Every finding on record at Rosegate Village

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 2 of 3 observations. Staff hair was not covered while in the kitchen, food preparation, and serving areas. (Cook 2, Culinary Aide 3) Findings include: During a kitchen observation, on 1/13/26 from 11:25 a.m. to 11:35 a.m., the following was observed:- [NAME] 2 was observed working at the steamtable that held the noon meal foods. [NAME] 2 was observed taking the starting food temperatures and plating the noon meal. [NAME] 2 was observed wearing a white hair net that covered the hair above his ears to the top of his head. He was also observed wearing a beard restraint that covered the facial hair near the jaw line, below the ears and surrounding the lip area. [NAME] 2's facial hair, approximately one-half inch in length, located in front of the ears, was observed to not be covered. - Culinary Aide 3 was observed walking through-out the kitchen area and near the steamtable that held the noon meal foods. Culinary Aide 3 was observed wearing a white hair net. Culinary Aide 3's hair, in front of his ears and in the middle of his forehead area, approximately 2 inches in length, was observed to not be covered. During a follow-up kitchen observation, on 1/13/26 from 12:20 p.m. to 12:35 p.m., the following was observed: - [NAME] 2 was observed working at the steamtable that held the noon meal foods. [NAME] 2 was observed plating the noon meal and taking the ending food temperatures. [NAME] 2 was observed wearing a white hair net that covered the hair above his ears to the top of his head. He was also observed wearing a beard restraint that covered the facial hair near the jaw line, below the ears and surrounding the lip area. [NAME] 2's facial hair, approximately one-half inch in length, located in front of the ears, was observed to not be covered. - Culinary Aide 3 was observed walking through-out the kitchen area and near the steamtable that held the noon meal foods. Culinary Aide 3 was observed wearing a white hair net. Culinary Aide 3's hair, in front of his ears and in the middle of his forehead area, approximately 2 inches in length, was observed to not be covered. During an interview on 1/13/26 at 12:40 p.m., the Dietary Manager indicated dietary staff were to keep their hair covered while in the kitchen. On 1/13/26 at 1:45 p.m., the Executive Director provided a copy of the Culinary Personal Hygiene policy, dated May of 2025, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all employees working in the culinary department must wear a clean hair restraint which effectively covers all hair.employees with facial hair.must wear a beard restraint that effectively covers all facial hair. On 1/13/26 at 3:00 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-26, effective April 16, 2025, indicated, .food employees shall wear hair restraints, such as hair coverings or nets, beard restrains.that are designed and worn to effectively keep their hair form contacting .exposed foods. 3.1-21(i)(2)3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a resident was referred to the State-designated authority contractor for a Level I screening Resident Review (PASARR) mental health assessment for new diagnosis for mental illness evaluation and determination for 2 of 2 residents reviewed for PASARR. (Residents 12, Resident 79) Findings include: 1. On 1/15/26 at 11:35 a.m., Resident 79's clinical record was reviewed. The diagnoses included, but were not limited to, chronic diastolic (congestive) heart failure and major depressive disorder. Resident 79 was admitted to facility on 9/24/24 with a PASARR (Pre-admission Screening and Resident Review) Level I completed. On 9/24/24, a new diagnosis of psychotic disorder with hallucinations due to known physiological condition was added without a new PASARR Level I completed. A Quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated Resident 79 was moderately cognitively impaired. 2. On 1/15/26 at 1:05 p.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and anxiety. Resident was admitted to facility on 10/11/24 with a PASARR Level I completed. On 5/1/25 a new diagnoses of psychotic disorder with hallucinations was added without a new PASARR Level I completed. A Quarterly Minimum Data Set (MDS) assessment. dated 10/22/25, indicated Resident 12 was severely cognitively impaired. During an interview on 1/15/26 at 11:35 a.m. the Executive Director indicated that a PASARR Level I should be completed with any new diagnoses and a PASARR Level I was not completed for Resident 79 and Resident 12. On 1/15/26 at 11:35 a.m., the Executive Director provided a copy of an American Senior Communities Indiana PASARR Policy, dated 11/2017, and indicted that it was the current policy. The policy indicated it was the policy of the facility to ensure that any Pre-admission Screening and Resident Review (PASARR) recommendations which impact those with Intellectual, Mental Disability or related conditions were completed as prescribed and PASARR assessments were updated with significant changes in mental or physical status. 3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on record review and interview, the facility failed to hold blood pressure medications for a resident with low blood pressure per the physician orders for 1 of 26 clinical record reviews. (Resident 98) Finding includes: On 1/16/26 at 11:45 a.m., the clinical record of Resident 98 was reviewed. The diagnoses included, but was not limited to, venous insufficiency and hypertension. The Physician Orders included, but was not limited to: - Metoprolol succinate tablet, extended release 24 hour, 50 milligrams (mg), administer 50 mg, by mouth one time a day. Hold if systolic blood pressure is less than 110, or heart rate less than 60, initiated 1/8/26. - Lisinopril tablet 20 mg, by mouth one time a day, hold if systolic blood pressure is less than 110, initiated 1/8/26. A Vital Sign Record, dated 1/9/26, indicated Resident 98's systolic blood pressure was 90. A Medication Administration Record, dated January 2026, indicated lisinopril and metoprolol were administered on 1/9/26. During an interview on 1/16/26 at 12:03 p.m., the Director of Nursing indicated the lisinopril and metoprolol should have been held on 1/9/26 as indicated by the physician's order. During an interview on 1/20/26 at 8:55 a.m., the Director of Nursing indicated the facility was unable to provide a specific policy for following physician orders. The facility was to follow state and federal regulations. 35-(g)(2)

Based on interview and record review, the facility failed to protect the residents' rights to be free from misappropriation of property for 1 of 2 allegations of misappropriation of property. (RN 3, Resident D, Resident E) Findings include: During an interview on 2/20/25 at 9:40 a.m., the Administrator indicated that during a facility wide audit, it was brought to management's attention on 1/29/25 that a few narcotic count sheets, whose counts were correct and had been initially thought to be fine, appeared to have medications signed out for residents who had been out at the hospital at the time of the suspicious administration. The two suspicious narcotic administration sheets, one for Resident D and one for Resident E, had each been signed out by RN 3. RN 3 had a drug screening test on 1/29/25 after the reasonable suspicion was discovered from the medications signed out for residents who were not physically in the building. RN 3 tested positive for both opioids and benzodiazepines. RN 3 did not confess to taking the residents' medications, telling the Administrator RN 3 had taken hydrocodone from an old prescription that belonged to RN 3 and that RN 3 had taken Xanax from a family member's prescription. RN 3 was terminated for misappropriation of resident medications for the suspected drug diversion. On 2/20/25 at 11:55 a.m., the clinical records for Resident D was reviewed. The diagnoses for Resident D included, but were not limited to, chronic lymphocytic leukemia (a type of cancer that affects white blood cells), pneumonia, and congestive heart failure (a condition where the heart can't pump blood effectively). The Scheduled 5-Day MDS assessment, dated 1/21/25, indicated Resident D was cognitively intact. A physician's order, initiated 1/16/25, indicated Resident D had hydrocodone-acetaminophen 5-325 mg, ordered once as needed every six hours. Resident D's narcotic count sheet for the hydrocodone-acetaminophen 5-325 mg order had a tablet signed out on 1/28/25 at 8:00 a.m. by RN 3. Resident D was transferred out to the hospital on 1/21/25 and did not return to facility. On 2/20/25 at 11:55 a.m., the clinical records for Resident E was reviewed. The diagnoses for Resident E included, but were not limited to, sepsis (a severe potentially life-threatening infection) and congestive heart failure. The Significant Change in Status MDS assessment, dated 2/4/25, indicated that Resident E had severe cognitive impairment. A physician's order, initiated 1/3/25 and discontinued 1/30/25, indicated Resident E had oxycodone (a prescription-controlled opioid substance used to treat pain) 5 mg, ordered every four hours as needed. Resident E's narcotic count sheet for oxycodone 5 mg order had a tablet signed out for 1/8/25 at 8:00 a.m. by RN 3. Resident E was transferred out to the hospital on 1/7/25 and did not return to the facility until 1/29/25. During an interview on 2/20/25 at 11:05 a.m., the Administrator stated RN 3 did not ever admit to taking any medications, however, the drug diversions had most likely occurred based on the two narcotic sheets signed out by RN 3 for residents who were not in the building at the alleged administration time. On 2/20/25 at 11:05 a.m., the Administrator provide a copy of the facility's abuse policy, titled Abuse Prohibition, Reporting, and Investigation, dated for February 2010, and indicated it was the policy in use by the facility. A review of the policy indicated that residents are to be free from abuse, including, but not limited to, misappropriation of resident property. This citation relates to Complaints IN00451925 and IN00452436. 3.1-28(a)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse when a CNA spit in a resident's face for 1 of 3 residents reviewed for abuse. (Resident B, CNA 1) Findings include: On 1/15/25 at 8:23 a.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 12/23/24. A review of the incident report indicated CNA 1 spit in Resident B's face. The clinical record for Resident B was reviewed on 1/15/25 at 8:54 a.m. The diagnoses included, but were not limited to, stress compression fracture of first lumbar vertebrae and chronic obstructive pulmonary disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 1/7/25, indicated Resident B was severely cognitively impaired. During an interview on 1/15/25 at 9:35 a.m., the Administrator indicated, on 12/23/24 at approximately 9:15 p.m., Licensed Practical Nurse (LPN) 1 called her to report that CNA 1 spit at Resident B. CNA 1 was terminated after the investigation was completed. During an interview on 1/15/25 at 9:58 a.m., LPN 1 indicated Resident B was being aggressive and combative with staff, so LPN 1 and three CNA's went in Resident B's room to try to provide care. During care Resident B slapped CNA 1 in the face. LPN 1 attempted to redirect Resident B, then Resident B spit in CNA 1's face. At that time, CNA 1 said oh no way and spit back in Resident B's face. LPN 1 immediately removed CNA 1 from Resident B's room. During an interview on 1/15/25 at 10:15 a.m., CNA 2 indicated she was at the nurse's station when CNA 1 walked to the nurse's station and said she had to go home because she spit in Resident B's face. On 1/15/25 at 10:20 a.m., the Administrator provided a copy of CNA 1's written statement, dated 12/23/24. A review of the written statement indicated when CNA 1 was providing care to Resident B, Resident B spit in CNA 1's face. CNA 1 spit back at Resident B. CNA 1 lost it for a minute. On 1/15/25 at 10:20 a.m., the Administrator provided a copy of LPN 1's written statement, dated 12/23/24. A review of the written statement indicated while LPN 1 was assisting with Resident B's care, Resident B spit in CNA 1's face. At that time, CNA 1 said oh no way and spit back in Resident B's face. An Employee Communication Form, dated 12/24/24, indicated CNA 1 spit at Resident B. CNA 1 statement confirmed the incident occurred. CNA 1 was notified by phone that the abuse allegation was substantiated and CNA 1 was terminated for violating the resident abuse policy. On 1/15/25 at 8:23 a.m., the DON provided a copy of a facility policy, dated 6/2023, titled Abuse Prohibition, Reporting, and Investigation, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to provide each resident with an environment that is free from abuse. This citation relates to Complaint IN00450012. 3.1-27(a)(1)

Based on interview and record review, the facility failed to follow the abuse policy and ensure an alleged perpetrator of abuse was immediately removed from the facility for 1 of 3 allegations of abuse reviewed. (CNA 1) Findings include: On 1/15/25 at 8:23 a.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 12/23/24. A review of the incident report indicated CNA 1 spit in Resident B's face. During an interview on 1/15/25 at 9:58 a.m., LPN 1 indicated Resident B was being aggressive and combative with staff, so LPN 1 and three CNA's went in Resident B's room to try to provide care. During care Resident B slapped CNA 1 in the face. LPN 1 attempted to redirect Resident B, then Resident B spit in CNA 1's face. At that time, CNA 1 said oh no way and spit back in Resident B's face. LPN 1 immediately removed CNA 1 from Resident B's room. LPN 1 went to the employee break room to call the Administrator and CNA 1 walked to the restroom, which was not in sight of the break room. When LPN 1 got to the nurse's station CNA 1 was walking out of the restroom. LPN 1 asked CNA 1 to write a statement then escorted her out of the facility. LPN 1 did not supervise CNA 1 after they left Resident B's room until after LPN 1 returned to the nurse's station and CNA 1 walked out of the restroom. During an interview on 1/15/25 at 10:15 a.m., CNA 2 indicated she was at the nurse's station when CNA 1 walked to the nurse's station and said she had to go home because she spit in Resident B's face. CNA 2 did not see CNA 1 at any point after she spit in Resident B's face until CNA 1 walked to the nurse's station. On 1/15/25 at 8:23 a.m., the DON provided a copy of a facility policy, dated 6/2023, titled Abuse Prohibition, Reporting, and Investigation, and indicated this was the current policy used by the facility. A review of the policy indicated any staff member implicated in the alleged abuse will be removed from the facility at once. This citation relates to Complaint IN00450012. 3.1-28(d)

Based on interview and record review, the facility failed to ensure that written Notice of Transfer and Discharge was provided to the resident and resident's representative for 3 of 3 residents reviewed for written transfer and discharge notification. The transfer and bed-hold appeal process was not provided to the resident or the resident representative. (Resident 42, Resident 107, Resident 279) Findings include: 1. On 10/30/24, at 4:30 p.m., Resident 42's clinical record was reviewed. The diagnoses included, but were not limited to, fractured femur (thighbone) and Alzheimer's disease. The face sheet indicated Resident 42 had a resident representative. The Significant Change Minimum Data Set (MDS) assessment, dated 10/21/24, indicated Resident 42 was severely cognitively impaired. The clinical record's census tab indicated Resident 42 was transferred to the hospital emergency department on 10/11/24. The ASC Hospital-ER (emergency room ) Transfer Form document, dated 10/11/24, indicated Resident 42 was transferred to the hospital emergency department for a facility-initiated hospital transfer on 10/11/24 at 9:15 a.m. The document also indicated the following: -The resident representative was notified of Resident 42's condition, reason for transfer, and location of transfer. -The resident and the resident representative were provided the transfer form and the bed-hold policy. -The transfer form lacked specific details regarding the appeal rights, process, and contact information related to the bed-hold policy. 2. On 10/29/24 at 11:29 a.m., Resident 107's clinical record was reviewed. The diagnoses included, but were not limited to, fractured femur (thighbone) and Alzheimer's disease. The face sheet indicated Resident 107 had a resident representative. The Quarterly Minimum Data Set (MDS) assessment, dated 8/6/24, indicated Resident 107 was severely cognitively impaired. The clinical record's census tab indicated Resident 107 was transferred to the hospital emergency department on 4/26/24. The ASC Hospital-ER (emergency room ) Transfer Form document, dated 4/26/24, indicated Resident 107 was transferred to the hospital emergency department for a facility-initiated hospital transfer on 4/26/24 at 12:00 p.m. The document also indicated the following: -The resident representative was notified of Resident 107's condition, reason for transfer, and location of transfer. -The resident and the resident representative were provided with the transfer form and the bed-hold policy. -The transfer form lacked specific details regarding the appeal rights, process, and contact information related to the bed-hold policy. 3. On 10/29/24, at 11:29 a.m., Resident 279's clinical record was reviewed. The diagnoses included, but were not limited to, malnutrition, COPD (Chronic Obstructive Pulmonary Disease), and persistent postprocedural fistula (a fistula that stems from an abscess or infection). The face sheet indicated Resident 279 had a resident representative. The New Admission Minimum Data Set (MDS) assessment, dated 10/20/24, indicated Resident 279 was cognitively intact. The clinical record's census tab indicated Resident 279 was transferred to the hospital emergency department on 10/17/24. The ASC Hospital-ER (emergency room ) Transfer Form document, dated 10/17/24, indicated Resident 279 was transferred to the hospital emergency department for a facility-initiated hospital transfer on 10/17/24 at 9:57 a.m. The document also indicated the following: -The resident representative was notified of Resident 279's condition, reason for transfer, and location of transfer. -The resident and the resident representative were provided with the transfer form and the bed-hold policy. -The transfer form lacked specific details regarding the appeal rights, process, and contact information related to the bed-hold policy. During an interview on 10/30/24 at 1:01 p.m., Resident 279 and his representative indicated on 10/17/24 the resident was transferred to the hospital. The facility informed them of the transfer; however, no written documentation of the transfer or the bed-hold policy was provided to them. During an interview on 10/31/24 at 11:18 a.m., the Director of Nursing Services (DNS) indicated Resident 42, Resident 107 and Resident 279 were facility-initiated transfers to the hospital emergency department. The ASC Hospital-ER Transfer Form document was provided to the residents and their resident representatives. The transfer document included the bed-hold policy; but lacked the following appeal process information: - The name, address (mail and email), telephone number of the State entity which receives such appeal hearing requests. - Information on how to obtain an appeal form. - Information on obtaining assistance in completing and submitting the appeal hearing request. - The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. 3.1-12(a)(9)(D)

Based on interview and record review, the facility failed to ensure complete and accurate documentation for 2 of 21 residents reviewed. (Resident B, Resident C) Findings include: 1. On 10/28/24 at 10:00 a.m., the clinical record of Resident C was reviewed. The diagnoses included, but were not limited to, end stage renal disease, myocardial infarction (a heart attack), COPD (a lung disease causing breathing difficulties), and dependence on renal dialysis (treatment that removes excess fluid, waste, and toxins from the blood). A physician's order report, dated for active orders for 10/1/24 through 10/31/24 included, but was not limited to: An order with a start date of 10/19/24 and a discontinued date of 10/20/24, to obtain a daily weight for Resident C with special instructions to notify MD (Medical Doctor) of a weight gain of three pounds in one day or of five pounds in a week once a day at 5:00 a.m. An order with a start date of 10/20/24 and no end date to obtain a daily weight for Resident C with special instructions to notify MD (Medical Doctor) of a weight gain of three pounds in one day or of five pounds in a week once a day on the 6:30 a.m. through 2:30 p.m. shift. A review of resident's vitals indicated a weight recorded for Resident C on 10/19/24 of 236 pounds. Resident C's record lacked documentation of any other recorded weights. During an interview the DON (Director of Nursing) indicated that the weights should have been obtained and recorded in the electronic healthcare record daily as ordered. 36746 2. On 10/30/24 at 9:45 a.m., the clinical record of Resident B was reviewed. The diagnoses, included but were not limited to, disorders of bone density and structure, and osteopenia. A Hospice Note, dated 9/26/24 at 10:25 a.m., indicated bruising and pallor of the right lower extremity. Stat (immediate) x-ray ordered for bruising along entire right shin and knee. On 10/30/24 at 10:33 a.m., the Administrator provided a State Reportable Incident, dated 9/27/24. The reportable indicated during routine care, staff noted a new on-set of bruising to Resident B's right lower leg. Root cause determined to be osteopenic bones as well as chair positioning. The facility reportable indicated Resident B had bumped her leg on the table in the dining room. A Physicians Progress Note, dated 9/30/24 at 12:10 p.m., indicated a fracture of upper end of right tibia, traumatic bruising of multiple sites of the lower extremity. Resident B was frail with generalized osteoarthritis of multiple sites. A Care Plan, dated 8/10/20, indicated Resident B was at risk for skin beak down. The interventions included but were not limited to, assess and document skin condition weekly and as needed. Resident B's clinical record lacked documented weekly skin assessments for 9/16/24, 9/23/24, and 9/30/24. During an interview on 10/30/24 at 1:33 p.m., the Director of Nursing indicated the weekly skin assessments should have been documented in the residents clinical record. On 10/31/24 at 1:11 p.m., the Administrator provided a policy titled Documentation Guidelines for Nursing, dated July, 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated Purpose: To accurately document in an organized manner all information related to the resident in the medical record. This Federal tag relates to Complaint IN00444626. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 4 of 5 observations. Cold food was not maintained at or below 41 degrees Fahrenheit, staff hair was not covered, food was not labeled and closed, and the dumpster lids were not closed. (Dietary Manager, Cook 2, Cook Aide 3) Findings include: 1. During the initial kitchen observation with Cook 2, on 6/20/23 from 11:20 a.m. to 12:20 p.m., the following starting temperatures were recorded for foods being held at the steam table unit for the noon meal: pureed bread was 130 degrees Fahrenheit (F); egg salad was 50 degrees F; pureed salad was 50 degrees F; and chopped hard boiled eggs were 52 degrees F During a follow up kitchen observation with Cook 2 and the Dietary Manager (DM), on 6/20/23 from 1:25 p.m. to 2:15 p.m., the following temperatures were recorded for foods being held at the steam table unit for the noon meal: lettuce was 51 degrees F; diced ham chunks were 52 degrees F; diced turkey chunks were 50 degrees F; shredded cheese was 54 degrees F; and egg salad was 50 degrees F; During an interview at that time, the DM indicated the holding food temperatures were to be at or below 41 degrees F for the cold foods. During a follow up kitchen observation with the DM, on 6/20/23 from 2:30 p.m. to 2:40 p.m., the following temperatures were recorded for foods having been held at the steam table unit for the noon meal: lettuce was 44 degrees F; diced ham chunks were 49 degrees F; diced turkey chunks were 52 degrees F; shredded cheese was 50 degrees F; chopped hard boiled eggs were 43 degrees F; and egg salad was 46 degrees F; During an interview at that time, the DM indicated the cold foods were not maintained at the required holding temperatures. 2. On 6/20/23 from 11:20 a.m. to 12:20 p.m., the Dietary Manager (DM) was observed walking through out the kitchen area. The DM was observed to have hair in front of the ears and at the neckline, approximately 2 inches in length, that was observed to not be covered. Cook 2 was observed walking through out the kitchen area. Cook 2 was observed to have hair braids from the top of her ears to the top of her head, that was observed to not be covered. Cook Aide 3 was observed walking through out the kitchen area. Cook Aide 3 was observed to have hair at the neckline that was approximately 3 inches in length and a short ponytail/bun just above the neckline that was observed to not be covered. The same was observed on 6/20/23 from 1:25 p.m. to 2:15 p.m., 6/20/23 from 2:30 p.m. to 2:40 p.m., and 6/21/23 from 9:30 a.m. to 9:40 a.m. On 6/21/23 at 9:38 a.m., a sign posted on an entrance/exit kitchen door was observed. A review of the sign indicated, Dietary personnel .Hairnet required. During an interview on 6/21/23 at 9:40 a.m., the DM indicated all staff hair was to be kept covered while in the kitchen. 3. On 6/21/23 at 9:30 a.m., the dry storage pantry area was observed with the Dietary Manager (DM). The following was observed: a. One large plastic bin next to the hand washing sink was half full of a white powdered substance. The bin's lid was observed to not be closed and it lacked a label to indicate what was inside the bin. b. In the dry storage area, observed 2 small plastic bins on a shelf. The bins were partially full of a white substance. The bin lids were observed to not be closed. During an interview at that time, the DM indicated the bins were to be kept closed and labeled to identify the container's contents. 4. On 6/21/23 at 9:36 a.m. the dumpster area, located approximately 30 feet from the kitchen's rear door, was observed with the Dietary Manager (DM). The following was observed: a. The dumpster area had 2 large dumpsters. The dumpster on the left was observed to have 4 top lids. Two of the four top lids were observed to not be closed. b. The area surrounding the dumpster area had multiple used plastic gloves, empty plastic gallon containers and other debris on the ground. c. A large uncovered plastic trash can was observed between the two dumpster containers. Inside the uncovered trash can was a partially filled plastic bag that held unidentifiable debris. During an interview at that time, the DM indicated the dumpster lids were to be kept closed and the area was to be kept free of debris. On 6/21/23 at 10:33 a.m., the Administrator provided a copy of the Culinary Personal Hygiene policy, dated May 2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all employees working in the culinary department must wear a clean hair restraint which effectively covers all hair . On 6/21/23 at 10:33 a.m., the Administrator provided a copy of the American Senior Communities: Food Storage policy, dated May 2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .containers with covers must be used for .Bulk foods . On 6/21/23 at 10:51 a.m., the Administrator provided a copy of the FDA Food Code 2022, chapter 5, Water, Plumbing, and Waste policy and indicated it was the current policy in use by the facility. A review of the policy indicated, .receptacles and waste handling units for REFUSE .used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers . On 6/21/23 at 10:51 a.m., the DM provided a copy of the American Senior Communities: Food Temperatures policy, dated June 2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .the facility will maintain proper food temperature control to prevent food borne illness .cold food will be held at or below 41 degrees F . On 6/21/23 at 3:45 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-24, effective November 13, 2004, indicated, .potentially hazardous food shall be maintained as follows .maintain food at a temperature of forty-one (41) degrees Fahrenheit or less .working containers holding food or food ingredients that are removed from their original packages for use in the retail food establishment, such as .flour .sugars .shall be identified with the common name of the food .such as .sugar .closed containers .food employees shall wear hair restraints .hair coverings or nets .that are designed and worn to wear effectively keep their hair from contacting .exposed food .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside .accumulation of debris .are minimized .effective cleaning is facilitated around .the unit . This Federal tag is relates to Complaints IN00407655 and Complaint IN00408396. 3.1-21(i)(2) 3.1-21(i)(3) 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure residents were transferred per plan of care with the right amount of assistance to prevent falls for 3 of 3 residents reviewed for falls. This resulted in one resident sustaining a left distal femur fracture and a right proximal femur fracture. (Resident D, Resident C, Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/14/22 at approximately 12:00 p.m. when the facility failed to ensure a resident was transferred with a mechanical lift per plan of care. This resulted in the resident sustaining a left distal femur fracture and a right proximal femur fracture. The Director of Nursing was notified of the Immediate Jeopardy on 4/14/22 at 12:30 p.m. The Immediate Jeopardy was removed on 5/2/22 at 2:00 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: 1. During a tour of the facility on 4/28/22 at 12:33 p.m., Resident B was observed hanging above his wheelchair in a mechanical lift. CNA 1 (Certified Nursing Assistant) was the only staff member in Resident B's room while he was up in the mechanical lift. During an interview on 4/28/22 at 12:35 p.m., CNA 1 indicated she made a mistake and was supposed to have another staff member with her when using a mechanical lift. The clinical record for Resident B was reviewed on 4/28/22 at 12:36 p.m. The diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], and muscle weakness. The Annual Minimum Data Set (MDS) assessment, dated 2/27/22, indicated Resident B was cognitively intact, was totally dependent for transfer and required physical assistance of at least 2 staff. A care plan, dated 7/16/19 and current through 6/2/22, indicated Resident B required assistance with activities of daily living (ADLs) including bed mobility, transfers, eating and toileting related to [CONDITION(S)], depression, neuromuscular dysfunction bladder, hypertension, irritable bowel syndrome, [CONDITION(S)], and weakness, prefers to keep bed in high position. The interventions included, but were not limited to, assist of 2 staff with transfers as needed with mechanical lift. A current Physician's orders indicated transfer with mechanical lift with assistance of 2 staff members, initiated 7/17/19. On 4/29/22 at 11:30 a.m., Resident B indicated he would not answer any questions regarding transfers with the mechanical lift. During an interview on 4/28/22 at 2:48 p.m., the Director of Nursing indicated there should have been at least 2 staff members in Resident B's room when he was being transferred with the mechanical lift. On 4/29/22 at 10:15 a.m., the Director of Nursing provided a document, titled Mechanical Lift . Skills Validation, dated 3/2012, and indicated this was the current skills validation used during training. A review of the document indicated Two (2) staff is required at all times when using a mechanical lift. 2. During an interview on 4/28/22 at 1:00 p.m., Resident C indicated she had a fall recently, but she was not able to remember how she transferred or how many staff members assisted her. The clinical record for Resident C was reviewed on 4/28/22 at 1:10 p.m. The diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], and physical debility. A Significant Change MDS assessment, dated 3/30/22, indicated Resident C was not cognitively intact and required extensive assist for transfers with at least 2 staff members for physical assist. A care plan, dated 12/9/16 and current through 7/7/22, indicated Resident C required assistance with ADLs including bed mobility, transfers, eating and toileting related to weakness, pain, incontinence, [CONDITION(S)], type 2 diabetes mellitus, depression, anxiety, shortness of breath with exertion. The interventions included, but were not limited to, transfer with assistance of 2 staff members. A John Hopkins Fall Risk Assessment Tool, dated 3/29/22 at 7:39 a.m., indicated Resident C was a high fall risk. A current Physician's order indicated transfer with assistance of 2 staff members, initiated 10/26/21. A Nurse's progress note, dated 4/23/22 at 10:17 p.m., indicated One of the CNA [sic] was transferring resident from the wheelchair to bed, then [Resident C] lost her balance, CNA had to let her sit on the floor, when [Resident C] sat on the floor, CNA was still holding her and called for help, did not hit anything, denies pain at this time, scheduled pain med already was given 15 min before the incident . During an interview on 4/29/22 at 8:43 a.m., CNA 2 indicated she normally worked the hall that Resident C resided, and Resident C only required assistance of 1 staff member for transfers with her walker. CNA 2 indicated she was supposed to use a care sheet so she knew how to transfer residents. At that time, CNA 2 did not have a care sheet with her. On 4/29/22 at 8:44 a.m., CNA 2 provided a copy of a care sheet, dated 4/12/22, and indicated this was the current care sheet used by the staff. A review of the document indicated Resident C was to be transferred with assistance of 2 staff members. During an interview on 4/29/22 at 8:45 a.m., the Director of Nursing indicated there should have been at least 2 staff members assisting Resident C to transfer. 3. During an interview on 4/28/22 at 12:23 p.m., the Director of Nursing indicated after a facility investigation she thought Resident D fractured her legs by sliding down in her shower chair during a shower. The clinical record for Resident D was reviewed on 4/28/22 at 1:38 p.m. The diagnoses included, but were not limited to, [CONDITION(S)], muscle weakness, and Alzheimer's dementia. The Quarterly MDS assessment, dated 3/30/22, indicated Resident D was not cognitively intact and was totally dependent for bathing and transfers with physical assistance from at least 2 staff members. A care plan, dated 1/22/18 and current through 4/19/22, indicated Resident D required assistance with ADL's including bed mobility, transfers, eating and toileting related to right ankle fracture, non-weight bearing to right lower extremity, impaired mobility, pain, weakness, incontinence, history of cerebral infarction, [CONDITION(S)], restless leg syndrome, [CONDITION(S)] without current pathological fracture, [CONDITION(S)], [CONDITION(S)], peripheral vascular disease and [CONDITION(S)]. The interventions included, but were not limited to, up ad lib with a mechanical lift and assist of 2 staff to wheelchair . A John Hopkins Fall Risk Assessment Tool, dated 3/29/22 at 7:42 a.m., indicated Resident D was a high fall risk. A Nurse's Progress Note, dated 4/14/22 at 1:03 p.m., indicated [Resident D's] leg have been steadily getting more weak recently. However, this shift, resident c/o [complained] new pain to left leg. Reports pain mostly in the thigh/knee area. Hurts to palpate. No swelling or bruising noted at this time. Cannot lift leg without pain. Resident does not recall injuring leg. Reports it feeling like it is 'twisted'. Spoke with NP [nurse practitioner]. New order noted for x rays. An Imaging Radiology Report, dated 4/14/22 at 9:53 p.m., indicated .Results: Fracture of the distal femoral shaft with malalignment. A Nurse's Progress Note, dated 4/14/22 at 11:40 p.m., indicated, Resident sent to emergency room for evaluation and treatment related to acute femoral fracture. A Nurse's Progress Note, dated 4/14/22 at 1:32 a.m., indicated the facility received a call from the emergency room physician who stated the resident also had a right hip fracture with the left femoral fracture and the resident would be admitted to the hospital. A Hospital Discharge Summary, dated 4/21/22 at 4:38 p.m., indicated the resident had dementia at baseline and could not recall the events that led up to the emergency room visit. Per the chart, the nursing home reported to emergency room that the nursing home attempted to move the resident without a mechanical lift on Thursday resulting in the resident accidentally twisting her left leg. The resident and nursing home deny fall. When the resident arrived to the emergency room the resident was noted to have bilateral legs flexed and rotated which prompted additional x-rays to be completed. The x-rays revealed a commuted fracture of the right proximal femur and a displaced oblique fracture the left distal femur. During an interview on 4/29/22 9:40 a.m., CNA 3 indicated she and CNA 4 transferred Resident D from her bed to a shower chair without using a mechanical lift. She believed Resident D pivoted wrong during that transfer. She learned that Resident D required a mechanical lift for transfers when she was told Resident D's legs were fractured. She was not aware the facility had a CNA care sheet until after the incident. Resident D should have transferred using a mechanical lift. On 4/28/22 at 11:00 a.m., the Director of Nursing provided a copy of a facility policy, titled Fall Management Program, and indicated this was the current policy used by the facility. A review of the policy indicated Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors. The Immediate Jeopardy, that began on 4/14/22, was removed on 5/2/22 when the facility inserviced the facility staff on transfers and mechanical lift transfers, 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 761. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure the dressing on a surgical wound was dated indicating when the dressing was last changed for 1 of 4 residents reviewed for wound care. (Resident 112) Finding includes: During an observation on 4/8/22 at 8:57 a.m., observed Resident 112 in her room. Resident 112 remove her right sock from her foot to show a gauze dressing wrapped around her foot. The gauze dressing was observed to have a dark orange brown stain on plantar portion near toes, the gauze was rumpled and loose in appearance, and the dressing was undated. During an interview at that time, Resident 112 indicated that the dressing had not been changed in days. During an observation on 4/11/22 at 1:30 p.m., observed Resident 112 in her room. Resident 112 remove her right sock from her foot to show a gauze dressing wrapped around her foot. The gauze dressing observed to have very slight dark orange brown stain on plantar portion near toes. The dressing was undated. During an interview at that time, Resident 112 indicated that the dressing had been changed on 4/9/22 but had not been changed on 4/10/22. On 4/7/22 at 1:49 p.m., the clinical record of Resident 112 was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 3/18/22, indicated that resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing was ordered for once a day. During an interview on 4/12/22 at 10:35 a.m., RN (Registered Nurse) 4 indicated it was the facility standard practice for any wound treatment or dressing changed to be dated and initialed. On 4/12/22 at 8:30 a.m., the DON (Director of Nursing) provided a facility policy titled Dressing Change Clean Technique (Incision or Wound), dated January 2010 and indicated it was the current policy in use by the facility. A review of the policy indicated that the step after applying a treatment and/or dressing per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-37(a)

Based on record review and interview, the facility failed to provide a care plan for 2 of 4 residents reviewed for behaviors. (Resident 26, Resident 106) Findings included: 1. On 4/13/22 at 10:16 a.m., Resident 26's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An IDT (interdisciplinary team meeting) note, completed on 04/11/22 at 11:30 a.m., included, Resident banging hand on table .Care plan updated and current interventions revised as applicable . A Quarterly MDS (Minimum Data Set) assessment, dated 3/13/22, indicated the resident had not demonstrated behaviors during the assessment period. The clinical record lacked a person-centered care plan with approaches and interventions for physical behaviors. During an interview on 4/13/22 at 9:35 a.m., the Director of Nursing (DON) indicated Resident 26 did not have a care plan for physical behaviors. 2. On 4/13/22 at 8:47 a.m., the Administrator provided a copy of Incident Number 32, dated 11/27/21 at 6:45 a.m. The incident indicated: Brief Description of Incident: 11/27/21 staff [was] alerted to room by the sound of commotion. Upon entering room, [Resident 200] was seated on [Resident 106] bed and [Resident 106] struck [Resident 200] on the right knee with the remote to bed. On 4/11/22 at 1:55 p.m., the clinical record of Resident 106 was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 3/13/22, indicated Resident 106 had not exhibited behavioral issues during the assessment period. The clinical record lacked a person-centered care plan with approaches and interventions for physical behaviors toward others. During an interview on 4/13/22 at 9:35 a.m., the Director of Nursing (DON) indicated Resident 106 did not have a care plan for physical behaviors. On 4/13/22 at 9:45 a.m., the Director of Nursing provided a policy titled: IDT Comprehensive Care Plan Policy, dated January 2011, and indicated it was the current policy being used by the facility. A review of the policy indicated, .each resident will have a comprehensive person-centered care plan .The care plan will include measurable goals and specific interventions based on residents needs and preferences to promote the resident's highest level of functioning . 3.1-35(a)

Based on interview and record review, the facility failed to ensure services were provided for a resident with dementia for 1 of 5 residents reviewed for dementia care. Aggressive behaviors were not prevented and escalated when an aggressive resident hit another resident. (Resident 335 and Resident 6) Findings include: On 4/7/22 at 10:30 a.m., the Administrator provided a copy of Incident Number 338, dated 2/27/22 at 6:30 p.m. The incident indicated: Brief Description of Incident: Residents were seated at a table in the activity area engaged in independent activities after dinner. Staff member alerted by [Resident 335] yelling out and when she turned around [Resident 6] was making [physical] contact with her [Resident 335] face. On 4/8/22 at 10:33 a.m., the clinical record of Resident 6 was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 1/5/22, indicated Resident 6 had severe cognitive impairment and physical behaviors toward others one day during the assessment period. An Annual MDS assessment, dated 4/1/22, indicated Resident 6's current behavior status was worse. A Certified Nursing Assistant CNA task sheet (a from provided to the CNA's with information and services to be provided to each individual resident), currently being used by the facility, indicated Resident 6 had Behavior: paranoid delusional statements that people are bad and not to trust them. Insinuating others are out to get him. Often caused by overstimulation and causes anxiety/agitation towards others. The task sheet lacked services, interventions, and instructions for Resident 6's physical behavior towards others. A Psychiatry progress note, dated 3/29/22, indicated Resident 6's had aggression: physical, and verbal, towards staff. Resident 6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The clinical record lacked a person centered care plan with approaches identified services and interventions to be provided to prevent physical behaviors toward others. During an interview on 4/8/22 at 10:19 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident 6 became combative at times when staff provided care. Nothing triggers him, you never know when its [physical behavior] going to happen. Resident 6's physical behavior were unpredictable. On 4/12/22 at 1:33 p.m., the Director of Nursing provided a policy titled: IDT Comprehensive Care Plan Policy, dated January 2011, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy: Create an organized, resident-centered review on a routine basis to improve communication.as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms. 3.1-37(a)

Based on interview and record review, the facility failed to ensure adequate supervision of a dependent resident during care to prevent a resident from falling out of bed for 1 of 3 residents reviewed for accidents (Resident B) . Findings include: On 5/24/2021 at 11:00 a.m., the clinical record of Resident B was reviewed. Diagnoses included, but were not limited to: [CONDITION(S)] (chronic obstructive pulmonary disease), CHF (congestive heart failure), and A-fib (atrial fibrillation). An Admission Minimum Data Set (MDS) assessment, dated 3/31/21, indicated resident B's cognitive status was cognitively intact. A care plan, (undated), indicated Resident B had a performance deficit, required assistance with activities of daily living (ADL's), needed assist of 2 staff due to limited bed mobility, and assessed to be a fall risk. A progress note, dated 5/7/21 at 9:36 a.m., indicated .witnessed fall 5/6/2021 9pm. resident was in bed with staff assisting with incont care [incontinent care]. resident along with staff caring resident stated they had turned resident over to perform incont care resident was to close to edge then rolled out of bed. resident was lying face forward on the floor between bed and wall. [sic] . Interview with PCA (personal care aide) 1, on 5/24/21 at 2:24 p.m., indicated she and PCA 2 went in to assist Resident B with personal care. PCA 1 and PCA 2 turned Resident B onto her left side and had the resident put her right arm out to steady herself against the wall. PCA 2 realized she did not have an incontinence brief to change the resident, PCA 2 sent PCA 1 to get a brief from a closet outside of the room. PCA 2 had one hand on resident's side and turned to get a washcloth off of the bedside table. Resident B indicated she was rolling off of the bed and proceeded to roll off the bed onto the floor landing on her face and elbows. Resident B did not lose consciousness and wanted to get off of the floor. PCA 2 told PCA 1 to go get a CNA (certified nursing aide) and to not move the resident. Interview with PCA 2, on 5/24/2021 at 3:52 P.M., indicated she and PCA 1 went into resident B's room for bed check and possible change with peri care (private area care). Both PCA's rolled the resident onto her side facing the wall and the resident placed her arm on wall for support. PCA 2 indicated she had forgot to grab an incontinence brief and sent PCA 1 out into the hall to get one. As PCA 1 was coming back into room, PCA 2 took one hand off of resident to grab a washcloth, the resident indicated she was rolling and fell off the bed onto the floor face down. Resident B did not lose consciousness, however she wanted to get up as her elbow was hurting. PCA 2 advised the resident they could not get her up and send PCA 1 to get CNA 1. Interview with CNA 1, on 5/24/2021 at 4:06 p.m., indicated when she entered the room she observed Resident B to be lying face down on the floor between the bed and the wall, wanting to get up because her knees was hurting. CNA 1 left the resident's room to get the nurse. Written statement from LPN (licensed practical nurse) 1, dated 5/24/21 (time not indicated), indicated she was informed by CNA 1 Resident B had fallen from the bed while staff was performing pericare. LPN 1 assessed the resident, applied first aid to skin injuries on bilateral (both) elbows and assisted the resident back into bed with CNA 1. Resident B had no change in mental status and neuro checks and vital signs were within normal limits. She indicated PCA 2 told her she had kept one hand on the resident while turning for a washcloth, however the resident started to roll out of bed and PCA 2 was unable to stop her from falling. This Federal tag relates to Complaint IN 615. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure dietary staff's facial hair and hair was restrained while in the food prep area of the kitchen. This had the potential to affect 141 of 141 residents residing in the facility who received food items from the kitchen. The facility also failed to ensure food items in 1 of 3 resident snack refrigerators were dated and labeled to identify to whom the items belonged. This had the potential to affect 32 of 32 residents who had access to the 200 hall resident snack refrigerator. Findings include: 1. On 11/12/19 from 10:20 a.m. to 10:35 a.m., during the initial kitchen tour, observed lunch cook 2 in the kitchen food prep area. Lunch cook 2 was prepping foods for the noon meal. Lunch cook 2 was observed to have half inch long facial hair that was observed to not be covered. Also, lunch cook 2 was observed to have hair, 2 inches in length, near the base of his neck. The hair was hanging outside of the hair restraint and was not covered. Interview, on 11/12/19 at 10:40 a.m., the DM (Dietary Manager) indicated all hair was to be covered while in the kitchen. Interview, on 11/12/19 at 12:55 p.m. the DM indicated 141 residents received food from the kitchen. On 11/14/19 at 3:12 p.m., the Director of Nursing provided a copy of the Dietary Personal Hygiene policy, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. A review of the policy indicated, .personal cleanliness .wear a clean hat and/or other hair restraint .dietary employees with facial hair should also wear a beard restraint. On 11/15/19 at 2:55 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective (MONTH) 13, 2004, indicated, .food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to wear effectively keep their hair from contacting .exposed food . 2. On 11/12/19 at 10:45 a.m., observed the 200 hall resident snack refrigerator unit. The freezer section of the unit contained food items that lacked any dates or resident names for whom the food items belonged. The food items included: -small ice pack -gallon jug of frozen water -one pint container of Ben and Jerry's cookies and cream cheese cake ice cream -one box of Deans popsicles with 6 unopened popsicles -individual serving of Green Giant's broccoli and cheese -individual serving of Banquet's salisbury steak meal -individual serving of Jimmy Dean's breakfast bowl -unidentified wrapped food item Interview, on 11/12/19 at 10:50 a.m., the DM (Dietary Manager) indicated the 200 hall resident snack refrigerator unit was for resident food items only and all items were to be labeled with the date for when the item was put into the refrigerator unit as well as who the food item belonged. Interview, on 11/14/19 at 2:10 p.m., the Director of Nursing indicated 32 residents had access to the 200 hall resident snack refrigerator for their personal refrigerated food items. All food items were to be labeled with the resident's name and dated. On 11/14/19 at 3:12 p.m., the Director of Nursing provided a copy of the Food Brought in by Family and Visitors policy, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. A review of the policy indicated, .if food must be stored, it will be labeled with the resident's name, the date the item was brought in and the date by which it should be consumed or discarded . On 11/15/19 at 3:30 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective (MONTH) 13, 2004, indicated .refrigerated, ready-to-eat, potentially hazardous food prepared and held in a retail food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a baseline careplan was developed for a resident recently treated for [REDACTED]. (Resident 134) Findings include: The clinical record of Resident 134 was reviewed on 11/14/19 at 10:57 a.m. [DIAGNOSES REDACTED]. Resident 134 was admitted to the facility on [DATE]. A Pre-Admission Assessment (performed at the hospital, by the facility, dated 10/22/19), indicated the resident was in contact isolation due to the [DIAGNOSES REDACTED]. An Admission Nursing Observation Report, dated 10/25/19, indicated, .Skin .Petechiae (tiny purple or brown spots on the skin) present: Chest arms and buttocks from Scabies . The Medication Administration Record [REDACTED]. Scabies: [DIAGNOSES REDACTED]. Does treatment fail? Yes, and evidence of previous treatment should not exclude the [DIAGNOSES REDACTED]. Parasites Fact Sheet (10/31/17) was retrieved on 11/19/19 from the Centers for Disease Control (CDC) website. Review of the fact sheet indicated, Scabies is a skin condition caused by mites. It commonly leads to intense itching and a pimplelike skin rash that may affect various areas of the body. Scabies is contagious and can spread quickly in areas where people are in close physical contact .Scabies can spread easily under crowded conditions where close body and skin contact is common. Institutions such as nursing homes .are often sites of scabies outbreaks . The clinical record lacked a baseline careplan which addressed monitoring Resident 134 for recurrent scabies. Interview, on 11/14/19, at 10:30 a.m., Nurse Practitioner 6 indicated on 11/11/19, she had examined Resident 134 and determined the resident should be in isolation for a reoccurrence of scabies. On 11/14/19 at 10:00 a.m., the Director of Nursing (DON) provided a policy, dated 10/2017, titled, IDT (interdisciplinary team) Baseline Care Plan, and indicated it was the policy currently used by the facility. Review of the policy indicated, Baseline Care Plan .will be initiated within 48 hours of admission to the facility .will include .The instructions needed to provide effective and person-centered care that meets professional stands of quality care; The resident's immediate health and safety needs . On 11/15/19 at (:02 a.m., the DON indicated a baseline care plan had not been developed which addressed monitoring Resident 134 for signs and symptoms of recurring scabies had not been developed when the resident was admitted to the facility.

Based on observation, record review, and interview, the facility failed to ensure a resident had a person-centered care plan developed and implemented for a resident that had communication difficulty due to non-verbal status with severe cognitive impairment for 1 of 30 residents reviewed for care plans. (Resident 62) Findings: The clinical record for Resident 62 was reviewed on 11/14/19 at 2:49 p.m. [DIAGNOSES REDACTED]. The significant change Minimum Date Set (MDS) assessment, dated 9/21/19, indicated Resident 62 was rarely understood and only sometimes understands. The Brief Interview for Mental Status (BIMS) assessment indicated Resident 62 was severely cognitively impaired. Resident 62's record lacked a plan of care (P[NAME]) with interventions for a communication deficit. Interview, on 11/15/19 at 10:30 a.m., the Director of Nursing (DON) indicated staff who were familiar with Resident 62 were usually able to identify their needs and requests. Interview, on 11/15/19 at 11:12 a.m., the wound care nurse indicated she was familiar with Resident 62 and was usually able to determine what the resident needed or requested by her body and head movements and eye contact. Interview, on 11/18/19 at 9:24 a.m., the DON indicated she was unable to locate a P[NAME] or interventions for Resident 62 in regard to communication difficulties. On 11/18/19 at 8:30 a.m , the DON provided a policy with the last revision dated 10/2019, titled: IDT Comprehensive Care Plan Policy, and indicated it was the current policy in use by the facility. A review of the policy indicated, .that each resident will have a comprehensive person-centered care plan developed .The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the residents highest level of functioning including medical, nursing, mental, and psychosocial needs. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to revise the comprehensive person centered care plan for a resident with hand contractures for 1 of 1 resident reviewed for hand contracture care plan development. (Resident 94) Findings include: On 11/13/19 at 11:02 a.m., observed Resident 94 resting in bed. Resident 94 was observed to have hand contractures. Observed a rolled white wash cloth in the palm of Resident 94's right hand. The clinical record of Resident 94 was reviewed on 11/15/19 at 8:41 a.m. [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment, dated 10/15/19, indicated Resident 94 had contractures of the right and left hands. The comprehensive care plan for Resident 94's bilateral hand contractures, lacked an intervention that included the use of rolled wash cloths in the palm of both hands. Interview, on 11/15/19 at 10:45 a.m., Certified Nursing Assistant 1 indicated, for the past several months, rolled wash cloths had been placed in Resident 94's palms. Interview, on 11/15/19 at 1:50 p.m., the Director of Nursing indicated, as of 10/24/19, the facility's nursing measures included rolled wash cloths for both of Resident 94's palms. The care plan was to have been updated to include the rolled wash cloths for both palms, however; the care plan had not been updated. On 11/18/19 at 8:30 a.m., the Director of Nursing provided a copy of the IDT-Comprehensive Care Plan Policy, dated (MONTH) 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote resident's highest level of functioning including medical, nursing, mental and psychological needs .to improve .physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level of relieve symptoms .care plan problems, goals and interventions will be updated based on changes in resident assessment/condition . 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure a resident received short acting insulin as prescribed by a physician 1 of 6 residents reviewed for quality of care in medication administration. (Resident 51) Findings include: Interview, on 11/12/19 at 3:48 p.m., Resident 51 indicated she often did not get her insulin close to her meal time like she was supposed to. The clinical record of Resident 51 was reviewed on 11/15/19 at 9:58 a.m. [DIAGNOSES REDACTED]. Diabetes is a disease which affects the body's ability to metabolize sugar in the blood, due to the pancreas not producing enough insulin. Diabetic [MEDICAL CONDITION] is nerve damage caused by high blood sugar levels. A quarterly Minimum Data Set assessment, dated 9/16/19, indicated Resident 51 was independent in her ability to make decisions. A careplan, developed on 5/19/19 and current through 1/9/20, indicated a problem of, Resident is at risk for adverse effects of [MEDICAL CONDITION] (high blood sugar) or [DIAGNOSES REDACTED] (low blood sugar) related to use of glucose lowering medication and/or [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME]is a medication which helps the body to metabolize insulin. The Nursing 2014 Drug Handbook, 34th Edition, indicated [MEDICATION NAME]onset of action is 15 minutes after injection and should be given 10 - 15 minutes before a meal. Know Your Blood Sugar Numbers: Use Them to Manage Your Diabetes (March (YEAR)) was retrieved on 11/19/2019 from the Centers of Disease Control website. The guidance included, What are target blood sugar levels for people with diabetes? The range right before a meal is 80 - 130. Interview, on 11/18/19 at 1:37 p.m., Unit Manager 10 indicated if nurses gave medications later than when scheduled, they were supposed to document the reason for the late administration. The Medication Administration Record [REDACTED] 11/7/19 - Resident's blood sugar before breakfast was 152. [MEDICATION NAME] scheduled for 8:00 a.m., administered at 1:01 p.m. The residents blood sugar level at 12:00 p.m., prior to the lunch meal, was 229. No documentation was provided regarding the reason for late administration. 11/11/19 - Resident's blood sugar before breakfast was 293. [MEDICATION NAME] scheduled for 8:00 a.m., administered at 9:07 a.m. The resident's blood sugar level at 12:00 p.m., prior to the lunch meal, was 277. No documentation was provided regarding the reason for the late administration. Interview, on 11/18/19 at 9:30 a.m., Resident 51 indicated she usually eats her breakfast in the dining room around 8:00 a.m. On 11/18/19 at 11:58 a.m., the Director of Nursing provided a policy, dated 1/1/13, titled General Dose Preparation and Medication Administration and indicated it was the policy currently used by the facility. Review of the policy indicated, Verify each time a medication is administered that it is the correct .time, for the resident . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to adequately monitor the side effects of a resident who was prescribed an anticoagulant for 1 of 5 residents reviewed for unnecessary drugs. (Resident 131) Findings include: On 11/14/19 at 10:30 a.m. the clinical record of resident 131 was reviewed. [DIAGNOSES REDACTED]. Current 2019 physician's orders [REDACTED]. The Nursing 2014, drug handbook, indicated Adverse Reactions: Skin: .bruising (localized bleeding under the skin). During an observation, on 11/14/19 at 10:00 a.m., observed Resident 131 to have one round, greenish, quarter size bruise to the middle of their chest. Interview, at that time, Resident 131 indicated he was not aware of how he he got the bruise. An admission Minimum Data Set assessment, dated 10/30/19, indicated Resident 131's cognitive status was moderately impaired. A care plan, with a start date of 10/30/19 and current through 2/1/20, indicated, problem: Resident is at risk for bleeding/bruising related to use of antiplatelet medication. Goal: Resident will remain free of adverse effects of antiplatelet medication. Interventions included, but were not limited to, document abnormal findings, notify the Physician, and observe for bruising. Medication Administration Record [REDACTED]. The records indicated no bruise was assessed. An skin Event Report, dated 11/13/19, indicated Resident 131's skin had no existing skin alterations. No bruise assessed. Interview, on 11/14/19 at 1:00 p.m., the DON indicated the bruise had not been documented on the last skin assessment (event). The DON indicated the bruise appeared old. On 11/15/19 at 2:30 p.m., the Director of Nursing provided a policy titled Skin Management Program, dated 2/2015, and indicted it was the current policy being used by the facility. A review of the policy indicated, .Procedure for alterations in skin integrity 4. All newly identified areas after admission will be documented on the New Skin Event . 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure a resident had proper supervision to prevent a fall while using a bed pan which resulted in a fall and neck fracture for 1 of 3 residents reviewed for falls (Resident #B). Findings include: The closed clinical record for Resident #B was reviewed 9/10/14 at 10:20 a.m. [DIAGNOSES REDACTED]. A current Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive status (BIMS-13) was intact (could make wants and needs known). The MDS also indicated the resident was at risk for falling. A care plan dated 6/5/14, indicated the resident was at risk for falls due to a history of falling and had a non-ambulatory status related to a recent CVA, DVT and pain. The care plan goal was the resident would be free from fall related injuries. Interventions in place to prevent a fall included wheelchair and bed alarms, non-skid footwear, therapy to screen and treat as needed, and call light within reach. An Occupational Therapy Plan of Care dated 6/6/14, indicated Resident #B was evaluated and was unable to maintain balance without moderate/maximum support. An "Event Report" dated 7/9/14, indicated the resident was found (unwitnessed) on the floor in his room. Resident #B reported to the nurse he could not find the remote (call light attached to the remote) so he placed himself on the floor. Prior documentation in the Nurses notes indicated Resident #B was having difficulty identifying and using the call light. A low profile mat was added to the left side of the bed and bright tape was placed on the call light to identify it. An "Event Report" dated 7/11/14 at 11:55 a.m., indicated the resident was found on floor in his room. Prior to the fall the resident had been in bed on the bed pan. Resident #B reported to the nurse he was reaching for the remote and fell out of bed. The "Event Report" indicated the remote and call light were clipped to the resident. X-ray report of the neck was negative for injury. A CT Scan (cat scan) was ordered on [DATE], for continued complaints of neck pain. On 7/15/14, the family requested the CT Scan to be canceled and the resident sent to the ER. A hospital ER note dated 7/15/14, indicated the resident had a CT Scan of the cervical spine and the report revealed a C2 (cervical vertebrae #2) fracture. During an interview with CNA #1 on 9/11/14 at 9:35 a.m., she indicated she was taking care of the resident when he fell . She sat the resident up in bed, provided the resident with the bedpan, and then left the room at his request. She further indicated the resident always requested her to leave the room when he was using the bedpan. In a few minutes he started yelling that he had fallen. She found him on the mat on the floor on his left side (CVA affected side). During an interview with Occupational Therapist #2 on 9/11/14 at 12:00 p.m., she indicated the resident was not appropriate for a bedside commode or toileting in the bathroom due to poor trunk control. A bedpan would be appropriate for him. A current facility policy dated 7/01, revised 9/2013 and titled, "Fall Management Program" and provided by the Administrator on 9/11/14 at 12:50 p.m., indicated: "Policy: It is the policy of (name of facility) to ensure residents residing within the facility will maintain maximum functioning through the establishment of physical ... guidelines to prevent injury related to falls." This Federal tag relates to the Complaint IN 595. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide and ensure a resident received the highest practicable physical care, in that when a resident had breathing difficulties and displayed increased [MEDICAL CONDITION], the nursing staff failed to act immediately and inform the resident's physician of a decline in the resident's condition which included increased shortness of breath, increased [MEDICAL CONDITION], pain and requiring hospital treatment, for 1 of 3 residents reviewed a sample of 6. (Resident "B"). Findings include: The record for Resident "B" was reviewed on 03-15-12 at 11:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident had recently been discharged from a local area hospital on 12-05-11 and returned to the facility with instructions for the nursing staff to "Contact information: MD for worsening ascites, abdominal pain, confusion or temperature of > (greater) 100.5." In addition, the resident had a physician order for [REDACTED]. in 24 hours call (name of physician)." Review of the resident's current plan of care dated 02-02-12, indicated "Problem [MEDICAL CONDITION]." "Approach - approach start date 12-13-11, observe for altered mental status, increased pain, abdominal distention and discomfort, n/v (nausea/vomiting), increased weakness/debility, decreased appetite." A subsequent plan of care dated 02-02-12, indicated "Acute [MEDICAL CONDITION]." "Approach - approach start date 12-13-11, observe for s/s (signs and symptoms) of SOB (shortness of breath), increased [MEDICAL CONDITION], pain or elevated B/P (blood pressure), refer to MD (Medical Doctor) as needed." An addition plan of care dated 02-02-12, indicated "Resident is at risk for fluid imbalance related to diuretics and fluid restriction." "Approach - approach start date 12-05-11 - observe for s/s of dehydration/fluid overload: dry pale mucous membranes, skin tenting, decreased urinary output, SOB (shortness of breath), dyspnea, increased [MEDICAL CONDITION], lethargy, increased wts. (weights), increased abdominal girth." Review of the nurses notes indicated the following: "02-17-12 at 2245 (10:45 p.m.) HR (heart rate 92, oxygen saturation 93% on room air, (blood pressure) 138/70, T (temperature) 98.2, RR (respiratory rate) 18. No needs currently, no c/o (complaints of) pain, minor SOB (shortness of breath), no dyspnea (difficulty in breathing). Pt. (patient) does not desire any intervention at this time, occasional NP (non productive) cough, lungs - (arrow pointing downward) volume with crackles in bases and rhonchi present bil. (bilateral) expiratory wheezing present. BS (bowel sounds) positive times 4, abdomen does appear slightly distended, but soft. Pt. states had BM yesterday evening (02-16). Pulses equal / reg. (regular) BUE (bilateral upper extremities)." "02-18-12 at 0100 (1:00 a.m.) (B/P) 127/76, P 108, oxygen saturation 90 % on room air, RR 20, T 96.7. Pt c/o SOB, lungs are diminished all lobes with inspiratory / expiratory wheezing present. Pt. c/o pain in back also (5/10). Intervention inhaler 2 puffs, neb. (nebulizer) tx. (treatment) and pain tx. with prn (as needed) [MEDICATION NAME] (a pain medication). Pre treatment O2 (oxygen 90%, shallow breathing, post intervention (arrow pointing downward) wheezing, deep breathing and O2 98 %. Pt. A & O (alert and oriented) times three. pedal pulses palpable bil. (bilateral) with 3 + [MEDICAL CONDITION] BLE (bilateral lower extremities). Pt. tachacardic <sic> with minor murmur present." "02-19-12 at 2:00 p.m. - ... Abd. (abdomen) firm / dist. (distended) LS (lung sounds) slightly exp. (expiratory) wheezes - productive cough with green sputum - MD notified. Res. req. (requested) Pro-air (an inhaler) at 1:45 p.m. for wheezing, + effective, +2 pit. (pitting) [MEDICAL CONDITION] to BUE (bilateral upper extremities), bruising noted to BUE...." "02-19-12 at 2315 (11:15 p.m.) (BP) 116/67, P 102, T 97.8, O2 93% room air, RR 20. Pt. has c/o SOB also wheezing present at this time. Inspiratroy / expiratory, lung sounds diminished throughout. Will treat with [MEDICATION NAME] (inhaler). Pt. has c/o pain in shoulder. Educated pt. on importance of turning deep breathing and coughing to prevent atelectasis/pneumonia. Abd. distended and BLE (bilateral lower extremities) [MEDICAL CONDITION] 3+ - heels elevated d/t (due to) severe abdominal distension putting pressure on diaphragm and lungs. Keeping HOB (head of bed) elevated > (greater than) 30 degrees." "02-20-12 (day shift) BP 115/61, (P) 95, O2 92 % - room air, (respirations) 20. (Arrow pointing upward) 3.4 # (pounds) - called Dr. (Doctor) to report (arrow pointing upward) wt. gain - Dr. wants res. (resident) sent to (name of local area hospital) ER (emergency room ) for eval. (evaluation)." From the time the nurse assessed the resident at 11:15 p.m., the physician was not notified of the resident's condition for approximately 6 1/2 hours later, when the day shift nurse weighed the resident and discovered the resident with a 3.4 pound weight gain. Review of the facility policy on 03-23-12 at 10:00 a.m., titled "Resident Change of Condition," and dated as "revised 3/10, indicated the following: "POLICY (bold type) It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely and effective intervention occurs." "PROCEDURE - 2. Acute Medical Change a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician." This Federal tag relates to IN 048. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop 3 pressure ulcers within 19 days of admission, for 1 of 5 residents reviewed for pressure ulcers in a total sample of 24. (Resident #47) Findings include: The clinical record for Resident #47 was reviewed on 1/26/12 at 10:30 a.m. and indicated the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The 1/18/12 admission MDS (minimum data set) assessment for Resident #47 indicated: bed mobility - extensive assistance/one person physical assist, transfer - extensive assistance/one person physical assist, walk in room - activity occurred only once or twice/one person physical assist, Is the resident at risk for developing pressure ulcers/yes, Does this resident have one or more unhealed pressure ulcer(s) at stage 1 or higher/no, BIMS (Brief Interview for Mental Status) score/15 (highest possible score indicating resident is cognitively intact). The 1/6/12 entry on the Interdisciplinary Progress Notes indicated "Skin assessment done (symbol for "no") areas noted... Skin very healthy looking." The 1/6/12 Nursing Admission Assessment indicated "Resident (symbol for "with")(symbol for "no") skin issues noted...". The 1/6/12 Pressure Wound Risk assessment indicated the resident was at risk for developing skin breakdown. Proceed to care plan with appropriate interventions. The 1/6/12 skin breakdown careplan indicated the resident was at risk for skin breakdown due to decreased mobility and incontinent of bowel. The goal indicated on the care plan was resident would be free from skin breakdown. The approaches indicated on the care plan were to turn and reposition at least every 2 hours and side rails in grab bar position to promote independence in bed. The 1/9/12 entry on the Interdisciplinary progress Notes indicated "IDT met to review resident for siderails. Determined 1/4 rails in grab bar position for assistance (symbol for "with") bed mobility..." The CNA Skin Check Detail Report indicated CNA #1 saw a new skin problem located on the buttocks area on 1/21/12. During interview with CNA #1 on 1/26/12 at 3:15 p.m., she indicated the area referenced above was bleeding when she noticed it on 1/21/12 and she told RN #1 right away. The 1/21/12 Skin Issue Investigation form for Resident #47 completed by RN #1 indicated the area on the coccyx was 0.6 cm x 0.3 cm x 0.1 cm with red granulation. Question #4 on this form asked "After interviewing staff, how would you conclude the injury happened (if not witnessed)?" The written answer was "The wound area on coccyx was a result of pressure area." The written recommendation to prevent recurrence on this form was "EPC cream (incontinent cream) relieving direct pressure from coccyx as much as possible." The 1/25/12 Wound Progress Note indicated 3 pressure wounds...a stage III right buttock wound measuring 3.2 cm x 3.0 cm x 0.1 cm, an unstageable left buttock wound measuring 2.0 cm x 2.0 cm x 0.1 cm, and an unstageable sacrum wound measuring 0.7 cm x 0.5 cm x 0.1 cm. An observation of the wound area was made on 1/27/12 at 11:35 a.m. The affected area was the size of a fist with pink surrounding the wounds with areas of red spots. The actual wound size on the right buttock looked about the size of an index fingernail bed. The EPC cream was covering the pink area just above this wound disenabling full view of the entire wound. No siderails were affixed to Resident #47's bed during this observation. During interview with the DON on 1/27/12 at 1:35 p.m., she indicated there was no evidence to prove Resident #47 was turned and repositioned as care planned. An interview was conducted with Resident #47 on 1/27/12 at 2:00 p.m. He indicated staff never turned and repositioned him the first couple of weeks he resided at the facility. He stated, "I've never had siderails to help me turn myself. I wish I did. It would have been helpful. I'm sitting more now because it's more difficult to stand. There's pain on my bottom." During this interview, maintenance came in to install siderails at 2:10 p.m. on 1/27/12. The resident stated to maintenance "Oh, it's a little late coming." 3.1-40(a)(1)