to the kitchen because the staff were feeding someone else. They wouldn't want the resident's food to get cold so it would go back to the kitchen. She indicated there were 2 staff on the hall to feed the residents, one nurse and one CNA. She indicated if there were three residents who needed to be fed, then one resident's meal would go back to the kitchen to stay hot because the other staff have to be in the dining room to assist with meals. 9) During a confidential family interview on 11/20/11, the family member indicated when the family member eats meals in the room, the food is cold. 10) During a confidential resident interview on 11/21/11, the resident indicated the food is always cold when it is served in the room. The resident indicated the staff were not asked to warm up the food because when they were asked, it took them 30 minutes to bring the food back to the resident. 11) During an observation on 11/21/11 at 12 p.m., the SDC (Staff Development Coordinator) was passing noon meal trays on the Skilled Unit. QMA #9 was feeding a resident in their room, while the SDC was passing trays to other residents on the unit. The resident's noon meal trays were completely passed at 12:15 p.m. The test tray on the food cart included fish, spinach, scalloped potatoes, corn bread, milk, and blueberry pie. Upon tasting and obtaining temperatures of the test tray, the spinach was luke warm at 115.3 degrees, the fish was cool at 103.9 degrees, the potatoes were cool at 115 degrees, the corn bread was cool and the milk was warm at 51.3 degrees. 12) Resident #S's record was reviewed on 11/29/11 at 9:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident's Quarterly MDS assessment, dated 08/09/11, indicated the resident required extensive assistance by two or more staff for bed mobility. The resident's CNA care guide, indicated the resident required two plus assistance for toileting and was totally dependent for transfers. During an interview on 11/29/11 at 10:10 a.m., LPN #15 indicated the Director of Nursing came in to work as a CNA on 11/25/11 night shift due to a call off. A Nurses' Note, dated 11/25/11 at 8:30 a.m., indicated the resident had been changed for incontinence about 30 minutes prior to being found on floor. During an interview on 11/29/11 at 11:15 a.m., the Director of Nursing indicated she worked 11/25/11 during the night. She indicated she had just checked and changed the resident and turned her prior to the fall. She indicated she had provided the care to the resident by herself. The facility schedules from 11/23/11 through 11/28/11, received from the Assistant Director of Nursing as correct, indicated on the core unit, there were two nurses and two CNAs scheduled for the Core Unit (East, South, and West Hall) on the 10 p.m. to 6 a.m. shift on November 23, 24, 27, and 28, 2011. The Schedules indicated there were two additional staff members scheduled for the Special Care and Skilled Units on November 23,24, 27, and 28. The CNA Care Guides, received from the Unit Manager and the Director of Nursing as current, dated 11/29/11, indicated there are a total of 67 residents on the Core Unit, and 37 residents required two or more assistance with toileting and 27 residents required assistance of one person for toileting, which leaves three residents who need set-up for toileting. This Federal tag relates to Complaint IN 610. 3.1-17(a)

Based on record review and interview, the facility failed to provide interventions to prevent the development of pressure ulcers and failed to obtain and clarify physician orders [REDACTED]. This affected 1 of 5 residents reviewed with orthotic devices in a sample of 11. (Resident #G) Findings include: The record for Resident #G was reviewed on 12/6/10 at 1:50 p.m. The resident's [DIAGNOSES REDACTED]. A physician order [REDACTED]. Review of the physical therapy notes, dated 11/15/10, indicated advised for ankle foot contracture orthosis and knee contracture to reduce the contracture and prevent the deformity. A physician order, dated 11/15/10 at 1:55 p.m., indicated physician therapy clarification order: physical therapy to treat the patient for 5 times a week times 4 weeks for orthotic, bed mobility, stretching of bilateral lower extremities and positioning and passive range of motion and active range of motion of bilateral lower extremities. A physical therapy note, dated 11/17/10, indicated ankle foot contracture boot was applied to patient to reduce the calf muscle contracture and prevent stiffness. A nursing note, dated 11/17/10 at 1:00 p.m., indicated the resident's sister called and was updated on the resident's condition and new splint for legs. A nursing note, dated 11/19/10 1:30 p.m., indicated awaiting leg braces for contractures. A physical therapy note, dated 11/24/10, indicated Patient received orthosis for left knee contracture. A nursing note, dated 11/25/10 at 5:00 a.m., indicated the resident was tolerating braces well. no signs or symptoms of increased pain or discomfort. A nursing note, dated 11/27/10 at 4:00 a.m., indicated no signs or symptoms of increased pain, seemed to be adjusting to splints well. At 9:20 a.m., bilateral low extremity splints in place. No signs of symptoms pain or discomfort. A nursing note, dated 11/28/10 at 9:00 a.m., indicated upon removing multi podus boots for shower and skin check a 6 cm (centimeter) by 5 cm un-stageable (full thickness tissue loss) area, eschar (thick, leathery necrotic or devitalized tissue, frequently black or brown) area to the bottom outer aspect of the right foot. The right foot was red and warm to touch around the eschar area. There were three Stage I (intact skin with nonblanchable redness of localized area) noted to the top of foot measuring 8 cm by 3 cm, 4 cm by 1 cm, and 2.5 cm by 0.5 cm. The Director of Nursing (DoN) and resident's sister were informed. The on call physician was notified and a new order was received for Keflex. At 10:00 p.m., the resident's foot was open to air and elevated off of the bed with a pillow between feet. A physician order, dated 11/28/10 at 10:00 a.m., indicated a diagnosis/problem of right foot [MEDICAL CONDITION] and an order for [REDACTED]. A physician order, dated 11/28/10 at 10:00 a.m., indicated a diagnosis/problem of right foot ulcer and an order to leave open to air, notify primary physician in the morning. A nursing note, dated 11/29/10 at 1:15 a.m., indicated no adverse reaction of Keflex antibiotic for right foot ulcer. The right foot ulcer remained open to air. The area surrounding the ulcer to the bottom outer eschar area was red and warm. The top of the resident's foot remains red and slightly [MEDICAL CONDITION]. The right leg was elevated off of the bed and pillows remain between feet. At 10:10 a.m., the resident's primary physician was notified. An entry with no time, indicated the primary physician was in to see the resident and would like the resident directly admitted to the hospital to treat and evaluate the wound. A physician order [REDACTED]. Physical therapy clarification: add to plan of care; left knee brace to address developing knee flexion contracture; wear schedule to increase to six hours/shift; release and check skin integrity every two hours. A physician order, dated 11/29/10 at 12:00 p.m., indicated a diagnosis/problem of right foot ulcer and direct admit to the hospital. Review of the therapy notes indicated the resident was seen by the therapist on 11/15, 11/16, 11/17, 11/18, 11/19, 11/22, 11/23, 11/24, 11/26, and 11/27/10. Review of the weekly skin integrity data collection sheets indicated the resident had skin checks on 11/17, 11/24, and 11/28/10. Review of the reportable incident with investigation on 12/7/10 at 11:00 a.m., indicated on 11/28/10 an un-stageable wound was found on the right foot of Resident #G measuring 6 cm by 5 cm. The physician and family were notified immediately. The top of the right foot was red. The resident was assessed for pain and signs and symptoms of infection. The resident was sent to the hospital with anticipated return to the facility. An Incident Follow-up and Recommendation form indicated the incident took place on 11/28/10. CNA found a black area to the resident's right foot. The resident had multi podus boot in place. The boots were removed and the heel was evaluated. An order was received to the leave the area open to air and Keflex was initiated. The resident was sent to the hospital for IV (intravenous) antibiotics. Provided in the investigation of the incident was a hospital note, dated 12/4/10, which indicated, "Pressure sores and wounds are under control. The patient's wound care is continued." Provided in the investigation of the incident was a hospital note, dated 12/5/10, which indicated, the resident was other wise doing well except for a right PICC (peripheral intravenous catheter) which was causing swelling of the hand. The line was to be removed. The resident seemed to be stabilizing. "Wound care seems to be improving." A written interview with the physical therapist via telephone, dated 11/28/10 at 11:16 a.m., was included in the investigation of the reportable incident. The interview indicated that he removed the bilateral ankle contracture boots for each therapy session; however he stated, "I don't remove her socks." He did not see any wounds on her feet secondary to foot coverage (socks). A written interview with the physical therapist, dated 11/28/10 at 11:22 a.m., was included in the investigation of the reportable incident. The interview indicated when asked why an orthotic clarification order was not written he responded sadly, "I just forgot." A corrective action form, dated 11/30/10, for the physical therapist indicated description of event: "A physician's orders [REDACTED]." Consequence to the facility : Resident with an unstable area with scare measuring 6 cm by 5 cm to the bottom outer aspect of the right foot. and Stage I areas to top of foot measuring 8 cm by 3 cm, 4 cm by 1 cm and 2.5 cm by 0.5 cm. The resident was sent to the hospital. Interview with the Regional Rehabilitation Director on 12/6/10 at 2:15 p.m., indicated Resident #G had been wearing multi podus boots. Her wounds were found on 11/28/10 during her shower. She had been seen by the therapist on 11/27/10 and he had removed her boots but did not remove her socks. There resident had been evaluated by the physical therapist on 11/15/10. It was initially thought the resident would receive the multi podus boots on 11/16/10, however the therapist did not place the boots on the resident until 11/17/10. Interview with LPN on 12/7/10 at 7:35 a.m., indicated the Resident #G had skin checks on Wednesdays and Sundays. The LPN also indicated she had done the skin check on 11/24/10 and the resident did not have on any boots or socks and there were no areas noted to the resident's feet. She also indicated later that day she saw the boots and that was the first time she had noticed them. She asked the CNA if she had removed the boots and the CNA indicated "no." She further indicated she knew the resident was to get the boots due to a therapy evaluation. She did not work again for a few days. She indicated she was the nurse who observed the wounds to the resident's foot. She also indicated she had seen the therapist putting the boots on the resident. She further indicated she did not know if there was an order for [REDACTED]. Interview with the Administrator, Social Service, DoN, and Nurse Consultant on 12/7/10 at 11:35 a.m., indicated there was indicated the resident had skin checks on 11/24/10 and 11/25/10 with no open areas. It was also indicated that the only order for the multi podus boots was one indicated orthotic. There was no order for when the resident was to wear the boots, how long or for skin checks. Interview with the Rehabilitation Service Manager on 12/7/10 at 12:00 p.m., indicated she was not sure but she believes the resident received the multi podus boots and the left knee brace on the same day, 11/17/10. She also indicated there was no order written for the multi podus boots. There was an order for [REDACTED]. This Federal tag relates to Complaint IN 016. 3.1-40(a)(1)