Every finding on record at Signature Healthcare of Muncie

Based on observation, interview, and record review, the facility failed to ensure dishware and utensils were washed in a method to ensure proper sanitization. This deficient practice had the potential to impact 111 of 111 residents who consumed food prepared in the facility's kitchen. Findings include: During an observation of dishwasher testing, on 3/16/26 at 10:35 a.m., the Dietary Manager tested the dishwasher on three separate occasions. Each attempt registered no sanitizing solution in the final rinse water. The Dietary Manager obtained a second container of sanitation test strips and ran the dishwasher cycle again, which resulted in an indication of no sanitizing solution in the final rinse. The facility testing log, posted on the wall in the dish room, indicated the sanitizer that morning had indicated 100 parts per million (ppm). The signature of the person who completed the test was illegible. When interviewed, no employee present in the dietary department indicated they made the log entry. The two employees working in the dish room when the Dietary Manager completed the testing indicated they had not made the entry. The Dietary Manager did not know who had made the entry regarding sanitizer solution level.A copy of a facility poster located in the dishwasher room, provided by the Corporate Nurse Consultant via email on 3/18/26 at 1:37 p.m., indicated:Sanitizing Dish Machinewash temperature range: 120 to 140rinse temperature range 120 to 140chemical sanitizing PPM (parts per million) range between 50 and 100 During an interview on 3/16/26 at 3:10 p.m., the Dietary Manager indicated she believed there had been a problem with the proper testing and documentation of dishwasher sanitation for about one month. During an interview on 3/30/26 at 9:00 a.m., the Corporate Nurse Consultant indicated only one of the facility's residents did not consume food orally. All other 111 residents ate meals prepared in the facility's kitchen. A facility document, dated March 16, 2026 at 2:26 p.m., titled [dishwasher maintenance company's name] report, and provided via email by the Interim Administrator in 3/16/26 at 2:42 p.m., indicated the following:Parts replaced: squeeze tube, - sanitizer inspecting and updating to optimize and protect equipment operation .Machine condition: issue found inspecting machine health for optimal water and energy consumption.,Comments: here was some clogging on the bottom nozzle. replaced arm. A current facility document titled Education on using a low temp dishwasher, provided by the Corporate Nurse Consultant on 3/18/26 at 1:37 p.m. indicated the following: .All dishware, serviceware, and utensils will be cleaned and sanitized after each use. All dining service staff will be knowledgeable in the proper techniques for processing dirty dishware. Through the dish machine and proper handling of sanitized dishware, all dish machine water temperatures will be maintained in accordance with manufacturer's recommendation for low temperature or high temperature machines. Temperature and/or sanitizer concentration logs will be completed as appropriate. All dishware will be air dried and properly stored Check sanitizer concentration, use the chemical test strips regularly to confirm the chlorine concentration is sufficient ( 100 to 200 parts per million).to test the concentration run a rack through the cycle, while the rack is running at the end of the machine where the rack will come out, stick a test strip inside the machine towards the top, where the sprayers are spraying. You will see the strip turn color, remove the strip and compare it to the color chart on the bottle of test strips. Record the concentration on the log. 410 IAC (Indiana Administrative Code) 16.2-3.1 -21(i)(3)

Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from involuntary seclusion related to placement in a secured unit without meeting criteria when the facility failed to ensure a locked dementia unit was approved by the Indiana Department of Health prior to the unit being locked and failed to ensure residents who resided on the unit required a locked unit to treat a medical/behavioral condition for 5 of 5 residents reviewed of 18 who resided on the secured unit. (Residents 6, 87, 94, 12, and 3).Findings include:During the entrance conference, on 3/16/26 at 9:48 a.m., the Interim Administrator indicated the facility had a secure dementia unit.An Alzheimer's/Dementia Special Care Unit, State Form 48896, dated 3/17/26 and provided via email by the Corporate Nurse Consultant on 3/18/26 at 12:50 p.m., indicated the following:The facility did not have a mission or philosophy statement concerning the needs of residents with Alzheimer's disease, a related disorders or dementia.The criteria for admission, transfer, and discharge included: a physician's evaluation/diagnosis, staff evaluations, psychiatric evaluation/diagnosis, and a family conference.The Alzheimer's dementia care program was located in a separate, locked unit. During an interview on 3/18/26 at 12:50 p.m., the Corporate Nurse Consultant indicated the corporation was unable to provide a dementia disclosure form completed prior to 3/17/26.During an interview on 3/19/26 at 9:42 a.m., the Regional Clinical Support, [NAME] President of Clinical Operations, and [NAME] President of Operations all indicated they could not locate record of a Certificate for Occupancy being issued by IDOH (Indiana Department of Health) and would contact their home office to begin working toward getting the proper authorization for securing the dementia unit.During an interview on 3/20/2026 at 11:16 a.m., LPN 23 and LPN 4, who were identified by the facility as being a part of the team to secure the dementia unit, indicated the facility had chosen to lock the dementia unit in response to an identified need for secured dementia care in the Delaware County community. During an interview on 3/20/2026 at 12:55 p.m., QMA 19 indicated she had worked on the dementia unit in December 2025, before the facility locked the unit. She was unaware of any concerns regarding residents' unsafe wandering prior to the doors being locked. No residents who currently resided on the unit displayed exit seeking behaviors. One resident did pace, but was not exit seeking.During an interview on 3/20/2026 at 12:58 p.m., LPN 20 indicated she was knowledgeable of the residents who resided on the secured dementia unit. Prior to the doors being locked in January 2026, there was a resident who walked and paced but they did not attempt to exit the unit. Since the unit doors were locked in January 2026, she had not noticed residents displaying exit seeking behaviors. She did not know why the decision was made to lock the dementia unit.During an interview on 3/20/2026 at 1:01 p.m., LPN 21 indicated she had worked on the dementia unit prior to the doors being locked in January 2026. She had not witnessed any residents exit seeking before the doors were locked. She had not witnessed any residents exit seeking after the doors were locked.During an interview on 3/20/2026 at 1:03 p.m., C.N.A. 22 indicated the residents on the dementia unit sometimes paced, but they did not exit-seek. 1 Resident 6's clinical record was reviewed on 3/17/26 at 3:11 p.m. Current diagnoses included major depressive disorder, generalized anxiety disorder, diabetes mellitus, and vascular dementia. The resident had lived in their current room prior to the unit being locked in January of 2026.The resident had a 1/27/26 at 4:20 p.m., Social Service Note, which indicated the resident's representative had been contacted and informed the resident's hall was being transitioned to a locked unit.The resident had a 1/28/26 physician's order to admit to gated community due to vascular dementia. Special Instructions: include reason for admission to gated community.A 1/28/26 Secured Unit Observation document indicated the observation was unscheduled and being completed due to the initiation of a gated community. The form indicated an IDT (Interdisciplinary Team) team meeting, consisting of at least a nurse, social services, MD/NP (medical doctor or nurse practitioner), had met to evaluate for placement for a secured unit. A care plan was developed at this time. The resident was not identified as a risk for elopement.An 8/27/25 care plan indicated the resident had cognitive loss due to dementia. An approach to this problem was to provide a home-like therapeutic environment.The resident had a 12/3/25, MDS (Minimum Data Set) assessment , completed prior to her residing on a secured unit, which indicated the resident was severely cognitively impaired, had moderate depression, and displayed no maladaptive behaviors during the assessment, including wandering.A 1/30/26 care plan problem/need indicated the resident was placed in a locked unit as a least restrictive approach to protecting the resident and assuring his or her health and safety.The resident did not have a care plan problem/need related to risk for elopement or exit seeking behaviors.The resident had a 3/5/26 MDS assessment, completed after she resided on a secured unit, indicated the resident was severely cognitively impaired and displayed no maladaptive behaviors during the assessment, including wandering.Prior to the resident order to reside on a dementia unit, the resident had no documentation of exit seeking behaviors from 10/1/25 to 1/28/26.Prior to the 1/27/26 order for the resident to reside on a dementia unit, the clinical record lacked: a. An assessment of the resident's need for a secure dementia unit,b. Documentation regarding a care conference held in conjunction with the resident's representative to address the need for a secured dementia unit,c. An assessment or evaluation completed by the resident's physician, which determined the resident's need for a secured dementia care unit,d. An IDT note which addressed the resident's need for a secured dementia unit.e. Documented incidents of wandering for the period of time from 12/1/25 to 3/16/26.The clinical record indicated the resident's room was not relocated on 1/28/26. The change in the resident's services on 1/28/26 was the unit was locked on that date. During an observation on 3/16/ 26 at 12:36 p.m., Resident 6 was in the activity and dining area of the dementia unit.During an observation on 3/19/26 at 12:12 p.m., the resident exited the dining room and took herself to her bathroom. 2. Resident 87's clinical record was reviewed on 3/17/26 at 3:15 p.m. Current diagnoses included Alzheimer's disease, anxiety, mood disturbance, and unspecified dementia. The record indicated the resident resided in the same room they lived in prior to the unit being locked. A 1/27/26, 4:03 p.m. Social Service Note indicated the resident's guardian had been notified of the plan to transition the residents' hall to a locked unit. The resident had a 1/28/26 order to admit to gated community due to Alzheimer's. Special instructions include reason for admission to gated community.A 1/28/26 observation form for a Gated Community Assessment indicated the assessment was unscheduled and had been completed due to consent for gated community and a care plan had been developedThe resident had a 1/26/26 care plan problem/ need regarding placement in a locked unit as the least restrictive approach to protect the resident and assure his/ her health and safety.The resident had a 2/17/26 care plan problem/ need regarding the risk for elopement due to seeking behaviors. The resident's clinical record from 10/1/25 to 2/1/26 lacked documentation of any elopement attempts during this period of time.The resident had an 11/12/20 care plan problem/ need regarding a potential for decline in mood related to a diagnosis of dementia.Prior to the 1/27/26 order for the resident to reside on a dementia unit, the clinical record lacked: a. An assessment of the resident's need for a secure dementia unit,b. Documentation regarding a care conference held in conjunction with the resident's representative to address the need for a secured dementia unit,c. An assessment or evaluation completed by the resident's physician, which determined the resident's need for a secured dementia care unit,d. An IDT note which addressed the resident's need for a secured dementia unit.e. Documented incidents of wandering for the period of time from 12/1/25 to 3/16/26.The clinical record indicated the resident's room was not relocated on 1/28/26. The change in the resident's services on 1/28/26 was the unit was locked on that date. During an observation 3/17/26 at 10:31a.m., Resident 87 was in bed, her eyes were closed, her mouth was open.During an observation on 3/19/26 at 11:19 a.m., the resident was in her room visiting with a guest.During an observation on 3/19/26 at 12:09 p.m., the resident was eating lunch in the dementia unit dining room. 3. Resident 94's clinical record was reviewed on 3/17/26 at 3:19 p.m. Current diagnoses included vascular dementia, peripheral vascular disease, and hypertension. The resident had a physician's order, dated 1/26/26, to admit to grated community due to vascular dementia, mild with agitation special instructions include reason for admission to gated community. A 1/27/26 at 4:28 p.m., Social Service Note indicated the resident's guardian had been notified of a plan to transposition the residents hall to a locked unit. The record indicated the resident had not relocated his room of residence following this order.The resident had a 1/29/26 Observation for Secure Unit form, which indicated the observation was unscheduled and was completed due to initiation to gated community.The resident had a 1/26/26 care plan problem/ need regarding resident placed in locked unit as least restrictive approach to protect the resident and assure his/her health and safety.The resident had a 2/26/26 care plan problem/ need regarding risk for social isolation due to syncope and collapse.The resident had a 2/17/26 care plan problem need regarding a risk for elopement due to exit seeking behaviors. The resident's clinical record lack documentation of elopement attempts during this time period.A 2/21/26, quarterly, MDS assessment indicated the resident was severely cognitively impaired, had minimum depression and had displayed no maladaptive behaviors during the assessment period including wandering.Prior to the 1/27/26 order for the resident to reside on a dementia unit, the clinical record lacked: a. An assessment of the resident's need for a secure dementia unit,b. Documentation regarding a care conference held in conjunction with the resident's representative to address the need for a secured dementia unit,c. An assessment or evaluation completed by the resident's physician, which determined the resident's need for a secured dementia care unit,d. An IDT note which addressed the resident's need for a secured dementia unit.e. Documented incidents of wandering for the period of time from 12/1/25 to 3/16/26.The clinical record indicated the resident's room was not relocated on 1/28/26. The change in the resident's services on 1/28/26 was the unit was locked on that date. During an observation on 3/17/26 at 10:33 a.m., Resident 94 was resting on the bed in his room.During an observation on 31926 at 11:18 a.m., the resident was resting on the bed in his room.During an observation on 3/19/26 at 12:10 p.m., the resident was in the dining room on the secure dementia unit. 4. Resident 12's clinical record was reviewed on 3/17/26 at 3:31p.m. Current diagnoses include Alzheimer's disease, major depressive disorder, and autistic disorder.The resident had a 1/6/26 significant MDS assessment which indicated the resident, was severely cognitively impaired and had displayed no maladaptive behaviors during the assessment period including wandering.The resident had a 1/27/26, 4:12 p.m., Social Service Note, which indicated the resident's representative, had been notified of a plan to transition the residence hall to a locked unit.The resident had a 1/28/26 physician's order to admit to gated community due to dementia. Special instructions include reason for admission to gated community.A 1/28/26, Observation for Secured Unit form indicated the observation was unscheduled and had been completed due to the initiation of gated community.The resident had a 1/30/26 care plan problem/ need to place in a locked unit as least restrictive approach to protect the resident and assure his/her health and safety.The resident had a 1/29/26, quarterly, MDS assessment which indicated the resident was severely cognitively impaired and had displayed no maladaptive behaviors during the assessment period, including wandering.Prior to the 1/27/26 order for the resident to reside on a dementia unit, the clinical record lacked: a. An assessment of the resident's need for a secure dementia unit,b. Documentation regarding a care conference held in conjunction with the resident's representative to address the need for a secured dementia unit,c. An assessment or evaluation completed by the resident's physician, which determined the resident's need for a secured dementia care unit,d. An IDT note which addressed the resident's need for a secured dementia unit.e. Documented incidents of wandering for the period of time from 12/1/25 to 3/16/26.The clinical record indicated the resident's room was not relocated on 1/28/26. The change in the resident's services on 1/28/26 was the unit was locked on that date.During an observation on 3/16/26 at 12:49 p.m., Resident 12 propelled his wheelchair out of the dementia unit dining room.During an observation on 3/17/26 at 10:32 a.m., Resident 12 was resting on the bed in his room.During an observation on 3/19/26 at 11:18 a.m., the resident was resting on the bed in his room.During an observation on 3/19/26 at 12:10 p.m., the resident was seated at a table in the dining room on the dementia care unit.5. Resident 3's clinical record had been reviewed on 3/17/26 at 3:35 p.m. Current diagnoses included neurocognitive disorder with Lewy bodies, cognitive communication deficit, and visual hallucinations.The resident had a 1/30/26 physician's order to admit to gated community due to neurocognitive disorder with Lewy bodies. Special instructions include reason for admission to gated community.The resident had a 1/27/26 4:39 p.m., Social Service Note, which indicated the resident's representative, was notified of the plan to transition the residence hall to a locked unit.A 1/30/26 Secure Unit Observation form indicated the observation was unscheduled and was completed due to initiation of gated community.The resident had a 1/30/26 care plan problem/need regarding placed in the lock unit as least restrictive approach to protect the resident and assure his/her health and safety.The resident had a 2/17/26 care plan problem/need due to risk for elopement due to exit seeking behaviors.A 12/30/25 admission, MDS assessment indicated the resident was in cognitively, intact, had moderately severe depression and displayed no maladaptive behaviors during the assessment period including wandering.Prior to the 1/27/26 order for the resident to reside on a dementia unit, the clinical record lacked: a. An assessment of the resident's need for a secure dementia unit,b. Documentation regarding a care conference held in conjunction with the resident's representative to address the need for a secured dementia unit,c. An assessment or evaluation completed by the resident's physician, which determined the resident's need for a secured dementia care unit,d. An IDT note which addressed the resident's need for a secured dementia unit.e. Documented incidents of wandering for the period of time from 12/1/25 to 3/16/26.The clinical record indicated the resident's room was not relocated on 1/28/26. The change in the resident's services on 1/28/26 was the unit was locked on that date. During an observation on 3/17/26 at 11:33 a.m., Resident 3 was participating in an activity in the dementia dining room.During an observation on 3/19/26 at 11:22 a.m., the resident was participating in an activity in the dementia unit dining room.A current facility policy titled Resident Rights , last reviewed on January 31, 2026, and provided by the Corporate Nurse Consultant via email on 3/18/26 at 3:26 p.m., indicated the following: .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility.All residents have the right to be /will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . These rights include the residents' rights to:.2. Residents are entitled to exercise his or her rights and privileges as a resident of the facility and as a citizen or resident of the United States to the fullest, extent possible without interference, coercion or discrimination or reprisal. A current facility policy titled Dementia Care which was last reviewed January 31, 2026 and provided via email by the Corporate Nurse Consultant on 3/18/26 at 12:50 p.m., indicated the following: .To enhance the quality of life and care for residents with dementia: The goal for our residents with dementia is to provide an environment that upholds their dignity and worth as individuals in an environment that is peaceful, calm, safe and accepting, thus enabling them to reach their full potential Care not only focuses on meeting the physical needs of the resident, but also social, emotional and spiritual, and/or assisting the resident to maintain optimal quality of life through respectful, gentleness and understanding A current facility policy titled Abused, Neglect and Misappropriation of Property which was last reviewed, January 31, 2026 and provided the Interim Administrator via an email on 3/16/26 at 1:51 p.m., indicated the following: .Involuntary seclusion means separation of a resident from other residents or from his or her room or confinement to his or her room, (with or without roommate,)theses against the residents will or the will of the residents legal representative Placement of a cognitively impaired resident on a locked unit for therapeutic and safety reasons is not involuntary seclusion, so long as the residents representative, if any, agrees the placement and is involved in the resident's care, and care and services are provided to the resident in accordance with his or her care plan. The placement of a resident on a locked unit shall be implemented as the least restrictive alternative for the least amount of time necessary to treat the resident's symptoms and protect the resident's safety. 410 IAC (Indiana Administrative Code) 16.2-3.1 -27(1)(4)

Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed prior to leaving medications unattended in a resident's room for 1 of 8 residents observed for medication administration (Resident 29). Finding includes: During a continuous medication administration observation, beginning on 3/18/26 at 9:12 a.m., RN 3 prepared the following medications for Resident 29: acetaminophen (Tylenol) 325 mg (2 tabs), acetazolamide 250 mg (for fluid retention), bumetanide (for swelling) 1 mg, carvedilol 12.5 mg (for hypertension), multivitamin, ferrous sulfate (iron) 325 mg, omeprazole 40 mg (for gastroesophageal reflux disease) delayed release, and spironolactone 25 mg (for fluid around the lungs). She took the medications into Resident 29's room. Resident 29 questioned why an additional pill was in the medication cup. RN 3 indicated the resident took acetazolamide on Mondays, Wednesdays, and Fridays for the resident's swelling. The resident indicated she did not want to take another water pill. She took enough of them already. RN 3 encouraged the resident to take the medication, and Resident 29 declined. RN 3 was uncertain which of the pills was the acetazolamide. She left the medication cup containing the medications in the resident's room and walked to the medication cart, approximately five feet down the hallway from the resident's doorway. She did not have a line of vision into the resident's room from the medication cart. She obtained the acetazolamide medication card from the medication cart and brought it into the resident's room. The resident poured the medications in the medication cup onto her bedside table and looked through the medications. RN 3 removed the acetazolamide. Then, Resident 29 questioned the identity of each pill. The nurse left the room, went to the medication cart (in the same area as above), and obtained all the medication cards to identify each specific pill. She returned to the resident's room and went over the medications. During an interview, on 3/18/26 at 9:52 a.m., RN 3 indicated she did not think about bringing the medications back out to the cart with her when the resident questioned the medications. If the medications had contained a narcotic, she would not have left the medication unattended with the resident. Resident 29's clinical record was reviewed 3/18/26 at 11:23 a.m. Diagnoses included essential hypertension, pulmonary hypertension (high blood pressure in the lung arteries), pleural effusion (abnormal buildup of fluid around the lungs), acute on chronic systolic (congestive) heart failure, anemia, and gastroesophageal reflux disease without esophagitis. Current orders included the following: acetaminophen 325 mg - two tabs every six hours as needed for mild pain, acetazolamide 250 mg every Monday, Wednesday, and Friday, bumetanide 1 mg daily, carvedilol 12.5 mg twice a day, multivitamin daily, ferrous sulfate 325 mg daily, omeprazole - delayed release 40 mg daily, and spironolactone 25 mg daily. A Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident was cognitively intact. The resident's clinical record did not contain a medication self-administration assessment or order. During an interview, LPN 4 indicated medications should not be left in the residents' rooms out of the line of sight unless the resident had a self-administration of medication order. During an interview, LPN 5 indicated medications should not be left unattended at the residents' bedsides. During an interview, the DON indicated medications should not be left with a resident out of the line of sight of the nurse unless the resident had a self-administration of medication order. A current facility policy, dated 2007, titled Storage of Medication, provided by the Corporate Nurse Consultant on 3/19/26 at 2:02 p.m., indicated the following: . The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. A current facility policy, revised 6/24/24, titled Self-Administration Medication, provided by the Corporate Nurse Consultant on 3/19/26 at 2:02 p.m., indicated the following: .Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to promote and protect a resident's right to make choices concerning his personal attire when going outdoors to smoke for 1 of 1 residents reviewed for choices. (Resident 43) Findings include:During an interview on 3/18/26 at 10:48 a.m., Resident 43 indicated on the previous evening (3/17/26 at 4:30 p.m.), the Interim Administrator had informed him he had to wear a hood up to go out to smoke. The resident indicated he did not want to wear a hood, and it was his right to refuse to wear his hood up. He was wearing a hooded coat over a hooded sweatshirt and was dressed for cold weather. The Interim Administrator told him, I make the rules here. The resident indicated the Interim Administrator put hands on me! The Interim Administrator put his hands on the resident's shoulders and yanked the hood up on the resident's head. The resident then pushed the hood down. The Interim Administrator again yanked the hood back up on the resident's head. This action was followed by the resident pushing the hood back down. The Interim Administrator then yanked the hood on the resident's head a third time. The resident indicated he was embarrassed and humiliated by this action and felt he had been treated like a child. Other residents were present and witnessed the action, which increased his embarrassment.Confidential interviews were conducted during the survey.Confidential interviews regarding the smoke break on 3/17/26 at 4:30 p.m. indicated the following:a. The Interim Administrator yanked Resident 43's hood up on his head. The resident pushed the hood back down and the Interim Administrator yanked the hood up a second time. The Interim Administrator treated the resident like he was a child. He put hands on him and that was wrong.b. The Interim Administrator yanked the hood up on Resident 43's head two times. They believed he made the resident feel like he was being treated like a child.c. The Interim Administrator put the hood up on Resident 43's head. The resident indicated to them he felt like he was being treated like a child. Resident 43's clinical record was reviewed on 3/18/26 at 2:01 p.m. Current diagnoses included depression, atrial fibrillation, and chronic obstructive pulmonary disease (COPD).A 2/16/26 Minimum Data Set (MDS) assessment indicated the resident was cognitively intact, had moderate depression, and had not displayed any maladaptive behaviors during the assessment period. The resident had current care plan problems/needs regarding the following:The resident wished to smoke. This care plan problem originated 8/12/25 and was revised 2/25/26. The approach to this care plan problem did not include the need to wear a hood or hat when smoking.The resident was at risk for an altered mental state due to depression. This care plan problem originated 8/12/25 and was revised 2/25/26.The resident displayed verbal expressions of distress related to depression. This care plan problem originated 2/21/26 and was revised on 2/25/26.A 10/22/25 Smoking Assessment indicated the resident was safe to participate in supervised smoking. No section of the assessment indicated a hat or hood should be worn when smoking.A 10/23/25 IDT (Interdisciplinary Team) note indicated the resident had attended a resident council meeting to discuss the smoking policy. A facility abuse investigation Witness Statement, provided by the Corporate Nurse Consultant via email on 3/20/26 at 1:45 p.m., indicated the following: Witness name: [Interim Administrator's name] Witness title: Administrator.On March 17, 2026, the first and second smoke breaks of the day had been canceled due to outside temperatures. Around 4: 30 p.m. a few of the smokers approached me about having a 4:30 smoke break, the wind chill was 17. I reluctantly agreed to take them out to have one cigarette if they would agree to wear their heaviest coats and have hats or hoods to protect their head. All that were present agreed. I then went to get the smoking box to distribute cigarettes when I returned and started to distribute cigarettes. [Resident 43's name] joined the group . [Housekeeper 17] assisted me with handing out cigarettes at that time. I reminded all of the residents to put their hoods up before we went outside. [Resident 43] refused to comply and started to self propel towards his room. At that point I turned to him and said you can go back to your room if you want to, but the temperature (sic) going down there most likely will not be another smoke break after dinner. He then turned around and accepted a cigarette from [Housekeeper 17] as the residents were being assisted through the doorway, [Resident 43] refused to put his hood up saying that he didn't want to and didn't have to. One of the other residents started to reach over and pull his hood up, and I pulled his it up from the other side. At this point, [C.N.A. 18] from the east wing arrived to supervise, and I headed to stand down meeting. A facility abuse investigation Witness Statement, provided by the Corporate Nurse Consultant via email on 3/20/26 at 1:45 p.m., indicated the following: Witness name: [C.N.A. 18's name]Witness title C.N.A.On March 17, 2026, around 4:30 p.m., I was in the main dining room to see if they needed assistance with taking residents out to smoke. When I came into the dining room, they were heading out the open door to the patio. Cigarettes had already been passed out. I then went out and stayed with the residents. For their smoking times I didn't witness any interaction between [the Interim Administrator] and [Resident 43]. [Resident 43] was complaining and stated that [the Interim Administrator] put his hood on him. He did not say anything about him physically touching him. Untitled documents included in the facility investigation of the allegation of abuse on March 17, 2026, provided by the Corporate Nurse Consultant via email on 3/20/26 at 1:45 p.m., indicated:a. Resident 112's statement: The administrator pulled [Resident 43's] hood up and [resident's name] didn't want it on. [The Interim Administrator] said it was cold out here. You need your hood up on coat. Told him to leave him alone, not abuse , but [Resident 43] has rights, and if he didn't want to wear it , he doesn't have to. b. Resident 46's statement: Put my hood up, which was nice. He asked everybody to put hood up, he didn't do anything wrong. He was not abusive at all, don't know why [Resident 43 and another resident] made a big deal about it. They didn't like anything that's not their idea. A current facility policy titled Resident Rights, last reviewed on January 31, 2026, provided by the Corporate Nurse Consultant via email on 3/18/26 at 3:26 p.m., indicated the following: .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility.All residents have the right to be /will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life These rights include the residents' rights to: .2. Residents are entitled to exercise his or her rights and privileges as a resident of the facility and as a citizen or resident of the United States to the fullest, extent possible without interference, coercion or discrimination or reprisal. A current facility policy titled Abused, Neglect and Misappropriation of Property which was last reviewed, January 31, 2026, which was provided the Interim Administrator via an email on 3/16/26 at 1:51 p.m., indicated the following: .Mental abuse.Includes, but it's not limited to humiliation, harassment, threats of punishment or deprivation, withholding of goods or services or any other statement or behavior that a reasonable person would consider to be humiliating, demeaning, or threatening to a resident. A facility document titled Resident Council Meeting Minutes, dated October 2025 (Day illegible), provided by the Corporate Nurse Consultant via email on 3/18/26 at 3:26 p.m., indicated the following: .Smoking changes: LOA (leave of absence) Smokers can now go out on the patio and smoke. Just sign out. No one can go outside of the building. More lights are needed on the patio. Supervised smokers stay the same 3 x (times) a day. The notes did not include the need for a hat or hood when smoking in inclement, weather. The document lacked indication that smoking attire was discussed. A current facility policy titled Facility Smoking/Non-Smoking Policy last reviewed January 30, 2026, was provided by the Corporate Nurse Consultant via email on 3/18/26 at 3:26 p.m., and indicated the following: .1. Residents who wish to use smoking products will be evaluated, and this will be documented in the electronic medical record (EMR) .The policy did not address clothing, hats or hoods. 410 IAC (Indiana Administrative Code) 16.2-3.1 - 3(u)(3)

Based on interview and record review, the facility failed to ensure a written notice of transfer/discharge and a bed hold policy were provided to the resident and/or resident representatives and information was communicated to the receiving facility to ensure continuity of care for 3 of 4 resident's reviewed for hospitalization. (Resident's 105, 113, and 30) Findings include: 1.Resident 105's record was reviewed on 3/17/2026 3:38 p.m Medical diagnoses included vascular dementia, chronic kidney disease, and heart failure. A 1/15/26 quarterly Minimum Data Set (MDS) indicated the resident was severely cognitively impaired. A 1/22/26, nurse's note indicated the resident was found pale, hypoxic (low oxygen saturation), and breathing strenuously. 911 was called for transfer to the emergency room (ER). The Physician, facility management, and resident's daughter were made aware of her transfer. A 1/22/26 Change of Condition event note indicated a notice of transfer/discharge was reviewed and given to the resident. The clinical record lacked notification of transfer to the receiving facility and review of the notice of transfer/discharge and bed hold policy with the resident's representative. During an interview on 3/20/26 at 11:36 a.m., the Corporate Nurse Consultant (CNC) indicated when a resident is transferred to a hospital or other facility, staff call report to the receiving facility and provide Emergency Medical Services (EMS) with a continuing care document that includes resident medications, code status, diagnoses, and the most recent set of vital signs. A notice of transfer/discharge is reviewed with and provided to the resident. If a resident is not cognitively intact, the notice of transfer/discharge and bed hold policy are reviewed and sent with/to the resident's representative. 2.Resident 113's record was reviewed on 3/17/26 at 3:48 p.m. Diagnoses included multiple sclerosis, pneumonia, other disorders of the lung, severe protein-calorie malnutrition, dysphagia, pharyngeal phase, and adult failure to thrive. A 1/16/26 quarterly MDS assessment indicated the resident was cognitively intact. A nurse's note, on 3/3/26 at 11:00 p.m., indicated the staff entered the resident's room and found the resident lethargic, with facial drooping, increased confusion, and weakness. The nurse practitioner (NP) was notified and issued new orders to transfer the resident to the hospital for evaluation and treatment. The resident's representative was informed. The clinical record lacked notification of the transfer to the receiving facility and review of the notice of transfer/discharge and bed hold policy with the resident or the resident's representative. During an interview, on 3/20/26 at 9:59 a.m., LPN 4 indicated when a resident was sent to the hospital, the physician, family, and hospital were notified. The resident's face sheet, a continuity of care document that included orders and code status, were sent with the resident. The bed hold and transfer/discharge notice was reviewed with the resident and sent along as well. A hospital transfer sheet was documented in the record and contained all the aforementioned information. During an interview, on 3/20/26 at 10:17 a.m., LPN 16 indicated when a resident was transferred to the hospital, the physician was notified for an order, transportation was notified, and the receiving hospital was notified and given a report of the resident's condition. A bed hold and the transfer/discharge paperwork were filled out and signed by the resident or the resident's power of attorney (POA) if the resident was cognitively impaired. The paperwork was copied and given to the resident or POA and the emergency medical technicians. The resident's condition, the physician notification, the family notification, and the hospital notification was documented. During an interview, on 3/20/26 at 10:20 a.m., LPN 5 indicated when a resident was transferred to the hospital, the physician was notified, the family was notified, an SBAR (situation, background, assessment, recommendation) form was filled out, and a transfer to hospital and bed hold policy were completed with the resident. 3.Resident 30's clinical record was reviewed on 3/18/26 at 1:06 p.m. Diagnoses included right sided hemiplegia (paralysis) and hemiparesis (weakness) following cerebrovascular disease, type 2 diabetes mellitus, and chronic congestive heart failure. A 12/21/25, quarterly MDS assessment indicated the resident was cognitively intact. A 3/15/26, discharge MDS assessment indicated the resident discharged with a return anticipated. A 3/15/26, progress note indicated the resident was found on the floor. Resident 30 was yelling out in pain and unable to verbalize how she fell. Her speaking was mumbled and non-sensical. She was unable to follow basic instructions. Resident 30 was sent to the hospital for evaluation and treatment. The facility director, physician, and the resident's family were notified. A 3/15/26, fall event note, indicated the resident reported pain and hitting her head and teaching would occur upon return from the hospital. A 3/15/26, online e-Interact Nursing Home to Hospital Transfer Form indicated the resident was sent to the emergency room. The form lacked a resident or resident representative signature. The clinical record lacked indication the resident and/or resident representatives were provided with a copy of the notice of transfer/discharge form and/or the bed hold policy. During an interview, on 3/20/26 at 1:01 p.m., the CNC indicated she was unable to locate the notice of transfer/discharge forms or bed hold policies provided to residents and/or resident representatives requested. A current facility policy titled, Transfer/Discharge Notice, revised 2/3/2025, and provided by the CNC on 3/20/26, indicated the following: . This policy establishes procedures to ensure appropriate notice, documentation, and support for safe and orderly transitions.2. Documentation: When a resident transfers or discharges: v. Information provided to the receiving provider should include the following: When the facility transfers or discharges a resident, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. 1. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident; b. Resident representative information including contact information; c. Advance Directive information d. All special instructions or precautions for ongoing care, as appropriate; e. Comprehensive care plan goals; and f. All other necessary information, including a copy of the resident's discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.7. Before a facility transfers or discharges a resident: 1. Notify the resident and resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.8. Timing of the Notice: .b. Notice must be made as soon as practicable before transfer or discharge when-.iv. An immediate transfer or discharge is required by the resident's urgent medical needs.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed for 1 newly admitted resident of 2 residents reviewed for tube feeding. (Resident 47)Finding includes: Resident 47's clinical record was reviewed on 3/17/26 at 3:18 p.m. Diagnoses included acute pancreatitis without necrosis or infection, gastrostomy status, and unspecified protein-calorie malnutrition.Current physician orders included enteral feeding tube site care- cleanse site with normal saline and cover with dry dressing once daily (3/13/26) and Jevity 1.5 (feeding tube nutrition) 52 ml per hour via feeding tube to run every shift when not eating during meal service (3/13/26).The clinical record lacked a baseline care plan.A 3/5/26, progress note indicated the resident admitted to the facility with a feeding tube in place.During an interview on 3/20/26 at 1:06 p.m., LPN 14 indicated she was uncertain who was responsible for completion of residents' baseline care plans for new admissions.On 3/20/26 at 1:10 p.m., RN 15 indicated the admitting nurse was required to follow the new admission assessment checklist which included the baseline care plan. If the admitting nurse did not get the baseline care plan finished, the next shift nurse was required to ensure it was completed within 24 hours. Upon finishing the baseline care plan and new admission checklist, they were given to the Unit Manager or placed in the Unit Manager's mailbox. It was not acceptable when the resident's baseline care plan was incomplete.On 3/20/26 at 1:22 p.m., the Corporate Nurse Consultant indicated the facility was unable to provide a baseline care plan for Resident 47. The baseline care plan should have been completed within 48 hours of admission.A current facility policy, reviewed 1/31/25, titled Baseline Care Plan Policy, provided by the Corporate Nurse Consultant on 3/20/26 at 11:27 a.m., indicated the following: Policy Statement Plan is developed and implemented to promote continuity of care and communication among facility stakeholders to increase resident safety and safeguard against adverse events that are most likely to occur right after admission. GUIDELINE: 1. The Baseline Care Plan will be developed and implemented within 48 hours of a resident's admission.410 IAC (Indiana Administrative Code)16.2-3.1-30(a)

Based on interview, observation, and record review, the facility failed to provide services to prevent complications related to clogging and skin impairment around the insertion site for a resident with a feeding tube for 1 of 2 residents reviewed for tube feeding. (Resident 47)Finding includes: During an interview on 3/17/26 at 10:57 a.m., Resident 47 indicated she had a feeding tube and only received her tube feeding through the night. She took her medications by mouth and ate some food by mouth, but it was painful to eat. The facility staff managed her feeding tube. They performed feeding tube site care every other day. Resident 47's clinical record was reviewed on 3/17/26 at 3:18 p.m. Diagnoses included acute pancreatitis without necrosis or infection, gastrostomy status, and unspecified protein-calorie malnutrition.Current physician orders included enteral feeding tube site care- cleanse site with normal saline and cover with dry dressing once daily (3/13/26) and Jevity 1.5 (feeding tube nutrition) 52 ml per hour via feeding tube to run every shift when not eating during meal service (3/13/26). A 3/10/26, admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. Nutritional approaches lacked a feeding tube on the admission assessment. The resident required set-up assistance from staff for eating. A current care plan, dated 3/6/26, indicated the resident was at risk for complications related to the feeding tube enteral feeding. Interventions included the following: provide skin care to the insertion site as needed (3/6/26) and report complications to the MD (3/6/26).A 3/5/26, progress note indicated the resident arrived at the facility with a feeding tube to the abdomen. The feeding tube insertion site lacked any signs of infection.A progress note, dated 3/11/26 at 8:00 a.m., indicated the resident's feeding tube was clogged. Attempts were made to flush the feeding tube with warm water and a 60 ml syringe using a gentle push-pull technique and de-clogger which were unsuccessful. On 3/11/26 at 9:15 p.m., the resident's clogged feeding tube was flushed using the gentle push-pull technique and flushed with ease. The clinical record lacked the following: physician notification of the resident's g-tube being clogged, orders to unclog the feeding tube, documentation of changes to the feeding tube site, and physician notification of the feeding tube site drainage, tenderness, and redness. During an observation on 3/19/26 from 8:11 p.m. to 8:27 p.m., RN 13 entered the resident's room to provide feeding tube site care. No feeding was running during the observation. RN 13 performed hand hygiene and donned a pair of gloves. Resident 47's feeding tube split gauze dressing contained tan drainage and was dated 3/19/26. The feeding tube insertion site had redness noted approximately one fourth of an inch out and surrounding the feeding tube. RN 13 placed normal saline (wound cleanser) on gauze and cleansed from the insertion site outward. The resident was guarded and told the nurse the site was tender during feeding tube site care. The resident indicated the rubber bumper on the feeding tube had moved outward and had previously been directly against her abdomen. The rubber bumper had half an inch gap between the resident's skin during the observation. The feeding tube tenderness and redness was new. During an interview, RN 13 indicated she needed to report the drainage, redness and tenderness to the physician since the resident indicated this was a change from her normal baseline. During an interview on 3/20/26 at 10:07 a.m., LPN 14 indicated she had taken report from RN 13 when she began her shift at 7:00 a.m. RN 13 had not reported any concerns about Resident 47's feeding tube. She was unable to find anything in the clinical record regarding a change in condition of the resident's feeding tube site or physician notification of any concerns regarding the resident's feeding tube site. Drainage, redness, and tenderness at the tube feeding insertion site should have been reported to the physician immediately, passed on in report to the next nurse for continuity of care, and documented in the resident's clinical record. Upon review of the 700 Unit Report Sheet from RN 13, LPN 14 indicated no concerns were written on the report sheet. Failure to report concerns regarding the feeding tube could result in an untreated infection. On 3/20/26 at 10:25 a.m., the Infection Preventionist (IP) indicated any change in condition related to the feeding tube such as clogging, redness, tenderness, and drainage should have been reported immediately to the physician and documented in the resident's clinical record. A tube feeding policy was requested.A facility policy for feeding tubes was not provided prior to facility exit on 3/20/26.A current facility policy, revised 1/31/25, titled Skin Integrity,, provided by the Corporate Nurse Consultant on 3/20/26 at 11:25 a.m., indicated the following: .The facility will ensure that.1. A resident receives care, consistent with professional standards of practice, to prevent avoidable skin integrity issues and does not develop avoidable skin integrity issues unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing. Procedure 3. Recommend ongoing observation of skin integrity by licensed nursing staff. 4. The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified. A current facility policy, reviewed on 1/31/26, titled Notification of Change of Condition, provided by the Corporate Nurse Consultant on 3/20/26 at 11:25 a.m., indicated the following: POLICY. To ensure appropriate individuals are notified of changes in condition. GUIDELINES. 2. Documentation of notification or notification attempts should be recorded in the resident electronic medical record. 3. The resident and/or representative (if applicable), and medical provider should be notified of a change in condition. The medical provider will provide guidance related to the change in condition.410 IAC (Indiana Administrative Code) 16.2-3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to post current and accurate nursing staff information daily for residents and visitors. This deficiency had the potential to affect 114 of 114 residents in the facility.Findings include:During an observation on 3/16/26 at 9:23 a.m., the facility nurse staffing, dated 3/11/26, was posted on a clipboard at the front receptionist desk. The nursing staff posting, dated 3/11/26, included the following:Census: 116 Number of Registered Nurses (RN): Day shift hours: 15.50, Evening shift hours: 9.00, Night shift hours: 0.00, and Total hours: 24.50.Number of Licensed Practical Nurses (LPN): Day shift hours: 24.00, Evening shift hours: 29.50, Night shift hours: 30.00, and Total hours: 83.50. Number of Certified Nursing Assistant (CNA): Day shift hours: 72.50, Evening shift hours: 47.00, Night shift hours: 43.50, and Total hours: 163.00.During an observation on 3/17/26 at 9:55 a.m., the facility nurse staffing, dated 3/17/26, was posted on a clipboard at the front receptionist desk. The nursing staff posting, dated 3/17/26, included the following:Census: 83 Number of Registered Nurses (RN): Day shift hours: 22.00, Evening shift hours: 9.50, Night shift hours: 24.00, and Total hours: 55.50.Number of Licensed Practical Nurses (LPN): Day shift hours: 8.50, Evening shift hours: 14.00, Night shift hours: 1.00, and Total hours: 23.50. Number of Certified Nursing Assistant (CNA): Day shift hours: 69.00, Evening shift hours: 70.50, Night shift hours: 41.50, and Total hours: 181.00.During an interview, on 3/20/26 at 1:30 p.m., the Scheduler indicated he was new to the position, and this was his first week. His shift started as early as 6:30 a.m. and he utilized an online system that populated the staff posting form. He indicated he intended to prepare the daily staff posting the night before, as he was leaving. The staff posting needed to be current and accurate. The census number and hours worked for each nursing position was included, such as Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA). He planned to print the staff posting for the weekends on Friday evenings and have the weekend manager ensure the correct day is available to residents and visitors.During an interview, on 3/20/26 at 1:30 p.m., the Corporate Nurse Consultant indicated the staff posting should have been updated daily from 3/11/26 through 3/16/26. The facility would not have had accurate staff posting available to residents or visitors over the weekend. The staff posting for 3/18/26 should have contained an accurate census number. The facility utilizes an online system to populate the staff posting forms and she would need to ensure the system was updating appropriately.A current facility policy, revised 1/30/26, provided by the Corporate Nurse Consultant on 3/20/26 at 11:30 a.m., indicated the following: . 1. On a daily basis, at the beginning of the shift, the facility must have posted or available for review the following data. 2. The facility will post the following information on a daily basis: Facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. registered nurses, b. licensed practical nurses or licensed vocational nurses, and c. certified nurse aides., and the Resident census. 3. The facility will post the nurse staffing data mentioned above daily at the beginning of each shift.

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies.Findings include:Review of the Summary Statement of Deficiencies, for the facility's last annual recertification and licensure survey completed on January 23, 2025, indicated the facility had deficiencies related to failure to ensure the self-administration of medications assessment was completed prior to medications being left unattended in a resident's room.During an interview, on 3/20/26 at 2:03 p.m., the VP of Operations indicated the Quality Assessment and Assurance (QAA) committee met quarterly to review current facility concerns. The QAA committee utilized an online program to assist with streamlining the process, assessing trends, and documentation of these meetings. The areas of concern cited previously in a survey would be followed per the plan of correction, which was usually for a period of six (6) months. If the audit tools indicated continued deficiency, then the facility would extend the time frame this area was reviewed. However, if the audit tools showed compliance with the regulation, then the reviews would end.During an interview, on 3/20/26 at 2:03 p.m., the Corporate Nurse Consultant indicated the company completed mock surveys and paid special attention to the areas previously cited in surveys to ensure continued compliance. The facility did not have any current QAPI or Performance Improvement Plans (PIP's) in place for ensuring self- administration assessments were completed prior to medications being left unattended in a resident's room.Repeat concerns regarding self-administration of medications were cited during the March 20, 2026, survey as follows:Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed prior to leaving medications unattended in a resident's room for 1 of 8 residents observed for medication administration (Resident 29). A current facility policy, revised 1/31/26, titled, Quality Assurance/Performance (QAPI) Program Policy, provided by the Corporate Nurse Consultant on 3/16/26 at 2:01p.m., indicated the following: . It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care. QAPI supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance with addressing care and management systems. 6. The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. 7. The QAPI committee will review, and coordinate audits and assessments based on the QAPI. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. d. Problem areas - the aspect of care has tended in the past to produce problems for staff or residents. Cross reference F554 410 IAC (Indiana Administrative Code) 16.2-3.1-52(b)(2)

Based on interview, observation, and record review, the facility failed to follow enhanced barrier precautions during feeding tube site care for 1 of 2 residents reviewed for tube feeding. (Resident 47)Finding includes: During an interview on 3/17/26 at 10:57 a.m., Resident 47 indicated staff managed her feeding tube. Staff did not wear a gown over their clothing when they manipulated her feeding tube.Resident 47's clinical record was reviewed on 3/17/26 at 3:18 p.m. Diagnoses included acute pancreatitis without necrosis or infection, gastrostomy status, and unspecified protein-calorie malnutrition.Current physician orders included enteral feeding tube site care- cleanse site with normal saline and cover with dry dressing once daily (3/13/26) and enhanced barrier precaution every shift (3/9/26).A 3/10/26, admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.A current care plan, dated 3/16/26, indicated the resident required enhanced barrier precautions related to enteral feeding. Interventions included personal protective equipment as indicated (3/16/26). During an observation on 3/19/26 from 8:11 p.m. to 8:27 p.m., RN 13 entered the resident's room to provide feeding tube site care. An enhanced barrier precaution sign was in place to the left of the door and a canister below it contained personal protective equipment readily available. RN 13 performed hand hygiene and donned a pair of gloves. Resident 47's feeding tube split gauze dressing contained tan drainage and was dated 3/19/26. RN 13 removed the split gauze dressing with both hands and placed it into the trash along with the dirty gloves. Hand hygiene was not completed. The feeding tube insertion site had redness noted approximately one fourth of an inch out surrounding the feeding tube. RN 13 donned a clean set of gloves and performed feeding tube site care by placing normal saline (wound cleanser) on gauze and cleansed from the insertion site outward. RN 13 leaned in against the resident's bed sheet and blanket with her right pant leg as she placed the new split gauze dressing at the insertion site. A gown was not worn by RN 13 during the feeding tube site care.During an interview on 3/19/26 at 8:28 p.m., RN 13 indicated she did not wear a gown during the resident's feeding tube site care. She did not notice the enhanced barrier precaution sign to the left of the door until she exited the room. Enhanced barrier precautions were required for residents with medical devices to prevent contamination and infections.On 3/20/26 at 10:25 a.m., the Infection Preventionist (IP) indicated EBP was required for any manipulation of the feeding tube. A gown and gloves were required during feeding tube care. A current facility policy, reviewed 1/31/26, titled Enhanced Barrier Precautions, provided by the Corporate Nurse Consultant on 3/20/26 at 11:26 a.m., indicated the following: . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Guideline 2. Enhanced Barrier Precautions (EBP) are additional measure to attempt to decrease transmission of Multidrug-Resistant Organisms (MDRO). 5. EBP are indicated for residents who have chronic wounds and or indwelling medical devices regardless of MDRO status. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)

Based on observation, interview, and record review, the facility failed to distribute food with the correct temperatures for safety and palatability. This deficient practice had the potential to affect 114 of 114 residents who received food from the facility kitchen. Findings include:During a test meal tray temperature check observation on 2/20/26 at 12:47 p.m., accompanied by the Dietary Manager, the following was observed: Milk temperature was 46 degrees Fahrenheit (F) and coleslaw was 64.2 degrees F. The Dietary Manager indicated the temperature was too high for the milk to be served.During an interview on 2/20/26 at 11:40 a.m., the Dietary Manger indicated food had temperature checks prior to plating and placed in the meal carts. The food was then delivered to the appropriate halls for food distribution.A current policy, dated 5/2014, titled Food: Quality and Palatability was provided by the Administrator on 2/24/26 at 3:46 p.m. The policy indicated the following: Policy StatementFood will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature.Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.Definitions Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burns.This citation relates to Intakes 2733549 and 2744835.3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to complete neurological assessments as indicated by facility protocol following falls for 1 of 3 residents reviewed for accidents. (Resident C)Finding includes:Resident C's clinical record was reviewed on 11/17/25 at 2:42 p.m. Diagnoses included vascular dementia, cerebral infarction, essential primary hypertension, repeated falls, unspecified fracture of facial bones, unsteadiness on feet, and generalized muscle weakness. Current orders included tramadol (narcotic for pain) 25 mg three times daily as needed for pain, metoprolol succinate (blood pressure) 25 mg 0.5 tablet once daily, and aspirin (blood thinner for coronary artery disease) 81 mg once daily. A physician order for clopidogrel (blood thinner for coronary artery disease) 75 mg once daily was ordered on 7/15/25 and discontinued on 11/14/25. Review of the Medication Administration Records for August, September, October and November 2025 indicated the resident was taking both aspirin and clopidogrel during those months. Clopidogrel was discontinued by hospice on 11/14/25. An 11/4/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. Resident C required partial assistance from staff for toileting hygiene, toileting transfers, chair/bed-to-chair transfers, and bathing. He required supervision for lower body dressing, donning and doffing footwear, and for walking 10 feet. The resident used a wheelchair for mobility. He had one fall with injury and 1 fall with major injury since the prior assessment. Resident C's current care plans included the following:A 7/16/25 problem of risk for fall related to a history of falls. Interventions included encourage/assist resident to assume a standing position slowly (7/16/25), provide nonskid footwear (7/16/25), provide visual cues for resident to ask for assistance prior to transfers (8/18/25), staff to assist the resident back to bed right after meals (9/29/25), keep frequent used items in reach (9/30/25), walk to dine as tolerated (10/14/25), and silent bed alarm as tolerated (11/4/25). A 7/17/25 problem of risk for bleeding/bruising related to medication. Interventions included the following: Observe for signs and symptoms of bleeding such as nose bleeds, Report abnormal finding to the physician/nurse practitioner (7/16/25)., and report to the physician any abnormal bleeding (7/16/25). An 11/6/25 problem of multiple fractures of the face secondary to a fall. Interventions included report emergence of hematoma or hemorrhage (11/6/25). Review of Resident C's unwitnessed fall events in the clinical record included the following:Fall with no injury in the resident's room on 8/17/25 at 1:37 a.m. Fall with no injury in the resident's room on 9/25/25 at 8:00 a.m. Neurological assessments #12, #13, and #14 were blank. Fall in the resident's room with bleeding laceration to the right eyebrow on 9/30/25 at 4:30 p.m. Neurological assessments #10, #11, #12, #13, and #14 were blank. Fall with no injury in the resident's room on 10/13/25 at 10:00 a.m. Fall with multiple facial fractures in the resident's room on 11/4/25 at 2:25 a.m. A progress note, dated 11/4/25 at 8:50 a.m., indicated the Administrator and the Nurse Practitioner evaluated the resident this morning. The resident's forehead and nose were still bleeding at this time. Bruising was noted on the resident's left eye. An order was received to send the resident to the emergency room for evaluation. A CT Maxillofacial without IV Contrast, dated 11/4/25, indicated the following impression: Acute nasal bone fractures are comminuted and mildly displaced to the right with some depression of the fracture fragments on the left. Acute fractures are also evident along the right greater than left maxillary frontal processes and nasal septum, which is displaced and buckled. Scalp and nasal dorsum soft tissue injury extends inferiorly to involve the walls of the nasal vestibule with thickening along the cartilaginous nasal septum and asymmetric left nasal valve stenosis. An osseous defect along the anterior wall of the right external auditory canal is suspicious for an acute tympanic plate fracture. During an observation on 11/18/25 at 12:18 p.m., Resident C was seated in his wheelchair in the dining room with non-skid socks noted on his feet. The resident had dark purple discoloration on his bilateral lower periorbital portion of his face. On 11/18/25 at 2:20 p.m., the DON indicated, during review of neurological assessments for Resident C's unwitnessed falls on 9/25/25 and 9/30/25, the neurological assessments should have been completed with unwitnessed falls and falls when the resident hit their head. There were blank neurological assessments for Resident C's 9/25/25 and 9/30/25 unwitnessed falls. The DON indicated the facility lacked a policy regarding fall prevention, unwitnessed falls, and neurological assessments. During an interview on 11/18/25 at 3:05 p.m., LPN 4 indicated unwitnessed falls and falls when a resident hit their head required immediate neurological assessment initiation. She indicated the neurological assessments were completed on the fall event note and the facility also provided a paper neurological assessment sheet for them to utilize and reference a couple of weeks ago. A request was made for a copy of the paper format titled Neuro Check Times Guidance Chart. LPN 4 indicated she would ask the DON for a copy for review. On 11/18/25 at 3:23 p.m., LPN 5 indicated unwitnessed falls and falls when a resident hit their head required immediate neurological assessment initiation and ongoing neurological assessments that were to be completed entirely over multiple shifts. She indicated she also had a paper copy to reference for the neurological assessments. LPN 5 indicated she would ask the DON for a copy for review. On 11/18/25 at 3:44 p.m., RN 6 indicated it was not acceptable to leave the neurological assessments incomplete or blank because one would not be able to identify a change in the resident's neurological status without them. Neurological assessments should be initiated immediately and completed every 15 minutes x4, then every 30 minutes x 4, then every hour x 4, then every 4 hours x 4. On 11/18/25 at 4:03 p.m., the Administrator indicated the facility would not provide a copy of the Neuro Check Times Guidance Chart for review because it was not the facility's policy or procedure. She indicated neurological assessments were required to be completed with unwitnessed falls and falls when residents hit their head. On 11/18/25 at 4:19 p.m., LPN 7 indicated she was on duty when Resident C had an unwitnessed fall in his room on 11/4/25. She heard a noise and ran to the resident's room where she found the resident on the floor lying on his right side with his plastic coffee mug still in his hands. Resident C's nose was bleeding, and he was trying to wipe the blood away with the coffee mug in his hands. Resident C explained he hit his nose on the floor. He was close to the entrance door of his room near his roommate's bed, laughing, and talking to his roommate while lying in the floor. His wheelchair was still back by his bed as though he had forgotten it. He denied pain. She stopped his nose bleed and assessed the resident to include neurological assessments. He was assisted into the restroom, cleaned him up from the bleeding, and then assisted back to bed. She called the on-call provider services line that could be utilized for non-emergent situations and was unable to speak with anyone. She felt it was not an emergency since the resident was not exhibiting pain and was laughing. She left a message about the fall on the provider service line. On 11/18/25 at 4:39 p.m., RN 8 indicated nursing staff followed the fall event note so they would know what had to be completed when they had an unwitnessed fall. This citation relates to Intakes 2660002 and 2662023. 3.1-37(a)

A. Based on interview and record review, the facility failed to report to the Indiana Department of Health (IDOH) an unusual occurrence, related to potential neglect, when an unprescribed controlled medication was found in a dependent resident's system during a hospital stay for 1 of 3 residents reviewed for neglect. (Resident B)Findings include:Resident B's clinical record was reviewed on 10/22/25 at 11:09 a.m. Diagnoses included unspecified dementia, essential primary hypertension, unspecified asthma, unspecified convulsions, and heart failure. The medication allergy list included gabapentin. Physician's orders included levothyroxine (thyroid medication) 25 milligrams (mg) by mouth once every morning and primidone (seizure medication) 50 mg by mouth at bedtime. An 8/20/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She required set-up assistance from staff for eating, oral hygiene, toileting hygiene, and rolling left to right. The resident did not take opioids. A hospital progress note, dated 9/25/25 at 9:51 a.m. indicated the resident arrived with altered mental status. The emergency medical services reported concern about the resident's low respiratory rate, hypoxia, low blood pressure when the resident was transported to the hospital from the facility. The family requested a urine drug screen due to concerns that the resident may have received her roommate's medications again at the facility. A hospital progress note, dated 9/25/25 at 12:17 p.m., indicated upon arrival the resident was very lethargic with respirations of 5, temperature 96.6 degrees, and oxygen saturation of 85% to 88%. There was a concern with a medication mix up per the extended care facility with the roommate's medications of gabapentin and morphine (narcotic pain medication). The resident's urine drug screen was positive for barbiturates and opiates. The resident did not take opiates. After collection of the urine drug screen, the resident received Narcan (life-saving medication to reverse the effects of an opioid overdose). The resident was admitted to the hospital for altered mental status. During an interview on10/24/25 at 4:03 p.m. , the DON indicated the facility would have reported Resident B's unusual occurrence on 9/25/25 to the Indiana Department of Health if the night shift nurse said she made a medication error. It was not reported because the facility did not find an error. The facility followed the IDOH guidelines for reporting potential alleged neglect. A current facility policy, last reviewed 1/31/25, titled Abuse, Neglect and Misappropriation of Property, provided by the Administrator on 10/22/25 at 11:30 a.m., indicated the following: POLICY STATEMENT.It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin. and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are. reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The Facility Administrator is responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law. Immediately. All alleged violations involving abuse, Neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. In other words, all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately, as defined in this paragraph. Cross reference F610 This citation relates to Intakes 2634309 and 2641871. 3.1-28(c)

Based on interview and record review, the facility failed to complete a thorough investigation of an unusual occurrence related to potential neglect when an unprescribed substance was found in a resident during a hospital stay for 1 of 3 residents reviewed for neglect. (Resident B)Findings include:Resident B's clinical record was reviewed on 10/22/25 at 11:09 a.m. Diagnoses included unspecified dementia, essential primary hypertension, unspecified asthma, unspecified convulsions, and heart failure. The medication allergy list included gabapentin (seizure medication). Physician's orders included levothyroxine (thyroid medication) 25 milligrams (mg) by mouth once every morning and primidone (seizure medication) 50 mg by mouth at bedtime. An 8/20/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She required set-up assistance from staff for eating, oral hygiene, toileting hygiene, and rolling left to right. The resident did not take opioids. A care plan, revised 8/26/25, indicated the resident had an allergy to gabapentin. Interventions included do not give anything on the allergy list to the resident (3/15/20). A progress note, dated 8/25/25 at 11:00 a.m., indicated the provider and the resident representative were notified regarding an (in error) administration of gabapentin (neuropathy) 300 milligram (mg) and clopidogrel (anti-platelet) 75 mg by mouth. An event note, dated 8/25/25 at 12:29 p.m., indicated Resident B was given her roommate's medication in error due to responding to the wrong name twice. A progress note, dated 8/25/25 at 3:28 p.m., indicated Resident B had dementia and at baseline could not identify who she was. A hospital progress note, dated 8/25/25 at 3:45 p.m., indicated Resident B was administered her roommate's medications at the skilled nursing facility. Review of a progress note, dated 9/25/25 at 8:12 a.m. indicated the CNA informed a nurse that the resident was off. Vitals were obtained with temperature 97.7 degrees, pulse 66, respirations 16, oxygen saturation 93% on room air, and blood pressure 85/42. The CNA informed the nurse that the resident had stated that she felt like her next breath was going to be her last one. The resident was encouraged to drink her fluids and eat some breakfast. The resident took sips and shook her head no to eating and drinking more. The resident was assisted to her room where she was assisted in bed with her head down and feet up to assist with low blood pressure. The provider was notified and new orders were received for labs. The provider planned to see the resident that day. A progress note, dated 9/25/25 at 8:15 a.m., indicated an assessment was completed and the resident was observed to be increasingly lethargic. The resident indicated she had never felt that way before. Family wanted the resident to be sent to the ER upon their arrival at the facility. A progress note, dated 9/25/25 at 9:00 a.m., indicated the family arrived and emergency medical services were contacted to transport the resident to the emergency room for evaluation. A progress note, dated 9/25/25 at 9:15 a.m., indicated the resident exited the building via stretcher with emergency medical services and family. A hospital progress note, dated 9/25/25 at 9:51 a.m. indicated the resident arrived with altered mental status. The emergency medical services reported concern about the resident's low respiratory rate, hypoxia, low blood pressure when the resident was transported to the hospital from the facility. The family requested a urine drug screen due to concerns that the resident may have received her roommate's medications again at the facility. A hospital progress note, dated 9/25/25 at 12:17 p.m., indicated upon arrival the resident was very lethargic with respirations of 5, temperature 96.6 degrees, and oxygen saturation of 85% to 88%. The resident got up and went to breakfast at the extended care facility and indicated she did not feel well. The resident told staff she thought she was going to take her last breath. Staff noted she was lethargic. Family were at the bedside and noted they saw the resident yesterday and she was in her normal state of health. The resident's pupils were small and the resident had no verbal communication. She had a low heart rate with trace lower extremity swelling. There was a concern with a medication mix up per the extended care facility with the roommate's medications of gabapentin and morphine (narcotic pain medication). The resident's urine drug screen was positive for barbiturates (controlled medications) and opiates. The resident did not take opiates. After collection of the urine drug screen, the resident received Narcan (life-saving medication to reverse the effects of an opioid overdose). The resident was admitted to the hospital for altered mental status. During entrance conference on 10/22/25 at 10:20 a.m., the Administrator and DON provided recent facility investigations, which lacked an investigation for Resident B for 9/25/25. During an interview on 10/23/25 at 9:27 a.m., the DON indicated Resident B had one prior medication error and it occurred on 8/25/25. She had to review the record to see if an investigation was conducted regarding a potential medication error on 9/25/25. Review of the facility investigation for the unusual occurrence on 9/25/25, included the following information: Seventy-one resident questionnaires contained two questions that could be answered yes/no, but the resident's roommate (potential witness) was not included. None of the questionnaires were dated, timed, nor indicated who completed the questionnaires with the residents. Thirty-one skin assessments were completed on 9/25/25 with no skin issues identified. The investigation lacked any statements from pertinent staff who were on duty or may have cared for Resident B when/surrounding the date and time when the unusual occurrence happened. No statements were included from emergency medical services staff who transported Resident B from the facility to the hospital on 9/25/25. No resident or representative statements from those who were at the facility the morning Resident B was sent out to the hospital were included in the facility investigation. Resident C's clinical record was reviewed on 10/23/25 at 12:30 p.m. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, fibromyalgia, unspecified epilepsy, other chronic pain, and expressive language disorder. Physician's orders included clopidogrel (anti-platelet) 75 mg by mouth once daily, gabapentin 300 mg by mouth three times a day, levetiracetam (seizure) 500 mg by mouth two times a day, and morphine 60 mg extended-release tablet by mouth two times a day. The MAR indicated Resident C received gabapentin 300mg cap, levetiracetam 500 mg tab, and morphine 60 mg extended-release tablet on 9/25/25 at 6:05 a.m. A 9/8/25, annual, MDS assessment indicated Resident C was severely cognitively impaired. Resident C required partial assistance from staff for toileting hygiene, upper body dressing, bathing, rolling left and right, toilet transfers, and chair to bed transfers. She required substantial assistance from staff for lower body dressing. A manual wheelchair was used for mobility. The resident was taking opioids. A current care plan, revised 9/21/25, indicated Resident C had impaired communication related to expressive aphasia. She is able to answer yes/no questions, nod head yes/no, uses hand gestures, uses communication board, and is able to say some words. Interventions included the following: use communication techniques to facilitate interaction; use preferred name; identify yourself with each contact; and face the resident when speaking and make eye contact (8/15/19), have the resident to use her communication board in her electronic device (12/9/20), and observe for non-verbal cues (3/2/23). During an interview, on 10/22/25 at 7:32 p.m., LPN 3 indicated on 9/24/25 at 11:00 p.m., she took over the 100 Unit and worked until 7:00 a.m. on 9/25/25. LPN 3 was not familiar with the residents nor the staff. When unfamiliar with the residents, LPN 3 asked the residents their name and date of birth prior to medication administration to ensure the correct medications were administered to the correct resident. No residents were unable to state their name and date of birth on the 100 Unit on her shift from 9/24/25 – 9/25/25. No one assisted LPN 3 with the medication administration on the shift and there were no problems getting the medications passed. There were a few refusals that were documented and some narcotics LPN 3 administered on the 100 Unit during that shift. LPN 3 did not ask other staff to assist with identifying the residents. Mid-morning on 9/25/25, the DON contacted LPN 3 at home and told LPN 3 the resident in question had become unresponsive, sent to the hospital and tested positive for an unprescribed narcotic. The DON led LPN 3 to believe the resident had been administered the narcotic erroneously. During an interview on 10/23/25 at 1:07 p.m., Resident C was seated in her wheelchair in her room, unable to verbalize her name and date of birth , but she was able to point to her name on her tablet and confirmed yes when her birthdate was stated. She remembered the date Resident B declined and was sent out of the facility. Resident B had not returned to the facility since that time. Resident C indicated she normally received medications early in the morning. On the day Resident B was sent out, Resident C seen a nurse come into their room that morning. The nurse came into their room early in the morning and administered medication to Resident B, but she did not administer any early medications to Resident C that morning. Resident C indicated Resident B typically walked around the room with her walker and ate breakfast and lunch in the dining room. Resident C was concerned and had reported that morning to a management staff member about her concern that Resident C had not received her medications early that morning and Resident B had received medication. Confidential interviews were conducted during the course of the survey and indicated the following: Resident B was typically known to walk with her walker to the dining room with standby assistance each morning for breakfast. Resident B was not known to become lethargic on days shift after taking her medications. Resident B was unable to state her date of birth due to cognitive impairment. Resident B was not familiar with what medications she took and when handed a cup of pills would just tip the cup up and take whatever was in the medication cup without question. Resident C had aphagia with difficulty conveying her message but understood and could answer questions appropriately. It was better to ask questions that could be answered with yes and no for Resident C. Resident C knew her medications and always checked her medications to ensure they were correct before she took them. Due to the aphasia, Resident C was unable to state her name and date of birth . Resident C was not known to report she had not received her medications once she had received them for the day. Both Residents B and C took their medications whole. On 9/25/25, Resident B was her normal self around 6:00 a.m. that morning. Around approximately 7:15 a.m., upon assisting Resident B out of her room and towards the dining room with her walker, she seemed a little out of breath, more confused, and began shuffling her feet when the resident was just a few steps out of her room. As a result, the resident was assisted to the dining room for breakfast in the wheelchair. While on the way to the dining room, LPN 3 was giving report to LPN 4 at the nurses' station. Upon passing the nurses' station, LPN 3 was asked if Resident B had any concerns throughout the night shift. LPN 3 responded that everything had been normal. While in the dining room, Resident B told CNA 5 and CNA 6 she thought her next breath may be her last. They immediately stopped RN 7 and asked for her to evaluate Resident B because the resident did not seem to be herself. RN 7 immediately took over. The morning of 9/25/25, Resident B was a little more sleepy than usual when she got dressed. Once the resident was in the dining room in the wheelchair, Resident B was more confused and lethargic. The resident made the statement she thought her next breath was going to be her last breath. This information was immediately shared with RN 7 who assessed the resident. LPN 3 was also stopped just prior to leaving the facility to be asked if Resident B had been ill through the night. LPN 3 denied any concerns. Once RN 7 assessed the resident, they communicated with LPN 4 who was assigned to the 100 Unit, then another staff member assisted Resident B back to her room. The resident had not eaten or drank for breakfast. Typically, the resident ate fairly well for breakfast. Resident B had visitors, who notified staff that Resident B wasn't breathing right and her color was off. RN 7 was immediately notified and LPN 4 also came to the room. Nursing put oxygen on the resident. The resident was transferred to the hospital. Once Resident B was sent out to the hospital, it was recognized that Resident C was crying, initially thought to be out of concern. Resident C understood but had difficulty verbalizing. As a result, it took some time to console and communicate with Resident C. After several questions, Resident C communicated she had not received her medications early that morning, Resident B had received medications early that morning, and Resident C was worried because she believed Resident B had been given her medications in error early that morning. LPN 4 on the 100 Unit was immediately notified. The DON was not in her office so the ADON was immediately notified and requested to go directly to Resident C's room to inquire with more questions. When the ADON went in Resident C's room the ADON confirmed with Resident C that Resident B was believed to have received Resident C's medications early that morning. The ADON left the resident room and was then seen talking with the DON. The status of the reported concern was unknown. During an interview on 10/23/25 at 1:42 p.m., the ADON indicated she was at the facility on 9/25/25 when Resident B was sent out for a change of condition. She could not remember if anyone brought any information to her attention regarding Resident B and Resident C and their medications. She could not remember if she had spoken to Resident C, and she could not recall if she went to Resident B and Resident C's room that day. On 10/24/25 at 4:03 p.m., the DON indicated she was aware of the previous medication error that occurred on 8/25/25, when Resident B received Resident C's medications, as the DON had assisted in the facility's investigation. She was notified on 9/25/25 around 9:00 a.m. that Resident B did not eat well, and they were going to send the resident out for shortness of breath. The DON and Administrator had completed the facility investigation for 9/25/25. The hospital Case Manager contacted the DON on 9/25/25, asked about the medication list, and notified her the resident tested positive for opiates on the drug screen. Resident B did not have orders for opiates and the DON was aware. She did not communicate with the hospital that Resident B had previously received Resident C's medication on 8/25/25. Resident C could have answered yes/no questions, but she could not state her name and date of birth . Resident C's cognition was impaired, so a statement was not taken from her. They did not have staff statements because they did not find anything on their end. On 10/24/25 at 4:54 p.m., the Administrator indicated she had not collected any statements because the DON talked to the nursing staff. The facility could not confirm who had been spoken with since no statements were collected. No further information was provided. The article, Morphine, dated 3/27/25, was retrieved on 11/14/25 at 10:03 a.m. from the National Institute of Health (NIH) website https://www.ncbi.nlm.nih.gov/books/NBK526115/#article-25271.s8. The guidance included : According to the Centers for Disease Control Prevention (CDC) guidelines, clinicians should not use extended-release/long-acting opioids, including morphine, to treat acute pain or initiate opioid treatment for subacute or chronic pain. Due to their longer half life and duration of effects, such as respiratory depression, ER/LA opioids should be reserved for severe continuous pain. Toxicity. Signs and Symptoms of Overdose. Morphine can potentially be a lethal medication when not used properly. This medication causes a host of symptoms related to CNS depression. Severe respiratory depression is the most feared complication of morphine in cases of overdose. Acute morphine overdose can be present with a variety of symptoms, including respiratory depression, skeletal muscle flaccidity, cold and clammy skin, hypoglycemia, bradycardia, hypotension, constricted pupils, pulmonary edema, somnolence progressing to coma, partial or complete airway obstruction. The article, Extended-release morphine sulfate in treatment of severe acute and chronic pain, dated 9/21/10, was retrieved on 11/17/25 from the NIH website at https://pmc.ncbi.nlm.nih.gov/articles/PMC3004644/. The guidance included: Pharmacodynamics. It takes approximately 30 minutes for the immediate-release morphine formulation to reach the central nervous system, and 90 minutes for the extended-release formulation. A current facility policy, last reviewed 1/31/25, titled Abuse, Neglect and Misappropriation of Property, provided by the Administrator on 10/22/25 at 11:30 a.m., indicated the following: POLICY STATEMENT.It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin. and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated. The organization's policy is that the Facility Administrator, or his or her designee, will conduct a reasonable investigation of each such alleged violation. This citation relates to Intakes 2634309 and 2641871. 3.1-28(d)

Based on interview and record review, the facility failed to thoroughly assess and intervene to promote the healing of pressure injuries for 1 of 3 residents reviewed for injuries (Resident C). Finding includes:Resident C's clinical record was reviewed on 9/30/25 at 9:39 a.m. Diagnoses included fracture of unspecified part of neck of right femur, chronic kidney disease, stage 3, severe protein-calorie malnutrition, and dementia. Orders included wound nurse practitioner (NP) to provide wound management assessment and treatment by provider as needed (9/9/25), heel protectors while in bed, as tolerated (9/9/25), pressure relieving/redistribution mattress (9/8/25), pressure redistribution cushion to wheelchair (9/8/25), quetiapine (antipsychotic) 100 mg daily, trazodone (antidepressant) 100 mg daily, and sertraline (antidepressant) 25 mg daily. An admission Minimum Data Set (MDS) assessment, dated 9/12/25, indicated the resident was severely cognitively impaired. She had an impairment to her functional range of motion to her lower extremity on one side. She required substantial/maximal staff assistance for eating, oral hygiene, and personal hygiene. She was dependent on staff assistance for toileting hygiene, upper and lower body dressing, showering and bathing, putting on/taking off footwear, bed mobility, and transfers. She was always incontinent of bowel and bladder. She had a stage 2 (partial-thickness skin loss involving epidermis/dermis) unhealed pressure injury upon admission to the facility. An initial care plan for skin (9/8/25) included the following interventions: turn and reposition for comfort with care, elevate heels, provide pressure relieving device in chair, use lift sheet to reposition in bed, ensure resident in clean and dry, ensure adequate hydration, observe nutritional intake, encourage resident to float heels while in bed, and inspect skin when repositioning, toileting, and assisting with activities of daily living (ADLs) - notify nurse of adverse findings. A care plan for risk for pressure injury related to decreased mobility was initiated on 9/9/25 with a goal that skin will be intact, free of redness, blisters, discoloration or open areas over bone prominences through the next review date. Interventions included apply lotion after showering/bathing (9/9/25), avoid prolonged skin to skin contact (9/9/25), provide pressure relieving device: pressure relieving mattress, chair cushion (9/9/25), treatment per physician order (9/9/25), and weekly skin review (9/9/25). A nursing progress note, dated 9/8/25 at 6:05 p.m., indicated the resident was admitted to the facility. The resident was confused and drowsy. She had a right femoral neck fracture. A surgical site had a nonremovable dressing with surrounding edema. She had redness to her coccyx area, a stage 2 pressure injury on her right elbow, and red/purple discoloration to both her heels. An admission observation detail report, dated 9/8/25 at 6:13 p.m., indicted the resident had skin impairment upon admission and was at a high risk for developing pressure injuries. A skin integrity event, dated 9/8/25 at 6:50 p.m., indicated the resident had a pressure injury to the right elbow with the length of 1.7 cm and a width of 1.2 cm. The DON/wound nurse was notified to enter the findings into the wound management system. Immediate interventions included elevate heels, provide pressure relieving device in chair, turn and reposition for comfort with care, ensure the resident is clean and dry, and avoid positioning the resident directly on skin breakdown. A dietary progress note, dated 9/17/25 at 4:47 p.m., indicated the resident had a stage 2 pressure injury on elbow and redness to coccyx mentioned on nursing notes. A wound NP progress note, dated 9/23/25 at 6:01 p.m., indicated the resident had a pressure injury to the right elbow, coccyx, right heel, and left heel. The pressure injuries had previous treatments of dry dressing. The right elbow and coccyx pressure injuries were staged as unstageable (full-thickness loss of skin and tissue where the depth is obscured by yellow stringy or black, brown dead tissue). The left and right heels were staged as deep tissue injuries (DTI) (non-blanchable, purple or maroon discoloration of skin). The note indicated to look at wound management in the electronic medical record for a full wound assessment and for treatment recommendations. The right elbow, coccyx, left heel, and right heel had new recommendations based on the assessment that was completed. Associated wound care treatments were to be referenced under the orders in the resident's electronic medical record. The resident demonstrated an overall decline in wounds consistent with terminal illness/end of life. The NP recommended the staff discuss hospice consult with the resident and/or family due to the current wound care impact on the quality of life. The recommendations were discussed with the DON. The wound management detail report indicated a stage 2 pressure injury to the right elbow was identified on 9/8/25 (report created 9/18/25). The length was 1.7 cm, width 1.2 cm, and depth 0.1 cm. The report lacked additional assessments and measurements for the right elbow. The report lacked documentation for the coccyx and the heels. A nursing progress note, dated 9/24/25 at 7:45 a.m., indicated the resident was sent to the hospital. A hospital provider progress note, dated 9/25/25 at 12:00 p.m., indicated the right elbow pressure injury was a stable scab with no redness. The area was crusted/scabbed and brown in color. The area measured 1.0 cm long by 0.8 cm wide and was unstageable. The area was present upon admission to the hospital. A hospital provider progress note, dated 9/25/25 at 12:45 p.m., indicated the left heel and right heels were black/purple in color. The right heel pressure injury measured 1.0 cm long by 1.0 cm wide with no depth. The left heel pressure injury measured 3.0 cm long by 3.5 cm wide with no depth. Both were staged as DTIs. The areas were present upon admission to the hospital. A facility care plan for pressure injuries was initiated 9/25/25 with a goal that the resident's pressure injuries would heal without complications. Interventions included apply dressings per physician order (9/25/25), assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelialization, and condition of surrounding skin (9/25/25), and use moisture barrier product to perineal area (9/25/25). During an interview, on 9/3025 at 3:30 p.m., the DON indicated she had measurements for the resident's pressure injuries on a spreadsheet. She or the ADON rounded with the wound NP. Sometimes the resident would be unavailable for the NP because of therapy or appointments. In that case, the DON would check on the resident's pressure injuries, measure them and provide whatever else was needed. The spread sheet was not part of the resident's clinical record, and she should have put the measurements in the clinical record. Review of the spreadsheet for 9/16/25 indicated the resident had an unstageable pressure injury with measurements of 1.2 cm long by 1.2 cm wide and no depth, had a DTI to the right heel with measurements of 1.5 cm long by 1.2 cm wide, and had a DTI to the left heel with measurements of 3.0 cm long by 3.0 cm wide. The spread sheet contained measurements of wounds and no other wound characteristics. The spreadsheet lacked documentation of an area to the resident's coccyx. During an interview, on 10/1/25 at 9:54 a.m., RN 3 indicated when a resident was admitted to the facility, skin issues were documented in the admission observation, and a skin event was opened. When a skin event was opened, it prompted the user to put in a treatment for the area. Sometimes, skin issues would be documented in the progress notes. The skin areas that were open were measured, but not necessarily the ones that were not open like bruises or redness. If the nurse was unable to complete the skin assessment, the next shift would do the skin assessment. During an interview, on 10/1/25 at 10:52 a.m., RN 4 indicated when a resident was admitted a skin assessment was performed. Pressure injuries were measured and put into a skin event. If the pressure injury did not have a treatment, the DON and the NP would be informed to get an order to treat the area. The wound NP assessed the pressure injuries each week and assessed the skin of all new admissions. During an interview, on 10/1/25 at 11:52 a.m., the DON indicated she was unable to locate wound measurements in the electronic record for the resident's right elbow pressure injury other than on admission or wound measurements for the other pressure injuries in the resident's clinical record. She indicated the heel protectors were the treatment utilized for the right and left heel DTIs. The right elbow stage 2 pressure injury was left open to air and utilized turning and repositioning for bony prominences per nursing measures. The resident had a private caregiver who kept the resident repositioned and propped with pillows. The resident had an order for a pressure relieving/redistribution mattress as well. She was unable to locate a specific treatment order for the right elbow. For the coccyx pressure injury, the CNAs routinely applied moisture barrier creams to the resident with incontinence care as a nursing measure. The application of moisture barrier cream was not typically a physician's order. She was unable to locate a specific order for treatment for the coccyx pressure injury. A care plan for the pressure injuries was not implemented until 9/25/25 other than those listed in the initial baseline care plan. Review of a treatment administration record for 9/8/25 through 10/1/25, provided by the DON on 10/1/25 at 2:51 p.m., indicated a weekly skin assessment was performed on 9/9/25, 9/16/25, and 9/23/25. The assessment was signed off as existing skin impairment. The special instructions indicated Open an appropriate event for newly identified skin issues. No additional documentation was listed. A facility policy, revised 1/31/25, provided by the DON on 10/1/25 at 2:51 p.m., titled Skin Integrity, indicated the following: .A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing.Upon admission, the licensed nurse shall complete the initial skin check and obtain orders from the physician/practitioner for any area of impaired skin integrity that may not have orders in place when the resident is admitted to the facility from other healthcare settings or home.The Nurse Leader/Wound Nurse shall document all impaired skin integrity areas such as: pressure, stasis, surgical incision, or diabetic ulcers in the EMR [electronic medical record] on an ongoing basis or until closed or the resident has been discharge. This citation relates to Intake 2621648. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to notify a resident's representative and/or family when an accident, resulting in injury, occurred for 1 of 1 resident reviewed for accidents. (Resident M)Findings include:Resident M's closed clinical record was reviewed on 9/15/25 at 2:40 p.m. Diagnoses included type 2 diabetes mellitus, hypothyroidism, chronic obstructive pulmonary disease (COPD), major depressive disorder, and mild intellectual disabilities.Resident M's first emergency contact was a community social services employee and the second contact was a relative. Current physician's orders included buspirone 5 milligrams (mg) twice daily for depression, and diclofenac sodium gel 1% to be applied to right knee for pain four times a day.An admission Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident was cognitively intact, did not exhibit hallucinations, delusions, or behaviors, and had an intellectual disability. It was very important for Resident M's family and/or close friends to be involved in discussions about her care. Participation in assessment and goal setting indicated active participants included the resident and her family in the assessment process. The resident's cognitive skills for daily decision making were not assessed.A care plan, initiated on 8/13/25, indicated Resident M had a left ankle fracture. Interventions included providing medication for pain and elevating the affected area while in bed to manage swelling.A care plan, initiated on 8/11/25, indicated Resident M was at risk for bleeding/bruising related to medication. Interventions included administering medications as ordered, avoiding use of razors, and advising the resident and family to report symptoms of abnormal bleeding and/or bruising to the nurse.A progress note, dated 8/11/25 at 11:13 a.m., indicated CNA 5 was assisting Resident M back to her room after a shower. The resident dropped her soap, and they stopped in the hallway. Resident M lifted her (left) foot to grab the soap and then hit the wheel of the wheelchair. No swelling or bruising was noted. The Nurse Practitioner was made aware.A progress note, dated 8/12/25 at 3:45 a.m., indicated the ADON performed a head-to-toe skin assessment for Resident M. The resident stated she hit her foot on the foot pedal of the wheelchair. She did not complain of pain or discomfort. Nursing would continue to monitor the resident.A progress note, dated 8/12/25 at 9:15 a.m., indicated Resident M complained of left ankle pain. The MD assessed the resident and gave an order for a left ankle x-ray. The order was placed, and the resident was aware.The clinical record lacked documentation to indicate the resident's family or representative were notified of the accident or injury.A progress note, dated 8/12/25 at 3:02 p.m., indicated Resident M received a left ankle x-ray. The conclusion was an acute distal fibula (ankle) fracture. The NP was informed. A new order was received to send the resident to a local orthopedic clinic. The resident was made aware.The clinical record lacked documentation to indicate the resident's family or representative were notified of the appointment.A progress note, dated 8/12/25 at 5:26 p.m., indicated Resident M went to the orthopedic appointment and returned safely to the facility. Another x-ray was done at the orthopedic clinic. Resident M was placed in a non-removable splint. The resident was to be non-weight bearing on the left lower extremity. She was encouraged to elevate the affected area when in bed to manage swelling. A follow-up appointment was scheduled for 8/19/25. The resident was made aware.The clinical record lacked documentation to indicate the residents' family or representative were notified of the x-ray report and/or the follow-up appointment.An NP progress note, dated 8/13/25, indicated Resident M complained of left ankle pain and was seen by the MD who ordered an x-ray. The x-ray came back positive for fracture, so the resident was sent to the orthopedic clinic and received another x-ray of her left ankle. She was placed in a hard splint with no weight bearing orders. The resident stated she could not believe she broke her ankle. Staff reported the resident hit her left foot on the wheel of the wheelchair after coming back from the shower.During an interview with Resident M's Emergency Contact 1 on 9/15/25 at 11:43 a.m., she indicated the facility did not contact her about the accident or fracture. She did now know if treatment was provided until the day after the accident when a fracture was confirmed. Resident M was at the facility for rehabilitation after a total right knee replacement. The fracture happened within a week of her entering the facility for rehabilitation. During an interview with the DON on 9/16/25 at 9:51 a.m., she indicated she was told by RN 7 of a phone conversation Resident M had with her relative about the accident. Since RN 7 knew family was aware, he did not contact the family or the representative.During an interview with Resident M's second emergency contact on 9/16/25 at 10:40 a.m., she indicated Resident M was able to understand medical information, but it depended on how it was explained to her. The day her foot was hurt, Resident M called her and told her about the accident. Resident M was at the orthopedic clinic when she contacted her. The resident thought her foot was broken. Nobody from the facility communicated with the emergency contact. She contacted the facility and was told by a nurse that the resident's foot was fractured. The emergency contact left several messages for the DON. She called at 7:40 p.m. (she did not remember the date) and was told to call back at 10:00 p.m. because the nurse was busy providing care for another resident.During an interview with RN 7 on 9/16/25 at 2:50 p.m., he indicated he was aware of the accident on 8/11/25. The next morning, during rounds, the MD ordered an x-ray of the left ankle. The facility transportation took the resident to the orthopedic clinic for evaluation. On the day of the accident, Resident M told her relative about what happened. Facility policy was to contact family and/or resident representative(s), but unfortunately, he did not. In retrospect, he should have contacted the resident's representative and/or family about the accident/injury.A current facility policy, titled Accidents and Incidents, provided by the DON on 9/16/25 at 2:47 p.m., indicated the following: . The intent is to ensure the facility provides an environment that is free from accidents and incidents that are avoidable, the facility investigates these occurrences with applicable documentation, and appropriate reporting is completed as applicable .2. The following data, as applicable, shall be included in the residence medical record.f. The resident's representative, as applicable, notification.A current facility policy, titled Notification of Change of Condition, provided by the DON on 9/16/25 at 2:42 p.m., indicated the following: . To ensure appropriate individuals are notified of changes in condition.The facility must inform the resident, consult with the residents physician, and notify, consistent with his or her authority, the resident's representatives when there is. B. A significant change in the resident's physical, mental, or psychosocial status. 2. Documentation of notification or notification attempts should be recorded in the resident's electronic medical record. 3. The resident and/ or representative, and the medical providers, should be notified of a change in condition. The medical provider will provide guidance related to the changing conditions.This citation relates to Intake 2607823.3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from willful intimidation and verbal abuse by a staff member for 1 of 1 resident reviewed for abuse. (Resident N) This deficient practice was corrected on 8/24/25, prior to the start of survey, and was therefore past noncompliance.Findings include:Resident N's clinical record was reviewed on 9/15/25 at 10:38 a.m. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting his right, dominant side, chronic obstructive pulmonary disease (COPD), chronic kidney disease, generalized anxiety disorder, major depressive disorder, unsteadiness on feet, dementia without behavioral disturbance, and congestive heart failure.Current physician's orders included hydrocodone-acetaminophen 10-325 milligrams (mg) every six hours for pain, memantine 10 mg twice a day for dementia, sertraline 100 mg once a day for depression, alprazolam 0.25 mg twice a day for anxiety, and galantamine 8 mg twice a day for dementia.An annual Minimum Data Set (MDS) assessment, dated 6/12/25, indicated Resident N was cognitively intact, did not exhibit hallucinations, delusions, or behaviors, required set up/clean up for eating, oral hygiene, rolling left to right, and sitting to lying. The resident required partial to moderate assistance with toileting hygiene, showering, sit-to-stand movements, and transfers from chair to bed and to/from the toilet. Right-sided impairment affected both the upper and lower extremities. Resident N used a wheelchair for mobility.A current care plan, dated 6/17/25, indicated Resident N had a diagnosis of insomnia. Interventions included observing changes in moods/behaviors as evidenced by trouble sleeping and/or changes in sleeping patterns, administered medications as ordered, offering to get the resident out of bed and/or ask if he would like to watch television, and encourage the resident to change position in bed.A current care plan, dated 6/17/25, indicated Resident N had impaired cognitive skills related to a diagnosis of Alzheimer's dementia. Interventions included providing a home-like environment with visible clocks and/or calendars, glare free lighting, a consistent routine, safety checks, appropriate sensory stimulation, and avoiding constant noise levels if possible. Sensory input was to be limited when the resident was agitated. Dignity and privacy were to be promoted by conversing with the resident and when providing care. If Resident N was unable to complete a task independently, staff was to provide cues, prompting, and demonstration. Communication techniques, like using the resident's preferred name, identifying yourself with each contact, facing the resident when speaking and making eye contact were to be used to facilitate interaction. Staff were to use brief, simple, consistent words, cues, and statements. If the resident was agitated or restless, he was to be re-approached later. Care was to be explained before being provided. A current care plan, dated 6/17/25, indicated Resident N had inappropriate behaviors of yelling and being combative with staff when receiving care or medication. He would demand his medication, grab the medication cup from the medication cart and consume the medication(s), and yell at staff if he was awakened before noon. Interventions included respecting the resident's preference to be as independent as possible, asking the resident what kind of assistance he needed, educating the resident about appropriate behavior with staff and others, assessing for pain, and conversing with the resident. Resident N was to be allowed to verbalize his thoughts. A current care plan, dated 6/17/25, indicated Resident N had right-sided hemiparesis related to a cerebrovascular accident (stroke). Interventions included allowing the resident to participate in self-care activities to the highest possible level, providing adequate rest periods between self-care activities, providing private, non-distracting environment(s) for self-care activities, praising his efforts, allowing sufficient time for him to complete self-care, monitoring for the presence of pain/intolerance during self-care activities, and encouraging maximum participation during self-care activities.A progress note, dated 8/24/25 at 12:59 a.m., indicated Resident N was involved in a verbal altercation with staff. The resident was removed from the situation and staff provided emotional support. The resident's spouse and the Nurse Practitioner were notified. An interdisciplinary team (IDT) progress note, dated 8/24/25 at 2:26 p.m., indicated the verbal altercation was reported, the resident was assessed and denied concerns at that time. Psychosocial monitoring was ongoing.A review of the investigation file, provided by the DON on 9/16/25 at 11:22 a.m., indicated the following: On 8/24/25, staff reported an allegation of a verbal altercation between (CNA 2) and (Resident N). The resident was immediately removed and assessed by a nurse. The DON, Administrator (ADM), MD, and family were notified. (CNA 2) was suspended. (Resident N) stated Every time I tried to go one way, he (CNA 2) would put his foot next to my wheelchair. I yelled at him to stop. He told me to get up and walk. I can't walk. He laughed and was trying to be funny to irritate me. He didn't say anything else to me. He just wouldn't get out of my way. A couple of the nurses came. Yes, I feel safe here. I've been here for four years, and this has never happened. The statement was signed by Resident N.An undated statement by CNA 3 indicated the following: (Resident N) asked when he would get his medications. I then went to ask his nurse, but (he) started yelling. (CNA 2) came to help. I heard (CNA 2) try to calm him down. (Another resident) started cursing at Resident N because her daughter was here and was upset hearing him yelling. (CNA 2) stepped in to intervene between the two residents. (The other resident) walked away and Resident N continued to yell and curse. I walked towards (Resident N) and (CNA 2). (CNA 2) then started cursing at (Resident N). 'B***h a** nig***, I will beat your a**. F*** you.' (Resident N) was yelling 'F*** you - get away from me and give me someone in charge'. (QMA 4) came out into the hallway. (CNA 2) started walking away saying 'This b***h a** nig**'. (Resident N) was in his wheelchair and following (CNA 2). (QMA 4) intervened and attempted to take (Resident N) back to his room. (Resident N) would not initially allow us to move him. (CNA 2) told (Resident N), Get up. Oh. You can't stand. That's unfortunate.'An undated statement by LPN 8 indicated the following: I was leaving the break room when (QMA 4) approached me to tell me what was going on. I heard (a) commotion and walked towards it. I saw (CNA 2) standing near (Resident N). (CNA 2) walked away at that time. (Resident N) was yelling about his medications. I reminded him that he had already received his medications. I went through everything, and he calmed down and went to his room. (QMA 4) explained what happened with (CNA 2) and (Resident N). I then told (QMA 4) to call the DON to notify her. (CNA 2) walked to the clean utility room and stayed until he was asked by two nurses to leave per the DON. I did not hear (CNA 2) yelling at the resident. I only heard (Resident N) yelling. I made sure he was safe and was assisted to his room. He has been in his room since, per his usual. He has not been upset since the incident.A statement by QMA 4 indicated the following: I was in (another resident's) room when I heard yelling. I went to the hallway and saw (CNA 3) and (CNA 2) towards the front of the hall. (Resident N) was yelling he gets his medication at 11:00 p.m. (Resident N) was upset (CNA 2) was trying to help him get to his room. (CNA 2) told (Resident N), 'Man, f*** you. You're a b**** a** nig**.' (Resident N) started yelling, 'F*** you. I want my f***ing pills.' I intervened and tried to get (Resident N) to his room. (Resident N) put his foot down so I couldn't push his wheelchair. (CNA 2) started yelling, 'You're your meds.' I notified (LPN 8). (LPN 8) was able to reassure (Resident N) that he had taken his medications and was able to take him to his room. (CNA 2) then walked away. I then notified the DON.During a phone interview with CNA 3 on 9/16/25 at 2:18 p.m., she indicated she was in the front hallway between two other hallways. Resident N became agitated because he was not getting his 11:00 p.m. medications. He got medication to help him sleep at that time. At first, CNA 2 tried to calm Resident N. Another resident's daughter was upset because of the yelling. Resident N and the other resident were yelling and arguing. Approximately two minutes later, CNA 2 became more aggressive and told Resident N to calm down, but Resident N would not listen. Eventually, Resident N started calling CNA 2 names and that was when CNA 2 started standing in front of Resident N's wheelchair, escalating the argument. QMA 4 tried to break up the argument, but Resident N refused to go to his room. CNA 3 tried to get Resident N to move, but he grabbed the side-rails on the wall and would not move. CNA then told Resident N to Stand up. Oh, that's unfortunate, you can't stand up. LPN 8 finally told Resident N he had already received his medications. CNA 2 walked away, into the break room or the bathroom. CNA 3 and QMA 4 went to talk to LPN 8. QMA 4 then reported the incident to the DON. During a phone interview with QMA 4 on 9/16/25 at 2:28 p.m., she indicated she was in another resident's room when she heard shouting from the hallway. QMA 4 went to the hallway where Resident N and another resident were shouting at each other because Resident N's shouting had caused her daughter to cry. CNA 2 tried to get Resident N to go back to his room, but Resident N refused. CNA 2 started yelling and cussing at Resident N. CNA 2 told Resident N he was a 'B**** a** nig**' and he (the CNA) was going to beat his (Resident N's) a**. CNA 2 said Get up and get your own damn medicine. Oh, wait. You can't. QMA 4 and CNA 3 intervened and tried to get Resident N away from the situation. Resident N stuck his feet on the floor and would not let them move him. Resident N was very opinionated and would get into arguments with the staff over his medications sometimes. He had already received his medications but did not think he had. LPN 8 assured Resident N he had already received his medication. QMA 4 witnessed CNA 2 talking to himself, cussing and saying things like This place don't want to mess with me. LPN 8 told QMA 4 to contact the DON to report the incident.During an interview with Resident N on 9/17/25 at 2:17 p.m., he indicated CNA 2 was not making any sense and was being rude. CNA 2 would not let Resident N get two words in. CNA 2 raised his voice - there was no need for him to be yelling. He was very rude for no reason. Resident N indicated he had no problems with other staff, had returned to his normal routine, and was not adversely affected by the incident.CNA 2 was not available for interview during the survey. A current facility policy, titled Abuse, Neglect and Misappropriation of Property, provided by the DON on 9/16/25 at 2:00 p.m., indicated the following: .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the facility administrator, the State Survey Agency, and other appropriate state and local agencies in accordance with federal and state law. The organization will include screening, training, prevention, identification, investigation, protection, and reporting to provide protection for the health, welfare, and rights of each resident residing in the facility . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability.The deficient practice was corrected on 8/24/25 after the facility implemented a systemic plan that included the education of staff regarding the facility's abuse policy, interviewed and/or assessed other residents for abuse, completed an Interdisciplinary Team (IDT) review of the incident, and planned for Quality Assurance activities to mitigate reoccurrence of the deficient practice. This citation relates to Intake 2598489.3.1-27(a)(b)

Based on record review and interview, the facility failed to report a suspected drug diversion to the appropriate regulatory agencies for 4 of 6 residents reviewed for narcotic medication administration. (Residents H, J, K, and M) Findings include: 1. Resident H's record was reviewed on 7/2/25 at 10:45 a.m. Diagnoses included migraine, osteoarthritis (bone pain), fibromyalgia (nerve pain) , and chronic pain syndrome. Physician orders included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 milligram (mg) give one tablet by mouth every four hours only while awake. Resident H's electronic medication administration record (eMAR) indicated she received a dose of oxycodone on 6/2/25 scheduled at 6:00 p.m. but was charted at 8:22 p.m. with the comment per lpn by LPN 15. A dose of oxycodone scheduled for 6/2/25 at 10:00 p.m. was charted on 6/3/25 at 9:39 a.m. as not given due to condition, signed by QMA 20. A dose scheduled for 6/3/25 at 2:00 a.m. was charted as refused on 6/3/25 at 4:10 a.m. by QMA 2 due to the resident sleeping. Resident H's narcotic sign out sheet, provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m., indicated LPN 15 signed out a dose of oxycodone-acetaminophen on 6/2/25 at 10:00 p.m. with forty-two tablets remaining. The times of 12:00 a.m. and 2:00 a.m. were printed on the narcotic sheet, but had no signature, amount given, or amount remaining. A photograph of the resident's narcotic card provided concurrently with the count sheet indicated thirty-eight tablets remained. Thirty-nine oxycodone should have remained. During an interview with the Corporate Nursing Consultant on 7/3/25 at 10:02 a.m., she indicated that during an interview with Resident H, the resident indicated LPN 15 gave her pain medication early and she received two oxycodone tablets. During an interview with Resident H, on 7/3/25 at 10:26 a.m., she was unable to recall being given medications early on 6/2/25 and 6/3/25. 2. Resident K's record was reviewed on 7/2/25 at 10:42 a.m. Diagnoses included spina bifida (spinal cord defect), bilateral above knee amputations, and chronic pain syndrome. Physician orders included oxycodone-acetaminophen 5-325 mg give 1 tablet by mouth every 4 hours while awake. The resident's eMAR indicated doses of oxycodone-acetaminophen scheduled for 6/3/25 at 12:00 a.m. was administered by QMA 2 at 3:21 a.m. due to patient care, and he refused his scheduled 4:00 a.m. dose on 6/3/25. The resident's narcotic sheet, provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m., indicated doses were signed out by LPN 15 on 6/2/25 at 8:00 p.m., 6/3/25 at 12:00 a.m. with the comment not given signed by LPN 16, and 6/3/25 at 4:00 a.m. with the comment not given signed by LPN 16 and 6/3/25 at 2:00 a.m. by QMA 2. A medication card for comparison was not provided prior to exit. 3. Resident L's record was reviewed on 7/2/25 at 11:58 a.m. Diagnoses included COPD, peripheral vascular disease, and chronic pain syndrome. Physician orders included oxycodone 5 mg give 5 mg by mouth every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The resident's eMAR indicated doses of oxycodone scheduled on 6/2/25 at 10:00 p.m. were given on 6/3/25 at 4:00 a.m. and a dose scheduled 6/3/25 at 6:00 a.m. was given by LPN 16. The resident's narcotic count sheet provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m. indicated a dose of oxycodone was signed out by LPN 16 on 6/3/25 at 1:00 a.m. and 6/3/25 at 6:00 a.m. During an interview with LPN 16 on 7/3/25 at 9:43 a.m. she indicated a dose of oxycodone for resident L was due at 12:00 a.m. She took the medication out of the card and indicated QMA 19 gave the medication. She was unable to recall which medications she administered and which medications QMA 19 administered on 6/3/25. LPN 16 indicated it was not appropriate for someone to remove a medication from the card and another person administer the medication. 4. Resident M's record was reviewed on 7/2/25 at 10:47 a.m. Diagnoses included COPD, opioid use, restless legs syndrome, other chronic pain, and radiculopathy (nerve pain) of the lumbar (lower back) region. Physician orders included, oxycodone-acetaminophen 10-325 mg give 1 tablet every 4 hours as needed for pain. The resident's eMAR indicated she was given doses of oxycodone-acetaminophen on 6/2/25 at 4:51 p.m. and 6/3/25 at 10:22 a.m. The resident's narcotic count sheet provided by the Corporate Nurse Consultant on 7/3/25 at 10:08 a.m., indicated doses of oxycodone-acetaminophen were signed out by LPN 15 on 6/2/25 at 10:00 p.m., 6/3/25 at 2:00 a.m., and 6/3/25 at 6:00 a.m. A medication card for comparison was not provided prior to exit. During an interview on 7/3/2025 at 10:05 a.m., the Corporate Nurse Consultant indicated when she was informed of the concern of missing medications, she reviewed the medication carts for the 200 and 400 Halls and the narcotic count books. The narcotic counts were off, but they thought the discrepancies could be explained because the medications had been documented as signed out early. The Corporate RN did not compare the narcotic sheets with the Medication Administration Record during the investigation, nor report the concerns to the appropriate regulatory agencies. During an interview with the Corporate Nurse Consultant on 7/3/25 at 10:53 a.m., she indicated no medication reconciliation was performed for Resident M for the doses signed out on 6/2/25 at 10:00 p.m., 6/3/25 at 2:00 a.m., and 6/3/25 at 6:00 a.m. During an interview on 7/3/2025 at 7:41 a.m., QMA 2 indicated during the third shift on 6/2/2025 a nurse went home due to illness. At approximately between 5:00 a.m. and 5:30 a.m., she counted the medication cart for the 400 Hall with LPN 16. The narcotic count was not correct and she believed some medications were missing. QMA 2 indicated it appeared LPN 15 had signed out some of the mediations in advance. LPN 16 and QMA 2 reported the discrepancies to the unit manager. During an interview on 7/2/2025 at 9:48 a.m., LPN 16 indicated she was informed by CNA 17 that none of the medication on the 200 Hall had been passed and residents were complaining. Upon finding the nurse for that hall (LPN 15), LPN 16 found her in the bathroom. Her speech was slurred and she appeared disheveled, swaying and unable to stand up straight. LPN 15 was sent home and gave the medication cart keys to LPN 16. LPN 16 did not count the narcotic boxes due to it being a busy night. During an interview on 7/2/2025 at 9:53 a.m., Unit Manager 18 indicated on 6/3/2025 at 5:15 a.m. she received a phone call from LPN 16 stating that LPN 15 had been sent home and the narcotic count was off. The Unit Manager was en route to the facility and indicated she would investigate the concern when she arrived. The Unit Manager investigated the medication carts for the 200 and 400 Halls and found the counts to be off. The Unit Manager interviewed alert and oriented residents, and reported the concern to the Corporate Nurse at 6:22 a.m. Review of a current policy, dated 5/27/2016, titled Abuse, Neglect and Misappropriation of Property was provided by the DON on 7/1/2025 at 12:04 p.m. The policy indicated the following: .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and Sate law. ***Reporting Guidelines:*** Any allegation of neglect, exploitation, mistreatment or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. Cross reference F755. This citation relates to complaints IN00461866. 3.1-28(c)

Based on interview and record review, the facility failed to conduct a through investigation of an suspected drug diversion for 4 of 6 residents reviewed for medication admnistration. (Residents H, K, L,and M) Findings include: 1. Resident H's record was reviewed on 7/2/25 at 10:45 a.m. Diagnoses included migraine, osteoarthritis (bone pain), fibromyalgia (nerve pain) , and chronic pain syndrome. Physician orders included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 milligram (mg) give one tablet by mouth every four hours only while awake. Resident H's electronic medication administration record (eMAR) indicated she received a dose of oxycodone on 6/2/25 scheduled at 6:00 p.m. but was charted at 8:22 p.m. with the comment per lpn by LPN 15. A dose of oxycodone scheduled for 6/2/25 at 10:00 p.m. was charted on 6/3/25 at 9:39 a.m. as not given due to condition, signed by QMA 20. A dose scheduled for 6/3/25 at 2:00 a.m. was charted as refused on 6/3/25 at 4:10 a.m. by QMA 2 due to the resident sleeping. Resident H's narcotic sign out sheet, provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m., indicated LPN 15 signed out a dose of oxycodone-acetaminophen on 6/2/25 at 10:00 p.m. with forty-two tablets remaining. The times of 12:00 a.m. and 2:00 a.m. were printed on the narcotic sheet, but had no signature, amount given, or amount remaining. A photograph of the resident's narcotic card provided concurrently with the count sheet indicated thirty-eight tablets remained. Thirty-nine oxycodone should have remained. During an interview with the Corporate Nursing Consultant on 7/3/25 at 10:02 a.m., she indicated that during an interview with Resident H, the resident indicated LPN 15 gave her pain medication early and she received two oxycodone tablets. During an interview with Resident H, on 7/3/25 at 10:26 a.m., she was unable to recall being given medications early on 6/2/25 and 6/3/25. 2. Resident K's record was reviewed on 7/2/25 at 10:42 a.m. Diagnoses included spina bifida (spinal cord defect), bilateral above knee amputations, and chronic pain syndrome. Physician orders included oxycodone-acetaminophen 5-325 mg give 1 tablet by mouth every 4 hours while awake. The resident's eMAR indicated doses of oxycodone-acetaminophen scheduled for 6/3/25 at 12:00 a.m. was administered by QMA 2 at 3:21 a.m. due to patient care, and he refused his scheduled 4:00 a.m. dose on 6/3/25. The resident's narcotic sheet, provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m., indicated doses were signed out by LPN 15 on 6/2/25 at 8:00 p.m., 6/3/25 at 12:00 a.m. with the comment not given signed by LPN 16, and 6/3/25 at 4:00 a.m. with the comment not given signed by LPN 16 and 6/3/25 at 2:00 a.m. by QMA 2. A medication card for comparison was not provided prior to exit. 3. Resident L's record was reviewed on 7/2/25 at 11:58 a.m. Diagnoses included COPD, peripheral vascular disease, and chronic pain syndrome. Physician orders included oxycodone 5 mg give 5 mg by mouth every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The resident's eMAR indicated doses of oxycodone scheduled on 6/2/25 at 10:00 p.m. were given on 6/3/25 at 4:00 a.m. and a dose scheduled 6/3/25 at 6:00 a.m. was given by LPN 16. The resident's narcotic count sheet provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m. indicated a dose of oxycodone was signed out by LPN 16 on 6/3/25 at 1:00 a.m. and 6/3/25 at 6:00 a.m. During an interview with LPN 16 on 7/3/25 at 9:43 a.m. she indicated a dose of oxycodone for resident L was due at 12:00 a.m. She took the medication out of the card and indicated QMA 19 gave the medication. She was unable to recall which medications she administered and which medications QMA 19 administered on 6/3/25. LPN 16 indicated it was not appropriate for someone to remove a medication from the card and another person administer the medication. 4. Resident M's record was reviewed on 7/2/25 at 10:47 a.m. Diagnoses included COPD, opioid use, restless legs syndrome, other chronic pain, and radiculopathy (nerve pain) of the lumbar (lower back) region. Physician orders included, oxycodone-acetaminophen 10-325 mg give 1 tablet every 4 hours as needed for pain. The resident's eMAR indicated she was given doses of oxycodone-acetaminophen on 6/2/25 at 4:51 p.m. and 6/3/25 at 10:22 a.m. The resident's narcotic count sheet provided by the Corporate Nurse Consultant on 7/3/25 at 10:08 a.m., indicated doses of oxycodone-acetaminophen were signed out by LPN 15 on 6/2/25 at 10:00 p.m., 6/3/25 at 2:00 a.m., and 6/3/25 at 6:00 a.m. A medication card for comparison was not provided prior to exit. During an interview on 7/3/2025 at 10:05 a.m., the Corporate Nurse Consultant indicated when she was informed of the concern of missing medications, she reviewed the medication carts for the 200 and 400 Halls and the narcotic count books. The narcotic counts were off, but they thought the discrepancies could be explained because the medications had been documented as signed out early. The Corporate RN did not compare the narcotic sheets with the Medication Administration Record during the investigation, nor report the concerns to the appropriate regulatory agencies. During an interview with the Corporate Nurse Consultant on 7/3/25 at 10:53 a.m., she indicated no medication reconciliation was performed for Resident M for the doses signed out on 6/2/25 at 10:00 p.m., 6/3/25 at 2:00 a.m., and 6/3/25 at 6:00 a.m. Cross reference F609 and F755. This citation relates to complaints IN00461866. 3.1-28(d)

Based on interview and record review, the facility failed to ensure controlled medication administration was accurately documented and medication amounts reconciled according to facility policy for 4 of 6 residents reviewed for medications (Residents H, K, L, and M) Findings included: 1. Resident H's record was reviewed on 7/2/25 at 10:45 a.m. Diagnoses included migraine, osteoarthritis (bone pain), fibromyalgia (nerve pain) , and chronic pain syndrome. Physician orders included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 milligram (mg) give one tablet by mouth every four hours only while awake. Resident H's electronic medication administration record (eMAR) indicated she received a dose of oxycodone on 6/2/25 scheduled at 6:00 p.m. but was charted at 8:22 p.m. with the comment per lpn by LPN 15. A dose of oxycodone scheduled for 6/2/25 at 10:00 p.m. was charted on 6/3/25 at 9:39 a.m. as not given due to condition, signed by QMA 20. A dose scheduled for 6/3/25 at 2:00 a.m. was charted as refused on 6/3/25 at 4:10 a.m. by QMA 2 due to the resident sleeping. Resident H's narcotic sign out sheet, provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m., indicated LPN 15 signed out a dose of oxycodone-acetaminophen on 6/2/25 at 10:00 p.m. with forty-two tablets remaining. The times of 12:00 a.m. and 2:00 a.m. were printed on the narcotic sheet, but had no signature, amount given, or amount remaining. A photograph of the resident's narcotic card provided concurrently with the count sheet indicated thirty-eight tablets remained. Thirty-nine oxycodone should have remained. During an interview with the Corporate Nursing Consultant on 7/3/25 at 10:02 a.m., she indicated that during an interview with Resident H, the resident indicated LPN 15 gave her pain medication early and she received two oxycodone tablets. During an interview with Resident H, on 7/3/25 at 10:26 a.m., she was unable to recall being given medications early on 6/2/25 and 6/3/25. 2. Resident K's record was reviewed on 7/2/25 at 10:42 a.m. Diagnoses included spina bifida (spinal cord defect), bilateral above knee amputations, and chronic pain syndrome. Physician orders included oxycodone-acetaminophen 5-325 mg give 1 tablet by mouth every 4 hours while awake. The resident's eMAR indicated doses of oxycodone-acetaminophen scheduled for 6/3/25 at 12:00 a.m. was administered by QMA 2 at 3:21 a.m. due to patient care, and he refused his scheduled 4:00 a.m. dose on 6/3/25. The resident's narcotic sheet, provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m., indicated doses were signed out by LPN 15 on 6/2/25 at 8:00 p.m., 6/3/25 at 12:00 a.m. with the comment not given signed by LPN 16, and 6/3/25 at 4:00 a.m. with the comment not given signed by LPN 16 and 6/3/25 at 2:00 a.m. by QMA 2. A medication card for comparison was not provided prior to exit. 3. Resident L's record was reviewed on 7/2/25 at 11:58 a.m. Diagnoses included COPD, peripheral vascular disease, and chronic pain syndrome. Physician orders included oxycodone 5 mg give 5 mg by mouth every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The resident's eMAR indicated doses of oxycodone scheduled on 6/2/25 at 10:00 p.m. were given on 6/3/25 at 4:00 a.m. and a dose scheduled 6/3/25 at 6:00 a.m. was given by LPN 16. The resident's narcotic count sheet provided by the Corporate Nurse Consultant on 7/2/25 at 10:36 a.m. indicated a dose of oxycodone was signed out by LPN 16 on 6/3/25 at 1:00 a.m. and 6/3/25 at 6:00 a.m. During an interview with LPN 16 on 7/3/25 at 9:43 a.m. she indicated a dose of oxycodone for resident L was due at 12:00 a.m. She took the medication out of the card and indicated QMA 19 gave the medication. She was unable to recall which medications she administered and which medications QMA 19 administered on 6/3/25. LPN 16 indicated it was not appropriate for someone to remove a medication from the card and another person administer the medication. 4. Resident M's record was reviewed on 7/2/25 at 10:47 a.m. Diagnoses included COPD, opioid use, restless legs syndrome, other chronic pain, and radiculopathy (nerve pain) of the lumbar (lower back) region. Physician orders included, oxycodone-acetaminophen 10-325 mg give 1 tablet every 4 hours as needed for pain. The resident's eMAR indicated she was given doses of oxycodone-acetaminophen on 6/2/25 at 4:51 p.m. and 6/3/25 at 10:22 a.m. The resident's narcotic count sheet provided by the corporate nurse consultant on 7/3/25 at 10:08 a.m., indicated doses of oxycodone-acetaminophen were signed out by LPN 15 on 6/2/25 at 10:00 p.m., 6/3/25 at 2:00 a.m., and 6/3/25 at 6:00 a.m. A medication card for comparison was not provided prior to exit. During an interview with the Corporate Nurse consultant on 7/3/25 at 10:53 a.m., she indicated no medication reconciliation was performed for resident M for the doses signed out on 6/2/25 at 10:00 p.m., 6/3/25 at 2:00 a.m., and 6/3/25 at 6:00 a.m. An untitled facility document was provided by the Corporate Nurse Consultant on 7/3/25 at 11:05 a.m. indicated the following: 1. How many medications were ordered to be given? .2. All medications given AND documented immediately after administered? .6. Medications area given within at least 60 minutes before or after scheduled times? . During a concurrent interview, she indicated the document was part of the orientation check off process and was given to all staff authorized to give medications. A current facility policy provided by the Corporate Nurse Consultant on 7/2/25 at 12:08 p.m. and titled, Controlled Medication, indicated the following: .2. At each shift change or when keys are rendered, a physical inventory of all controlled medication is conducted by two staff members who are either license nurses, medication technicians, or appropriate staff per state regulations and is documented on the controlled medications accountability record. This is completed as follows: a. The licensed nurse or medication technician surrendering the keys, along with the licensed nurse or medication technician assuming the keys will review the controlled medication accountability book for each resident's medication(s) for each resident in the narcotic drawer. The licensed nurse or medication technician surrendering the keys along with the licensed nurse or medication technician assuming the keys will ensure the count of the remaining medications (s) match the medication accountability book b. Any medication count discrepancies or medication card count discrepancies that can't be reconciled by the licensed nurse and/or medication technician need to be reported to the Director of Nursing (DON) immediately. A current facility policy provided by the Corporate Nurse Consultant on 7/2/25 at 12:08 p.m. and titled, Drug Diversion, included the following: .2. Any medications discrepancies that can't be reconciled by the licensed nurse and/or medication tech or for any suspected drug diversions of medications, need to be reported to the Director of Nursing (DON) immediately. 3. All suspected incident of drug diversions will be thoroughly investigated. 4. Any discrepancies that cannot be reconciled, will be reported to all appropriate government licensing, regulatory, and law enforcement agencies. A current facility policy provided by the Corporate Nurse Consultant on 7/3/25 at 10:51 a.m. and titled, Medication Administration General Guidelines, indicated the following: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose 14. Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. 4. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. 5. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaints or symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature or initials of person recording administration or initials of person recording effects This citation relates to Complaint IN00461866. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure effective monitoring and services were provided when Resident B requested to be transferred to the hospital after experiencing acute abdominal pain with nausea for 1 of 3 residents reviewed for change in condition. This deficient practice resulted in the resident a delay in treatment that required emergent hospitalization for treatment of a perforated bowel with sepsis (severe infection throughout body), a hemicolectomy (a surgical intervention to permanently open the bowel), intravenous (IV) antibiotic therapy via a PICC (a central intravenous line) line, and a permanent colostomy. Findings include: Resident B's closed clinical record was reviewed on 4/15/24 at 11:00 a.m. Diagnoses included paroxysmal atrial fibrillation, fracture of lower end of right femur, acute embolism and thrombosis of deep veins of right lower extremity, rheumatoid arthritis, type 2 diabetes mellitus, and constipation. The most recent admission Minimum Data Set (MDS) assessment, dated 11/29/23, indicated Resident B was cognitively intact, made herself understood, and understood others. She had not experienced a change in mental status. She received medications at high-risk for side effects, including diuretics and opioids. She was dependent on others for toileting, and was frequently incontinent of bowel. The resident's December 2023 physician orders included, but were not limited to, the following: Observe resident closely for significant common side effects related to opioid medication use such as sedation, dizziness, nausea/vomiting, constipation, physical dependence, tolerance, respiratory depression, delayed gastric emptying, hyperalgesia (over-medicating), immunologic and hormonal dysfunction, muscle rigidity, and myoclonus (muscle jerking) every shift (dated 11/23/23), hydrocodone-acetaminophen (opioid pain medication) 10-325 mg, one tablet orally for pain every 4 hours as needed (order date 11/22/23), furosemide (diuretic) 20 mg, three tablets to equal 60 mg once daily (ordered 11/22/23-12/1/23), furosemide 40 mg, one tablet twice daily (ordered 12/1/23-2/2/24), observe resident closely for significant common side effects related to diuretic medication use such as dark urine, irregular heartbeat, fatigue lethargy, convulsions, nausea/vomiting, diarrhea/constipation, cramping, and weakness (order date 11/22/23), and bisacodyl (laxative) 10 mg suppository once a day as needed for constipation (order date 12/22/23). The resident's Medication Administration Record (MAR) for December 2023 indicated the following: Hydrocodone-acetaminophen 10-325 mg was given 55 times between 12/1/23 and 12/24/23 for chronic pain and recent femur fracture, the side effect of constipation was documented on 12/22/23 for opioid use, and a bisacodyl suppository was given on 12/24/23 at 9:33 p.m. The resident's December 2023 bowel movement record indicated Resident B had a medium, formed bowel movement on 12/20/23. A nurse progress note, dated 12/22/23 at 1:11 p.m., indicated the resident complained of constipation. The resident's abdomen was soft and not distended, with active bowel sounds heard in all quadrants. The physician was informed and a new order for bisacodyl suppositories once a day as needed was received. A Change in Condition form was initiated for constipation and indicated the system of concern was gastrointestinal related to constipation. A nurse progress note, dated 12/23/23 at 6:34 p.m., indicated the resident complained of pain and was medicated with an as-needed medication for constipation, with no results. The progress note lacked a pain assessment, did not identify the area of pain, and lacked an abdominal assessment. A nurse progress note, dated 12/23/23 at 6:39 p.m., indicated the resident continued to complain of pain with no bowel movement. The resident's December 2023 bowel movement record indicated two large bowel movements on 12/23/23. The consistency of the bowel movements was not indicated. The resident's December 2023 meal intake report indicated she did not eat lunch or dinner on 12/23/23 and 12/24/23. A nurse progress note, dated 12/24/23 6:34 a.m., indicated the resident complained of pain and experienced two bouts of yellowish-green emesis (vomiting). The resident was medicated with an as needed Zofran (antiemetic). The progress note lacked a pain assessment, did not identify the area of pain, and lacked an abdominal assessment. A nurse progress note, dated 12/25/23 at 5:00 a.m., indicated the resident was found having black coffee ground appearing emesis and severe abdominal pain. The as needed medications were documented as ineffective. The resident requested to be sent to the emergency room . The resident rated the abdominal pain as 9 out of a scale of 1-10. The physician was made aware, and an order to send the resident to the emergency room for evaluation and treatment was received. 911 was called for transport. A late-entry nurse progress note, dated 12/25/23 at 5:23 a.m., for 12/24/23 at 9:31 p.m., indicated the resident complained of nausea and vomiting, and abdominal pain. The resident indicated the pain had started a few days prior and she had been trying to digitally remove stool by herself. The resident requested as needed medication for constipation and nausea/vomiting. The medication was administered. The progress note lacked an abdominal assessment. Review of assessments and progress notes for 12/23/23 after 1:11 p.m. through 12/24/23 before 5:00 a.m. lacked indication of physician notification and abdominal assessments. The hospital emergency room note, dated 12/25/23 at 6:23 a.m., indicated the resident presented with the chief complaint of constipation and vomiting. The resident complained of abdominal pain and indicated her last bowel movement was one week prior. She had a history of constipation issues, but indicated it had never been this bad. She reported she had attempted to remove the stool herself, and the night prior, the facility nurse had tried to digitally remove an impaction (bowel movement stuck in or near the rectum). The abdominal pain had started 3 days prior and was rated as a 10 on a scale of 1-10. The resident had not been taking stool softeners while taking pain medications. Assessment of the abdomen indicated it was soft and mildly distended with hypoactive bowel sounds. The resident was alert and oriented to person, place, and time. The abdominal CT (radiology imaging) indicated moderate pneumoperitoneum (air or gas in the abdominal cavity) with concerns of bowel perforation. Surgical intervention was initiated. The resident was also determined to be septic. An inpatient hospital discharge summary, dated 1/30/24, indicated the resident had been admitted for peritoneal infection after a perforated bowel. The resident had been found to be septic and required laparotomy washout (surgical cleaning of abdomen) and left hemicolectomy with end colostomy (an opening in the abdomen for the intestine to allow elimination of bowel contents). A progress note, dated 2/2/24 at 12:40 p.m., indicated the resident was readmitted to the facility from the hospital. The resident arrived with a PICC line for I.V. antibiotic administration and a colostomy bag. During an interview, on 4/15/24 at 11:53 a.m., Resident B's family member indicated they had been visiting the resident on 12/24/23. The resident was complaining of abdominal pain and requested to be sent to the hospital. The resident was sent to the hospital the next day and had to have surgery for a colostomy. During an interview on 4/15/23 at 1:16 p.m., RN 1 indicated, on 12/22/24, Resident B had complained of constipation. An order for medication was received from the Nurse Practitioner (NP). RN 1 did not administer the medication since it was the end of the shift, and passed the information on to the oncoming shift. RN 1 indicated Resident B had been digitally removing stool from the rectum themselves. During an interview, on 4/15/24 at 1:32 p.m., CNA 2 indicated, on 12/24/24, during the day shift ending at 6:00 p.m., the family of Resident B had requested the resident be sent to the hospital. CNA 2 indicated the resident was not acting like herself; she was sweaty and screaming out, which was unusual for her. The CNA reported the request to LPN 3 and was told LPN 3 thought the resident was overreacting, and LPN 3 was unable to send the resident out without permission. CNA 2 did not report this information to another nurse. During an interview, on 4/15/24 at 1:53 p.m., Unit Manager 4 indicated Resident B had previously reported a history of constipation and had never really had regular bowel movements. During an interview, on 4/15/24 at 2:38 p.m., the Weekend Supervisor indicated Resident B was sent to the hospital after she started vomiting. The Weekend Supervisor denied seeing the resident in any acute distress. During an interview, on 4/15/24 at 2:56 p.m., the Weekend Supervisor indicated she had been unaware of the resident requesting to be sent out to the hospital. The Weekend Supervisor indicated if she had known Resident B had asked to go the the hospital, she would have sent the resident to the hospital. During an interview, on 4/16/24 at 10:16 a.m., LPN 3 indicated she did not know Resident B, as she had never taken care of her before 12/24/23. The resident was bedridden and was placed on the bedpan and bedside commode several times and never had any results. The resident also indicated she felt like she was going to vomit and requested an emesis basin. The resident requested to be sent to the hospital. LPN 3 reported this to the Weekend Supervisor and was told this was normal behavior for the resident and not to send her out. LPN 3 indicated the resident was in pain and was administered pain medication. She did not document these interactions or observations in the clinical record. She did not notify the physician of the resident's condition, nor the resident's desire to be sent to the hospital. During an interview, on 4/16/24 at 1:03 p.m., the Regional Care Consultant indicated if the resident requested to be sent to the hospital, it should have been documented in the clinical record and the physician should have been notified and the resident sent out. Per the facility bowel protocol, if a resident had not had a bowel movement in three days (72 hours) the protocol would have been initiated. RN 99, who worked 12/25/23 and was assigned care of Resident B and sent resident to the hospital, declined interview on 4/26/24. A current facility policy, dated 9/15/23 and titled Notification of Change of Condition, was provided by the Unit Manager on 4/16/24 at 12:45 p.m. The policy indicated the following: .Policy .To ensure appropriate individuals are notified of changes in condition. Guidelines 1. The facility must inform the resident, consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is: a. An accident involving the resident which results in an injury and has the potential for requiring physician intervention, b. A significant change in the resident's physical, mental, or psychological status. c. A need to alter treatment significantly. d. A decision to transfer or discharge a resident from the facility. 2. Documentation of notification or notification attempts should be recorded in the resident electronic medical record. 3. The resident and/or representative (if applicable), and medical provider should be notified of a change in condition. The medial provider will provide guidance related to the change in condition. 4. If unable to contact the physician, depending on the significance of the change, the facility may contact the Medical Director, as appropriate A current facility policy, dated 9/20/23 and titled Bowel Management for Constipation, was provided by the Regional Care Consultant on 4/16/23 at 1:46 p.m. The policy indicated the following: .Policy Statement The facility will be alert for and determine the need for dietary and/or other interventions to treat chronic and/or acute episodes of constipation. Guideline: 1. Resident bowel movements are monitored and documented in the medical record. 2. Residents with no bowel movement for 3 days will be evaluated for potential interventions as indicated, as appropriate for resident, or per MD orders. This citation relates to complaint IN00432324. 3.1-37(a)

Based on interview and record review, the facility failed to ensure fall prevention interventions and adequate supervision were in place for 1 of 3 residents reviewed for falls (Resident C). This deficient practice resulted in Resident C sustaining a fracture of the neck of the humerus bone. Findings include: The clinical record for Resident C was reviewed on 9/23/21 at 10:29 a.m. Diagnoses included but were not limited to, left humerus fracture, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], muscle weakness and lack of coordination. The most recent significant change Minimum Data Set (MDS) assessment, dated 5/19/21, indicated the resident was moderately cognitively impaired. She required two-person assistance with bed mobility and transfers. She had both upper and lower one-side impairment with range of motion. A health care plan, initiated on 1/14/20 and revised 9/23/21, indicated the resident was a fall risk related to impulsive behavior, poor safety awareness and a non-compliance with transfers. An intervention was established on 12/30/20 to attempt to keep the resident in common area while awake. Another health care plan, initiated 6/4/21 and revised 9/23/21, indicated the resident was non-compliant with waiting for assist with transfers, resulting in falls. The non-compliance was related to cognitive impairment. On 6/4/21, a new intervention was established to attempt to keep resident in common area while awake. An Inter-disciplinary Team (IDT) note, dated 12/30/20 at 9:40 a.m., indicated the resident was up without assistance and fell . An intervention was implemented to keep the resident in the common area when awake. A fall risk assessment, dated 7/7/21, indicated the resident had 1 or more falls in the past 6 months and required assistance and supervision with mobility, transfers or ambulation. The fall risk score was 23, which indicated she was high risk for falls. The progress notes indicated the following: 8/1/21 at 4:31 p.m., Resident continues on increased rounding every 15 minutes. 8/8/21 at 4:43 a.m., Resident continues on 15 minute monitoring. 8/9/21 at 6:36 a.m., Resident continues on 15 minute monitoring. 8/10/21 at 12:03 a.m., Resident continues on increased rounding every 15 minutes. 8/16/21 at 8:28 p.m., Resident has made one attempt to stand today in the hall. Resident continues on the 15 minute monitoring. 8/22/21 at 6:35 a.m., Resident continues on 15 minute monitoring. 8/24/21 at 11:53 p.m., Resident continues on 15 minute Resident sitting at nurses' station at this time because she stated she was not ready for bed yet. 8/29/21 at 4:04 p.m., Resident continues on 15 minute checks. A progress note, dated 8/29/21 at 7:30 p.m., indicated Patient sitting up right in wheelchair in room. The resident refused to use the call light and transferred herself to the bathroom. The resident was getting off the toilet without assistance and fell on to the floor. The resident was observed in an upright position and used the call light after the resident was on the floor. The resident complained of pain in her left arm pain, discomfort, back pain and right side pain when coughing. At 7:55 p.m., the physician was notified and ordered an x-ray. An IDT note, dated 8/30/21 at 10:15 a.m., indicated interventions included reviewing bedtime preference with nursing staff and family. A progress note, dated 8/30/21 at 1:59 p.m., indicated the resident continued to complain of pain on her left shoulder and received Tylenol routinely. The resident was currently out to an appointment. A progress note, dated 8/30/21 at 5:23 p.m., the resident returned from the orthopedic appointment with a new order to leave her arm in the sling and swathe except for bathing. A follow-up appointment was made for 2-weeks. An orthopedic visit, dated 8/30/21, indicated the resident now had 3 proximal humerus fractures identified on the x-rays obtained at the facility. The order included to sling and swath full-time with the exceptions of bathing On 8/31/21 at 3:43 a.m., resident complained of left arm and back pain. On 8/31/21 at 11:45 p.m., resident complained of left arm and back pain and was given Tylenol. On 9/14/21 at 3:05 p.m., the resident returned from her appointment with an order to begin range of motion with her arm. A progress note, dated 9/20/21 at 6:25 a.m., indicated the resident remained at the nurses' station until ready for bed. During an interview on 9/23/21 at 1:33 p.m., the Director of Nursing (DON) indicated the incident was reported to the Indiana State Department of Health (ISDH), but they did not have any staff statements since all the information was on either the event or Situation, Background, Appearance, Review (SBAR) form. The nurse who wrote the information related to the fall was from an agency and she did not believe she had worked at the facility since. The DON indicated the resident was able to self-propel and may have left the nurses' station and then went into her bathroom and fell . During the exit conference, the Administrator indicated since the care plan stated attempt to keep at the nurses' station, he was unsure of the concern. No information was provided on exit related to staff attempting and failing to keep the resident at the nurses' station while she was awake on 8/29/21. A review of a current policy titled, Falls provided by the DON on 9/24/21 at 2:30 p.m., indicated the following: POLICY STATEMENT It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. GUIDELINE: 1. All residents will have a comprehensive fall risk assessment Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. .4. Interdisciplinary (IDT) / Director of Nursing (DON) or designee reviews during At Risk Meeting. a. Identify additional referrals, consults, and interventions. b. Document resident response to intervention This Federal Tag relates to complaint IN 423. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure adequate supervision and interventions were in place to prevent multiple falls for 1 of 3 residents reviewed for falls (Resident B). This deficient practice resulted in Resident B sustaining multiple rib fractures, pain and hospitalization . Findings include: The clinical record for Resident B was reviewed on 5/14/21 at 9:50 a.m. Diagnoses included but were not limited to, multiple fractures of ribs on left side, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (CVA), muscle weakness and lack of coordination. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/19/21, indicated the resident was moderately cognitively impaired. She required one-person assistance with bed mobility, transfers, dressing and toileting. She had both upper and lower one-side impairment with range of motion. A health care plan, initiated on 1/14/20, indicated the resident was a fall risk related to weakness, impaired balance, CVA and [CONDITION(S)]. Interventions included, but were not limited to, toilet every two hours, establish a bedtime routine and offer to lay down after meals. A physician's order, dated 11/30/2020, indicated to toilet the resident every two hours. The order was discontinued on 1/24/21. A progress note, dated 1/11/21 at 11:46 a.m., indicated Resident B was found on the floor outside of the dining room, lying on her left side. The resident was asked what happened and she pointed to a piece of paper on the floor and indicated she was trying to pick it up. The staff were educated to make sure the meal tickets were served with the trays. On 12/30/20, the care plan included an intervention included to keep resident in common area while awake. On 1/11/21, the care plan included an intervention to ensure the dining room was free of clutter. A progress note, dated 2/5/21 at 1:32 a.m., indicated the resident was heard yelling for help. She was found on the floor in her room. She indicated she was trying to transfer from her wheelchair to bed. Resident B stated her hip hurt but denied pain once in bed. The resident was in a well-lit room watching TV in her wheelchair before the fall. On 2/5/21 at 9:40 a.m., a new order was received to obtain x-rays of the left hip related to pain from fall. No fractures were noted on the x-ray. An internal fall investigation report, dated 2/5/21, indicated the resident attempted to self-transfer. The CNA reported the resident wanted to stay up and watch television in her room. A John's Hopkins Fall Risk assessment, dated 2/5/21, indicated the resident was a moderate fall risk. A progress note, dated 2/24/21 at 6:50 a.m., indicated the resident had a witnessed fall by a CNA. An internal fall investigation report, dated 2/24/21 at 6:05 a.m., indicated the resident slipped while self-transferring in the bathroom trying to getting up from the toilet. The CNA went to turn down the bed and was on her way back when she observed the resident attempt to transfer and lost her balance. The CNA was educated to not leave the resident alone in the bathroom and to follow the care guide for Resident B. A counseling session, dated 2/26/21, indicated the CNA did not follow the care guide and left the resident unattended in the bathroom, which resulted in a fall. An internal fall investigation report dated 3/20/21 at 12:10 p.m., indicated the resident was found on floor in the dining room, reaching for something and fell out of wheelchair. The wheelchair was not locked and it slid out from under the resident. The staff were educated on keeping dining room clean before and after meals. A John's Hopkins Fall Risk assessment, dated 4/21/21, indicated the resident was a high fall risk. A progress note, dated 5/9/21 at 3:42 a.m., indicated a CNA was walking by Resident B's room at 3:15 a.m. and noticed she was not in bed. She heard the resident calling for help and found her on the floor, leaning up against a trash can. The resident stated she was trying to get dressed. She was assisted back to bed and was noted to have an abrasion to her left mid-back and a small laceration. Resident B was given Tylenol at 3:40 a.m. for pain. She continued to complain of pain with movement. The physician and family were notified of the fall. A change of condition form, dated 5/9/21 at 4:22 a.m., indicated when the resident was moving or taking a deep breath, her condition worsened. The resident had an abrasion to the left mid-back. A pain evaluation completed 5/9/21 at 4:30 a.m., indicated the resident was complaining of pain that was described as aching and burning. The pain was moderate and persistent. She exhibited frowning, grimacing and moaning. A progress note, dated 5/9/21 at 7:33 a.m., indicated the physician ordered a STAT (immediate) portable x-ray. The focus was to be on the ribs and Tylenol was given again at 7:00 a.m. for pain. During an interview on 5/17/21 at 8:33 a.m., the DON indicated the portable x-ray tech arrived to the facility at 1:03 p.m. She indicated she spoke to the contracted diagnostic company and they try to do a stat order in less than 4 hours during the week and for the weekend it was more like 4-6 hours. On 5/9/21 at 3:45 p.m., the family arrived and requested the resident be sent to the hospital. The resident was admitted to the hospital for X-rays and pain. An Interdisciplinary Team (IDT) note, dated 5/10/21 at 10:26 a.m., indicated the resident was getting up to get dressed and fell . She complained of pain and an x-ray was obtained and showed no fractures, but left lower lobe infiltrate. Review of an Indiana Department of Health report, provided by Director of Nursing (DON) on 5/14 at 8:48 a.m., indicated on 5/9/21 at 3:15 a.m., the resident was found on floor near trash can and the trash can was broken. The abrasion to the mid-back fit the part of the trash can that was broken. The resident was transported at 3:45 p.m. to the local hospital. The resident was found to have fractured ribs 7-12 and [MEDICATION(S)] spinal vertebrae fracture on T11 and T12. Resident B returned to the facility on [DATE] and required no surgical intervention. On 5/13/21, the care plan included an intervention to keep the bed in the lowest position and a mat next on the floor. A facility investigation indicated the root cause was self-transfer. A witness statement by RN 1, indicated when she arrived the resident was on the floor and the trash can was broken behind her. Tylenol was given for pain and a neurological assessment was initiated. The resident later complained of pain after Tylenol was given and the physician was notified. The resident did not appear in distress, but did appear uncomfortable. A witness state provided by CNA 2, indicated the resident was in her wheelchair when she arrived to work. The resident asked to be laid down and the CNA laid her down at 8:00 a.m. and she slept until 10:30 a.m. The resident then got up and was seated in her wheelchair ready for lunch. She did not appear to be in distress, but uncomfortable. During an interview on 5/14/21 at 11:30 a.m., CNA 2 indicated when she got to work, the resident was up in her wheelchair. She laid her down after breakfast and she seemed fine. She did complain about the gait belt, but thought it was because of the abrasion on her back. She was one you had to keep an eye on at all times and she will often take herself to the bathroom and forget she needs help. She was surprised at the extent of her injuries. During an interview on 5/14/21 at 11:36 a.m., CNA 3 was asked about the day the resident fell since she had charted her activities of daily living on 5/9/21 prior to her being sent to the hospital. She indicated the resident was hard-headed and would do want she wants to do and did not recall her being in any pain. During an interview on 5/17 at 12:01 p.m., the DON indicated the resident was on increased rounding for falls and she was to be toileted every 2 hours. She indicated staff were documenting the increased rounding in progress notes, but there was no place they were documenting them taking her to the bathroom every 2 hours. A review of a current policy titled, Falls provided by the DON on 5/17/21 at 1:53 p.m., indicated the following: POLICY STATEMENT It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. GUIDELINE: 1. All residents will have a comprehensive fall risk assessment Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. .4. Interdisciplinary (IDT) / Director of Nursing (DON) or designee reviews during At Risk Meeting. a. Identify additional referrals, consults, and interventions. b. Document resident response to intervention This Federal Tag relates to complaint IN 693. 3.1-45(a)(1) 3.1-45(a)(2)