Every finding on record at River Bend Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to notify the physician of a change of health condition for 1 of 3 residents reviewed. The physician was not notified of new skin impairment. (Resident D) Finding includes: On 6/30/26 at 10:52 a.m., Resident D was interviewed and indicated he had skin impairment to his bottom.On 6/30/26 at 1:11 p.m., Resident D's clinical record was reviewed. Diagnoses included but were not limited to, hypertension, tobacco use, morbid (severe) obesity due to excess calories, localized edema, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified atherosclerosis of native arteries of extremities, bilateral legs, peripheral vascular disease, unspecified, type 2 diabetes, chronic diastolic (congestive) heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident D's cognition was intact. Care plans were reviewed and included but were not limited to:The resident is at risk for pressure ulcers due to weakness, hx (history) of CVA (cerebrovascular accident) date initiated 8/6/19, revision 2/20/20, target date 10/3/26. Interventions included but were not limited to: perform weekly skin checks and document, inform resident/MD/family/caregivers of any new aea of skin breakdown, date initiated 8/6/19. Actual/potential for skin integrity impairment r/t (related to) chronic progressive disease, friction, lack of sensation, mobility deficit, obesity, date initiated 7/1/21, revision 2/2/22, target date 7/4/26. Interventions included but were not limited to: Monitor and report any reddened areas to MD (medical doctor), Document on flow sheet: if skin is intact, mark Y. If skin is reddened or has open areas, mark N. Report any new openings to Registered staff, date initiated 7/1/21. Orders were reviewed and included but were not limited to: Weekly skin assessment every night shift every Tues, order date 5/27/26. Triad hydrophilic wound dress external paste (wound dressing) apply to bilateral buttocks topically every shift for MASD (moisture associated skin damage) cleanse with wound cleanser, pat dry, apply paste and leave open to air, order date 1/22/26. Triad hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically as needed for soilage. Cleanse with wound cleanser, pat dry, apply triad paste and leave open to air, order date 1/22/26. Weekly skin assessment forms were reviewed from 3/12/26- 7/1/26. 3/12/26 - Skin condition: open area, pre- existing. Site: coccyx. Description: Pre existing open area to sacrum, tx (treatment) q (every) shift with Triad , wound NP (Nurse Practitioner) follows weekly. 4/3/26- Skin condition: open area. Other: pre- existing open area to sacrum, tx q shift with Triad, wound NP follows weekly.6/1/26- Skin condition: Dry, pre-existing , redness. Other: Reddened areas to buttocks, treatment in place. No open areas at this time. 6/3/26- Skin condition: Skin intact, pre-existing redness. Other: buttocks with treatment in place. 6/5/26- Other: Has pre-existing shallow open areas to buttocks that already have treatments ordered, otherwise no new areas noted. 6/10/26- Skin condition: Pre-existing open area. Other: Small areas to buttocks with tx in place and is effective. Pt (patient) denies pain to areas. Site: Right buttock- small area, Left buttock- small area.6/24/26- Skin condition: Redness. Other: L (left) thumb next to nail has pus filled pocket. Seen by NP today, topical et, oral antibiotics ordered. 7/1/26-Other: L. thumb, continues oral and topical ABT(antibiotics) as ordered. The form did not document the skin impairment observed to the bilateral buttocks and coccyx on 7/1/26 at 1:20 p.m. The above dates were the only skin assessment forms in the clinical record from 3/12/26- 7/1/26. The TAR (Treatment Administration Record) was initialed for weekly skin assessments completed. A wound NP skin assessment form with a visit date of 3/10/26 at 10:00 a.m., was reviewed and included but was not limited to the following: Wound #1 - Upon examination, the Right buttock MASD shows complete epithelialization with no signs of infection or inflammation. Healing is complete, and the wound is now fully closed. Education/Plan: Education provided to: nursing staff, patient.A progress note dated 3/10/26 at 11: 31 a.m. indicated Resident was seen by wound care NP [name] n(sic) 3-10-26, wound #1 right buttock shows complete epithelialization with no signs of infection or inflammation. Healing is complete, wound is fully closed. On 7/1/26 at 10:56 a.m., the DON indicated the wound NP comes in once a week on Thursdays, the last date Resident D was seen was on 3/10/26 and the NP indicated his skin was healed. If a new skin area is found by staff it is reported to the DON, area is measured, it is reported to the wound NP and the regular NP, the DON should have been told by staff of any open areas to Resident D's skin. On 7/1/26 at 1:17 p.m., the DON indicated the only forms found for weekly skin assessments were what was in the clinical record, forms should be filled out weekly for skin assessments. At 1:20 p.m., the DON was observed to measure Resident D's skin areas to his buttocks and coccyx. The DON indicated the following for the assessment: Left buttock: L(length) 4 cm(centimeter) x W (width) 4 cm, red area , not open Right buttock: L 5.5 cm x W 5.4 cm, red area, open area in center L 1 cm x W .5 cm. Coccyx: circular red area 4 cm x 3 cm. Reddened area above circular area to coccyx: L 3 cm x W 4.5 am.On 7/1/26 at 2:07 p.m., RN 2 indicated the nurse does weekly skin assessments, are supposed to document findings on a form in PCC (Point Click Care), put initials on the MAR (Medication Administration Form). If a new open area is found measurements are taken, the DON, doctor, and family are notified. If a new order is given it is put in the orders. On 7/1/26 at 2:25 p.m., the Administrator provided the current policy on notification of changes with a revision date of 2025. The policy included but was not limited to: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .3.Circumstances that require a need to alter treatment. This may include: a. New treatment, b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition .a. The facility must still contact the resident's physician and notify resident's representative, if known .This citation relates to Intake 3027544 and 3006524. 410 IAC (Indiana Administrative Code) 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records; skin assessment forms were not documented weekly in the clinical record, did not include all of the current skin impairments for 1 of 3 residents reviewed for nursing services. (Resident D) Finding includes: On 6/30/26 at 10:52 a.m., Resident D was interviewed and indicated he had skin impairment to his bottom.On 6/30/26 at 1:11 p.m., Resident D's clinical record was reviewed. Diagnoses included but were not limited to, hypertension, tobacco use, morbid (severe) obesity due to excess calories, localized edema, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified atherosclerosis of native arteries of extremities, bilateral legs, peripheral vascular disease, unspecified, type 2 diabetes, chronic diastolic (congestive) heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident D's cognition was intact. Care plans were reviewed and included but were not limited to:The resident is at risk for pressure ulcers due to weakness, hx (history) of CVA (cerebrovascular accident) date initiated 8/6/19, revision 2/20/20, target date 10/3/26. Interventions included but were not limited to: perform weekly skin checks and document, inform resident/MD/family/caregivers of any new aea of skin breakdown, date initiated 8/6/19. Actual/potential for skin integrity impairment r/t (related to) chronic progressive disease, friction, lack of sensation, mobility deficit, obesity, date initiated 7/1/21, revision 2/2/22, target date 7/4/26. Interventions included but were not limited to: Monitor and report any reddened areas to MD (medical doctor), Document on flow sheet: if skin is intact, mark Y. If skin is reddened or has open areas, mark N. Report any new openings to Registered staff, date initiated 7/1/21. Orders were reviewed and included but were not limited to: Weekly skin assessment every night shift every Tues, order date 5/27/26. Triad hydrophilic wound dress external paste (wound dressing) apply to bilateral buttocks topically every shift for MASD (moisture associated skin damage) cleanse with wound cleanser, pat dry, apply paste and leave open to air, order date 1/22/26. Triad hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically as needed for soilage. Cleanse with wound cleanser, pat dry, apply triad paste and leave open to air, order date 1/22/26. Weekly skin assessment forms were reviewed from 3/12/26 - 7/1/26.3/12/26 - Skin condition: open area, pre- existing. Site: coccyx. Description: Pre existing open area to sacrum, tx (treatment) q (every) shift with Triad , wound NP (Nurse Practitioner) follows weekly. 4/3/26- Skin condition: open area. Other: pre- existing open area to sacrum, tx q shift with Triad, wound NP follows weekly.6/1/26- Skin condition: Dry, pre-existing , redness. Other: Reddened areas to buttocks, treatment in place. No open areas at this time. 6/3/26- Skin condition: Skin intact, pre-existing redness. Other: buttocks with treatment in place. 6/5/26- Other: Has pre-existing shallow open areas to buttocks that already have treatments ordered,otherwise no new areas noted. 6/10/26- Skin condition: Pre-existing open area. Other: Small areas to buttocks with tx in place and is effective. Pt (patient) denies pain to areas. Site: Right buttock- small area, Left buttock- small area.6/24/26- Skin condition: Redness. Other: L (left) thumb next to nail has pus filled pocket. Seen by NP today, topical et, oral antibiotics ordered. 7/1/26-Other: L. thumb, continues oral and topical ABT(antibiotics) as ordered. The form did not document the skin impairment observed to the bilateral buttocks and coccyx on 7/1/26 at 1:20 p.m. The above dates were the only skin assessment forms in the clinical record from 3/12/26- 7/1/26. The TAR (Treatment Administration Record) was initialed for weekly skin assessments completed. A wound NP skin assessment form with a visit date of 3/10/26 at 10:00 a.m., was reviewed and included but was not limited to the following: Wound #1 - Upon examination, the Right buttock MASD shows complete epithelialization with no signs of infection or inflammation. Healing is complete, and the wound is now fully closed. Education/Plan: Education provided to: nursing staff, patient.A progress note dated 3/10/26 at 11: 31 a.m. indicated Resident was seen by wound care NP [name] n(sic) 3-10-26, wound #1 right buttock shows complete epithelialization with no signs of infection or inflammation. Healing is complete, wound is fully closed. On 7/1/26 at 10:56 a.m., the DON indicated the wound NP comes in once a week on Thursdays, the last date Resident D was seen was on 3/10/26 and the NP indicated his skin was healed. If a new skin area is found by staff it is reported to the DON, area is measured, it is reported to the wound NP and the regular NP, the DON should have been told by staff of any open areas to Resident D's skin. On 7/1/26 at 1:17 p.m., the DON indicated the only forms found for weekly skin assessments were what was in the clinical record, forms should be filled out weekly for skin assessments. At 1:20 p.m., the DON was observed to measure Resident D's skin areas to his buttocks and coccyx. The DON indicated the following for the assessment: Left buttock: L(length) 4 cm(centimeter) x W (width) 4 cm, red area , not open Right buttock: L 5.5 cm x W 5.4 cm, red area, open area in center L 1 cm x W .5 cm. Coccyx: circular red area 4 cm x 3 cm. Reddened area above circular area to coccyx: L 3 cm x W 4.5 am.On 7/1/26 at 2:07 p.m., RN 2 indicated the nurse does weekly skin assessments, are supposed to document findings on a form in PCC (Point Click Care), put initials on the MAR (Medication Administration Form). If a new open area is found measurements are taken, the DON, doctor, and family are notified. If a new order is given it is put in the orders. On 7/1/26 at 2:25 p.m., the Administrator provided the current policy on documentation of wound treatments with a revision date of 2025. The policy included but was not limited to: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes to treatment. 1. Wound assessments are documented on admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location .c. measurements: height, width, depth, underming, tunneling. d. description of wound characteristics . 4. additional documentation shall include, but it not limited to: .notifications to physician and/or responsible party regarding wound or treatment changes On 7/1/26 at 2:25 p.m., the Administrator provided the current policy for skin and wound management with a revision date of September 2022. The policy included but was not limited to: It is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing, and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcome .3. Ongoing weekly evaluations of resident's skin will completed and documented in PCC on the Weekly Skin Evaluation form .This citation relates to Intake 3027544 and 3006524. 410 IAC (Indiana Administrative Code) 3.1-50(a)(1)410 IAC (Indiana Administrative Code) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment for residents who resided in the facility for 1 of 2 units observed. Baseboards, walls, door trim on resident rooms were marred or had chipped paint, floors had debris built up. ( 200 unit) Findings include: On 7/1/26 at 9: 40 a.m., the following was observed on the 200 unit:Walls on the unit hallways were marred. room [ROOM NUMBER] had a large hole in the wall by the foot of the bed. The wall by the offices had a large chunk of drywall missing. Dirt build up around baseboards.Door trim around resident rooms were marred or had chipped paint.Floors on the hallways had dirt buildup in corners and around the double doors on the unit. The floor in the dining room had debris build up around baseboards and in corners.The elevator floor had dirt build up around the edges of the walls. The wrap around the elevator door frame outside of the elevator doors, was hanging/coming off on both sides. On 7/1/26 at 2:13 p.m., Housekeeper 3 indicated the floor technician recently got let go, the facility was down a housekeeper, floors should be cleaned daily. On 7/1/26 at 2:25 p.m., the Administrator provided the current policy on safe and homelike environment with a copyright date of 2025. The policy included but was not limited to: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment .410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 3 residents reviewed for abuse. ( Resident B)Finding includes: On 4/28/26 at 9:00 a.m., a state reportable with an incident date of 4/9/26 at 8:32 a.m. was reviewed. The incident included but was not limited to:Brief description of incident: 4/9/26 CNA (Certified Nursing Aide) [CNA 2] used inappropriate language with Resident [Resident B ] this morning during the provision of care. Follow up added: 4/15/26 Resident followed through 04/15/26 with no psychosocial distress notes. Follow-up will continue as needed. Verbal abuse substantiated . On 9/4/26 at 9:14 a.m., the Administrator indicated verbal abuse was substantiated after an investigation, he told the agency CNA 2 worked for, she would not be allowed back to the facility to work.On 4/29/26 at 9:38 a.m., the Administrator provided the current abuse policy with a revision date of 9/22. The policy included but was not limited to: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in subpart .The facility must not use verbal, mental, sexual, or physical abuse. corporal punishment, or involuntary seclusion. The resident has the right to be treated with respect and dignity .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .It includes, verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .This citation relates to Intake 2979415.410 IAC (Indiana Administrative Code) 16.2-3.1-27(b)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during four random observations. Odors were present in the facility. (Main lobby, Stocker Unit 1, Stocker Unit 2, Conference Room) Findings include: 1. On 1/22/26 at 9:40 A.M., The hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine. 2. On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent smell consistent with sewer gas. 3. On 1/28/26 at 9:05 A.M., the hallway outside of the conference room had a smell consistent with bowel movement. During an interview on 1/29/26 at 11:20 A.M., the Administrator indicated odors in the facility should be controlled by general routine cleaning and staff should increase cleaning in areas that are prone to odors. On 1/29/26 at 1:16 P.M., the Administrator provided a policy titled Environmental, dated 5/17, that indicated The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: pleasant, neutral scents; The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: institutional odors This citation relates to intake 2707708. 3.1-19(f)

Based on observation, interview and record review, the facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 4 of 4 medication carts observed. (North Hall Medication Cart, South Hall Medication Cart, Stocker 1 Medication Cart, Insulin Administration Cart, Resident W, Resident 13, Resident M) Findings include: Findings include:1.On 1/22/26 at 8:59 A.M., during a random observation of the North Hall Medication the following was observed:1/2 small round white pill2 medium round white pills1/2 large round white pill1 white capsule with the numbers (#) A-4691 large size stretch band2. On 1/22/2026 at 9:10 A.M., during a random observation of the South Hall Medication Cart the following was observed:1 container of pudding with a dated of 1/19/261 small round white pill with the # 051 large round white pill with the # 40971 large round white pill the # 66-4221 blue/light blue capsule with the # 6 and 20 Milligrams(mg)1 small round white pill with the # U-51 large round pill with the # DH-0201 large oval white pill with the #U-113. On 1/22/2026 at 9:20 A.M., during a random observation of the Stocker 1 Medication Cart the following was observed:1 bottle of Magnesium with no name1 bottle of Vitamin C 250 Mg with no name1 bottle of Lutein 20 with no name4. On 1/22/26 at 9:30 A.M., during a random observation of the Insulin Cart was observed:1 Lantus pen for Resident 13 with open date of 12/19/25 with no expiration date1 Lantus pen for Resident W with no open date or expiration date2 Lispro pens for Resident W with no open date or expiration date1 Lispro pen for Resident W with no open date1 unopened Lantus for Resident 451 [Product Name} glucometer for Resident name 45 noted to have 2 spots of blood on machineDuring an interview on 1/22/2026 at 9:05 A.M., Qualified Medicine Aide (QMA) 6 indicated there should be no pills in the medicine carts. She indicated the pills are placed in a drug buster solution and is reported to the Director of Nursing (DON).During an interview on 1/22/2026 at 9:30 A.M., Registered Nurse 8 (RN) indicated that insulin pen should have an open and expiration date. New insulin pens if not open should be refrigerated until needed. During an interview on 1/29/2026 10:27 A.M., the Infection Preventionist indicated ach resident has their own glucometer that should be cleaned in between use.On 1/29/26 at 1:29 P.M., the Administrator provided a current policy Storage of Medications and Biologicals dated 5/20/20. The current policy indicated .medication(s) labeled for individual residents are stored separately than floor stock.disposal of medication(s) should be completed for medication(s) without secure closure, outdated, contaminated or deteriorated.3.1-25(k)3.1-25(l)3.1-25(o)

Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 3 of 5 residents reviewed for hospitalizations, 1 of 1 residents reviewed for tube feeding, and 1 of 1 residents reviewed for urinary catheter. (Resident D, Resident C, Resident Y, Resident M, and Resident R)Findings include: 1. On 1/23/26 at 2:46 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, multiple sclerosis and quadriplegia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/20/25, indicated that Resident C was cognitively intact and was dependent on staff (staff does all the work) for all Activities of Daily Living (ADLs). The clinical record indicated the most recent care conference was completed on 11/21/24 at 2:55 P.M. A care conference note, dated 4/15/25, was in progress but had not been completed. On 1/29/26 at 10:12 A.M., the Social Services Director (SSD) provided care conference notes for Resident C dated 4/15/25, 7/8/25, and 9/30/25. All three notes were created in the electronic health record (EHR) and signed on 1/29/26. During an interview on 1/29/26 at 11:55 A.M., the SSD indicated that care conferences were completed every three months. She took notes about the care conference in a notebook and then entered it into the resident's EHR whenever she had the chance. She indicated that she had gotten behind on documentation. 2. On 1/23/26 at 2:30 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, chronic kidney disease and diabetes mellitus. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/19/25, indicated Resident D was cognitively intact, was dependent on staff (staff does all the work) for toileting, weighed 184 pounds (lbs), and had no weight loss. A care conference was completed on 11/11/25 at 1:00 P.M. with the resident in attendance. Notes indicated to continue with the current plan of care. A current risk for weight changes care plan, initiated 8/2/21, included, but was not limited to, the following intervention:Monitor weight and intake. A current noncompliance care plan, initiated 2/20/23, included, but was not limited to, the following intervention:Educate on the possible consequences of refusing care, treatments, medications, etc. and document. Physician orders included, but were not limited to:Weigh patient monthly every one month starting on the first for health monitoring, dated 10/1/25 and discontinued on 1/13/26Monitor weight weekly every Wednesday for health monitoring, 1/14/2026 A weight summary indicated the following weights had been obtained since 10/1/25:10/1/25 – 184.2 lbs1/1/26 – 166.4 lbs 1/2/26 166.4 lbs1/8/26 – 163.3 lbs The clinical record lacked documented weight refusals. An Interdisciplinary Team (IDT) note, dated 1/7/26 at 1:54 P.M., indicated that the resident had a three percent decrease in weight but no weight was recorded from October to January. The resident needed to be reweighed and an order to obtain weekly weights was given. Resident D's Treatment Administration Record (TAR) for November and December 2025 was reviewed. The monthly weights for November and December were blank and not signed by a staff member. During an interview on 1/29/26 at 1:21 P.M., the Director of Nursing (DON) indicated that Resident D was noncompliant with care, refused to be weighed in November and December, and staff did not document the weight refusals. 3. On 1/28/26 at 11:57 A.M., Resident R's clinical record was reviewed. Resident R was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/17/25, indicated Resident R was cognitively intact, was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, used oxygen therapy, and had an indwelling catheter. The following physician orders on the electronic medication and treatment administrations (eMAR/eTAR) indicated the following days Resident R's medications or treatments were not administered to the resident or refused by the resident: Lyrica Oral Capsule 100 MG (a pain relief medication) Give one capsule by mouth three times a day for Neuropathy Start Date 7/30/25 10/17/25 9 P.M. 10/22/25 6 A.M. 11/10/25 6 A.M. 12/13/25 6 A.M. 12/13/25 2 P.M. Check blood sugar before meals and at bedtime before meals and at bedtime for monitoring Start Date 7/27/25 10/30/25 9 P.M. 11/6/25 9 P.M. BIPAP Check water level and fill if needed with distilled water every evening shift Start Date 7/22/25 10/17/25 evening 11/7/25 evening 11/24/25 evening 12/12/25 evening 12/28/25 evening 1/2/26 evening BIPAP clean mask every day shift Start Date 7/23/25 11/24/25 day 12/17/25 day Offer small more frequent meals every shift for gastroparesis Start Date 10/17/25 10/19/25 night 10/21/25 night 11/28/25 night During an interview on 1/30/26 at 9:12 A.M., The Director of Nursing indicated staff who were working during missing eMAR/eTAR administrations stated they provided the medications/treatments, documentation was just missed at the time. 4. On 1/27/26 at 10:21 A.M., Resident M's clinical record was reviewed. Resident M was admitted on [DATE]. Diagnoses included, but were not limited to, congestive heart failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/25/25, indicated Resident M was mildly cognitively impaired and was dependent on staff (staff do all of the work) for toileting, bathing, and transfers. Physician orders included, but were not limited to: Insulin Lispro Subcutaneous Solution Pen injector 100 UNIT/ML (milliliters) Inject as per sliding scale: if 0 - 149 = 0; 150 - 179 = 1; 180 - 209 = 2; 210 - 239 = 3; 240 - 269 = 4; 270 - 299 = 5;300 - 999 = 6 and call MD, subcutaneously before meals Start date 7/16/25 The electronic medication administration record (eMAR) indicated the following days insulin lispro was not administered: 1/2/26 6 A.M. 1/6/26 6 A.M. 1/8/26 6 A.M. 1/10/26 6 A.M. 1/12/26 6 A.M. 1/13/26 6 A.M. 1/14/26 6 A.M. 1/15/26 6 A.M. 1/17/26 6 A.M. 1/20/26 6 A.M. 1/21/26 6 A.M. 1/22/26 6 A.M. 1/24/26 6 A.M. 1/25/26 6 A.M. During an interview on 1/29/26 at 11:46 A.M., The Director of Nursing indicated the night shift nurse obtained A.M. blood sugars for residents, gave blood sugar results to day shift nurse, and day shift nurse gave insulin at breakfast, sometimes it gets missed in documentation. 5. During an interview on 1/23/26 at 8:27 A.M., Resident Y's responsible party indicated the facility had not invited them to a care conference in the last six to eight months. On 1/23/26 at 2:23 P.M., Resident Y's clinical record was reviewed. Resident Y was admitted on [DATE]. Diagnoses included, but were not limited to, congestive heart failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/5/25, indicated Resident Y was severely cognitively impaired and was dependent on staff (staff do all of the work) for eating, toileting, bathing, and transfers. Resident Y's clinical record lacked quarterly care plan conferences since admission. Care plan conferences were requested on 1/29/26 at 8:51 A.M. On 1/29/26 at 10:18 A.M., the social services director provided quarterly care plan conferences on dated 10/28/25 (created on 1/29/26), 6/26/25 (created on 1/29/26), and 5/13/25 (created on 1/29/26). 3.1-50(a)(1) 3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure staff completed training related to dementia management for 4 of 5 staff, employed longer than one year, reviewed. (QMA 6, RN 14, CNA 15, and LPN 16) Finding includes: On 1/28/26 at 8:53 A.M., employee files were reviewed. QMA 6 started employment on 9/6/24. QMA 6 was missing two of three hours of dementia management related in-services required since 2024. RN 14 started employment on 11/3/24. RN 14 was missing two of three hours of dementia management related in-services required since 2024. CNA 15 started employment on 8/3/23. CNA 15 was missing three of three hours of dementia management related in-services required since 2024. LPN 16 started employment on 8/26/24. LPN 16 was missing one of three hours of dementia management related in-services required since 2024. Additional in-service trainings were requested and were not provided. During an interview on 1/29/26 at 1:32 P.M., the regional clinical support nurse indicated staff should have six hours first year and three hours annually of dementia related in-services. On 1/29/26 at 2:24 P.M., the Administrator provided a policy titled Staffing, Sufficient and Competent Nursing, dated 4/25, that indicated Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure programming for staff training results in nursing competency; gaps in education are identified and addressed; education topics and skills needed are determined based on the resident population

Based on observation, record review, and interview, the facility failed to ensure that a resident who had medication at bedside had a physician order for the medication to be kept at bedside and self-administer, a completed assessment to self-administer, and a care plan based on 2 of 3 residents reviewed for self-administration of medications. (Resident W and Resident 62) Findings include:1. On 1/23/2026 at 1:30 P.M., during a random observation, Resident 62 was observed lying in bed with a medication cup of unlabeled pills sitting on the over bedside table. There were a total of at 8 pills observed.The resident indicated the pills were A.M. medicines and did not know how long the pills had been there. On 1/23/2026 at 1:49 P.M., Resident 62's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes type 2, dialysis, and cerebral infarction. The Current Discharge with Return Anticipated Minimum Data Set (MDS) assessment dated [DATE], indicated Resident was cognitively intact and required dialysis. Resident 62 required set up for eating and hygiene, needed substantial help for dressing, and partial to moderate assistance for transferring. The current physician orders lacked an order for self-administration of medication. The current medical record lacked a self-administration assessment. The record lacked a care plan for self-administration of medications. During an interview on 1/23/2026 at 1:40 P.M., Qualified Medicine Aide (QMA) 7 indicated she did not know where the medications came from and were probably left from night shift. 2. On 1/27/26 at 9:30 A, M., during a random observation, Resident W was observed lying in bed with a medication cup containing 1 large white pill observed lying on the over bedside table. On 1/23/26 at 1:38 P.M., Resident W's clinical record was reviewed. Resident W's diagnoses included, but were not limited to, acute pulmonary edema and dysphagia, oropharyngeal phase.The Current Significant Change MDS assessment dated [DATE] indicated Resident W was cognitively intact. Resident W needed set help with eating, dressing, hygiene, and transferring.The clinical record lacked an order for self-administration of medications.The clinical record lacked a care plan for self-administration of medications.The clinical record lacked an assessment for self-administration of medication.During an interview on 1/27/26 at 9:10 A.M., with Housekeeper Aide 10 she indicated that she finds medications at the bedside several times, especially in the 400 hall. She indicated that she immediately would tell the nurse about the medications.During an interview on 1/27/26 at 10:22 A.M., QMA 6 indicated that no medication should be left at bedside. If medications are found, they should be destroyed and she will notify nurse.On 1/29/26 at 1:37 P.M., the Administrator provided a current policy Self-Administration of Medications reviewed 5/20/20. The policy indicated .the interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis .deferred this right to the facility. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process .all nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party . 3.1-11

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were performed on 2 of 2 random observations. Staff observed not utilizing the proper use of PPE of donning and doffing a gown when entering and exiting a room on Enhanced Barrier Protocol (EBP), did not utilize proper hand hygiene and changing gloves when performing tracheostomy suctioning, and locating a glucometer that was not cleaned after use. (Resident N, glucometer) Findings include:Findings include:1. On 1/22/26 at 9:30 A.M., during a random observation of the Insulin Cart, was observed to have a glucometer noted to have 2 spots of blood on the machine.2. On 1/23/2026 at 8:25 A.M., during a random observation of tracheal suction of Resident N, the following was observed:Resident N was noted to be on Enhanced Barrier Protocol due to a tracheostomy.Registered Nurse (RN)11 did not wash hands prior to donning gloves and did not place a gown of Personal Protective Equipment.2 Certified Nurses Assistants (CNA) 12 and 13 entered the room to help pull the resident up and neither donned gowns on for EBP, but they did have gloves. RN 11 paused tube feeding and obtained a tracheostomy care kit.Opened the kit with the same gloves, and also open sterile water container.Removed gloves, washed hands for 60 seconds with soap and water.Placed a sterile glove on the right hand.Touched the trach collar with a sterile gloved hand. Did not remove the glove or wash hands.Touched the suction catheter with a dirty gloved hand. Did not remove the dirty/soiled glove and change to a sterile one and wash hands.Passed a suction catheter into the tracheostomy with the suction on.Cleared the suction catheter with sterile water and proceeded to do 2 more passes with the suction catheter.Put the suction catheter into the container uncurled.Reattached trach collar.Removed gloves and then threw away the contaminated suction catheter. During an interview on 1/22/2036 at 9:30 A.M., Registered Nurse 8 (RN) indicated there should be no blood on glucometers, and the machines are cleaned in between each use.During an interview on 1/23/26 at 9:50 A.M., RN 11 indicated that she should have worn a gown.During an interview on 1/23/26 at 9:55 A.M., CNA 13 and CNA 12 should have worn gowns also.During an interview on 1/29/26 at 10:27 A.M., with the Infection Preventionist, she indicated if residents are in high contact circumstances, such as tracheostomy, there should be a sign for EBP sign on the door and wear proper PPE. She also indicated that if gloves were worn, the gloves should be changed when going from dirty to clean. When asked about cleaning glucometers, she indicated that glucometer should be cleaned after each use.On 1/29/26 at 1:23 P.M., the Administrator provided a policy Handwashing/Hand Hygiene dated October/ 2023. The policy indicated .hand hygiene is indicated with the following: performing an aseptic task.g. immediately after glove removal.Applying and removing gloves should be performed.Perform hand hygiene before applying non-sterile gloves.On 1/29/26 at 2:04 P.M., the Administrator provided a policy Personal Protective Equipment dated October/2018. The policy indicated .The type of PPE required for a task is based on. the type of transmission-based precaution.Personal protective equipment provided to our personnel includes but is not necessarily limited to a. gowns. (disposable, cloth, and/or plastic)); gloves (sterile, non-sterile) .On 1/29/26 at 2:44 P.M., the Administrator provided a current, non-dated policy, Assure Glucometer Platinum Policy. The policy indicated .The meter should be cleaned and disinfected after use on each patient. This citation relates to Intake 2707708. 3.1-18(b)3.1-18(l)

Based on interview and record review, the facility failed to consistently provide coordination between facility staff and hospice staff to meet residents' nursing needs for 1 of 1 residents reviewed for falls. Fall interventions were not installed on a resident's wheelchair which resulted in a fall with injury. (Resident S)Finding includes:During a confidential interview on 1/22/26 at 2:08 P.M., it was indicated that Resident S used to receive hospice services but did not receive hospice services any longer. The resident utilized Hospice Provider 1 for a while and then switched to Hospice Provider 2 due to communication issues. The resident discontinued hospice services altogether after Resident S fell in December and broke her hip.On 1/23/26 at 2:20 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, senile degeneration of the brain and muscle weakness. Resident S was admitted to the facility on [DATE].Resident S's most current Significant Change Minimum Data Set (MDS) Assessment, dated 12/15/25, indicated Resident S was not assessed for cognitive impairment because she was rarely or never understood, was independent in eating, and had no falls since the prior assessment on 12/18/25. Resident S refused to complete other Activities of Daily Living (ADLs) during the assessment period.Physician orders included, but were not limited to:Resident admitted on [DATE] to Hospice Provider 1 with diagnosis of senile dementia of the brain, all concerns/changes need to go through Hospice Provider 1, dated 7/17/24 with an end date of 12/11/25The clinical record lacked a physician order indicating that Resident S changed hospice providers.The most current fall risk assessment, dated 12/11/25, indicated Resident S was at a high risk for falls.A care conference was completed on 11/25/25 with Resident S's family member in attendance. Notes indicated to continue with the current plan of care.A resolved hospice care plan, initiated on 7/17/24 and resolved on 1/20/26, indicated that Resident S was admitted on [DATE] to Hospice Provider 1 and all concerns and changes needed to go through the hospice provider.The clinical record lacked care plans indicating that Resident S changed hospice providers.A current risk for falls care plan, initiated 7/27/16, included, but were not limited to, the following interventions:Anti rollbacks, initiated 4/25/24 and revised on 7/30/24Anti-tippers on wheelchair, initiated 5/8/24Hospice to install missing safety interventions to resident's wheelchair that they delivered, initiated 9/1/25A Long Term Care Status Form, dated 7/17/24 and signed by Hospice Provider 1, indicated that Resident S was admitted to hospice services on 7/17/24 and that Durable Medical Equipment (DME) would be provided by Hospice Provider 1. A health status progress note, dated 3/17/25 at 8:29 A.M., indicated Resident S had an unwitnessed fall while attempting to self-transfer. The following injuries were noted: hematoma measuring 2.5 centimeters (cm) by 2 cm by 1.5 cm to right hair line; abrasion measuring 0.5 cm by 0.3 cm by 0.1 cm to side of forehead; abrasion measuring 0.4 cm by 0.3 cm by 0.1 cm to temple; and abrasion measuring 0.5 cm by 0.3 cm by 0.1 cm to cheek.An Interdisciplinary (IDT) note, dated 3/17/25 at 9:16 A.M., indicated the root cause of the fall was unassisted transfer and weakness, and scoop mattress to be issued by hospice provider was added to the care plan.An incident note, dated 6/10/25 at 4:30 P.M., indicated Resident S had a witnessed fall while attempting to put a brief on her walker. No injuries were noted.An IDT note, dated 6/11/25 at 10:12 A.M., indicated the root cause of the fall was unassisted transfer and weakness, and resident to be issued floor pressure alarm was added to the care plan.A health status note, dated 8/30/25 at 4:01 P.M., indicated Resident S had an unwitnessed fall in her room. Resident S was noted to be on her floor mat without socks or a brief on.A risk management report, dated 9/1/25 at 6:45 P.M., indicated that Resident S had an unwitnessed fall in the common room. The resident's wheelchair was found beside her. It was noted that the region to the upper portion of the skull was bleeding and had swelling consistent with the size of a medium goose-egg. Her scalp was noted to have a small 2 cm skin tear. The resident was sent to the emergency room (ER) for evaluation and treatment. A health status note, dated 9/1/25 at 10:15 P.M., indicated Resident S returned from the emergency room (ER) with new orders to apply triple antibiotic ointment/bacitracin to scalp wound twice a day for ten days. ER staff indicated that the CT (computed tomography) scan of the resident's head and spine were negative as well as the x-ray of the pelvis. Resident S complained of her head hurting and as needed (PRN) morphine was administered.An IDT note, dated 9/1/25 at 11:13 P.M., indicated IDT met to review Resident S's fall on 8/30/25. The root cause of the fall was determined to be unassisted transfer and weakness. Resident to wear nonskid socks at all times as patient allows was added to the care plan.An IDT note, dated 9/1/25 at 11:17 P.M., indicated IDT met to review Resident S's fall on 9/1/25. The IDT review determined that the hospice-issued wheelchair did not contain the individualized fall interventions previously in place on facility-issued equipment. The Social Services Director (SSD) contacted Hospice Provider 1 to inform them of the concern regarding the appropriateness of the wheelchair. Hospice staff acknowledged the report and indicated they would address the issue and ensure correct fall interventions were installed onto the wheelchair. At that time, the facility provided appropriate seating equipment with all safety features in place and discussed with facility staff the importance of monitoring residents' equipment and to follow-up with hospice as needed. Hospice to install missing safety interventions to resident's wheelchair that they delivered was added to the care plan.A health status note, dated 10/13/25 at 3:35 A.M., indicated Resident S had an unwitnessed fall while attempting to self-transfer. No injuries were noted. The fall mat was observed to have slid away from the side of the bed.An IDT note, dated 10/14/25 at 1:10 P.M., indicated the root cause of the fall was unassisted transfer and weakness, and Dycem to be issued and placed under fall mat to decrease risk of mat shifting out of place was added to the care plan.A social services note, dated 11/17/25 at 9:56 A.M., indicated the SSD spoke with a nurse from Hospice Provider 1 regarding the ongoing concerns of the hospice company not providing equipment necessary for appropriate fall interventions for Resident S. The hospice nurse informed her that the anti-tippers and standard wheelchair were present, but not the anti-rollbacks. The hospice nurse questioned why the anti-rollbacks were necessary and indicated that it would take special approval for Hospice Provider 1 to order them. The SSD and Director of Rehab (DOR) explained the necessity for the anti-rollbacks as an intervention. Discussions with Hospice Provider 1 had occurred over the last three months in an attempt to resolve concerns with services provided. The note indicated DME is not being delivered appropriately, installed appropriately or labeled appropriately. Their company has ordered DME multiple times and state it's been delivered but the DME company is not installing the equipment and therefore is not being found in the facility. It is the responsibility of the DME company delivering the equipment, to install the equipment. The hospice company providing the DME need to label their equipment as well and not facility staff. This SSD called to discuss concerns with the resident's family as concerns have not improved. The family informed me they never chose (Hospice Provider 1) to begin with and were comfortable with switching hospice providers. This SSD informed (Hospice Provider 1) to perform a transfer, and referral has been sent to (Hospice Provider 2) as the family did not have any preference for hospice provider to continue with.A Transfer Statement, dated 11/17/25, indicated Resident S was transferring care from Hospice Provider 1 to Hospice Provider 2. The resident was discharged from Hospice Provider 1 on 11/17/25 and admitted to Hospice Provider 2 on 11/18/25.During an interview on 1/29/26 at 8:55 A.M., the DOR indicated that hospice providers were responsible for implementing all fall interventions of their clients. The facility had difficulty with one hospice provider who was ordering parts and having them delivered to the facility but not communicating with the facility that the parts were on the way or who the parts were for. That hospice provider was no longer welcome in the building.During a confidential interview on 1/29/26 at 11:04 A.M., it was indicated that the anti-rollbacks were not on the wheelchair when Resident S changed hospice companies. They were unsure when the anti-rollbacks were installed.During an interview on 1/29/26 at 12:25 P.M., the DOR indicated that when the facility discovered Hospice Provider 1 had not added the anti-rollbacks to Resident S's wheelchair, the facility moved Resident S into a facility wheelchair with anti-rollbacks and anti-tippers. There was a large period of time between when the anti-rollbacks were added to Resident S's care plan and when they were installed and she was unsure how long the resident went with the anti-rollbacks. She indicated that should not have happened.On 1/29/26 at 1:21 P.M., the Director of Nursing (DON) provided a hospice binder for Resident S from Hospice Provider 1. Hospice notes dated 6/26/25 and 7/23/25 were in the binder. At that time, scanned in hospice notes were reviewed. Hospice notes were dated 7/26/24, 9/4/24, 10/16/24, 11/18/24, 11/20/24, 11/25/24, 12/5/24, 12/26/24, 1/8/25, 1/15/25, 1/22/25, 2/5/25, 3/21/25, and 4/16/25. A hospice recertification plan of care update note, dated 1/8/25, indicated Add DME Wheelchair, Add DME Wheelchair Cushion, Add DME Wheelchair Footrest. The clinical record lacked documentation to indicate Hospice Provider 1 provided any other information about Resident S's care, including, but not limited to, care plan updates, medication changes, physician notes, care provided, fall interventions put in place, DME ordered and installed, and change of condition.During an interview on 1/29/26 at 2:36 P.M., the DOR indicated Hospice Provider 1 did not communicate with the facility and would just change things, including fall interventions, without telling the facility.During an interview on 1/29/26 at 3:17 P.M., the Social Services Director (SSD) indicated she was in charge of coordinating care between residents and hospice providers. The SSD started employment with the facility on 2/10/25 and Resident S was admitted to Hospice Provider 1 before she started employment. Part of the referral process to a hospice provider was to send the resident's plan of care, orders, post form, and anything else necessary to ensure the hospice provider was aware of what services the resident received to ensure continuity of care. The resident's wheelchair was switched to a hospice provided chair as soon as the hospice provider was able. She indicated that she was unable to provide any documentation of when Resident S was switched from a facility chair to the hospice chair and if the anti-rollbacks were attached when she was switched. She indicated that all communication and care plans were supposed to be placed in the hospice binder following the visit. Hospice Provider 1's nurse case manager was in the building two to three times a week to see the two residents that were receiving their services. Communication with Hospice Provider 1 was poor and communications were not always placed in the binder. She was unsure how long Resident S went without the anti-rollbacks attached to her wheelchair. At that time, the DOR indicated that she did not lay eyes on residents who did not receive therapy services regularly to monitor their equipment.On 1/23/26 at 10:10 A.M., the Administrator provided a hospice contract for Hospice Provider 1, dated 9/22/22, that indicated 'Hospice Services means those services provided to a Hospice Patient that are reasonable and necessary for the palliation and management of such Hospice Patient's terminal illness and are specified in a Hospice Patient's Plan of Care. Hospice Services include: . (vii) medical supplies . In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice Patient. Hospice retains primary responsibility for development of the Plan of Care . Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Facility Services under this Agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination. At, a minimum, Hospice shall provide the following information to Facility for each Hospice Patient residing at Facility: The most recent Plan of Care, medication information and physician orders specific to each Hospice Patient residing at Facility . Facility shall comply with Hospice Patient's Plan of Care and shall ensure Hospice Patients are kept comfortable, clean, well-groomed and protected from negligent and intentional harm including, but not limited to, accident, injury and infection.On 1/29/26 at 1:20 P.M., the Administrator provided a Hospice Program policy, revised July 2017, that indicated In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: . Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms.On 1/29/26 at 1:20 P.M., the Administrator provided an undated Hospice Service Agreement document that indicated Hospice is responsible for providing all Hospice services including.Provision, in a timely manner, of all supplies, medications and medical equipment needed for the palliation and management of the terminal illness and related conditions . Nursing Facility Responsibilities.Furnish 24 hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before Hospice care was elected . Communication with SNF/NF or ICF/MR representatives and other health care providers participating in the provision of care will include the following: Development of each provider's portion of the plan of care to assure that the plans are complimentary and reflect common goals and the resident/patient's expressed desire for hospice care. Documentation in all providers' clinical records, or other means to ensure continuity of communication and easy access to ongoing information. Role of hospice in delivering supplies or medications. Ordering, renewal, delivery and administration of medications. Role of the attending physician, and process for obtaining and implementing physician orders.On 1/29/26 at 1:20 P.M., the Administrator provided a Falls - Clinical Protocol, revised March 2018, that indicated If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed.3.1-37(a)

Based on observation record review, and interview, the facility failed to ensure there was an order and care plan for oxygen, tubing was properly dated, and there was an administration posted on door for 1 of 2 residents reviewed for oxygen administration.(Resident W) Finding includes:During a random observation on 1/22/26 at 10:27 A.M., Resident W was observed lying in bed with Oxygen (O2) tubing connected to concentrator with no date on the tubing or water bottle along with the nebulizer, and there was no oxygen administration sign on the door. During a random observation on 1/27/26 at 9:05 A.M., Resident W was observed lying in bed without oxygen on. The nebulizer face mask was observed on the floor and lacked a date on the tubing. Current physician orders lacked documentation of an oxygen order The current clinical record lack documentation of a care plan for oxygen.During an interview on 1/27/26 at 9:30 A.M., Hospice Provider 2 indicated residents on oxygen will have an order for the resident with them but should also have an order with the facility for O2.During an interview on 1/27/26 at 10:30 A.M., Registered Nurse (RN) 4 indicated there should be an order for oxygen for anyone utilizing it.On 1/29/26 at 1:42 P.M., the Administrator provided a current policy Oxygen Administration revised October 2010. The policy indicated .Verify that there is a physician's order.review the resident's care plan to assess for any special needs of the resident. Place an Oxygen in Use sign on the outside of the room entrance door. This citation relates to Intake 2707708. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to revise residents' care plans to reflect changes in condition for 1 of 2 residents reviewed for advanced directives and 1 of 2 residents reviewed for falls. An advanced directive care plan was not revised to reflect a full code status, and a fall intervention was not revised following a change of equipment. (Resident 18 and Resident 29)Finding includes:1. On 1/23/26 at 2:07 P.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome and peripheral vascular disease.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/1/25, indicated Resident 18 was cognitively intact and was independent in all Activities of Daily Living (ADLs).A care conference was completed on 12/23/25 at 5:02 P.M. with the resident in attendance. Notes indicated to continue with the current plan of care. Notes also indicated that the resident was a full code and wished to remain that way.Current care plans included, but were not limited to:Resident 18 has an advanced directive of DNR (do not resuscitate), dated 9/2/22 and last revised on 7/25/24Current physician orders included, but were not limited to:Full Code, dated 6/19/25An Indiana Physician Orders for Scope of Treatment (POST) Form, dated 8/1/25, indicated that Resident 18 wished to be full code.During an interview on 1/29/26 at 8:36 A.M., Licensed Practical Nurse (LPN) 16 indicated that Resident 18 was a full code.During an interview on 1/29/26 at 11:55 A.M., the Social Services Director (SSD) indicated that the MDS Coordinator revised the care plans as needed. Resident 18's advanced directives care plan needed to be changed to reflect his full code status.2. On 1/23/26 at 2:36 P.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, fracture of lower end of right tibia, osteoarthritis, and muscle wasting and atrophy.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated that Resident 29 had severe cognitive impairment, was dependent on staff (staff does all the work) for eating, toileting, and bathing, and had no falls since the prior assessment.A current fall risk assessment, dated 11/14/25, indicated that Resident 29 was at a high risk for falls.A care conference was completed on 12/30/25 at 11:15 A.M. with the resident in attendance. The care plan was reviewed.A current high risk for falls care plan, initiated 11/14/25, included, but were not limited to, the following interventions:Bright colored tape to call light, initiated 12/22/24 and revised on 1/31/25Sensor call light due to decreased ability to utilize standard call light, initiated on 1/27/25On 1/29/26 at 8:28 A.M., a pressure-sensitive pad call light was observed lying on Resident 29's bed. There was no bright tape on the call light.During an interview on 1/29/26 at 1:21 P.M., the Director of Nursing (DON) indicated that the intervention for the bright tape was for the old standard call light, and that intervention should have been removed from the plan of care when the call light was changed to the pressure-sensitive pad.On 1/29/26 at 1:23 P.M., the Administrator provided a current Comprehensive Person-Centered Care Plans policy, revised March 2022, that indicated Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented for 1 of 2 residents reviewed for falls and 1 of 1 residents reviewed for pressure ulcers. Fall interventions were observed out of place and wound treatment was not completed according to physician orders. (Resident S and Resident N)Findings include: 1. On 1/22/26 at 11:06 A.M., Resident S was observed sitting in her wheelchair in the small tv room next to the nurse's station wearing white socks. The socks did not have nonskid tread on the bottoms.On 1/23/26 at 2:20 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, senile degeneration of the brain and muscle weakness. Resident S's most current Significant Change Minimum Data Set (MDS) Assessment, dated 12/15/25, indicated Resident S was not assessed for cognitive impairment because she was rarely or never understood, was independent in eating, and had no falls since the prior assessment on 12/18/25. Resident S refused to complete other Activities of Daily Living (ADLs) during the assessment period.The most current fall risk assessment, dated 12/11/25, indicated that Resident S was at a high risk for falls.A care conference was completed on 11/25/25 at 11:30 A.M. with the resident's family member in attendance. Notes indicated to continue with the current plan of care.A current high-risk for falls care plan, initiated 7/27/16, included, but were not limited to the following interventions:The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide rails as ordered; and personal items within reach. This was initiated 7/27/15 and revised on 9/19/25Be sure the resident's call light is within reach and encourage use of it for assistance as needed, initiated 7/27/16 and revised on 9/19/25 Resident to wear nonskid socks at all times as patient allows, dated 8/30/25Resident's A.D. (assistive device) and w/c (wheelchair) to be stored in a safe location to be used with staff assist in order to assist the resident with mobility due to the resident's impaired cognition and decreased ability to sequence mobility safely, initiated 11/24/25The clinical record indicated Resident S sustained falls on the following dates since 1/1/25:3/17/25 at 8:29 A.M. - unwitnessed fall while attempting to self-transfer. The Scoop mattress was added to the plan of care.6/10/25 at 4:30 P.M. - witnessed fall while attempting to self-transfer. A floor pressure alarm was added to the plan of care.8/30/25 at 4:01 P.M. - unwitnessed fall while attempting to self-transfer. Nonskid socks at all times as the patient allows, was added to the plan of care.9/1/25 at 6:45 P.M. - unwitnessed fall while attempting to self-transfer. Hospice to install missing fall interventions was added to the plan of care.10/13/25 at 3:35 A.M. - unwitnessed fall while attempting to self-transfer. Dycem under the fall mat was added to the plan of care.11/24/25 at 5:10 P.M. - unwitnessed fall while attempting to self-transfer. Resident's A.D. and w/c to be stored in safe location to be used with staff assist in order to assist the resident with mobility due to the resident's impaired cognition and decreased ability to sequence mobility safely was added to the plan of care.12/8/25 at 8:25 A.M. - witnessed a fall while ambulating unassisted. A bed alarm and high floor mat was added to the plan of care. On 1/29/26 at 8:34 A.M., Resident S was observed lying in bed. The bed was positioned in the back on the right side of the room with the resident's feet pointing towards the door. The call light was observed under her bed. Her wheelchair was across from her bed next to a small half dresser in the middle of the left side of the room in the resident's line of sight.During an interview on 1/29/26 at 8:36 A.M., Licensed Practical Nurse (LPN) 16 indicated that Resident S's wheelchair was stored between her recliner, which was positioned at the foot of the bed, and the door because if it was in her line of sight she would try to self-transfer into it. At that time, she indicated that Resident S was capable of using her call light but usually yelled out when she needed help. 2. During an observation on 1/28/26 at 1:41 P.M., RN 8 performed hand hygiene, put a gown and gloves on, and entered Resident N's room. RN 8 pulled the curtain closed, turned Resident N to their left side, used the bed remote to lay the bed down, pulled the bed covers down, and used the pad under Resident N to wipe the paste off of Resident N's coccyx area. RN 8 changed gloves and used a cotton swab to mix collagen and triad (a zinc oxide paste) to Resident N's coccyx area. RN 8 did not cleanse the area before applying the paste. RN 8 did not pause Resident N's continuous tube feeding machine before laying the resident down. On 1/23/26 at 11:30 A.M., Resident N's clinical record was reviewed. Resident N was admitted on [DATE]. Diagnoses included, but were not limited to, chronic respiratory failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/19/25, indicated the resident was rarely or never understood and was dependent on staff (staff do all of the work) for eating, toileting, bathing, and transfers. Physician orders included, but were not limited to: Coccyx: cleanse with wound cleanser, pat dry, mix triad and collagen particle together, apply the mixture to the wound bed and leave open to air every day shift for wound Start Date 12/25/25 Diabetisource AC Oral Liquid (Nutritional Supplement) Give 55 ml/hr (milliliters/hour) via PEG (percutaneous endoscopic gastrostomy) Tube (a feeding tube into the stomach) every shift for peg tube continuous feeding Start Date 10/17/25 The current care plan included, but was not limited to: The resident has pressure ulcer or potential for pressure ulcer development related to vegetative state, no mobility, quadriplegia; Administer treatments as ordered and observe for effectiveness Date Initiated: 4/1/25 The resident requires tube feeding related to vegetative state with tracheostomy; Aspiration precautions: Keep head of bed elevated 45 degrees during tube feeding and for one hour after completion of tube feeding. Date Initiated: 4/1/25 During an interview on 1/29/26 at 10:27 A.M., the Infection Prevention Nurse indicated a resident who received continuous tube feeding should not be laid flat and staff should follow treatment orders as ordered by the physician. On 1/29/26 at 2:24 P.M., the Administrator provided a policy titled Enteral Nutrition, dated 11/18, that indicated Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. Risk of aspiration may be affected by improper positioning of the resident during feeding. This citation relates to Intake 2707708. 3.1-35(a)

Based on record review and interview, the facility failed to ensure that care conferences were conducted every 3 months in 3 of 18 residents reviewed for care conferences. (Resident 26, Resident N, Resident 7) Findings include:1. On 1/23/26 at 1:36 P.M., Resident 26's clinical record was reviewed. Diagnoses included, but were not limited to, undifferentiated schizophrenia and generalized anxiety disorder. The current Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident L was mildly cognitively intact. Resident 26 needed set up help to eat, for transfer and hygiene partial to moderate assistance, and substantial to maximum assistance for dressing and toileting. A Social Service note dated 4/29/2025 at 12:01 P.M., indicated the social worker had reached out to the resident's guardian to schedule a care conference and a message was left. The clinical record lacked any further documentation of care conferenced. During an interview on 1/27/26 at 8:35 A.M., the current Social Services Director indicated the previous social services director was behind with the conferences and that they were still trying to catch up with the conferences and this resident was one of them. 2. On 1/23/26 at 11:30 A.M., Resident N's clinical record was reviewed. Resident N was admitted on [DATE]. Diagnoses included, but were not limited to, chronic respiratory failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/19/25, indicated the resident was rarely or never understood and was dependent on staff (staff do all of the work) for eating, toileting, bathing, and transfers. The clinical record lacked quarterly care plan conferences held since 6/26/25. 3. On 1/23/26 at 11:16 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, vascular dementia.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/25, indicated Resident 7 was unable to be assessed for cognitive impairment because she was unable to complete the interview. Resident 7 was dependent on staff for all Activities of Daily Living (ADLs). A care conference was completed on 6/24/25 at 11:00 A.M. with the resident's family member attending by phone. The clinical record lacked documentation to indicate a care conference had been completed since 6/24/25.During an interview on 1/29/26 at 10:12 A.M., the Social Services Director (SSD) indicated that the last care conference completed for Resident 7 was on 6/24/25.During an interview on 1/29/26 at 11:55 A.M., the SSD indicated that care conferences were to be completed every three months.On 1/29/26 at 1:23 P.M., the Administrator provided a current Care Planning – Interdisciplinary Team policy, revised March 2022, that indicated Resident care plans are developed according to the timeframes and criteria established by 483.21 . The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.3.1-3(n)(3)3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 5 resident reviewed for unnecessary medications. (Resident 6)Finding includes:On 1/23/26 at 1:46 P.M., Resident 6's clinical record was reviewed. Resident 6 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/25, indicated Resident 6 was cognitively intact, was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, and received antianxiety medication during the seven day lookback period. Physician orders included, but were not limited to: hydroxyzine HCl Oral Tablet 25 MG (milligrams) Give one tablet by mouth every eight hours as needed for itching, Start Date 12/23/25.The electronic medication administration record (eMAR) indicated Resident 9 was given zero doses of hydroxyzine during December 2025.During an interview on 1/28/26 at 10:19 A.M., the Regional Clinical Support Nurse indicated Resident 9 did not receive an antianxiety medication during seven day lookback and was marked in error on the MDS assessment. On 1/29/26 at 2:24 P.M., the Administrator provided a policy titled Certifying Accuracy of the Resident Assessment, dated 11/19, that indicated Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. The information captured on the assessment reflects the status of the resident during the observation ( look-back) period for that assessment.

Based on observation, interview, and record review, the facility failed to ensure alternative supplements were provided to accommodate a resident's allergies. (Resident D) Findings include:On 11/24/25 at 10:48 A.M., Resident D's clinical record was reviewed. Resident D was admitted on [DATE]. Diagnoses included, but were not limited to, Type 2 Diabetes Mellitus.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated Resident D was severely cognitively impaired and completely dependent on staff (staff do more than half of the work) for eating, bathing, toileting, and transfers.Resident D's allergy list included, but was not limited to, milk and milk related products. Current physician orders included, but were not limited to:MedPass 2.0 (a dietary supplement) one time a day for weight; Start date 10/29/25A Registered Dietitian progress note, dated 10/2/25 at 10:39 A.M., indicated Resident D should not consume milk or milk related compounds due to a hives reaction, to consider this a true milk protein allergy, and for dietary staff to make Resident D's tray separately. During an observation on 11/25/25 at 8:36 A.M., LPN 8 indicated Resident D received MedPass 2.0 supplement daily with morning medications, and pointed out the carton of Med Pass 2.0. The first ingredient in MedPass 2.0 indicated milk as the first ingredient and a bold warning of contains milk. During an interview on 11/25/25 at 9:41 A.M., the Director of Nursing (DON) indicated Resident D should not be receiving a supplement that contained milk. On 11/25/25 at 10:52 A.M., the Administrator provided a policy titled Food Allergy and Intolerance, dated 7/23, that indicated Resident with food intolerances and allergies are offered appropriate substitutions for foods they can not eat.The citation relates to intake 2615764.

Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed for falls and weight loss. An x-ray of an emergent injury was delayed 24-hours and weekly weights were not completed as ordered. (Resident B)Findings include:On 11/24/25 at 9:54 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, age-related osteoporosis, and protein-calorie malnutrition.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/12/25, indicated Resident B was not assessed for cognitive function because the resident was rarely or never understood. Resident B was dependent on staff for transfers and toileting, required partial to moderate assistance of staff (staff does less than half of the effort) for eating, had no falls since the prior assessment, and weighed 104 pounds (lbs) with no significant weight loss.A. Physician orders included, but were not limited to:May obtain 4 views of right knee for pain and swelling, dated 9/4/25 at 4:37 P.M.STAT: May obtain 4 views of right knee for pain and swelling, dated 9/5/25 at 12:10 P.M.An incident note, dated 8/30/25 at 1:15 A.M., indicated Resident B was found on the floor on her fall mat. An assessment was completed with no injuries noted.Follow-up fall and pain assessments, dated from 8/30/25 through 9/3/25 at 10:41 P.M., indicated no injury or pain was noted.A health status note, dated 9/3/25 at 10:41 P.M., indicated Resident B was noted to have swelling and tenderness to her inner right thigh just above her knee. Nursing Home Triage (NHT) was notified.NHT call logs indicated that on 9/4/25 at 7:11 A.M., Nurse Practitioner (NP) 15 gave orders to NHT to obtain a 4-view x-ray of Resident B's right knee.NHT call logs indicated that on 9/4/25 at 9:16 A.M., NHT gave orders to Licensed Practical Nurse (LPN) 8 to obtain a 4-view x-ray of Resident B's right knee.A nursing note, dated 9/4/25 at 5:05 P.M., indicated an order was received for a 4-view x-ray of Resident B's right knee. The order was called in to (name of mobile x-ray company).A health status note, dated 9/4/25 at 7:40 P.M., indicated that (name of mobile x-ray company) called to confirm the x-ray order and said someone would be out in the morning to complete the x-ray. The resident's right knee and thigh was noted to have swelling and scattered bruising with no signs or symptoms of pain or discomfort.A nursing note, dated 9/5/25 at 11:40 A.M., indicated staff were transferring Resident B to her wheelchair for lunch using a mechanical lift when staff noticed the resident's right upper extremity was bruised and the right lower extremity was swollen and bruised, was warm to the touch, and appeared to be distorted. NHT was notified and a STAT order for 4-view of right knee was requested.An incident note, dated 9/5/25 at 4:20 P.M., indicated that (name of mobile x-ray company) was in the facility to obtain a 4-view x-ray of Resident B's right knee. The resident's right femur was broken. An order was received to send Resident B to the emergency room for evaluation and treatment. A health status note, dated 9/5/25 at 5:47 P.M., indicated that the resident had been transported to the hospital via ambulance.A hospital Discharge summary, dated [DATE] at 5:46 P.M., indicated that on 9/3/25 the resident developed swelling and pain on the sole of the right knee and an x-ray was ordered, but not obtained. During an interview on 11/25/25 at 8:55 A.M., the Director of Nursing (DON) indicated that she was unsure why LPN 8 waited eight hours to put in the order for the x-ray and notify (name of mobile x-ray company) of the order, and that orders should be put in upon receipt of the order.On 11/25/25 at 9:46 A.M., the DON provided an agenda for a license nursing meeting, dated 9/9/25, that indicated orders for x-rays are to be written when received and (name of mobile x-ray company) notified of the order. If (name of mobile x-ray company) is unable to obtain the x-ray in a timely manner, call NHT to obtain orders to transfer out to the hospital for x-ray to prevent a delay in care and treatment.On 11/25/25 at 9:46 A.M., the DON provided an Assessing Falls and Their Causes policy, revised March 2018, that indicated If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.B. Physician orders included, but were not limited to:Weekly weight - every day shift every Tuesday for monitoring per dietician, dated 11/26/24A current risk for altered nutritional / hydration status care plan, revised 2/19/25, included an intervention to monitor weights.A current nutritionally at risk care plan, revised 8/3/24, included an intervention to record and monitor weights.A health status note, dated 11/26/24 at 6:04 A.M., indicated Nurse Practitioner (NP) 2 was notified of a significant weight loss. NP 2 gave an order for the resident to be weighed weekly.An Interdisciplinary Team (IDT) note, dated 3/5/25 at 2:28 P.M., indicated that Resident B had 10% weight loss over 180 days. It was noted that the scales had been down for several weeks in the past possibly attributing to the weight loss.The Treatment Administration Record (TAR) from 12/1/24 to 9/2/25 was reviewed. The TAR indicated that weekly weights had been completed. The TAR lacked documentation to indicate what the weights were.The Weights and Vitals Summary from 12/1/24 to 9/2/25 was reviewed. The following dates lacked a recorded weight:12/312/1712/2412/311/211/282/112/182/253/183/254/14/84/224/295/205/276/106/176/247/17/157/227/29During an interview on 11/24/25 at 11:43 A.M., the Director of Nursing (DON) indicated that staff should put weights into the Weights and Vitals section of the electronic medication record (EMR). If the weights were not there, they were not done, and staff were probably checking off that they had completed it but hadn't actually done it.On 11/25/25 at 10:52 A.M., the DON provided a Weight Assessment and Intervention policy, revised March 2019, that indicated Weights will be recorded in each individual's medical record.The citation relates to intake 2615764.3.1-35(g)(1)

Based on interview and record review, the facility failed to notify a resident's emergency contact of an injury and subsequent x-ray order in 1 of 3 residents reviewed for falls. (Resident B)Finding includes:On 11/24/25 at 9:54 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, age-related osteoporosis, and protein-calorie malnutrition.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/12/25, indicated that Resident B was not assessed for cognitive function because she was rarely or never understood, was dependent on staff for transfers and toileting, required partial to moderate assistance of staff (staff does less than half of the effort) for eating, had no falls since in the prior assessment, and weighed 104 pounds (lbs) with no significant weight loss.Physician orders included but were not limited to:May obtain 4 views of right knee for pain and swelling, dated 9/4/25An incident note, dated 8/30/25 at 1:15 A.M., indicated Resident B was found on the floor on her fall mat. An assessment was completed with no injuries noted.A health status note, dated 9/3/25 at 10:41 P.M., indicated Resident B was noted to have swelling and tenderness to her inner right thigh just above her knee. Nursing Home Triage (NHT) was notified.A nursing note, dated 9/4/25 at 5:05 P.M., indicated an order was received for a 4-view x-ray of Resident B's right knee.An incident note, dated 9/5/25 at 4:20 P.M., indicated that (name of mobile x-ray company) was in the facility to obtain the 4-view x-ray of Resident B's right knee.The clinical record, including progress notes and events dated 9/3/25 at 10:41 P.M. to 9/5/25 at 4:20 P.M., lacked documentation to indicate Resident B's emergency contact was notified of the new injury or that an x-ray had been ordered.During an interview on 11/24/25 at 3:36 P.M., a family member indicated he was not notified of the new injury or that an x-ray had been ordered until after the resident had an order to be sent to the emergency room (ER).During an interview on 11/25/25 at 8:55 A.M., the Director of Nursing (DON) indicated that the emergency contact should have been notified about the resident's initial x-ray order.On 11/25/25 at 10:52 A.M., the Administrator provided a current Change in a Resident's Condition or Status policy, revised October 2010, that indicated Our facility shall promptly notify the .representative (sponsor) of changes in the resident's medical/mental condition and/or status . the Nurse Supervisor/Charge Nurse will notify the resident's responsible party of family when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source .The citation relates to intake 2615764.3.1-5(a)(2)

Based on record review and interview, the facility failed to provide notification of transfer and bed hold policy to residents or their representative in 4 of 4 residents reviewed for hospitalization s. (Resident 7, Resident 51, Resident 53, Resident 57) Findings include: 1. On 11/08/24 at 7:34 A.M., Resident 7's clinical record was reviewed. Diagnoses included but were not limited to fracture of neck and disorders of bone density. The Current Quarterly MDS (Minimum Data Set) Assessment indicated Resident 7 is moderately cognitively impaired. The clinical record lacked any transfer paperwork and bed hold policy when Resident 7 was emergently transferred to the hospital after a fall that resulted in a fractured neck on 7/27/24. During an interview on 11/8/24 at 2:00 P.M., the DON (Director of Nursing) indicated that she could not locate any transfer forms and that there should have been papers sent with resident to the hospital. 50827 2. On 11/08/24 at 2:08 P.M. Resident 51's clinical record was reviewed. The most recent Quarterly MDS (Minimum Data Set) Assessment on 9/17/2024 indicated the resident was cognitively intact, was independent in mobility, always continent, and had diagnoses that included but was not limited to cellulitis. Resident 51 had hospitalization s on 4/28/2024, 5/7/2024, and 11/8/2024. The record lacked a bed hold policy being provided to the resident for all three of the hospital transfers. 3. On 11/12/24 at 10:51 A.M., Resident 53's clinical record was reviewed, the diagnoses included, but were not limited to, diabetes mellitus type two and peripheral vascular disease. The most recent Quarterly MDS (Minimum Data Set) Assessment on 10/31/2024 indicated the resident was cognitively intact, used a wheelchair, required substantial to maximum assistance with transfering and toileting, required partial to moderate assistance with showering, and required supervision with bed mobility, was incontinent, and had an amputation. Resident 53's clinical record indicated hospitalization s on 9/17/2024 and 10/15/2024. The record lacked a bed hold policy being provided to the resident for both of the hospital transfers. 4. On 11/08/24, at 1:51 P.M., Resident 57's clinical record was reviewed, diagnoses included, but was not limited to, cancer, and hospice care. The most recent Quarterly MDS (Minimum Data Set) Assessment on 9/26/2024 indicated the resident was not cognitively intact. Resident 57's clinical record indicated they had been hospitalized on [DATE]. The record lacked a bed hold policy being provided to the resident for the hospital transfer. On 11/12/24 at 4:00 P.M., the DON (Director of Nursing) provided a current, non-dated policy Changes in Resident Condition or Status. The policy indicated the facility will notify the resident .of changes in the resident condition or status .nursing service will be responsible for notifying the resident .as each case applies .the resident is involved in an accident that results in injury .it is necessary to transfer the resident to a hospital . 3.1-12(a)(6)(A) 3.1-12(a)(25)

Based on observation, interview, and record review, the facility failed to ensure adequate safety measures were in place for safe transport for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident B obtaining injuries that resulted in medical intervention and fractures. (Resident B) Finding includes: On 9/9/24 at 10:30 a.m., two state reportable's for Resident B were reviewed and included, but were not limited to: State Reportable 1 Incident date: 8/28/24 Incident time: 2:01 p.m. Description added: 8/29/2024 Resident was out to an appointment. As the driver was taking her into the appointment the resident's foot caught beneath the wheelchair and twisted. Type of injury added: 8/29/2024 Fracture to her left ankle Immediate action added: 8/29/2024 Resident will have foot rests on her wheelchair when out for appointments. Driver was educated on safety. Resident was seen by ortho and sent to be fitted with a splint on 8/29/24. Therapy applied brace until resident was fitted for splint. Type of preventative measures taken: 8/29/2024 Therapy to evaluate for proper foot rests. Follow up added: 9/5/2024 Driver was interviewed and stated that resident's leg rests were not on her wheelchair because she self-propels when he took her for her appointment. The leg rests were available in the van. When he was pushing the resident into the appointment, the residents foot was caught under the wheelchair. Resident confirmed that foot was injured during transport. Driver was re-educated on safe transport on 8/29/24. His employment was terminated on 8/30/24. An audit was completed by 8/30/24 on all residents who use a w/c and foot pedals will were placed in a bag on the back of their w/c. All staff were re-educated on the facility's w/c policy by 8/31/24 or before working any shift. All new hires will be inserviced as well before providing any care to a resident. State Reportable 2 Incident date: 8/29/24 Incident time: 4:01 p.m. Description added: 8/30/2024 Resident was being transported to an appointment when she started sliding out of her chair. The driver stated that she had slid all the way out of her chair before he could pull over safely. Nursing staff met the driver and resident at their location asap [as soon as possible]. They evaluated the situation and called EMS [Emergency Medical Services]. Resident was taken to the hospital for evaluation and it was discovered that she had a fractured right ankle. Driver was suspended from driving pending investigation. The physician, responsible party, ED [Executive Director] and DON [Director of Nursing] were notified. Resident is being assessed for pain and discomfort and will appropriately address as indicated. SS [Social Services] to provide psychosocial support as indicated. Type of injury added: 8/30/2024 Fracture to right ankle Immediate action taken: 8/30/2024 Driver was suspended pending investigation. Type of preventative measures added: 8/30/2024 All staff will be educated on wheelchair safety before working their next shift. All Drivers [sic] will be educated on safety protocols while transporting residents before driving any residents. Follow up added: 9/5/2024 Driver reported that he thought he had put the seatbelt on properly. While interviewing the driver it was discovered that he hadn't put the seatbelt on properly. Driver had been educated on safe transport of wheelchair seated passengers on 7/26/24. Driver was terminated on 8/30/24. Resident reports that she continues to feel safe in the facility. All staff were re-educated on the facility's abuse/neglect by 8/31/24 or before working any shift. All new hires will be inserviced as well before providing care to any resident. All drivers re-educated and will successfully pass a return demonstration to ensure they are competent on safe transfers before they transport any resident in the facility van. On 9/9/24 at 10:50 a.m., the Administrator indicated incident one happened on 8/28/24, it was reported to him the next day, he reported it as a state reportable when he found out Resident B had sustained a fracture to her left ankle. The driver reported he had been pushing the wheelchair when the residents foot got caught under the wheelchair, footrests were not on, but were in the van, the driver knew they were supposed to be on the wheelchair. The Administrator indicated the driver had been educated on safe transport after the incident. The Administrator indicated incident two happened on 8/29/24 while Resident B was being transported in the facility van to an appointment, Resident B sustained a fracture to her right ankle. Resident B slid out of her wheelchair, the driver reported he thought he had properly secured the seatbelt, but had not, the driver had been educated on seatbelt use on 7/26/24 when it was added to the van. On 9/9/24 at 11:03 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, other fracture of right lower leg, other fracture of left lower leg, unilateral primary osteoarthritis, diabetes mellitus, and pain. A quarterly MDS (Minimum Date Set) assessment, dated 7/1/24, indicated Resident B's cognition was intact, wheelchair for mobility, bed mobility extensive two assist, transfer total dependence two assist, self care- toileting dependent, shower/bath substantial/maximal assist, lower body dressing dependent, substantial/maximal assist, wheel chair 150 feet, once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space dependent. Care plans included, but were not limited to: Alteration in musculoskeletel status related fracture to left ankle, fracture to right ankle, date revised on 8/30/24. Interventions included, but were not limited to: Foot pedals to be on wheelchair at all times when out of facility, initiated, 8/30/24. Wear splint to left foot/ankle and Ace wrap to right foot/ankle at all times until further orders, initiated 8/30/24. The resident is at risk for falls, gait/balance problems related to morbid obesity, impaired mobility, sit to stand lift, pain, poor eye sight, psychotropic use, revised on 7/26/24. Interventions included, but were not limited to, anticipate resident needs, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, ensure resident is wearing proper footwear such as non-skid socks when ambulating or in wheelchair, initiated 2/9/23. The resident has an ADL (Activities of Daily Living) self-care performance deficit related to OA (osteoarthritis), bladder incontinence, decreased mobility, revised on 7/26/24. Interventions included, but were not limited to, transfer: when resident utilizes wheelchair and is unable to propel self and needs assistance to be pushed then leg rest should be on wheelchair and for all transports out of facility leg rest should be utilized, initiated 8/30/24. The Progress Notes included, but were not limited to: On 8/28/24 at 6:20 a.m., Late entry: CNA reported that resident was complaining of pain to left foot when care was being provided. Upon assessment no swelling/bruising/redness noted. When foot touched and moved resident stated, Ow that hurts. This nurse inquired as to what had happened and resident stated, My foot went under the wheelchair earlier. It's no big deal it just hurts when it is moved some. I am going to see if it feels better later today. This nurse passed information on in report to dayshift to monitor foot for any changes. On 8/28/24 at 12:23 p.m., physicians order note, This morning, resident reported pain to left foot/ankle secondary to injury that occurred while out on appointment yesterday afternoon. Upon speaking with staff, learned that while out for afternoon appointment, resident did not have foot pedals on wheelchair and while propelling resident along sidewalk, her foot became stuck under chair at a backwards angle. Upon observation, noted swelling and faint bruising to left foot and ankle. Resident guarding when area is lightly palpated. Resident placed on non-weight bearing status and NHT (Nursing Home Triage) notified. Will obtain xray of left foot and ankle upon return from dialysis today. On 8/29/24 at 1:48 p.m., Residents x-ray to left foot and ankle came back positive for fracture. Notified NHT and made aware. Stated it was residents choice to got to emergency room or Ortho in the morning. Resident chose to got to Ortho urgent care in the morning. Notified ADON (Assistant Director of Nursing). On 8/29/24 2:31 p.m., Resident returned from appointment with order to have splint placed to left foot/ankle. Requires resident to go back to Ortho to have splint fitted. Rehabilitation Director came to unit to apply brace for stabilization until fitted for splint. On 8/29/24 at 4:37 p.m., Call made to residents daughter to inform that resident was in route to hospital due to fall in wheelchair van from wheelchair to floor of van. On 8/29/24 at 6:15 p.m., received call from hospital reporting resident had a mild right ankle fracture and will be sent back to facility tonight. DON notified and daughter updated. On 8/30/24 at 11:02 a.m., Spoke with resident this morning regarding pain for BLE (bilateral lower extremity) fractures. Resident did not make it to Ortho Urgent Care yesterday in order to have splint placed to left foot/ankle due to fall in transport van subsequent emergency department visit. Resident resting in bed at this time with the boot ortho therapy placed yesterday still in place to left lower extremity, right foot/ankle with Ace wrap in place from emergency department visit. On 9/5/24 at 1:27 p.m., Splint in place to left lower extremity this morning. Toes warm. Ace bandage wrap in place to right foot/ankle. Complaints of pain to bilateral lower extremities. As needed pain medication given per order and was effective. A Physical Therapy Note, date of services 6/25/24 through 8/26/24, indicated wheelchair mobility supervision or touching assistance for wheel 150 feet. The investigation to the state reportable's was reviewed on 9/10/24 at 9:00 a.m., and included but was not limited to the following statements and radiology reports. A statement dated 8/29/24 signed by the DON: Approximal [sic] 330pm [3:30 p.m.], the Administrator received a phone call from the Van driver indicating he needed help with [Resident B] related to her sliding out of the wheelchair into the van floor while riding back to the facility from a scheduled appointment. I went with multiple staff members to assist in getting the resident back to her wheelchair. Upon arrival [Resident B] was complaining of right ankle pain. Her right foot was bent to the right against the passenger side seat. She was sitting upright on the van floor with her back against bilateral foot pedals. EMS [emergency medical service] was called to transport to the hospital for evaluation. I spoke to the van driver to determine how resident was able to slide out of the wheelchair, he indicated he did not have the seat belt secured correctly. When I asked why he didn't secure the seatbelt correctly, I (sic) said I am not sure. A statement, dated 8/29/24, signed by the van driver: I took Ms [Resident B] to an appointment at [name of facility] at the pain clinic/Oncologist [sic], on my way up to the door her foot slipped under the chair and bent, sole up to the air. I stopped then and realized she didn't have her Foot [sic] rest on the chair. Every time before this incident she has always had her foot rest on. So when I Took [sic] her from her room, since they told me she was ready I took her out and didn't realize they weren't installed on there. A statement, dated 8/30/24, signed by the van driver I transported Ms [Resident B] to [name of facility] in [name of city] got there I got told that was was the wrong one. While I was still there I asked one of the Physical Therapist if he would help me pull her up in the wheelchair. He helped me, as we progressed to the right one, she started to slide again slowly. I thought she was safe with her seat belt on, I took all the slack out of the belt, but when made it to [name] exit she was 3/4's way out of her chair. The she said to just bring her back Nobody should have to ride like this she said. When I got to [name of street] and [name of street] she had completely slipped out of her chair. I pulled over at [name of store] To call [Administrator], to which he told me the nurses to meet me to help me get her out In the chair. When they arrived they attempted to get her back in the chair, but had to call 911 to get the EMT's [Emergency Medical Technicians] help and they took her to the hospital. A radiology report for the left ankle with an examination date and time of 8/28/24 4:49 p.m., included but was not limited to: Impression: 1. Acute nondisplaced oblique (slanted) coronal fracture through the lateral malleolus (bone on the outside of the ankle joint). 2. No joint subluxation or dislocation seen. 3. Severe diffuse osteopenia. A radiology final report for the right ankle with a created date of 8/29/24 at 10:08 p.m., provided by the DON on 9/9/24 at 11:47 a.m., included, but was not limited to: Impression: 1. The study is somewhat limited secondary to suboptimal positioning. There appears to be a minimally displaced fracture through the lateral malleolus. No dislocation is seen. A second radiology final report for the right ankle provided by the Administrator on 9/10/24, time unknown, had a created date of 8/29/24 at 6:05 p.m., and include, but was not limited to: Findings: No acute fracture, dislocation, or radiopaque foreign body. On 9/10/24 at 12:01 p.m., the Administrator indicated at the time of the first incident Resident B self-propelled herself in the wheelchair. On 9/10/24 at 12:30 p.m., Resident B indicated staff mostly push her in her wheelchair when she is out to appointments, she was not able to, foot rests were on most of the time, it was chaotic in her room before she left the faciity on the day of the first incident, there were five to six people in her room, and the foot rests were forgotten. Resident B indicated the second day when she slid out of her chair, the driver did not buckle her in, he did not put the seat belt on her, only strapped the legs of the wheelchair. Resident B indicated the driver laughed and asked her if she wanted him to strap her in, she said if he didn't want to put it on then don't, and he didn't. On 9/10/24 at 1:33 p.m., the Administrator provided the current resident transport policy with a revised date of August 2023. The policy included, but was not limited to: . All passengers must wear a seat belt, wheelchair passengers must have wheelchairs secured to van. Make sure the attachment straps are attached over the frame of the wheelchair. Residents must be securely restrained to the wheelchair . On 9/10/24 at 1:33 p.m., the Administrator provided the current policy on transporting a resident via wheelchair with a adopted policy date of 8/29/24. The policy included, but was not limited to: Residents who are unable to ambulate short or long distances either independently or with the assistance of staff will utilize a wheelchair for mobility. For safety purposes residents will not be transported (pushed) in wheelchairs without the use of leg rests. Guidelines: 1. If the resident is able to self-propel the wheelchair footrests may be off. However, if the resident is unable to propel the wheelchair- foot rests will be utilized .2. c. Always ensure proper positioning of the resident in the chair (sitting properly) to avoid falls .e. Always be alert and attentive to the resident for things- such as leaning forward or abruptly placing feet on floor -to prevent falls from wheelchair This deficient practice was corrected on 8/31/24 after the facility implemented a systemic plan of correction that included the following actions: all transportation staff was educated on safe transfers with return demonstrations, staff was educated on the facility wheelchair policy, staff was educated on abuse policy, with ongoing monitoring and audits. This citation relates to Complaint IN00437526. 3.1-45(a)(2)

Based on interview and record review, the facility failed to prevent sexual abuse from occurring when a female staff member had sexual relations with a male resident. The staff member reported the sexual occurrences and locations to the Administrator. (Resident F, Staff Member 1). This Immediate Jeopardy began on May 21, 2022, when the facility failed to prevent sexual abuse from occurring when a female staff member had sexual relations with a male resident. The Administrator, DON (Director of Nursing), Regional Administrator, and Regional Nurse were notified of the Immediate Jeopardy on June 14, 2022 at 1:20 P.M. Central time. The Immediate Jeopardy was removed on 6/16/22 at 2:30 p.m., 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: On 6/13/22 at 1:45 P.M., the report of sexual abuse by staff member to resident was reviewed. The report filed with Indiana Department of Health identified the incident occurred on 5/25/22 at 1:30 P.M. The investigation conducted by facility recorded the confession of the employee on 5/24/22 no time recorded. The employee claimed that she and Resident F started a very close friendship for a couple months. The nature of the relationship became sexual in the Middle of April the sex happened in hotels two times and 2-3 times inside the facility. Within the facility, it happened in the resident's room. She claims (name Resident F) pursued going to the sexual level of the relationship she stated it was consensual and let it go on too far. They got to the hotel riding together in an Uber they both made a commitment to keep their relationship secret .they spoke and texted over the phone regularly .once the sex started she was afraid if she did not engage in the sex acts that he would go tell someone .She was trying to keep him happy until he got released from the facility Dates of sexual acts listed were April 8 [hotel], May 21 [hotel], she did not remember the dates they had sex in the facility but both dates were in April. Signed by employee on 5/24/22, witnessed by two staff members on same date. The investigative folder included the Leave of Absence form that was signed by Resident F on 5/21/22 at 4:30 P.M. and the resident returned at 8:00 P.M. the same date. A nurse (LPN 1) working the 7 P.M. to 7 A.M. shift, signed the resident back in at 8:00 P.M. No other dates for 2022 had been recorded on the form. There were no other signatures as to the responsible party who was with the resident. The Cognitive Status Evaluation was included and indicated Resident F had no cognitive impairment. On 5/25/22 the Interim DON interviewed Resident F regarding sexual acts with the employee. (name) [Resident F] denied having any type of relationship with any staff member Resident again insisted that he had not had any relationship with anyone. On 6/13/22 at 2:30 P.M., the Administrator and the Nurse Consultant (previous Interim DON) were interviewed regarding the allegations. They described the resident as very mobile in his wheelchair, was able to walk with therapy and the use of a prosthesis, usually had sign on room door Knock before entering. He was in the midst of community placement discharge when allegation occurred and was discharged home with a family member on 5/26/22. He had an order that he May go LOA [Leave of Absence] with responsible party and medications. They also indicated the resident frequently refused to follow the physicians orders or complete therapy. Resident F's clinical record was reviewed on 6/13/22 at 2:30 P.M. The resident was identified as the responsible party for himself. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 4/15/22, identified the resident as cognitively intact; bed mobility and dressing was needing supervision and set up; transferring, toilet use and personal hygiene was needing two person assist. The Care Plans addressed the following: frequently refusing dressing changes to the pressure ulcers, self care deficit regarding the pressure ulcers, left below the knee amputation, pain medication use, incontinence, resistive to therapy and risk for falls. It also included the discharge planning for community placement. The clinical record did not address the allegation of sexual relations with a staff member, the follow up and/or assessment of the resident following the allegation. Multiple attempts to reach Staff Member 1 and Resident F were made but they could not be reached. On 6/13/22 at 1:45 P.M., the Abuse Policy, revised January 2000 was reviewed. The policy included, but was not limited to: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This included but is not limited to freedom from corporal punishment , involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. The Immediate Jeopardy, that began on 5/21/22, was removed on 6/16/22 when the facility began inservicing the facility staff on abuse policies and interviewed the residents for abuse, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 749. 3.1-27(a)(1)

Based on interview and record review, the facility failed to adequately supervise a resident at risk for falls, and utilized alarms in place of supervision. This deficient practice resulted in a [MEDICAL CONDITION] requiring sutures. This affected 1 of 4 residents reviewed for falls, in a sample of 7. Resident F Findings include: On 5/10/18 at 12:00 P.M., during the initial tour, the Director of Nursing (DON) indicated Resident F had fallen recently. The clinical record of Resident F was reviewed on 5/11/18 at 11:11 A.M. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 3/3/18, indicated Resident F had a memory impairment, and required extensive assistance of two+ staff for transfer. A test for balance during transitions and walking indicated Not steady, only able to stabilize with human assistance while walking and surface-to-surface transfer. Progress Notes included the following notations: 3/8/18 at 1:30 A.M.: Resident noted by staff at this time lying on floor on back with head propped on recliner. Resident alert with confusion . Assisted to w/c (wheelchair) by staff members x 2 3/8/18 at 11:25 A.M.: IDT (Interdisciplinary Team) post fall assessment: resident sustained [REDACTED]. Resident attempted to transfer self unassisted and fell in front of his recliner. Resident was attempting to get to the bathroom .Interventions in place. 4/11/18 at 2:56 P.M.: At 1350 (1:50 P.M.) resident yelled from his room that he needed help. CNA responded immediately and called for this nurse. Resident laying on the floor with his upper body laying between the back wheels of his wheelchair. Complete assessment done. When resident c/o (complained of) shoulder and neck pain when attempting to turn his head to the right, a staff nurse immobilized residents (sic) head and neck while this nurse called 911 4/11/18 at 8:14 P.M.: Resident was brought back via family from (name of hospital) .There were no fractures noted .Resident noted to have skin tear on left elbow for which dressing was applied at the ER. 4/12/18 at 10:49 A.M.: IDT post fall assessment .Resident attempted unassisted transfer out of bed to go to the bathroom. Resident lost his balance and fell beside the bed. Resident complained of neck and shoulder pain .Resident was sent to the ER for eval (evaluation) and treat. Resident did return to the facility .Interventions in place. 4/20/18 at 10:25 A.M.: Staff alerted to res (resident) being on floor in bathroom with laceration to the forehead, pressure applied per nursing staff. Res c/o (complains of) pain to head .ST (skin tear) noted to right index finger wound cleansed and steri strips applied .order received to send res to (name of hospital) for evaluation and treatment. 4/20/18 at 11:05 P.M.: Resident came back from ER approximately 4 pm .Orders were the following .Keep wound clean, dry and intact. Remove sutures in 5-7 days 4/23/18 at 2:36 P.M.: IDT post fall assessment: resident sustained [REDACTED].The resident was attempting to transfer himself from his wheelchair onto the toilet, lost his footing and fell . Resident c/o leg and head pain, order obtained to send to (name of hospital) for further assessment .resident sustained [REDACTED].interventions in place. A Care Plan, initially dated 3/2/17 and revised 4/20/18, indicated: Focus: The resident is at a high risk for falls r/t (related to) dementia, gait/balance problems. The Interventions included: 4/11/18 Offer to toilet after noon meal. 4/20/18 Ensure alarm box is kept out of Resident's reach. 9/22/17 Check Resident frequently throughout the night. Be sure the resident's call light is within reach and encourage to use it for assistance as needed. Non skid strips to floor in front of recliner. 3/2/17 Resident has bed and chair alarms. Check function and placement q (every) shift. On 5/11/18 at 2:10 P.M., the Assistant Director of Nursing (ADON) provided incident reports on the resident's 3 falls. None of the incident reports documented if an alarm was in place, or if it was sounding. The ADON indicated she knew the alarms were sounding when the resident fell on ,[DATE] and on 4/20. She indicated she was unsure if an alarm was on and/or sounding when the resident fell on ,[DATE]. On 5/11/18 at 2:30 P.M., the DON provided the current facility policy, Falls and Fall Risk, Managing, revised (MONTH) 2007. The policy included: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling This Federal tag relates to Complaints IN 301 and IN 193. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards for 1 of 3 reviewed for falls and 3 of 31 rooms observed for hot water temperatures. A resident was left while ambulating unassisted which resulted in a fracture to the left arm and hot water temperatures were above 120 degrees Fahrenheit. Findings include: 1. On 7/20/16 at 10:40 a.m., Resident #37's clinical record was reviewed. Resident #37's [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) Assessment, dated 4/12/16, indicated the resident had moderately impaired cognition. The MDS Assessment, further indicated the resident required extensive assistance of one person for locomotion on the unit. The Care Plans included, but were not limited to: (Name of Resident) has alteration in mobility regarding: transfers, ambulation, and positioning. The interventions included, but were not limited to: ambulates with walker and assist of one. The Progress Notes included, but were not limited to: On 4/23/16 at 10:02 a.m., a late entry for 9:15 a.m., indicated: The nurse was notified by the housekeeper that the resident was lying on the floor on their back and the CNA was cradling the resident's head. The note further indicated the resident indicated she was having numbness and tingling in the left arm and the arm was observed to be lying in an abnormal position. The collar bone appeared to be protruding out with bruising noted on the skin, but not broken. A skin tear was also noted on the left hand The note further indicated that the CNA reported she was ambulating the resident with a walker, when another resident was in a wheelchair leaning forward. The CNA reported she stepped away from the ambulating resident to assist the resident in the wheelchair when the ambulating resident fell . CNA further stated she had been distracted and this resulted in the residents fall. The resident was sent to the emergency room for evaluation and treatment. On 4/23/16 at 4:41 p.m., a note indicated a call had been placed to the hospital and had the resident had been admitted for a left humeral head fracture, left arm problems, and elbow/shoulder injury. On 7/26/16 at 10:55 a.m., the ADON indicated if a staff member was assisting a resident to ambulate and the staff member noticed another resident might fall, the staff member should call out for help. On 7/26/16 at 11:25 a.m., CNA #1 indicated she was ambulating Resident #37 from the dining room with a rolling walker. CNA #1 indicated a second resident was leaning forward in their wheelchair. CNA #1 indicated at that time she let go of Resident #37 and reached to assist the second resident. CNA #1 indicated at that time, Resident #37 fell . On 7/20/16 at 10:20 a.m., the Administrator provided the Fall Prevention Program policy, revised 10/19/12. The policy included, but was not limited to: It is the facility policy to ensure that the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. 2. On 7/18/16 at 11:49 a.m., a sign was observed at the North Unit Nursing station, which indicated to be careful when using the hot water because it got extremely hot. The North unit had 15 (fifteen) residents residing on it. a. On 7/18/16 at 11:53 a.m., Room #222's water temperature was observed to be 136 degrees Fahrenheit. On 7/19/16 at 9:36 a.m., Room #222's water temperature was observed to be 122 degrees Fahrenheit. This would have been the during the time of meal clean-up and/or laundry being done. b. On 7/18/16 at 11:55 a.m., Room #218's water temperature was observed to be 133 degrees Fahrenheit. This would have been during the time of meal clean-up and/or laundry c. On 7/18/16 at 11:58 a.m., Room #219's water temperature was observed to be 131 degrees Fahrenheit. This would have been during the time of meal clean-up and/or laundry. On 7/18/16 at 2:41 p.m., Unit Manager #2 indicated she was not sure why there was a sign posted regarding extremely hot water. On 7/18/16 at 3:29 p.m., CNA #2 indicated there had not been any hot water issues. On 7/18/16 at 3:43 p.m., the water temperatures of Room #222, Room #218, and Room #219, were observed with the Maintenance Supervisor. All the water temperatures were between 114-118 degrees Fahrenheit. The Maintenance Supervisor indicated a private company comes to the facility if there are any issues with hot water. On 7/19/16 at 7:46 a.m., the Administrator indicated a private company was in the facility on this date to inspect the hot water heaters. The Administrator further indicated they knew if laundry or dietary were functioning the hot water was okay, but there were pockets of time they knew the hot water was too hot therefore prompting the sign to be posted on the North Nursing Unit. On 7/19/16 at 7:59 a.m., the Administrator indicated the mixing valve had been replaced in December of 2015. On 7/19/16 at 9:58 a.m., the private company employees were interviewed. The employees indicated the hot water check valves were corroded and was intermittently causing hot water to get to flow through. The employees further indicated the situation had been corrected. On 7/26/16 at 1:49 a.m., the ADON provided the Surveyor Guidance for Identified Excessively Hot Tap Water Temperatures That May Cause Scald Burns in Health Care Facilities, dated 1/2002. The policy indicated hot water temperatures in nursing homes should not exceed 115 degrees Fahrenheit. 3.1-19(r)(2) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents, in that, alarms were not in place during a fall, residents were left unassisted in the bathroom, gait belts were not used during transfers for 3 of 5 residents reviewed for accidents and 1 of 4 nursing units. This resulted in Resident #133 receiving a second fracture and Resident #82 requiring sutures. (Resident #133, Resident #82, Resident #58) Findings include: 1. On 5/19/15 at 8:50 a.m., LPN #1 was interviewed. LPN #1 indicated Resident #133 had fallen recently and broken her hip but had not had surgery. On 5/19/15 at 2:53 p.m., Resident #133's clinical record was reviewed. Resident #133 was admitted on [DATE]. Resident #133's [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated 5/12/15, indicated Resident #133 was a high risk for falls. The progress notes included, but were not limited to: 4/21/15 at 10:31 p.m.: Resident fell at 7:45 p.m. No injuries noted and all parties were notified. Resident was in dining room and attempted to rise from wheelchair. She lost balance and fell . 5/5/15 at 1:30 p.m.: Resident found on floor laying on right side, in front of wheelchair.resident has no complaints of pain, no internal/external rotation noted, no lengthening or shortening noted, staples intact to left hip. 5/5/15 at 8:00 p.m.: Transferred to (Name of Hospital) via (Name of ambulance service) family notified resident fell at 1:30 p.m. out of wheelchair got orders.for bilateral hip x-ray's which was done and showed new fracture in left hip The Clinical Review, dated 5/6/15, indicated: Review of fall. Resident was observed lying on floor in front of wheelchair resting on right side. The Radiology Report, dated 5/5/15, indicated: The visualized osseous (bone) structures demonstrate an acute complete slightly displaced left subcapital hip fracture. The Care Plans included, but were not limited to: Resident has potential for falls related to history of falls, loses balance easily, left hip fracture, dated 4/22/15. The interventions included, but were not limited to, Pad alarm to bed and chair due to decreased safety awareness, dated 4/22/15. On 5/19/15 at 3:46 p.m., Resident #133 was observed in the common area watching television. The alarm to the wheelchair was observed in place. On 5/21/15 at 9:52 a.m., LPN #1 indicated Resident #133 had been admitted to the facility and had been discharged to the hospital for removal of orthopedic hardware from a previous surgery. The Resident had returned to the facility with five staples. LPN #1 indicated Resident #133 had fallen in the facility and received a hairline fracture to her left leg but surgery was not completed. LPN #1 could not locate documentation which indicated Resident #133's alarm was sounding when the resident fell . 2. During the initial tour on 5/18/15 at 11:00 a.m. Resident # 82 was observed to have a large bruise with swelling, bleeding and sutures on left side of head, she also had oozing blood from a pressure stocking on left leg. The clinical record of Resident # 82 was reviewed on 5/19/15 at 1:55 p.m. Resident #82 had [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set), dated 4/17/15, indicated the resident needed supervision with set up for toileting. The BIMS (Brief Interview for Mental Status) assessment indicated Resident #82 had a score of 12 out of 15 possible, which indicated mild cognitive impairment. A care plan, dated 11/11/14, included, but not limited to: Resident #82 had a potential for fall due to attempts to stand unassisted, loses her balance easily, and had an unsteady gait. The care plan further indicated the resident was to be up with assist of one person and use of an assistive device. The physician's orders [REDACTED]. The initial physician's was dated 1/14/15. The physical therapy notes indicated the resident was adamant about not trying to stand or bear weight. Resident #82 was discharged from physical therapy. A note also indicated Resident #82 was at a high risk for falls. A nurses note, dated 5/18/15 at 10:00 a.m., indicated Resident #82 was heard yelling help from the bathroom at 5:25 a.m. The note indicated Resident #82 was found lying on the bathroom floor on the left side next to the commode. Resident #82 was observed to have a 3 inch by 5 cm (centimeter) laceration with a hematoma around it and a large amount of bleeding. Neuro checks were completed with the pupils brisk, the grasps strong, and the resident was able to all extremities without pain. The note indicated Resident #82 had a 6 cm by 2 cm abrasion on the left knee which was not bleeding and the nurse was unable to approximate the skin. Resident #82 was transferred to a w/c (wheelchair) with assist of 3 persons and the resident was a total lift. The note further indicated the physician and the resident's brother were notified and the resident was transferred to the hospital at 6:10 a.m. A nurses notes, dated 5/18/15 at 10:30 a.m., indicated Resident #82 returned to the facility with sutures to the left side of the forehead. New physician's orders [REDACTED]. A follow-up review of the nurse's notes on 5/20/15 at 10:15 a.m., indicated Resident #82 remained on a follow-up fall assessment. The note further indicated Resident #82 was an extensive assist of one person with transfers due to unsteady gait with surface to surface transfers. During an interview on 5/19/15 at 10:50 a.m. RN #2 indicated the resident had been in bathroom alone and fell off of the commode. She indicated resident would use the shower bathroom instead of the room bathroom because it was bigger. During an interview on 5/20/15 at 11:30 a.m., the DON (Director of Nursing) indicated there were no written reports on incidents except in nurses notes. The DON indicated the fall had not been reported to the Indiana State Department of Health. During an interview on 5/21 at 11:45 a.m., the DON and the Adm (Administrator) indicated Resident #82 would often go into bathroom without assistance. They indicated the toilet seat was loose and when Resident #82 changed positions, the toilet seat slipped and the resident fell off. The Adm indicated the commode seat was to be repaired and/or replaced. During an interview on 5/21/15 at 2:00 p.m., Resident #82 indicated she frequently went to bathroom on her own. Resident #82 further indicated she was alone in bathroom on the morning of her fall. She indicated she had reached down to pick something up from the floor and fell on to the floor. 3. The clinical record of Resident #58 was reviewed on 5/20/15 at 9:15 a.m. Resident #58 had [DIAGNOSES REDACTED]. During a review on 5/20/15 at 9:15 a.m., the nurse's notes indicated that on 5/15/15, Resident #58 had been transferred from the wheelchair to the bed by a CNA. The note indicated Resident #58 became weak and was assisted to the floor. The note further indicated the CNA was unable to move the wheelchair out of the way due to the anti-rollback device on the chair. The note indicated the CNA had not used a gait belt when Resident #58 was transferred. The note further indicated interventions including, but not limited to, CNA provided education on importance of utilization of gait belt for all transfers, the resident was assessed, and vital signs were obtained. The note indicated no changes to the plan of care were recommended by the clinical review team. A care plan, dated 11/21/14, indicated Resident #58 had a history of [REDACTED]. The care plan further indicated Resident #58 would be walked a distance of 20 feet daily with a gait belt, rolling walker and staff assist of 1 (one). A quarterly MDS (Minimum Data Set) assessment, dated 2/18/15, indicated Resident #58 required extensive assist with ADL's (activities of daily living). The MDS indicated Resident #58 had a BIMS (Brief Interview for Mental Status) assessment score of 4 of possible 15 which indicated severe cognitive impairment. A cumulative physician's orders [REDACTED].#58 was to be up with assist to the wheelchair as tolerated. During an interview on 5/20/15 at 11:00 a.m., the DON (Director of Nursing) indicated Resident #58 had been lowered to the floor after becoming weak. The DON further indicated the CNA was not using a gait belt during the transfer of the resident back into bed. The DON indicated gait belts are to be used while transferring and/or walking all residents. On 5/26/15 at 5:00 p.m., the Administrator provided the Interdisciplinary Care Plan Policy and Procedure. The policy indicated its purpose was to act as a communication tool that allowed staff members to interact with on another regarding resident care and allow for a constant and consistent approach in the deliver of quality of care. During an interview on 5/26/15 at 5:00 p.m., the Administrator provided the Falls Prevention Program Policy. The policy indicated the facility was to ensure the resident's environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. 4. During an observation on 5/20/15 from 9:00 a.m. - 10:00 a.m., the common shower/bathroom door on the South unit, across from the nurses station, was observed to be swung out by staff into the hallway, striking three unidentified residents. No injuries were observed. During an observation on 5/21/15 at 10:00 a.m., the common shower/bathroom door was observed to be swung out by staff into the hallway, striking an unidentified resident. During an interview on 5/26/15 at 3:00 p.m., the DON (Director of Nursing) indicated she was not aware of anyone being hit by the common bathroom/shower room door. An interview with CNA # 2 indicated she was not aware of anyone being hit by the door. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 1 of 4 residents reviewed for pressure ulcers received the necessary treatment and services to prevent pressure ulcers, in that the resident received pressure areas on the buttocks from prolonged time on a bed pan. (Resident #29) Finding includes: Resident #29's clinical record was reviewed on 5/13/14 at 11:10 a.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pressure ulcer risk assessment, dated 3/30/14, indicated the resident had a score of 17. A score of 8 or above indicated high risk for skin breakdown. Resident #29 was readmitted to the hospital on [DATE] due to inability to manage her pain, and remained hospitalized until 3/30/14. The Nurses' Admission Record from that date indicated she had a bruise on her left hip and right hip and a red area on the right hip. The resident had received kyphoplasty of [MEDICATION NAME] vertebrae during the hospital stay and was to wear a brace when up in a chair. The resident's admission care plan (no date) indicated a risk for pressure sores and indicated she was to be encouraged to turn every 2 hours and as needed. Nurses' notes dated 4/7/14 at 9:46 a.m. indicated the resident experienced increased lethargy and confusion, decreased complaints of pain, physician notification and requests for laboratory tests at that time. The resident was transferred to the hospital on [DATE] at 10:22 a.m. The transfer record indicated the [DIAGNOSES REDACTED]." The resident required total assistance with activities of daily living and transfers. The transfer record section titled "Presence of Decubitus" indicated the resident had a "skin tear (L) (left) outer lower leg." The hospital records were reviewed on 5/14/14 at 8:35 a.m. The hospital history and physical, dated 4/8/14, indicated "skin excoriated in perineal area and red mark like from being on bed pan in lower back/gluteal area..." Hospital wound documentation, dated 4/8/14 at 6:19 p.m., indicated the following wounds: -Shear, right hip, abrasion to right hip. -Abrasion, right buttocks, open area and redness on right buttocks. Copies of pictures, obtained from the hospital risk manager on 5/14/14 at 8:40 a.m., indicated the following: The resident was positioned on the left side. The resident's bilateral buttocks were dark pink. A reddened curved 1-2 inch wide line was observed curving from the upper right buttock to the upper right thigh. Three to four areas appeared open along the line. The upper left thigh also had a line of redness. According to the hospital risk manager, the pictures were taken on 4/10/14. CNA #1 was interviewed on 5/14/14 at 11:00 a.m. She indicated the resident required total care, "we had to do everything for her." She indicated the resident was incontinent at times and wore incontinence briefs. She indicated the resident occasionally would tell them she had to go and they could use the bed pan. She indicated she had cared for the resident on 4/8/14 prior to her being sent to the hospital and the resident had not been placed on the bed pan during that morning. She thought there had been a problem with the bed pan the day before the resident went to the hospital. CNA #1 was interviewed again on 5/14/14 at 1:20 p.m. She indicated she had seen the resident's skin on 4/8/14 prior to the transfer to the hospital and there had been a large red ring on the buttocks; it looked like she had sat on the bed pan too long. The Director of Nurses (DoN) and the Administrator were interviewed on 5/14/14 11:15 a.m. The DoN indicated the night shift nurse had reported to him on the morning of 4/8/14 the resident had redness on her bottom and her condition had declined. He indicated he had interviewed the day shift nurse, LPN #1, that morning and she had told him there was a reddened area on the resident's bottom, but the skin was intact and nothing was mentioned about it looking like the rim of a bed pan. The resident was in the process of being transferred to the hospital and he did not have the opportunity to assess the area. The Administrator indicated they had interviewed a CNA from the night before and the CNA had denied the resident had been on the bed pan. The facility had investigated by interviewing nurses and CNAs who cared for the resident and no one would admit seeing the resident on the bed pan or knowing the resident had been on the bed pan. The night shift nurse had indicated to the Administrator she had noticed redness, but had not documented anything, and no one had indicated to her the redness appeared to be from a bed pan. The DoN indicated he found out about the concern over the resident potentially being left on the bed pan when hospital records were reviewed. The Administrator indicated she terminated three nurses and one CNA because she couldn't get a straight story. She indicated staff had been inserviced to leave the call light on if they put someone on the bed pan, so it would remind them to check on the resident and take them off. A Bed Pan Policy, dated 4/2014, was provided by the DoN on 5/14/14 at 3:51 p.m. The policy included, but was not limited to, the following: "Stay with resident in area, but give privacy and dignity @ all times. If you have to leave resident while on bed pan. Turn on call light until resident's need is met & resident is off bed pan." Inservice records, dated 4/11/14, indicated nursing staff were inserviced on the revised and updated policy. A Pressure Ulcer Prevention and Management policy and procedure was provided by the DoN on 5/14/14 at 3:52 p.m. Definitions on the policy included, but were not limited to, the following: "Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Stage I Pressure Ulcer - An observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area of the body may include changes in one or more of the following: -Skin temperature (warmth/coolness) -Tissue consistency (firm/boggy) -Sensation (pain/itching) and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. Stage II Pressure Ulcer - Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater." "If a resident is triggered at risk on the Pressure Ulcer Risk Assessment, preventive measures must be identified, implemented and recorded..." This Federal Tag relates to Complaint Number IN 830. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure care was provided according to the plan of care for 1 of 3 residents reviewed in a sample of 3 who met the criteria for review of pressure ulcers, the resident developed a pressure ulcer which worsened when care was not provided. (Resident #26) Findings include: The CNA Assignment Sheet provided by LPN #1 on 02/11/13 at 9:50 a.m., indicated Resident #26 was to be turned and repositioned every hour. On 02/11/13 at 11:09 a.m., Resident #26 was observed lying in bed on the right side. During an interview at that time, LPN #1 indicated the WCN (Wound Care Nurse) would be assessing Resident #26 related to a wound on the coccyx. LPN #1 further indicated at that time, the key to healing the pressure wounds was pressure relief. The coccyx wound was observed at that time, to have full thickness tissue loss with slough present. During an interview on 02/11/13 at 11:10 a.m., the WCN indicated, the wound on the coccyx was a Stage 3 pressure wound with slough and measured 2.8 X 1.5 X unable to determine with 0.1 (centimeter) cm bridging. During an interview on 02/12/13 at 9:05 a.m., LPN #1 indicated Resident #26 had a facility acquired pressure wound on the coccyx. LPN #1 further indicated at that time, the wound had been discovered on 01/31/13 as a Stage 2 wound that measured 1.8 X 0.3 X 0.2 and had progressed to a Stage 3 wound on 02/11/13. Resident #26 was observed on 02/12/13 at 8:45 a.m. lying in bed, positioned to the right side. Resident #26 was observed on 02/12/13 at 9:45 a.m. lying in bed, positioned to right side. Resident #26 was observed on 02/12/13 at 10:45 a.m., lying in bed, positioned to the right side. Resident #26 was observed on 02/12/13 at 11:15 a.m., lying in bed, positioned to the right side. Resident #26 was observed on 02/12/13 at 11:30 a.m., being transferred by CNA #1 and CNA #2 from the bed to the wheelchair. During an interview at that time, CNA #2 indicated Resident #26 was to be turned and repositioned every 2 (two) hours. CNA #2 further indicated at that time, Resident #26 had not been repositioned since being laid down at 8:45 a.m. (total of 2.75 hours) Resident #26 was observed on 02/14/13 at 8:30 a.m., sitting in a wheelchair in Dining room [ROOM NUMBER]. Resident #26 was then observed on 02/14/13 at 9:25 a.m., being transported in the wheelchair from the dining room to the common lounge. At 9:29 a.m., CNA #1 was observed transporting Resident #26 from the common lounge to the resident's room. During an interview at that time, the Maintenance staff #1 indicated work was in progress in the resident's room and CNA #1 would have to wait to transfer Resident #26 to bed. CNA #2 was then observed to place the resident in the hallway outside of the room. Resident #26 was observed at that time, to not be repositioned in the wheelchair. Resident #26 was observed on 02/14/13 at 9:59 a.m., to be lying in bed positioned on the right side. During an interview at that time, CNA #2 indicated Resident #26 had just been transferred to bed. CNA #1 further indicated at that time, Resident #26 had been transferred into the wheelchair at 7:30 a.m. that morning. (total of 2.5 hours) Resident #26 was observed on 02/14/13 at 11:30 a.m., to be transferred from the bed to the wheelchair. During an interview at that time, CNA #2 indicated Resident #26 had not been repositioned while in bed. (total of 1.5 hours) The clinical record of Resident #26 was reviewed on 02/14/13 at 10:02 a.m. The record indicated the [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 02/09/13, included, but was not limited to, and order for, "...turn and reposition every 1 (one) hour..." An Avoidability Evaluation of Pressure Ulcer from the attending physician dated 02/12/13, indicated, "Pressure ulcer is Unavoidable due to the following factors: Chronic bowel incontinence...resident refuses nutrition...significant weight loss..Summary:...pressure Ulcer is Unavoidable...". The evaluation lacked any documentation related to Resident #26 refusing care or preventative interventions. The Nurses' Admission Record dated 10/28/12, indicated Resident #26 had been admitted from an acute care hospital with no pressure wound on the coccyx. The most recent Pressure Ulcer Risk assessment dated [DATE], indicated Resident #26 was a high risk for pressure. A Wound Care Skin Integrity Evaluation dated 02/11/13, indicated Resident #26 had a facility acquired Stage #3 wound to the coccyx which measured 2.8 X 0.5 X 0.2 and included but, was not limited to, an intervention of, "...Turn schedule is q (every) 1 (one) hour at this time." The most recent Quarterly MDS (Minimum Data Set Assessment) dated 12/14/12, indicated Resident #26 experienced moderate cognitive impairment and required extensive assist of two staff for bed mobility. The care plan dated 01/31/13, for Stage 2 on coccyx included, but was not limited to, "...turn and reposition every two hours..." The Skin Management Program Policy and Procedure provided by MR #1 on 02/20/13 at 1:00 p.m., indicated,"...It is our policy that if an alteration does occur that the resident receives care and services to promote healing..." 3.1-35(g)(2)

Based on observation, interview, and record review the facility failed to ensure care was provided as ordered, for 1 of 3 residents reviewed in a sample of 3 who met the criteria for review of pressure ulcers in that, a resident who was admitted without a pressure ulcer, developed a pressure ulcer, and the ulcer deteriorated to a Stage 3 wound. (Resident #26) Finding includes: The CNA Assignment Sheet provided by LPN #1 on 02/11/13 at 9:50 a.m., indicated Resident #26 was to be turned and repositioned every hour. On 02/11/13 at 11:09 a.m., Resident #26 was observed lying in bed on the right side. During an interview at that time, LPN #1 indicated the WCN (Wound Care Nurse) would be assessing Resident #26 related to a wound on the coccyx. LPN #1 further indicated at that time, the key to healing the pressure wounds was pressure relief. The coccyx wound was observed at that time, to have full thickness tissue loss with slough present. During an interview on 02/11/13 at 11:10 a.m., the WCN indicated, the wound on the coccyx was a Stage 3 pressure wound with slough and measured 2.8 X 1.5 X unable to determine with 0.1 (centimeter) cm bridging. During an interview on 02/12/13 at 9:05 a.m., LPN #1 indicated Resident #26 had a facility acquired pressure wound on the coccyx. LPN #1 further indicated at that time, the wound had been discovered on 01/31/13 as a Stage 2 wound that measured 1.8 X 0.3 X 0.2 and had progressed to a Stage 3 wound on 02/11/13. Resident #26 was observed on 02/12/13 at 8:45 a.m. lying in bed, positioned to the right side. Resident #26 was observed on 02/12/13 at 9:45 a.m. lying in bed, positioned to right side. Resident #26 was observed on 02/12/13 at 10:45 a.m., lying in bed, positioned to the right side. Resident #26 was observed on 02/12/13 at 11:15 a.m., lying in bed, positioned to the right side. Resident #26 was observed on 02/12/13 at 11:30 a.m., being transferred by CNA #1 and CNA #2 from the bed to the wheelchair. During an interview at that time, CNA #2 indicated Resident #26 was to be turned and repositioned every 2 (two) hours. CNA #2 further indicated, at that time, Resident #26 had not been repositioned since being laid down at 8:45 a.m. (total of 2.75 hours) Resident #26 was observed on 02/14/13 at 8:30 a.m., sitting in a wheelchair in Dining room [ROOM NUMBER]. Resident #26 was then observed on 02/14/13 at 9:25 a.m., to be transported in the wheelchair from the dining room to the common lounge. At 9:29 a.m., CNA #1 was observed transporting Resident #26 from the common lounge to the resident's room. During an interview at that time, the Maintenance staff #1 indicated work was in progress in the resident's room and CNA #1 would have to wait to transfer Resident #26 to bed. CNA #2 was then observed to place the resident in the hallway outside of the room. Resident #26 was observed at that time, to not be repositioned in the wheelchair. Resident #26 was observed on 02/14/13 at 9:59 a.m., to be lying in bed positioned on the right side. During an interview at that time, CNA #2 indicated Resident #26 had just been transferred to bed. CNA #1 further indicated at that time, Resident #26 had been transferred into the wheelchair at 7:30 a.m. that morning. (total of 2.5 hours) Resident #26 was observed on 02/14/13 at 11:30 a.m., to be transferred from the bed to the wheelchair. During an interview at that time, CNA #2 indicated Resident #26 had not been repositioned while in bed. (total of 1.5 hours) The clinical record of Resident #26 was reviewed on 02/14/13 at 10:02 a.m. The record indicated the [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 02/09/13, included, but was not limited to, and order for, "...turn and reposition every 1 (one) hour..." An Avoidability Evaluation of Pressure Ulcer from the attending physician dated 02/12/13, indicated, "Pressure ulcer is Unavoidable due to the following factors: Chronic bowel incontinence...resident refuses nutrition...significant weight loss..Summary:...pressure Ulcer is Unavoidable...". The evaluation lacked any documentation related to Resident #26 refusing care or preventative interventions. The Nurses' Admission Record dated 10/28/12, indicated Resident #26 had been admitted from an acute care hospital with no pressure wound on the coccyx. The most recent Pressure Ulcer Risk assessment dated [DATE], indicated Resident #26 was a high risk for pressure. A Wound Care Skin Integrity Evaluation dated 02/11/13, indicated Resident #26 had a facility acquired Stage #3 wound to the coccyx which measured 2.8 X 0.5 X 0.2 and included but, was not limited to, an intervention of, "...Turn schedule is q (every) 1 (one) hour at this time." The most recent Quarterly MDS (Minimum Data Set assessment dated [DATE], indicated Resident #26 experienced moderate cognitive impairment and required extensive assist of two staff for bed mobility. The care plan dated 01/31/13, for Stage 2 on coccyx included, but was not limited to, "...turn and reposition every two hours..." The Skin Management Program Policy and Procedure provided by MR #1 on 02/20/13 at 1:00 p.m., indicated,"...It is our policy that if an alteration does occur that the resident receives care and services to promote healing..." 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the resident was free from physical and verbal abuse for 1 of 4 residents reviewed related to allegations of abuse in a sample of 8. (Resident F) Resident F was physically and verbally abused by the visiting spouse. The facility failed to plan and/or implement interventions to protect the resident from further abuse, and the visiting spouse repeated the verbal abuse. The reporting process for the second occurrence of abuse was not followed, and the facility failed to immediately plan and implement interventions to prevent further abuse. The deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 5/2/11 and began on 4/23/11. The Interim Administrator, Director of Nursing, Assistant Director of Nursing, and the Social Worker were notified of the Immediate Jeopardy on 5/2/11. The Immediate Jeopardy was removed on 5/4/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because the facility continued to inservice staff on abuse policies and procedures. Findings include: During Initial Tour of the facility on 5/2/11 at 4:30 a.m., from the hallway through the open door, a man in street clothes was observed seated in an easy chair in (room of Resident F). The light next to the chair was on, and the man was holding a book in his hands. During interview on 5/2/11 at 6:05 a.m., LPN #2 and CNA #3 who were on night shift duty on Resident F's hall, indicated the Resident F's husband is up all night, every night in the resident's room. They indicated that sometimes the husband catnaps in the chair. They indicated someone is with Resident F 24 hours a day. They indicated during the daytime, a hired sitter is with the resident, not to provide care but to alert the staff to the need for care. At this time, the resident's open door was knocked upon, and no response was received. Stepping into the room, the resident was observed lying quietly in bed on her left side. The man in the chair was observed to have his eyes closed, and his respirations were easy. Resident F's clinical record was reviewed on 5/2/11 at 6:25 a.m. The record indicated the resident was admitted to the facility on [DATE] following placement of a gastrostomy feeding tube. A Care Conference Note, dated 4/27/11, indicated in the section for Social Services, "Interview w/ (with) (name of Resident F's husband) regarding incident on 4/23/11. See Social Service Notes for more details." Social Service Progress Notes for 4/26/11 indicated, "Was notified of an incident that occurred over the weekend with resident & her husband. Staff reported husband grabbed her by the hair and shook her. Staff was assisting the resident with cleaning up. The husband thought she was being combative. He stated he had [MEDICATION NAME] he could give her. He was told all meds (medications) needed to go through the facility & be ordered by a physician. Spoke to the son (name of son) - he had prepared statement from his father. '(Name of husband) would like for us to hear both sides of the story. He feels we have rec'd (received) bad information. He feels the report being made would be false as it is currently written. We would be well-advised to listen to what he has to say before making the final report.' (Name of son) would not discuss any history of aggression or abuse with his father. He stated he would not discuss it over the phone. He also stated he would not likely discuss his parents at the meeting, but would be there for moral support. Supervised visitation has been put into place and a visit log has been placed in the resident room to ensure when someone is in the room with the resident. A mtg (meeting) has been scheduled with (name of husband and son) tomorrow at 2:00 p.m." Social Service Progress Notes for 4/27/11 at 2:00 p.m. indicated, "Social Services (name of SW #2), Administrator (name of Interim Administrator), Nursing (name of Compliance Nurse, LPN #3) met with (name of Resident F's husband) and son, (name of son). (Name of Resident F's husband) wanted to express his side of the story regarding the incident that occurred on 4/23/11. He admits his wife was upset & angry with the nurses for needing to change her. He admits he did grab her hair, but did not pull it and did not shake her head. He stated he did it because after [AGE] years of marriage he knows she does not like her hair being pulled. He states he would never give his wife his medication and understands all medicine must go through the physician and the facility. (Name of Resident F's husband) denies any wrong doing and states the staff is just out to get him. (Name of Interim Administrator), myself, and (Name of LPN #3) then spoke to (name of CNA #6) about the incident. She had given a written statement as to what happened. She states (name of Resident F's husband) grabbed her (Resident F) by the hair and shook her head. She states she did ask him to stop and told him that she had the situation under control. (Name of CNA #6) states she then reported it to the nurse on duty. A report was sent to the state dept (department) of health on 4/27/11." During interview on 5/2/11 at 6:15 a.m., LPN #2 indicated Resident F's son was in the resident's room with the resident and Resident F's husband until about 2:15 a.m. that morning, when the son indicated to LPN #2 he was going home to get some sleep. LPN #2 indicated the family was very concerned about the resident's care. LPN #2 indicated Resident F's husband does not assist with the resident's care - only staff provides care, but the husband calls for assistance as needed. During interview on 5/2/11 at 6:30 a.m., in regard to the Care Conference Note, dated 4/27/11, LPN #2 indicated he did not know anything about an incident with Resident F's husband. During interview on 5/2/11 at 7:05 a.m., CNA #3 was observed providing care on Resident F's hall. During interview at this time, CNA #3 indicated she wasn't aware of Resident F's husband ever being mean to Resident F. CNA #3 also indicated she usually worked upstairs (on the facility's second floor) but was providing the care on Resident F's hall at this time. Review of the facility's binder containing files of incidents reported to the Indiana State Department of Health included, but was not limited to, a report titled, "Facility Incident Reporting Form," for "Incident Date: 4/23/11 Incident Time: 6:15 a.m." Attached to the report was copy of a handwritten statement, dated 4/23/11. The statement indicated, "I (name of CNA #6) entered the room of (name of Resident F) to change her and get her dressed. She was wet, she was digging at her bottom with her nails keeping herself raw & soar (sic). I was holding her hands so she would not dig at herself. (Resident F's) husband kept saying to (name of Resident F) let go of her. I explained to him that I was the one holding her hands so that she didn't scratch herself. (Name of Resident F's husband) got up from his seat and grabbed (name of Resident F) by the hair of the head and began shaking her head by the hair of her head yelling let go of her. He made the statement that he had Adavan (sic) ([MEDICATION NAME] - antianxiety medication) in his pocket & that he would give her some. I explained that no he could not do that." Also attached to the Facility Incident Reporting Form was copy of an e-mail, dated 4/25/11 at 12:43 p.m., sent from (name of LPN #4) to LPN #3. The e-mail indicated, "On April 23, 2011, my two aides were discussing the care of a resident with me. One stated that the husband had tried to pull her hair while they were taking her to the bathroom. Aide made the commit (sic) that the husband was being mean to the wife. The second aide reported that he was not being mean to her he was trying to keep her from being combative while they were taking her to the bathroom. I was the nurse on the unit at the time and did not see or hear this take place. I was in the residence (sic) room frequently that shift and did not observe the husband being mean to his wife. He did report that she needed something to keep her calm at which point I called the on call physician and got orders for PRN (as needed) [MEDICATION NAME] 1 mg along with a urinalysis. She was placed on acute charting at that time for the [MEDICATION NAME] order." The Facility Incident Reporting Form indicated the following: In the section for Brief Description of Incident: "(Name of CNA #6) was providing patient care for resident following an incontinent episode with husband in room....According to husband during interview on April 27th around 2:00 p.m., husband states that he did grab his wife's hair but denied pulling or shaking of wife's head. Husband also denied offering his wife any medication, but does admit to carrying his own medication with him during his visits." In the section for Preventive Measures Taken: "Resident was monitored throughout weekend and acute charting was initiated following the placement of a new order for prn [MEDICATION NAME]. Recommended supervised visits. As of Monday April 25th, a personal sitter had been hired by family to sit at bedside to assist with care. A visitor log has been placed in the resident's room to be filled out by visitor or sitter. No further incidents of physical abuse have been noted. Nurse will be educated on facility policy regarding timely reporting of incidents of alleged abuse before next scheduled shift." On 5/2/11 at 8:20 a.m., two men were observed leaving the facility. One of the men was using a walker. During interview at this time, LPN #5 indicated the two men were Resident F's husband and son. LPN #5 indicated Resident F's son had come to the facility to pick up Resident F's husband, and a sitter was now in the room with Resident F. LPN #5 also indicated that was an "odd situation" in regard to Resident F's family. When asked to explain, LPN #5 indicated she didn't know what to say about it and "like you say, it's an odd situation." Interview with Social Worker (SW) #2 was completed on 5/2/11 at 8:35 a.m. SW #2 had come to the Conference Room where clinical records were being reviewed to locate the clinical record for Resident F. SW #2 indicated she wanted to put her note from Friday (4/29/11) about an incident with Resident F's husband into the clinical record. SW #2 indicated Resident F's husband had not been physically abusive but had called the resident names. SW #2 indicated (name of Resident F's husband) won't talk on the phone, because he is hard of hearing. She indicated he was in the military and that you "can tell he wants things done a certain way and expects it." SW #2 indicated Resident F had excoriation to her periarea, which is painful for her. SW #2 indicated she had contacted the local Ombudsman to brainstorm about possible ideas to manage the resident, so the resident's husband will be managed. SW #2 indicated the son doesn't want to intervene as best she can tell. SW #2 indicated the family has kept the resident at home until she had the [DEVICE] placed before admission. SW #2 indicated as far as she could tell, the resident had not had much change in care needs except for the [DEVICE] care. SW #2 indicated she didn't want to tell the resident's husband not to come in to visit. She indicated the problems between the resident and her husband had occurred during care in the morning. She indicated Resident F's husband has usually left the building before she arrives. SW #2 indicated she planned to give Resident F's husband and son information about resident abuse. In her hand SW #2 had a list of ideas on a red piece of paper, which she indicated were the ideas she and the Ombudsman discussed, and an envelope addressed with the names of Resident F's husband and son. The Social Service Progress Notes, dated 4/29/11 at 8:00 a.m., indicated, "Social Services was notified at 7:45 a.m. that another incident had occurred with (name of Resident F's husband). When I went to the resident room to address the incident (name of Resident F's husband) had already been picked up by his son, (name of Resident F's son). The sitter, (name of sitter) was still in the room. I questioned her about the happenings in the room. She states the CNAs were providing pericare because she had an incontinent episode. (Name of resident F) was combative because of the pain and confusion. She states, '(Name of resident F's husband) said stop acting like a 4 yr (year) old & told her to shut up.' She states he did not get physical with his wife. I then questioned CNA (name of CNA #6). She states (Name of Resident F's husband) doesn't understand that (name of Resident F) is in a lot of pain from how raw she is and is not trying to fight them in spite. She states he said, 'Shut up, (name of Resident F), Shut up (name of Resident F) - quit acting like a 4 yr old.' He also said, 'You can't talk to someone without a brain.' (Name of Resident F) then whispered to (name of CNA #6), 'Make him stop, make him stop!' (Name of CNA #6) states as she and other aid (sic) were leaving the room he went to the bedside & tried to tell resident that the staff was not trying to hurt her. I then questioned (name of CNA #4), the other CNA. She states he did tell her to shut up and yelled at her. She states this is not the first time. She states he has been verbally abusive with his wife and with staff in the past. She is not sure of the exact verbiage. I did try to contact (name of Resident F's son), but was unable to do so." Notes on 4/29/11 at 2:00 p.m., indicated SW #2 spoke with the Assistant Director of Nursing about the resident's "being so raw and uncomfortable." Notes on 4/29/11 at 2:30 p.m., indicated SW #2 spoke with the Ombudsman about the "ideas on plan of care. Will leave resident rights on abuse for (names of Resident F's husband and son)." During observation on 5/2/11 at 9:15 a.m., a young lady in street clothes was seated in the easy chair in Resident F's room. During interview at this time, she indicated she was the resident's private sitter and would be in the room today from 7:00 a.m. to 7:00 p.m. She also indicated she was employed by the facility as a housekeeper and would not be providing resident care. LPN #5 entered the room and indicated she would be providing the resident's water flush to the gastrostomy tube. Observed on a small table beside the easy chair was a list labeled in handwriting, "All Visitors Must Sign In" and a notebook with dates and handwritten notations. LPN #5 indicated she thought the visitor list was placed there by social services, and the sitter indicated the notebook belonged to the family and contained notes on the resident's care. During interview on 5/2/11 at 9:50 a.m. in regard to her report of family to resident physical abuse on 4/23/11, CNA #6 described the hair pulling and grasped the hair on the top of her own head and demonstrated a side to side jerking motion. CNA #6 indicated that almost every time she goes into the room, when the resident is combative, her husband yells at her. She indicated the resident says "Get him out of here." She indicated she is holding the resident's hands so she won't dig at herself. During observation of personal care for Resident F by CNAs #6 and #4 on 5/2/11 at 10:30 a.m., the resident was observed to repeatedly reach to the buttock and groin area, call out "Oh that hurts," and grab at the CNAs' hands during care. The buttocks near the anal area were observed to have small bright red areas and open an area on the tailbone. The resident calmed and closed her eyes when the care was completed. During interview with CNA #4 on 5/2/11 at 11:00 a.m., she reiterated her report as recorded in the Social Services Progress Notes for 4/29/11 at 8:00 a.m. CNA #4 indicated she had seen the sign in paper in the Resident F's room, but that no one had said to have people coming into the room to sign in on it. CNA #4 indicated, "That's his (Resident F's husband's) paper, I think." During interview on 5/2/11 at 2:15 p.m., the Interim Administrator and Compliance Nurse, LPN #3, indicated the incident of verbal abuse of Resident F by Resident F's husband on 4/29/11 had not been reported to them. An Immediate Jeopardy was identified on 5/2/11. The Immediate Jeopardy began on 4/23/11 when a visiting spouse physically and verbally abused his wife. The Interim Administrator, Director of Nursing, Assistant Director of Nursing, and the Social Worker were notified on 5/2/11 at 3:50 p.m. of the Immediate Jeopardy related to the failure to prevent physical and verbal abuse and implement policies related to prevention, investigation, protecting, and reporting abuse. The Immediate Jeopardy was removed on 5/4/11 at 4:00 p.m., when through observations, interviews, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy, and that the steps taken removed the immediacy of the problem. Review of policy and procedure, observations of staff and visitor interaction with residents, and staff interview related to inservicing on the facility's policy and procedure related to abuse, indicated staff was knowledgeable of what and to whom to report. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This federal tag is related to Complaints IN 836 and IN 748. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to ensure a staff member (RN # 1) accused of abuse by Resident I was immediately sent home, and was instead allowed to continue her shift for 5 hours, potentially affecting 39 residents residing on the North and South units on which the staff member worked, in a sample of 5 Units, and 1 of 3 residents reviewed for abuse in a sample of 8. Findings include: On 6/13/11 at 10:30 A.M., the Administrator provided a "Facility Incident Reporting Form," sent to the Indiana State Department of Health on 6/10/11. The form included: "...Brief Description of Incident:...At 2:50 am (sic) another aide responded to resident's call light and resident stated that nurse had hit her. Night supervisor notified of allegations...." An accompanying statement, dated 6/10/11, indicated, "...At 2:50am (sic) (CNA # 2) responded to resident's call light and states that resident told her 'that lady hit me again' and that a tall guy was with her. (LPN # 2), night supervisor was notified and spoke with nurse involved as well as resident. (LPN # 2) reports resident was 'pleasant and smiling' at this time...At approx 9:00 a.m., this administrator, the ADON, and the social worker met regarding the incident...No other alert/oriented residents had complaints of mistreatment...SW (social worker) also spoke with resident today and resident did not appear to have memory of any incident last night...(RN # 1) will be notified that she may return to work as scheduled." A facility "Employee Counselling (sic) Form," dated 6/11/11 and documented with LPN # 2's name, indicated, "...Type of Occurrence: Failure to immediately initiate suspension of staff member when knowledge was received of physical abuse allegation...Solution Discussed: Abuse policy review - with special focus on Reporting Procedures 'Any staff member alleged to have abused a resident will immediately be suspended from further time worked. The individual in charge of the staff member will initiate the suspension....' " On 6/14/11 at 12:05 P.M., the Administrator provided documentation that RN # 1 worked from 6/9/11 at 11:01 P.M. until 6/10/11 at 8:03 A.M. On 6/16/11 at 6:25 A.M., during interview with RN # 1, she indicated she notified her night supervisor at approximately 3:00 A.M., on 6/10/11 that Resident I had complained of RN # 1 hitting her. RN # 1 indicated she did not go into that resident's room for the remainder of her shift, but did work the remainder of her shift. On 6/15/11 at 8:45 A.M., the Assistant Director of Nursing provided the revised facility policy on "Abuse Prohibition," revised 2/11. The policy included: "...Purpose, To ensure that all allegations of abuse are investigated fully for possible substantiation...The alleged staff member will be relieved from his/her duties pending investigation..." This Federal Tag relates to Complaints IN 836 and IN 748. This deficiency was cited on 4/14/11 and 5/5/11. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-28(c)

Based on record review and interview, the facility failed to ensure its policy was followed related to timely reporting of allegations of abuse to the Administrator and State agency, and thoroughly investigating and protecting the resident during investigation for 1 of 4 residents reviewed related to abuse in a sample of 8. (Resident F) Resident F was physically and verbally abused by the visiting spouse, the allegation was not reported timely, and the resident was not protected from further abuse. A second allegation of abuse was not reported timely for investigation and protection of the resident. The deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 5/2/11 and began on 4/23/11. The Interim Administrator, Director of Nursing, Assistant Director of Nursing, and the Social Worker were notified of the Immediate Jeopardy on 5/2/11. The Immediate Jeopardy was removed on 5/4/11, but the facility remained out of compliance at the level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because the facility continued to inservice staff on abuse policies and procedures. Findings include: The facility's policy entitled "Abuse Prohibition" was requested and was provided on 5/2/11 at 11:00 a.m. on the Conference Room table.. Review of the policy indicated, "Policy: Allegations/suspicions/reports of abuse will be investigated immediately to ensure the safety and well being of the resident." The Procedure sections included, but were not limited to, "Any team member with knowledge of an alleged abuse incident will report it immediately to the unit/charge nurse, supervisor, nursing administration, DON (Director of Nursing), or Administrator....Nursing administration, DON, or Administrator will submit a written report to the appropriate state and local agencies...." The Prevention section included, but was not limited to, "Reported instances of any of the above situations will be investigated immediately and reported to the appropriate authorities and agencies....Review the situation and assess some of the following options: ...Is staff monitoring of the situation adequate to keep the resident from further harm? Is it necessary to consider contacting Adult Protective Services if a family member or guardian is involved? ...Witness statement should be documented as soon after the incident as possible. Nursing administration, DON, or Administrator will be notified immediately of any alleged incident so the investigative process can begin and precautionary measure taken to protect the resident from further problems." Resident F's clinical record was reviewed on 5/2/11 at 6:25 a.m. The record indicated the resident was admitted to the facility on [DATE] following placement of a gastrostomy feeding tube. A Care Conference Note, dated 4/27/11, indicated in the section for Social Services, "Interview w/ (with) (name of Resident F's husband) regarding incident on 4/23/11. See Social Service Notes for more details." Social Service Progress Notes for 4/26/11 indicated, "Was notified of an incident that occurred over the weekend with resident & her husband. Staff reported husband grabbed her by the hair and shook her. Staff was assisting the resident with cleaning up. The husband thought she was being combative. He stated he had [MEDICATION NAME] he could give her. He was told all meds (medications) needed to go through the facility & be ordered by a physician...." Review of facility binder containing files of incidents reported to the Indiana State Department of Health included, but was not limited to, a report titled, "Facility Incident Reporting Form," for "Incident Date: 4/23/11 Incident Time: 6:15 a.m." Attached to the report was copy of a handwritten statement, dated 4/23/11. The statement indicated, "I (name of CNA #6) entered the room of (name of Resident F) to change her and get her dressed. She was wet, she was digging at her bottom with her nails keeping herself raw & soar (sic). I was holding her hands so she would not dig at herself. (Resident F's) husband kept saying to (name of Resident F) let go of her. I explained to him that I was the one holding her hands so that she didn't scratch herself. (Name of Resident F's husband) got up from his seat and grabbed (name of Resident F) by the hair of the head and began shaking her head by the hair of her head yelling let go of her. He made the statement that he had Adavan (sic) ([MEDICATION NAME] - antianxiety medication) in his pocket & that he would give her some. I explained that no he could not do that." Also attached to the Facility Incident Reporting Form was copy of an e-mail, dated 4/25/11 at 12:43 p.m., sent from (name of LPN #4) to LPN #3. The e-mail indicated, "On April 23, 2011, my two aides were discussing the care of a resident with me. One stated that the husband had tried to pull her hair while they were taking her to the bathroom. Aide made the commit (sic) that the husband was being mean to the wife. The second aide reported that he was not being mean to her he was trying to keep her from being combative while they were taking her to the bathroom. I was the nurse on the unit at the time and did not see or hear this take place. I was in the residence (sic) room frequently that shift and did not observe the husband being mean to his wife. He did report that she needed something to keep her calm at which point I called the on call physician and got orders for PRN (as needed) [MEDICATION NAME] 1 mg along with a urinalysis. She was placed on acute charting at that time for the [MEDICATION NAME] order." The Facility Incident Reporting Form, in the section for Preventive Measures Taken, indicated, "Resident was monitored throughout weekend and acute charting was initiated following the placement of a new order for prn [MEDICATION NAME]. Recommended supervised visits. As of Monday April 25th, a personal sitter had been hired by family to sit at bedside to assist with care. A visitor log has been placed in the resident's room to be filled out by visitor or sitter. No further incidents of physical abuse have been noted. Nurse will be educated on facility policy regarding timely reporting of incidents of alleged abuse before next scheduled shift." A handwritten notation on the Facility Incident Reporting Form" indicated, "E-mailed to (name if Indiana State Department of Health employee) 4/27/11; 4/27/11 Faxed 5:10 by (name of Interim Administrator) to include statements 4 pages total." Interview with Social Worker (SW) #2 was completed on 5/2/11 at 8:35 a.m. SW #2 had come to the Conference Room where clinical records were being reviewed to locate the clinical record for Resident F. SW #2 indicated she wanted to put her note from Friday (4/29/11) about an incident with Resident F's husband into the clinical record. SW #2 indicated Resident F's husband had not been physically abusive but had called the resident names. The Social Service Progress Notes, dated 4/29/11 at 8:00 a.m., indicated, "Social Services was notified at 7:45 a.m. that another incident had occurred with (name of Resident F's husband). When I went to the resident room to address the incident (name of Resident F's husband) had already been picked up by his son, (name of Resident F's son). The sitter, (name of sitter) was still in the room. I questioned her about the happenings in the room. She states the CNAs were providing pericare because she had an incontinent episode. (Name of resident F) was combative because of the pain and confusion. She states, '(Name of resident F's husband) said stop acting like a 4 yr (year) old & told her to shut up.' She states he did not get physical with his wife. I then questioned CNA (name of CNA #6). She states (Name of Resident F's husband) doesn't understand that (name of Resident F) is in a lot of pain from how raw she is and is not trying to fight them in spite. She states he said, 'Shut up, (name of Resident F), Shut up (name of Resident F) - quit acting like a 4 yr old.' He also said, 'You can't talk to someone without a brain.' (Name of Resident F) then whispered to (name of CNA #6), 'Make him stop, make him stop!' (Name of CNA #6) states as she and other aid (sic) were leaving the room he went to the bedside & tried to tell resident that the staff was not trying to hurt her. I then questioned (name of CNA #4), the other CNA. She states he did tell her to shut up and yelled at her. She states this is not the first time. She states he has been verbally abusive with his wife and with staff in the past. She is not sure of the exact verbiage. I did try to contact (name of Resident F's son), but as unable to do so." Notes on 4/29/11 at 2:00 p.m., indicated SW #2 spoke with the Assistant Director of Nursing about the resident's "being so raw and uncomfortable." Notes on 4/29/11 at 2:30 p.m., indicated SW #2 spoke with the Ombudsman about the "ideas on plan of care. Will leave resident rights on abuse for (names of Resident F's husband and son)." During interview on 5/2/11 at 2:15 p.m., the Interim Administrator and Compliance Nurse, LPN #3, indicated the incident of verbal abuse of Resident F by Resident F's husband on 4/29/11 had not been reported to them. The Interim Administrator indicated the facility's protocol for reporting allegations of abuse had not been followed. An Immediate Jeopardy was identified on 5/2/11. The Immediate Jeopardy began on 4/23/11 when a visiting spouse physically and verbally abused his wife. The Interim Administrator, Director of Nursing, Assistant Director of Nursing, and the Social Worker were notified on 5/2/11 at 3:50 p.m., of the Immediate Jeopardy related to the failure to follow policies related to reporting, protecting residents, and investigating an allegation of physical and verbal abuse. The Immediate Jeopardy was removed on 5/4/11 at 4:00 p.m., when through observations, interviews, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy, and that the steps taken removed the immediacy of the problem. Review of policy and procedure, observations of staff and visitor interaction with residents, and staff interview related to inservicing on the facility's policy and procedure related to abuse\ indicated staff was knowledgeable of what and to whom to report. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This federal tag is related to Complaints IN 836 and IN 748. 3.1-28(c) 3.1-28(d)

Based on interview and record review, the facility failed to implement their policies on abuse prohibition, in that a staff member (RN # 1) accused of abuse by Resident I was not immediately sent home, and was instead allowed to continue her shift for 5 hours, potentially affecting 39 residents residing on the North and South units on which the staff member worked, in a sample of 5 Units, and 1 of 3 residents reviewed for abuse in a sample of 8. Findings include: 1. On 6/15/11 at 8:45 A.M., the Assistant Director of Nursing provided the revised facility policy on "Abuse Prohibition," revised 2/11. The policy included: "...Purpose, To ensure that all allegations of abuse are investigated fully for possible substantiation...The alleged staff member will be relieved from his/her duties pending investigation...." 2. On 6/13/11 at 10:30 A.M., the Administrator provided a "Facility Incident Reporting Form," sent to the Indiana State Department of Health on 6/10/11. The form included: "...Brief Description of Incident:...At 2:50 am (sic) another aide responded to resident's call light and resident stated that nurse had hit her. Night supervisor notified of allegations...." An accompanying statement, dated 6/10/11, indicated, "...At 2:50 am (sic) (CNA # 2) responded to resident's call light and states that resident told her 'that lady hit me again' and that a tall guy was with her. (LPN # 2), night supervisor was notified and spoke with nurse involved as well as resident. (LPN # 2) reports resident was 'pleasant and smiling' at this time...At approx 9:00 a.m., this administrator, the ADON, and the social worker met regarding the incident...No other alert/oriented residents had complaints of mistreatment...SW (social worker) also spoke with resident today and resident did not appear to have memory of any incident last night...(RN # 1) will be notified that she may return to work as scheduled." A facility "Employee Counselling (sic) Form," dated 6/11/11 and given to LPN # 2, indicated, "...Type of Occurrence: Failure to immediately initiate suspension of staff member when knowledge was received of physical abuse allegation...Solution Discussed: Abuse policy review - with special focus on Reporting Procedures "Any staff member alleged to have abused a resident will immediately be suspended from further time worked. The individual in charge of the staff member will initiate the suspension...." On 6/14/11 at 12:05 P.M., the Administrator provided documentation that RN # 1 worked from 6/9/11 at 11:01 P.M. until 6/10/11 at 8:03 A.M. On 6/16/11 at 6:25 A.M., during interview with RN # 1, she indicated she notified her night supervisor at approximately 3:00 A.M., on 6/10/11 that Resident I had complained of RN # 1 hitting her. RN # 1 indicated she did not go into that resident's room for the remainder of her shift, but did work the remainder of her shift. This deficiency was cited on 4/14/11 and 5/5/11. The facility failed to implement a systemic plan of correction to prevent recurrence. This Federal Tag relates to Complaints IN 836 and IN 748. 3.1-28(c)

Based on interview and record review, the facility failed to ensure a lap tray utilized for positioning was placed on a wheelchair, causing the resident to fall and obtain a laceration on her forehead, for 1 of 4 residents reviewed for falls, in a sample of 8. Resident A Findings include: The clinical record of Resident A was reviewed on 6/13/11 at 11:20 A.M. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 3/19/11, indicated Resident A had a short-term and long-term memory problem, was moderately impaired in cognitive skills for daily decision-making, was non-ambulatory, and required extensive assistance of one staff for transfer. A physician's orders [REDACTED]." An OT note, dated 4/1/11, indicated, "...Reason for Referral:...multiple medical complexities affecting positioning in wheelchair, general weakness and postural fatigue requiring OT intervention due to severe leaning and decreased safety in wheelchair...." A physician's orders [REDACTED]." A Care Plan, initially dated 5/23/09 and updated 4/15/11, indicated a problem of "Potential for falls R/T (related to): Attempts to stand unassisted. History of previous falls. Loses balance easily. Unsteady gait...." The Interventions included: "4/15/11 Deluxe tray (with) Quick release clamps to w/c to aide (sic) in positioning d/t (due to) poor posture." Nurse's Notes, dated 4/25/11 at 2:35 A.M., indicated, "Gotten up in w/c in TV lounge. Heard noise resident had fallen out of w/c. Has laceration to forehead (approximately) 3 cm (centimeters) length, width linear 0.1 cm edges approximated (and) steri striped (sic) (after) cleansing...Small am't (amount) bleeding from nose...Has red bruise area (approximately) 2 cm diameter on (right) knee...Denies pain except to head (and) nose...Assisted back into w/c by staff x (two)." The resident was transferred to the hospital on [DATE] at 4:00 A.M., and returned the same day at 7:10 A.M., with the steri strips left in place on the resident's forehead. On 6/13/11 at 12:15 P.M., the ADON (Assistant Director of Nursing) provided an "Incident/Accident Report," dated 4/25/11. The report included: "...Resident attempting to get up unassisted several times wanting to get up...resident gotten up per CNA in w/c, placed in TV lounge...Heard noise, resident on floor, w/c in normal position...Additional comments and/or steps taken to prevent recurrence: Education to new staff importance of CNA assignment sheet to keep on @ all times...." During interview at that time, the ADON indicated he was not employed by the facility on 4/25/11, and did not have additional information. On 6/16/11 at 6:25 A.M., during interview with RN # 1, she indicated she was the nurse working when Resident A fell on [DATE]. RN # 1 indicated a "new CNA" transferred the resident to a wheelchair, and did not place the lap tray on the wheelchair as ordered. On 6/15/11 at 10:45 A.M., the Assistant Director of Nursing (ADON) provided the current facility policy on "Falls Prevention," dated 9/08. The policy included: "Policy, To ensure that residents are safe and that appropriate preventive measures are initiated to minimize injuries related to falls...." This deficiency was cited on 4/14/11. The facility failed to implement a systemic plan of correction to prevent recurrence. This Federal tag relates to Complaint IN 724. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a bed alarm ordered for fall prevention was turned on (Resident A); failed to ensure alarms were not used in place of supervision; and failed to respond to alarms timely, resulting in a fall with a fractured hip (Resident B), for 3 of 3 residents reviewed for falls, in a sample of 6. Residents A, B, and C Findings include: 1. On 4/14/11 at 9:30 A.M., the facility compliance nurse provided the current facility policy on "Falls Prevention," dated 9/08. The policy included: "...To ensure that residents are safe and that appropriate preventive measures are initiated to minimize injuries related to falls. Procedure, If a fall occurs, the Falls Checklist will be initiated with all areas completed before the end of the shift the incident occurred...Nursing staff will document on the resident chart a thorough accounting of the incident as outlined in the Falls Checklist. Fall Preventive Measures...Motion Alarms (Bed/Chair)...Motion Sensors, Smart Floor Mat Alarm...Self-Releasing Alarm Belts, Restraints...All preventive measures must correlate with the resident's cognition level." 2. On 4/13/11 at 2:00 P.M., Unit Manager # 1 provided C.N.A. assignment sheets for her unit. The assignment sheets indicated that 23 residents resided on that unit. 17 of those 23 residents had some type of fall prevention alarm, to alert staff of unassisted rising. On 4/14/11 at 10:00 A.M., during interview with the compliance nurse, she indicated that her responsibility was to validate that "everything regarding a fall was documented properly, including updating the care plan." The compliance nurse indicated there was not "really an investigation on why a fall occurs," and that the usual intervention following a fall would be to add an alarm. 3. The closed clinical record of Resident B was reviewed on 4/13/11 at 1:20 P.M. Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission care plan, undated, indicated: "Falls/Safety Risk/Elopement Risk. Goal: Resident will remain free of injuries and falls. Keep call bell in reach. Enc. use of call light. Instruct resident on safety measures...Mobility alarm SPA (sensor pad alarm) bed (and) chair...." Nurses Notes included the following notations: 3/21/11 (untimed): "Mental status varies over the course of the day. Confused/forgetful. Decreased safety awareness...Up with assist x 1, wheelchair...." 3/23/11 "11p-7A": "...Confused/Forgetful, Decreased safety awareness...Up with assist...." 3/24/11 at 11:00 A.M.: "...Confused/Forgetful, Decreased safety awareness...Up with assist (of two)...Bathroom with assist...." 3/25/11 at 3:00 A.M.: "Res remains delusional @ this time D/T (due to) res thinks her family is here et this us a hotel...thinks that nephew was in the bed next to her...." 3/25/11 at 11:00 A.M.: "Alert (with) some confusion...needs extensive assist (with) ADL's (activities of daily living)...." 3/25/11 at 3:30 P.M.: "Res spa (sensor pad alarm) heard sounding, CNA went to resident's room, resident found lying on back on floor in front of closet. Denies pain, bruise noted to lateral left forehead...assisted to w/c (with) assist x 3...." 3/25/11 at 3:45 P.M.: "Prevantive (sic) to prevent recurrent fall - self-release seat belt...." The resident was transferred to the hospital on [DATE] at 4:45 P.M. A hospital discharge summary indicated, "...The patient was admitted ...initially because of weakness and falling down which they thought she just had a urinary tract infection. However, the patient was not able to walk and was hurting on her left side. It was found out the patient had a left femoral neck fracture...." On 4/13/11 at 2:15 P.M., during interview with the compliance nurse, she indicated she would not have considered Resident B interviewable. She indicated Resident B had attempted unassisted ambulation earlier on 3/25/11, "probably around 2:00 P.M.," and a sensor alarm was placed on the resident's bed and wheelchair. The compliance nurse indicated she did not know why documentation regarding the attempt at unassisted ambulation was not in the clinical record. The compliance nurse indicated she was not present when the resident fell , but thought the staff heard the alarm, and found her on the floor in her room. The compliance nurse indicated she had a "falls checklist" that she completes after a fall, to ensure staff called the family and physician and updated the care plan and assignment sheets. The compliance nurse indicated she did not know if the resident had transferred herself. 4. On 4/13/11 at 9:10 A.M., during the initial tour, Unit Manager # 1 indicated Resident A had fallen the previous night, and was not interviewable. Unit Manager # 1 indicated Resident A required a sensor pad alarm to her wheelchair and bed. Unit Manager # 1 indicated a tabs alarm was added to the wheelchair following the fall the previous night. At that time, Resident A was observed lying in bed. A request was made to determine if the resident's bed sensor alarm was functioning. Unit Manager # 1 checked the alarm, and indicated the alarm was not turned on. Unit Manager # 1 turned the alarm on, and instructed the resident to "Promise you won't get up without asking for help." Unit Manager # 1 indicated she did not know why the alarm was not turned on. The clinical record of Resident A was reviewed on 4/13/11 at 10:40 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 1/17/11, indicated the resident scored a 9 out of 15 on a cognitive assessment, required limited assistance of 1 staff for transfer and ambulation, and had not fallen since the previous assessment. A test for "Balance during transitions and walking" indicated "Not steady, only able to stabilize with human assistance" while moving from seated to standing position, walking, and surface-to-surface transfer. A "Fall Risk" assessment, dated 1/19/11, indicated Resident A had intermittent confusion, had 1-2 falls in the previous 3 months, had a balance problem while standing, required the use of an assistive device, and had a total score of 12. The assessment indicated, "Total score of 10 or above represents HIGH RISK" for falls. physician's orders [REDACTED]. to bed d/t decreased safety awareness." Nurse's Notes included the following notations: 4/12/11 at 10:00 P.M.: "Staff reports res (resident) yelling out 'nurse.' Upon entering res bathroom noted resident sitting on bottom of floor. W/C breaks (sic) locked. Res assessed for injury, none apparent...Res assisted off floor (with) extensive assist x (two) staff (and) gait belt...Res. placed to bed, alarms on et (and) functioning, call light within reach. TABS alarm added to res. w/c for preventative nursing measure related to decreased safety awareness." 4/13/11 at 1:00 A.M.: "Resident (up) getting in chair. Resident shut off bed alarm (before) getting out of bed. Instructed resident to leave alarms alone et call for help before getting up." A "Falls Care Plan," initially dated 10/31/10, indicated a problem of "History of falls...Contributing factors, Dementia, Arthritis...Use of w/c...Refusal of assistance, Refusal to use assistive devices." The approaches indicated, "Encourage to stay seated or wait for assistance before transferring after meals. Ensure frequently used items are within reach: Call system; Light cord; Water, Is at risk for falls; will use the following preventive measure: Bed bolsters to bed...4/12/11 TABS Alarm to w/c for n. (nursing) measure." On 4/14/11 at 9:00 A.M., the compliance nurse provided an "Incident/Accident Report," dated 4/12/11. The report included, "...Noted res on floor...(no) apparent injury, refer to nurses note...Additional comments and/or steps to prevent recurrence: tabs alarm to w/c." Documentation regarding a sensor alarm sounding or functioning was lacking. The compliance nurse indicated at that time that she was unaware if the prescribed sensor alarm sounded or not. 5. On 4/13/11 at 9:10 A.M., during the initial tour, the compliance nurse indicated Resident C had a [DIAGNOSES REDACTED]. On 4/13/11 at 11:30 A.M., Resident C was observed sitting in a wheelchair in a lounge, asleep. A self release seatbelt alarm was observed on the resident. No staff were observed interacting with the resident. The clinical record of Resident C was reviewed on 4/13/11 at 11:45 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/8/11, indicated Resident C had a short-term and long-term memory problem, was moderately impaired in cognitive skills for daily decision-making, required extensive assistance of two+ staff for transfer and bed mobility, and did not ambulate. A test for "Balance during transitions and walking" indicated "Not steady, only able to stabilize with human assistance" while moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. The MDS assessment indicated the resident had not fallen since the previous assessment. Nurses Notes included the following notations: 2/15/11 at 5:30 P.M.: "CNA approached Resident room et heard alarm sounding. Resident found in bathroom floor on (left) side...When resident asked what happened she stated 'was going to bathroom.' Resident toileted after writer evaluated." 2/15/11 at 5:45 P.M.: "(Physician) update on incident. Received new orders for UA, C/S (urinalysis, culture and sensitivity). Also received orders for self releasing seat belt...." A "Falls Care Plan," initially dated 6/10, indicated a problem of "History of falls...Contributing factors, Alzheimer's Diagnosis, Forgets to ask for assistance...Generalized weakness..." The approaches indicated, "...Encourage to stay seated or wait for assistance before transferring after meals...Is at risk for falls; will use the following preventive measure: Sensor pad to bed/recliner...12/7/10 tabs alarm to w/c, 2/15/11 Self releasing seat belt while in w/c." On 4/14/11 at 10:00 A.M., during interview with the compliance nurse, she indicated, "When (Resident C) was down the hall, we would hear the alarms, and by the time we would get there, she would be on the floor. So we moved her closer to the nursing station." The compliance nurse indicated the resident had experienced several falls. The compliance nurse indicated there was not a process in place to determine the cause of the falls. This federal tag relates to Complaint IN 724. 3.1-45(a)(2)