Every finding on record at Springhurst Health Campus

Based on interview and record review, the facility failed to correctly transcribe the hospital's discharge orders for 1 of 3 residents reviewed for accuracy of physician orders for a newly admitted resident. This deficient practice resulted in a resident not having a diagnosis of diabetes identified and not receiving his hospital discharged ordered insulin for five (5) days, which contributed to the resident having elevated (high) blood glucose, diminished cognitive levels, lethargy and being sent out to the local hospital. The resident was sent out to the local hospital on 2-13-26, at the request of the family. He was subsequently admitted to the local hospital the same date for altered mental status, possibly related to dehydration, infection or diabetic ketoacidosis. (Resident B) The Immediate Jeopardy began on 2/6/26 when the facility failed to correctly transcribe the hospital's discharge orders for a resident resulting in the resident not having a diagnosis of diabetes identified and not receiving his hospital discharged ordered insulin for five (5) days resulting in hospitalization for five days, extreme elevated blood glucose levels, and altered mental status as a result of possible diabetic ketoacidosis. The Administrator and Regional Nurse Consultant were notified of the Immediate Jeopardy on 3/20/26 at 3:40 p.m. Findings include:The clinical record of Resident B was reviewed on 3-18-26 at 11:02 a.m. The resident's diagnoses included, but were not limited to type 2 diabetes, acute upper respiratory infection and unspecified dementia (mental decline). His 5-day Minimum Data Set (MDS) assessment, conducted on 2-11-26, indicated he was severely cognitively impaired. The resident received hypoglycemic medications (insulin, designed to lower blood glucose levels) and had received one (1) insulin injection since his admission on [DATE]. The MDS assessment indicated during a drug regimen review, an issue had been identified which had potentially clinically significant issues and the identified issue had been brought to the attention of the medical provider. A review of Resident B's clinical record indicated his hospital discharge orders, dated 2-6-26, specified he had a diagnosis of type 2 diabetes and was to receive glargine (also known as Lantus insulin, a long-acting insulin) 16 units subcutaneously (under the skin) twice daily and was ordered to receive blood glucose (BG) monitoring before meals (or three times daily). These orders were not entered into the resident's electronic health record until 2-12-26. He was not ordered to continue the sliding scale insulin (short-acting insulin administered as based on the results of the BG levels) as he had received in the hospital. Additionally, the discharge orders indicated Resident B was to have monitoring of his blood sugar levels twice daily. In an interview with the Director of Health Services (DHS) and Executive Director (ED) on 3-18-26 at 1:05 p.m., the DHS indicated during an initial care planning meeting with Resident B's family member on 2-11-26, a family member inquired about the resident's BG levels. The hospital discharge summary initial page did not specifically mention the diabetes diagnosis, as it was located further into the document. Multiple facility staff, including herself (DHS), the MDS staff, the Nurse Practitioner and two facility nurses originally reviewed the discharge and entered the orders into the facility's electronic health record. She indicated the facility staff failed to locate the information initially, but with further inspection on 2-11-26, the information was located and acted upon at that time by notifying the resident's responsible party and the attending physician of the situation and ensured updated medication and care orders were received and initiated the same date. During the interview with the DHS and ED, they shared a copy of a document dated 2-11-26, and entitled, Investigation Summary. which indicated Resident B was admitted to the facility on [DATE], for a short-term rehab stay due to upper respiratory infection, weakness, dehydration, and hydrocephalus. The resident had poorly controlled diabetes. Diabetes monitoring orders for Lantus insulin, were not transcribed at admission. The medication error was discovered on 2-11-26, during a family meeting. The attending physician was immediately notified as to the occurrence with new orders obtained. The document's Summary of Investigation, indicated, A transcription error at admission was identified as the root cause. The team notified the provider and responsible parties, obtained updated orders, developed an action plan, provided staff education, and initiated ongoing audits. In an interview with the DHS on 3-19-26 at 9:58 a.m., the DHS indicated the post-incident staff education, the staff were educated on the need to complete both Occurrence, and Event, documents regarding any incidents. Although both documents are technically a part of each resident's clinical record, only the Occurrence, was viewable to non-staff persons. She did complete a late entry under 'Occurrence,' to address the medication transcription omission for the resident. Review of Resident B's prior hospitalization records, indicated Resident B's BG results while hospitalized indicated the following: on 2-6-26 at 8:42 a.m., the resident's BG level was 99 and at 12:05 p.m. the resident BS level was 277 (normal fasting blood glucose levels range from 70 to 100). Review of Resident B's hospital records, beginning on 2-13-26, indicated he was initially seen in the emergency room and later admitted to the hospital. His medical records indicated he had an elevated white blood count (blood cells that help to fight infections) that were elevated at 19.0. Additionally, it indicated his hospital admission diagnoses, included but were not limited to, altered mental status, possibly related to dehydration, infection, or diabetic ketoacidosis (a serious life-threatening complication of diabetes occurring when the body breaks down fat too quickly for energy, producing toxic acidic substance called ketones resulting from lack of insulin, leading to high blood sugar levels). It identified his diabetes as being uncontrolled at that time. He did discharge on [DATE], to an area nursing facility. A review of Resident B's BG results, were as followed: on 2-11-26 at 8:04 p.m., the resident's BG level was 399; on 2-12-26 at 11:39 a.m., the resident's BG level was 451; on 2-12-26 at 4:04 p.m., the resident's BG level was 496; on 2-12-26 at 10:27 p.m., the resident's BG level was 316; on 2-13-26 at 5:27 a.m., the resident's BG level was 360; on 2-13-26 at 8:38 a.m., the resident's BG level was 356; on 2-13-26 at 11:58 a.m., the resident's BG level was 422; and on 2-13-26 at 4:34 p.m., the resident's BG level was 354 (normal fasting blood glucose levels range was from 70 to 100). On 3-19-26 at 8:40 a.m., the ED provided a copy of a policy, reviewed by the facility on 12-12-25, entitled, Guidelines for Medication Error Reporting. This policy indicated it purpose as, In the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare. Notify the attending physician promptly of the error. Implement the physician orders. Notify the resident or responsible party. Initiate the appropriate Event form. Monitor the resident closely for 72 hours or as directed. Document the following in the resident's clinical record: A description of the error (brief); Name of the physician and time notified; Physician's subsequent orders. In an interview with the Corporate Nurse on 3-19-26 at 2:50 p.m., she indicated she could not locate any other policies related to medication errors. The past non-compliance Immediate Jeopardy began on 2-6-26. The Immediate Jeopardy was removed and the deficient practice corrected by 2-16-26, prior to the start of the survey, and was therefore past noncompliance after the facility implemented a systemic plan that included the following actions: immediate notification of the physician and the responsible party of the identified issues, obtaining updated physician orders, implementing those orders, educating the licensed nursing staff on the facility's policies related to transcribing physician orders and diagnoses from the discharging entity into the facility's electronic health record, initiated an audit system to ensure any resident admitted to the facility in the last 30 days, and ongoing, had accurately transcribed admission orders and diagnoses correctly documented into the facility's electronic health record system. This citation relates to Intake 2791421. 410 IAC (Indiana Administration Code) 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure sufficient nursing staff to provide activities of daily living (ADL) care, skin care treatments, and maintain residents' dignity. This deficient practice had the potential to affect 61 of 61 residents in the facility. Findings include: A confidential interview was conducted with a resident. They indicated there were not enough staff in the facility to help them. They forgot about them when they pressed their call light, and it made them feel unimportant. An interview was conducted with Resident P on 6/10/25 at 1:23 p.m. She indicated it took thirty minutes for staff to help her, after she pressed her call light. An interview was conducted with Resident S on 6/11/25 at 11:27 a.m. She indicated the facility was short staffed most of the time. An interview was conducted with Family Member 7 on 6/11/25 at 10:56 a.m. She indicated the facility was short staffed. The staff tried, but a lot of times, there was only one CRCA (Certified Resident Care Assistant) on duty for the hall, and one person couldn't do everything. The resident next door didn't get up until noon last Saturday. There was a time within the past three weeks that Resident Q had to wait 45 minutes for the CRCA to assist her to the restroom. Resident Q cried while waiting, saying she didn't do anything to deserve this. This made Family Member 7 cry too. The facility continued to accept more residents into the facility, but they couldn't take care of the ones they already had. The nurses felt the same way, and there were a lot of call-offs in the facility. An interview was conducted with Resident R on 6/10/25 at 1:51 p.m. She indicated staff called off a lot of the time. The call lights took a long time to be answered. She had incontinence accidents in bed, while waiting on her call light to be answered. She was incontinent and never knew when she had to go but would lay in bed soaked. It made her mad, ticked, having to wait so long on help. The Resident Council Meeting minutes for the past six months were provided by the Clinical Support on 6/12/25 at 10:47 a.m. The 12/9/24 minutes for the nursing department indicated, Can tell that they are short of help. The January 2025 council meeting was not held due to a Covid-19 outbreak. The 2/24/25 minutes for the nursing department indicated, Issues with medication not being on time and showers aren't on schedule The 3/17/25 minutes for the nursing department indicated, need more staff-aren't able to communicate with staff-not enough time for each resident; wish they listened for to [sic] concerns . The 4/21/25 minutes for the nursing department indicated, Need more: short staffed mostly nights and weekends. Call light waiting time seems a bit long ex. [example] waiting for pain pill and the nurse is assisting elsewhere-on another hall.) The 5/19/25 minutes for the nursing department indicated, Still seem a bit short however were educated on hiring and new scheduler starting. A telephone interview was conducted with RN (Registered Nurse) 9 on 6/12/25 at 12:40 p.m. She indicated she worked at the facility as needed, usually two days a week. She came in to work the night shift of 6/7/25, from 11:00 p.m. to 7:00 a.m. She clocked in and looked at the schedule. There was no nurse for the 100 hall and only once CRCA. RN 9 would have been the only nurse for the entire facility. RN 9 did not think she could be responsible for all the residents in the health care center and the assisted living. There were only two CRCAs and one QMA (Qualified Medication Aide) for everything. RN 9 called the DHS (Director of Health Services,) but she did not answer. She then called the ED (Executive Director), but he did not answer. She waited at the facility close to an hour, before she decided not to stay. She finally received a call back from the ADHS (Assistant Director of Nursing) around 12:30 a.m. on 6/8/25. When RN 9 arrived to work the night of 6/7/25, she relieved RN 2. There was also an LPN (Licensed Practical Nurse,) LPN 10, who was on-call and had already been there for 16 hours and was not going to stay. RN 9 clocked out around midnight. After RN 9 got home, she had a text message from the ADHS on 6/7/25 at 11:52 p.m. that read verbatim SOS [a Morse code distress signal that indicates a need for help, an emergency, or distress.) WE HAVE NO NURSE IN THE BUILDING. I CANNOT GET AHOLD OF ANYONE. I AM UNABLE TO COME IN AGAIN TONIGHT. CAN ANYONE COME IN AND ASSIST? RN 9 had no idea when a nurse came to the building. RN 9 indicated RN 2 was still in the facility when RN 9 left. RN 9 was told later that LPN 10 came back to the building and clocked in. RN 9 felt like the DHS never responded, and the ED was basically the same way. They got to figure it out. Staffing had been an ongoing issue for a year to a year and a half. An interview was conducted with RN 2 on 6/16/25 at 12:53 p.m. She indicated she worked the evening shift (3:00 p.m. to 11:00 p.m.) of 6/7/25. She left the facility between 11:30 p.m. and midnight. LPN 10 was still in the facility when she left. RN 2 indicated she normally worked the 300 hall on evening shift and could not get some of her work done while on duty, like completing an admission assessment, a skin assessment, or nurses' notes. She couldn't answer call lights timely. There was usually only one nurse and one CRCA for the hall. She didn't always finish her Medicare charting timely and would usually have to finish the next day. Management sometimes told her to backchart. If she didn't get something done, it may not get done for a week or so, and they will tell us to backdate a week to the admission. There was an admission weight she was told to document as having been taken on admission, but it was really done a week later. RN 2 could not recall who the resident was, but it was within the past month. It's just hard to get help in there. They were always telling staff to come in early and leave late, but that wasn't really feasible. Sometimes wound care didn't get done timely. On her last shift the evening of 6/13/25, the day shift nurse could not get around to skin care treatments on the 300 hall, so it was pushed off onto her on evening shift. RN 9 couldn't get to it either for two residents on the evening shift, Resident M and Resident N, so she charted it as not done. It was supposed to be done on day shift. An interview was conducted with CRCA 6 on 6/16/25 at 11:52 a.m. She indicated she worked the evening of 6/7/25. She indicated LPN 10 was at the facility the entire night and never left. The staff didn't realize she was still there, as she was in the assisted living portion of the facility, in another physical building. RN 9 left the facility, because she thought she was going to be the only nurse working that night but didn't know at the time that LPN 10 was in the assisted living. When LPN 10 came back to the skilled nursing part of the facility from assisted living, she couldn't leave until another nurse, LPN 8 arrived around 2:00 a.m. LPN 10 took a nap before LPN 8 arrived, because the CRCAs were supposed to wake her up if they needed her. CRCA 6 indicated she was unable to get her work done timely, as there was only one aide on the hall most of the time. The schedule was horrible. We need staff and nurses. When they were short staffed, residents had more behaviors, would grow impatient with staff's inability to assist them timely. She often could not do all of the scheduled showers for residents and would push it off onto the next shift. The evening shift CRCAs did not get breaks. It's hectic there, and they just keep bringing in more residents. An interview was conducted with CRCA 11 on 6/16/25 at 12:19 p.m. She indicated she worked the night shift of 6/7/25. LPN 10 was trying to clock out, but management wouldn't let her. LPN 10 clocked out for a bit, but had to clock back in. LPN 10 took a nap for two or three hours, but nothing happened in that time frame. CRCA 11 indicated none of the staff can get their work done while at the facility. She couldn't' get showers done for her residents. I just clean them up, and tell them sorry. It was hard to give residents the care they deserved. She rushed during care. It was to the point residents knew she was working alone, so they understood. I hate having to rush. I want to be able to spend my time being able to talk to them, and give them the attention they deserve. She normally worked the 200 hall and covered all twenty-something residents when she was working by herself. She worked by herself the last two times she worked the evening shift on the 200 hall. Recently, it's been going around, that they are falsifying shower sheets. An interview was conducted with LPN 12 on 6/16/25 at 1:32 p.m. She indicated she received a call the morning of 6/8/25 that there was no nurse in the building. Staff cared and tried their best, but they didn't feel they had the support of leadership. They all knew there were holes in the schedule and allowed it. Their DHS was never available by phone, text, or messaging. LPN 12 usually worked later than her eight hour shift to complete her work. Oftentimes, there was only one nurse and one CRCA for a hall with around 25 residents. She normally worked every other weekend, on various halls in the facility. There were a lot of residents who required lifts for transfers on the 200 hall. The scheduler was frustrated. One of the CRCAs mentioned the scheduler cursed at her. It's a lot for everyone. An interview was conducted with the Scheduler on 6/16/25 at 2:10 p.m. She indicated she just began working as the scheduler this month. The scheduler prior to her quit. She thought the facility was without a scheduler for a month or two, so nurse management was doing the schedule. Before she became the scheduler, they had issues with staffing. Nurse managers were trying to do their jobs, plus working the floor. The night of 6/7/25, RN 9 refused to take shift, because the other nurse who was supposed to work, called in, and RN 9 didn't want to be only nurse with a QMA. Residents and family had been complaining about staffing issues, that call lights were not being answered timely. CNAs told her they couldn't get showers done on their scheduled shift. The time sheets for all nursing staff from 6/7/25 to 6/8/25 were provided by the Clinical Support on 6/17/25 at 9:23 a.m. It indicated RN 9 was clocked in on 6/7/25 from 10:55 p.m. to 11:31 p.m. LPN 10 was clocked in on 6/7/25 from 6:57 a.m. to 6/8/25 at 12:30 a.m. and 6/8/25 from 1:10 a.m. to 10:13 p.m. LPN 8 was clocked in on 6/8/25 from 1:47 a.m. to 6/8/25 at 7:45 a.m. There was a forty-minute gap of time from 6/8/25 at 12:30 a.m. to 6/8/25 at 1:10 a.m. that no nurse was clocked in as working at the facility. LPN 10 was unavailable for interview. An interview was conducted with the ADHS on 6/17/25 at 10:26 a.m. She indicated LPN 10 was clocked out during those 40 minutes to take a nap but never left the campus. During this recertification and complaint survey, 6/10/25 to 6/17/25, three deficiencies were cited at an isolated or pattern level - F677 E, F684 D, and F550 D. 1. Cross reference F677 - Activities of Daily Living (ADL). Four of seven residents reviewed were not provided ADL care related to shaving and receiving care timely. 2. Cross reference F684 - Quality of Care. Three residents did not have skin care treatments completed as ordered and a medication allergy/sensitivity addressed timely. 3. Cross reference F550 - Dignity. Two residents were not treated with respect and dignity in regards to incontinence care. This citation relates to Complaints IN00461161, IN00461220, IN00460769, IN00461614, and IN00461308. 3.1-17(a)

Based on observation, interview, and record review, the facility failed to assist dependent residents with shaving per preference and provide activities of daily living (ADL) care in a timely manner for 4 of 7 residents reviewed for activities of daily living. (Resident E, Resident G, Resident L, and Resident J) Findings include: 1. The clinical record for Resident E was reviewed on 6/16/2025 at 1:20 p.m. The diagnoses included, but were not limited to, urinary tract infection and depression. A Minimum Data Set (MDS) assessment, dated 5/14/2025, indicated Resident E was cognitively intact, utilized an indwelling urinary catheter, and needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. An activities of daily living care plan, revised 6/2/2025, indicated to offer Resident E shaving on shower days and as needed. Resident E's shower days were Monday and Thursday. A depression care plan for Resident E indicated the staff were to encourage the resident to voice their feelings and provide support. During an interview and observation, on 6/10/2025 at 1:59 p.m., Resident E was sitting in his wheelchair. Resident E indicated he likes to wear a goatee but the staff here never have time to assist him with shaving the rest. He indicated he does not like to have the sides long. The areas he indicated were observed to have hair growth. Resident E said only one care assistant ever helps him shave, but she doesn't always have time either. He had not been assisted in shaving in over a week. During an observation on 6/11/2025 at 1:05 p.m., Resident E was observed to have continued facial hair growth in the areas he preferred to be shaved. He said that no one offered to assist him with shaving that morning. An interview was conducted with Certified Resident Care Assistant (CRCA) 11 on 6/16/2025 at 12:19 p.m. She indicated she was unable to get her work done there, including bathing and ADL needs for residents on the 200 hall, including Resident E. 2. During an observation and interview with Resident G on 6/11/25 at 11:18 a.m., Resident G was sitting in his room with facial hair all along his jawline and above his lip. Resident G indicated he had not had his face shaved in over two weeks and preferred to be shaved at least every other day. Resident G indicated he had been asking staff to shave him, but he was still waiting on them to do it. The clinical record for Resident G was reviewed on 6/12/25 at 2:16 p.m. The diagnoses included, but were not limited to, chronic kidney disease and generalized osteoarthritis. An admission MDS assessment, dated 5/20/25, indicated Resident G was moderately cognitively impaired and required partial/moderate assistance with personal hygiene. A skilled documentation note, dated 6/8/25, indicated Resident G was able to make his needs known. During an interview and observation with Resident G on 6/12/25 at 2:13 p.m., Resident G was sitting in his room with a shaved face. Resident G indicated, they finally got around to it. Resident G indicated he had been asking staff to be shaved, but no one has had the time to do it. Resident G's roommate, Resident 7, was sitting in the room during this observation and interview. Resident 7 indicated Resident G had not had his face shaved since he had been at the facility, which he was admitted to on 5/26/25. Resident 7 indicated he had heard Resident G talking to staff about wanting his face shaved, but they just got to it yesterday. An admission MDS for Resident 7, dated 5/26/25, indicated Resident 7 was cognitively intact. The plan of care for Resident G, dated 5/30/25, indicated the resident required assistance to complete self-care and mobility functional tasks. The interventions included, but were not limited to, offer facial shaving on shower days, prn (as needed), or as requested. During an interview with the Administrator on 6/16/25 at 2:49 p.m., he indicated nursing staff were responsible for residents being shaved. 3. The clinical record for Resident L was reviewed on 6/13/25 at 11:08 a.m. The diagnoses included, but were not limited to, dislocation of internal right hip prosthesis, retention of urine, and polyneuropathy. During an interview with Resident L on 6/11/25 at 10:40 a.m., Resident L indicated she cannot get up to go to the bathroom by herself and has had to wait up to 45 minutes to get help. She had laid in bed several times waiting on her call light to be answered and had to wait so long that she had an incontinent accident in bed. Resident L indicated at the time it makes her feel anxious for trying to hold it and wait, then embarrassed afterwards, because it would not have happened if she could have gotten help sooner from the time she called out. They just don't have enough help. She indicated she was usually continent of urine but cannot always hold it. An admission MDS assessment, dated 5/17/25, indicated Resident L was cognitively intact, used a walker and wheelchair, and required substantial assistance with toileting, sitting to lying, lying to standing, and sitting to stand. A plan of care for Resident L, dated 5/30/25, indicated the resident experienced episodes of incontinence due to decreased mobility and required assistance with ADL care/toileting. The interventions included, but were not limited to, offer and assist with toileting as needed and/or per request. 4. The clinical record for Resident J was reviewed on 6/12/25 at 10:04 a.m. The diagnoses included, but were not limited to, anemia and atrial fibrillation. During an interview with Resident J on 6/11/25 at 10:14 a.m., Resident J indicated her call light takes a long time to be answered, and she has had several times when she was waiting and was incontinent and had to lay in a wet bed. Resident J indicated it was embarrassing and uncalled for. She indicated she was continent of urine but was unable to hold it for long periods of time. The admission MDS assessment, dated 5/9/25, indicated Resident J was cognitively intact and was dependent with toileting hygiene, lying to sitting on the side of the bed, and sitting to standing. A progress note, dated 6/12/25, indicated Resident J was able to make her needs known and was continent of urine. This citation relates to complaints IN00461220, IN00461161, IN00460769, IN00461614, & IN00461308. 3.1-38(a)(2)(C) 3.1-38(a)(3)(A) 3.1-38(a)(3)(D)

Based on observation, interview, and record review, the facility failed to identify and initiate a thorough investigation into an alleged violation of abuse for 2 of 2 residents reviewed for abuse. (Residents D and H) Findings include: 1. Resident D's 6/6/25, 9:30 p.m. nurse's note, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN 5, indicated Resident was found in other residents room both were in w/c's, he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms . Both residents compliant with redirection. No injury noted, physically or mentally. ADHS notifie Resident D's 6/9/25, 4:38 p.m. IDT (Interdisciplinary Team) note, written by the DHS (Director of Health Services) indicated, Patient reviewed for visiting with other resident. Other resident entered room and they were having a conversation. He had his land on her leg and another on her shoulder. Patient is social and friendly. Encouraged to visit in common areas as she is confused at baseline. Patient followed by social services for psychosocial well being. An observation of Resident D and Resident H was made on 6/10/25 at 1:41 p.m. They were sitting in their wheelchairs in a common area across from the nurse's desk on their unit, visiting with each other and another resident. An interview was conducted with RN (Registered Nurse) 3 on 6/10/25 at 1:41 p.m., during the above observation. She indicated the three residents were like a little trio. They shared things like blankets, and said they were brother and sister or boyfriend and girlfriend. She stated, I'm just here observing them. Interviews were conducted with CRCA (Certified Resident Care Assistant) 6 on 6/11/25 at 1:06 p.m. and 6/11/25 at 1:49 p.m. She indicated she worked the evening of 6/6/25 and was the one who found Resident H in Resident D's room. It was dumbed (sic) down in the notes. They were both high functioning dementia patients, so they had to keep them up front by the nurse's station. It had been about five minutes since CRCA 6 laid eyes on Resident D and Resident H, before she saw them together in Resident D's room. Previously, they were together in the common area. She walked by Resident D's room while the nurse was passing medications. Resident H was touching Resident D's breasts, and his hand was almost going up her private area, up her right thigh. His hand was mid-thigh, on her right leg, going up it. He was touching her breast on the outside of her shirt, and she was not wearing any pants, as she had already taken them off. Resident H was in his wheelchair near the doorway, and Resident D was standing in front of him. They tried to keep an eye on Resident D. The facility constantly staffed that particular hallway with one CRCA, so it was hard to keep an eye on Resident D and Resident H with around 24 other residents on the hall. Resident D was standing in front of Resident H, not wearing any pants, but she was wearing her shirt. CRCA 6 asked them what they were doing. Resident D responded nothing. CRCA 6 had to pull them apart. CRCA 6 assisted Resident D back into her wheelchair, and assisted Resident H out of Resident D's room. Resident H responded by saying, Call the police. They're taking me away. Staff tried to keep them away from each other, and we eye them, but Resident D wanted to be around Resident H. I had never seen anything like this before. CRCA informed RN 5 of what she observed. RN 5 instructed CRCA to assist Resident H to bed, while RN 5 called the ADHS (Assistant Director of Health Services.) CRCA 6 was unsure what RN 5 reported to the ADHS. CRCA 6 was not told to do anything more than keep them apart. I know that's a reportable. The ED (Executive Director) was gone last week, and CRCA 6 was not sure where he was. CRCA 6 was the only staff member to witness the interaction between Resident D and Resident H. CRCA 6 informed RN 5 and the CRCA who relieved her on the next shift, of what she observed. CRCA 6 informed the oncoming CRCA to keep Resident D and Resident H away from each other, because they were touching each other. CRCA 6 did not report this to the ED, because he did not usually answer his phone, so she did not try to call him. CRCA 6 received abuse training annually, and she knew this was reportable, because she'd been an aide for seven years. CRCA 6 was not instructed to keep Resident D and Resident H away from each other until after the incident on 6/6/25. No one from management ever asked her about the incident afterwards, or asked her to write a statement, or interviewed her about it. An interview was conducted with RN 5 on 6/11/25 at 1:36 p.m. She indicated CRCA 6 found Resident D and Resident H together in Resident D's room the evening of 6/6/25. CRCA 6 was called to another hallway for a while that night. While RN 5 was passing medications, CRCA 6 noticed Resident D and Resident H were no longer sitting in the common area by the nurse's station, so CRCA 6 went into Resident D's room and there they both were. CRCA 6 informed RN 5 that Resident H had one hand on Resident D's shoulder, and the other on her leg. CRCA 6 did not inform her that Resident H was touching Resident D's breast, but did say chest area. CRCA 6 was upset when she came out of Resident D's room. I can't remember if she said chest or not, sorry. Then RN 5 called the ADHS, because she wasn't sure if it was a reportable incident. The ADHS had RN 5 look up both residents most recent cognitive assessments and informed her to make sure to keep them separated on the hall. Both cognitive assessments showed severe deficit. The ADHS called corporate, informed them, and was instructed to enter a note into each resident's medical record. RN 5 entered her notes, based on what she heard and what CRCA 6 said. RN 5 did not inform the ED, because he was out of town, so she started with the ADHS. RN 5 was not involved in physically separating Residents D and H that evening. By the time she came on the scene, both residents were each in their own rooms and had on regular attire. Resident D had the ability to put on and take off her own pants. CRCA 6 did not inform her that Resident D's pants were off. That would have been a whole situation My note would not have read like that had I known. An interview was conducted with the ADHS on 6/11/25 at 2:41 p.m. She indicated RN 5 called her the night of 6/6/25, and informed her that Resident H had his hands on Resident D's shoulder and leg, while conversing. RN 5 informed her they were fully clothed, and the encounter did not seem sexual in nature, just chatting, and that was it. The ADHS did not recall if she was informed of who actually found the residents together in Resident D's room. She normally clarified who witnessed an incident and talked to that person. The ADHS called corporate and informed them. An interview was conducted with the DHS, AIT (Administrator in Training,) Clinical Support, and MDS (Minimum Data Set) Support on 6/11/25 at 2:05 p.m. The DHS indicated Resident D and Resident H were close friends, who congregated in the common area. She looked into the 6/6/25 occurrence between Resident D and Resident H. Resident D would touch Resident H, and Resident H would touch back, but she thought it was just friendly. Resident D was very friendly. Resident H would put his hand on her (DHS) when he talked to her. To the DHS's knowledge, it was RN 5 who found Resident D and Resident H together in Resident D's room. The DHS did not speak with CRCA 6 about it, as she was unaware CRCA 6 was the one who found them, and she did not know Resident D's pants were not on at the time. The DHS read RN 5's note the following day and called RN 5 about it. CRCA 6 should have called her, the AIT, or the ED. The AIT, Clinical Support, and the MDS Support all indicated none of them had spoken to CRCA 6 about the occurrence on 6/6/25, and none of them were aware Resident D's pants were off, or that Resident H was touching Resident D's breast. The IDOH reportable incidents for the past six months was provided by Clinical Support on 6/11/25 at 9:30 a.m. There were no reportable incidents regarding the 6/6/25 occurrence between Resident D and Resident H. 2a. The clinical record for Resident H was reviewed on 6/10/25 at 12:11 p.m. His diagnoses included, but were not limited to, dementia. The 6/2/25 admission MDS (Minimum Data Set) assessment indicated he was severely cognitively impaired. The 6/11/25 care plan indicated he expressed interest in compassionate touching and did not have capacity to give consent. The 6/6/25, 9:30 p.m. nurse's note for Resident H, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN (Registered Nurse) 5, indicated, Resident was found in other residents room both were in w/c's [wheelchairs,] he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms . Both residents compliant with redirection. No injury noted, physically or mentally. ADHS [Assistant Director of Health Services] notified. 2b. The clinical record for Resident D was reviewed on 6/10/25 at 12:03 p.m. Her diagnoses included, but were not limited to, dementia. The 5/13/25 admission MDS Assessment indicated she was severely cognitively intact. The 6/11/25 care plan indicated she expressed interest in compassionate touching and did not have capacity to give consent. Resident D's 6/6/25, 9:30 p.m. nurse's note, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN 5, indicated Resident was found in other residents room both were in w/c's, he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms . Both residents compliant with redirection. No injury noted, physically or mentally. ADHS notified. Resident D's 6/9/25, 4:38 p.m. IDT (Interdisciplinary Team) note, written by the DHS (Director of Health Services) indicated, Patient reviewed for visiting with other resident. Other resident entered room and they were having a conversation. He had his land on her leg and another on her shoulder. Patient is social and friendly. Encouraged to visit in common areas as she is confused at baseline. Patient followed by social services for psychosocial well being. An observation of Resident D and Resident H was made on 6/10/25 at 1:41 p.m. They were sitting in their wheelchairs in a common area across from the nurse's desk on their unit, visiting with each other and another resident. An interview was conducted with RN (Registered Nurse) 3 on 6/10/25 at 1:41 p.m., during the above observation. She indicated the three residents were like a little trio. They shared things like blankets, and said they were brother and sister or boyfriend and girlfriend. She stated, I'm just here observing them. Interviews were conducted with CRCA (Certified Resident Care Assistant) 6 on 6/11/25 at 1:06 p.m. and 6/11/25 at 1:49 p.m. She indicated she worked the evening of 6/6/25 and was the one who found Resident H in Resident D's room. It was dumbed (sic) down in the notes. They were both high functioning dementia patients, so they had to keep them up front by the nurse's station. It had been about five minutes since CRCA 6 laid eyes on Resident D and Resident H, before she saw them together in Resident D's room. Previously, they were together in the common area. She walked by Resident D's room while the nurse was passing medications. Resident H was touching Resident D's breasts, and his hand was almost going up her private area, up her right thigh. His hand was mid-thigh, on her right leg, going up it. He was touching her breast on the outside of her shirt, and she was not wearing any pants, as she had already taken them off. Resident H was in his wheelchair near the doorway, and Resident D was standing in front of him. They tried to keep an eye on Resident D. The facility constantly staffed that particular hallway with one CRCA, so it was hard to keep an eye on Resident D and Resident H with around 24 other residents on the hall. Resident D was standing in front of Resident H, not wearing any pants, but she was wearing her shirt. CRCA 6 asked them what they were doing. Resident D responded nothing. CRCA 6 had to pull them apart. CRCA 6 assisted Resident D back into her wheelchair, and assisted Resident H out of Resident D's room. Resident H responded by saying, Call the police. They're taking me away. Staff tried to keep them away from each other, and we eye them, but Resident D wanted to be around Resident H. I had never seen anything like this before. CRCA informed RN 5 of what she observed. RN 5 instructed CRCA to assist Resident H to bed, while RN 5 called the ADHS (Assistant Director of Health Services.) CRCA 6 was unsure what RN 5 reported to the ADHS. CRCA 6 was not told to do anything more than keep them apart. I know that's a reportable. The ED (Executive Director) was gone last week, and CRCA 6 was not sure where he was. CRCA 6 was the only staff member to witness the interaction between Resident D and Resident H. CRCA 6 informed RN 5 and the CRCA who relieved her on the next shift, of what she observed. CRCA 6 informed the oncoming CRCA to keep Resident D and Resident H away from each other, because they were touching each other. CRCA 6 did not report this to the ED, because he did not usually answer his phone, so she did not try to call him. CRCA 6 received abuse training annually, and she knew this was reportable, because she'd been an aide for seven years. CRCA 6 was not instructed to keep Resident D and Resident H away from each other until after the incident on 6/6/25. No one from management ever asked her about the incident afterwards, or asked her to write a statement, or interviewed her about it. An interview was conducted with RN 5 on 6/11/25 at 1:36 p.m. She indicated CRCA 6 found Resident D and Resident H together in Resident D's room the evening of 6/6/25. CRCA 6 was called to another hallway for a while that night. While RN 5 was passing medications, CRCA 6 noticed Resident D and Resident H were no longer sitting in the common area by the nurse's station, so CRCA 6 went into Resident D's room and there they both were. CRCA 6 informed RN 5 that Resident H had one hand on Resident D's shoulder, and the other on her leg. CRCA 6 did not inform her that Resident H was touching Resident D's breast, but did say chest area. CRCA 6 was upset when she came out of Resident D's room. I can't remember if she said chest or not, sorry. Then RN 5 called the ADHS, because she wasn't sure if it was a reportable incident. The ADHS had RN 5 look up both residents most recent cognitive assessments and informed her to make sure to keep them separated on the hall. Both cognitive assessments showed severe deficit. The ADHS called corporate, informed them, and was instructed to enter a note into each resident's medical record. RN 5 entered her notes, based on what she heard and what CRCA 6 said. RN 5 did not inform the ED, because he was out of town, so she started with the ADHS. RN 5 was not involved in physically separating Residents D and H that evening. By the time she came on the scene, both residents were each in their own rooms and had on regular attire. Resident D had the ability to put on and take off her own pants. CRCA 6 did not inform her that Resident D's pants were off. That would have been a whole situation My note would not have read like that had I known. An interview was conducted with the ADHS on 6/11/25 at 2:41 p.m. She indicated RN 5 called her the night of 6/6/25 and informed her that Resident H had his hands on Resident D's shoulder and leg, while conversing. RN 5 informed her they were fully clothed, and the encounter did not seem sexual in nature, just chatting, and that was it. The ADHS did not recall if she was informed of who actually found the residents together in Resident D's room. She normally clarified who witnessed an incident and talked to that person. The ADHS called corporate and informed them. An interview was conducted with the DHS, AIT (Administrator in Training,) Clinical Support, and MDS (Minimum Data Set) Support on 6/11/25 at 2:05 p.m. The DHS indicated Resident D and Resident H were close friends, who congregated in the common area. She looked into the 6/6/25 occurrence between Resident D and Resident H. Resident D would touch Resident H, and Resident H would touch back, but she thought it was just friendly. Resident D was very friendly. Resident H would put his hand on her (DHS) when he talked to her. To the DHS's knowledge, it was RN 5 who found Resident D and Resident H together in Resident D's room. The DHS did not speak with CRCA 6 about it, as she was unaware CRCA 6 was the one who found them, and she did not know Resident D's pants were not on at the time. The DHS read RN 5's note the following day and called RN 5 about it. CRCA 6 should have called her, the AIT, or the ED. The AIT, Clinical Support, and the MDS Support all indicated none of them had spoken to CRCA 6 about the occurrence on 6/6/25, and none of them were aware Resident D's pants were off, or that Resident H was touching Resident D's breast. The IDOH reportable incidents for the past six months was provided by Clinical Support on 6/11/25 at 9:30 a.m. There were no reportable incidents regarding the 6/6/25 occurrence between Resident D and Resident H. The Abuse, Neglect, and Exploitation Procedural Guidelines policy was provided by Clinical Support on 6/10/25 at 12:30 p.m. It indicated, Identification .Any person with knowledge of or suspicion of suspected violations shall report immediately, without fear of reprisal The Shift Supervisor or Manager is identified as responsible for initiating and/or continuing the reporting process, as follows: iv. IMMEDIATELY notify the Executive Director. If the Executive Director is absent, they may appoint a designee Investigation i. The Executive Director is accountable for investigating and reporting Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. This citation relates to Complaint IN00461220. 3.1-28(e)

2. The clinical record for Resident F was reviewed on 6/11/25 at 10:30 a.m. His diagnoses included, but were not limited to, Parkinson's disease. An interview was conducted with Family Member 4 on 6/11/25 at 10:38 a.m. She indicated there was an incident involving Resident F and CRCA (Certified Resident Care Assistant) 15 in March 2025 in his room. Resident F had bowel issues. It wasn't a happy situation, and CRCA 16 had to clean it up. CRCA 16 said it was gross right in front of him. They filed a grievance about it. Family Member 4 received a call back afterwards, stating the facility would be doing more staff training. The grievance log for the past six months was provided by Clinical Support on 6/12/25 at 10:48 a.m. There were only two grievances associated with Resident F, both dated 3/6/25, and both filed by Family Member 4. One was in regards to his room not being stocked with wipes, briefs, and trash bags, as there was an incident on 3/4/25, where none of these items were available. The grievance was resolved by the DHS (Director of Health Services.) The other grievance was in regards to Resident F needing fortified foods and non-dairy items in his diet. Neither of these grievances referenced a CRCA making any rude comments while caring for Resident F. An interview was conducted with the Director of Health Services (DHS) on 6/12/25 at 11:30 a.m. She indicated she spoke with Resident F when she resolved the 3/6/25 supplies in room grievance. She thought Resident F's family member was standing outside of his room, when Resident F had to use the restroom. Resident F had issues with his bowels, as his pancreas didn't' function well, and he had to take enzymes before meals. She thought the CRCA said something to Resident F about it, but she could not recall it exactly. She did not think there was any documentation regarding the CRCA caring for Resident F after having a bowel movement, as it was just a conversation. The DHS recalled having talked to the SSD (Social Services Director) about it but couldn't remember what was said. An interview was conducted with the Social Services Director (SSD) on 6/12/25 at 1:12 p.m. She indicated she received word the following day about a customer service incident regarding Resident F and CRCA 16. Another CRCA, whom the SSD could not recall, informed her that CRCA 16 was acting distressed, making gagging noises, towards Resident F when she was walking past his room or after providing care to him. The SSD spoke with Resident F regarding the incident. Resident F informed the SSD that CRCA did not do this in front of him. As far as the SSD knew, CRCA 16 was provided education on it. The SSD also thought there was an in-service. The SSD did not have any documentation regarding this alleged incident but filled out a grievance about it. The SSD reviewed the two, 3/6/25, grievances regarding Resident F from the grievance log. The SSD indicated she thought this incident was in relation the dietary concerns regarding dairy items. The SSD thought they had a quick IDT (Interdisciplinary team) meeting at the time and discussed dairy items contributing to the smell of Resident F's bowel movements. On 6/13/25 at 10:50 a.m., Clinical Support provided CRCA 16's 4/1/25 Employee Counseling Record Form completed by the DHS. It indicated CRCA 16 received a verbal warning for customer service, negative tone, and body language when speaking to a resident. It did not reference who the resident was or what the specific customer service, negative tone, or body language concerns were. An interview was conducted with the Clinical Support on 6/13/25 at 11:30 a.m. She indicated CRCA 16's 4/1/25 Employee Counseling Record Form was a result of Resident F's 3/6/25 family grievance. The Resident Rights Guidelines policy was provided by the Clinical Support on 6/13/25 at 10:50 a.m. It indicated, Our residents have a right to .a. Be treated with dignity and respect f. Be treated fairly, courteously and with respect by all staff. This citation relates to Complaint IN00461161, IN00461220, IN00460769, IN00461614, and IN00461308. 3.1-3(t) Based on interview and record review, the facility failed to promote a resident's dignity by not providing care with respect for 2 of 4 residents reviewed for dignity. (Resident E and Resident F) 1. The clinical record for Resident E was reviewed on 6/16/2025 at 1:20 p.m. The diagnoses included, but were not limited to, urinary tract infection and depression. A Minimum Data Set (MDS) assessment, dated 5/14/2025, indicated Resident E was cognitively intact, and needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. A depression care plan for Resident E indicated the staff were to encourage the resident to voice their feelings and provide support. During an interview conducted between 6/10/25 to 6/17/25, Resident E indicated there were not enough staff on the night shift or in the early mornings. Many times, they are unable to get help with their activities or daily living when they get up and their call light will go up to an hour before someone answers. They stated when this happens it makes them feel unimportant and forgotten about. They indicated they have told staff, but staff say, they are busy, or they are the only CNA [certified nurse aide] on the floor.

Based on observation, interview, and record review, the facility failed to immediately report an allegation of abuse to the ED (Executive Director) and IDOH (Indiana Department of Health) for 2 of 2 residents reviewed for abuse. (Resident D and Resident H) Findings include: 1. The clinical record for Resident H was reviewed on 6/10/25 at 12:11 p.m. His diagnoses included, but were not limited to, dementia. The 6/2/25 admission Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired. The 6/11/25 care plan indicated he expressed interest in compassionate touching and did not have capacity to give consent. The 6/6/25, 9:30 p.m. nurse's note for Resident H, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN (Registered Nurse) 5, indicated, Resident was found in other residents room both were in w/c's [wheelchairs,] he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms. Both residents compliant with redirection. No injury noted, physically or mentally. ADHS [Assistant Director of Health Services] notified. 2. The clinical record for Resident D was reviewed on 6/10/25 at 12:03 p.m. Her diagnoses included, but were not limited to, dementia. The 5/13/25 admission MDS assessment indicated she was severely cognitively intact. The 6/11/25 care plan indicated she expressed interest in compassionate touching and did not have capacity to give consent. Resident D's 6/6/25, 9:30 p.m. nurse's note, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN 5, indicated Resident was found in other residents room both were in w/c's, he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms . Both residents compliant with redirection. No injury noted, physically or mentally. ADHS notified. Resident D's 6/9/25, 4:38 p.m. IDT (Interdisciplinary Team) note, written by the DHS (Director of Health Services) indicated, Patient reviewed for visiting with other resident. Other resident entered room and they were having a conversation. He had his land on her leg and another on her shoulder. Patient is social and friendly. Encouraged to visit in common areas as she is confused at baseline. Patient followed by social services for psychosocial well being. An observation of Resident D and Resident H was made on 6/10/25 at 1:41 p.m. They were sitting in their wheelchairs in a common area across from the nurse's desk on their unit, visiting with each other and another resident. An interview was conducted with RN (Registered Nurse) 3 on 6/10/25 at 1:41 p.m., during the above observation. She indicated the three residents were like a little trio. They shared things like blankets, and said they were brother and sister or boyfriend and girlfriend. She stated, I'm just here observing them. Interviews were conducted with CRCA (Certified Resident Care Assistant) 6 on 6/11/25 at 1:06 p.m. and 6/11/25 at 1:49 p.m. She indicated she worked the evening of 6/6/25, and was the one who found Resident H in Resident D's room. It was dumbed (sic) down in the notes. They were both high functioning dementia patients, so they had to keep them up front by the nurse's station. It had been about five minutes since CRCA 6 laid eyes on Resident D and Resident H, before she saw them together in Resident D's room. Previously, they were together in the common area. She walked by Resident D's room while the nurse was passing medications. Resident H was touching Resident D's breasts, and his hand was almost going up her private area, up her right thigh. His hand was mid-thigh, on her right leg, going up it. He was touching her breast on the outside of her shirt, and she was not wearing any pants, as she had already taken them off. Resident H was in his wheelchair near the doorway, and Resident D was standing in front of him. They tried to keep an eye on Resident D. The facility constantly staffed that particular hallway with one CRCA, so it was hard to keep an eye on Resident D and Resident H with around 24 other residents on the hall. Resident D was standing in front of Resident H, not wearing any pants, but she was wearing her shirt. CRCA 6 asked them what they were doing. Resident D responded nothing. CRCA 6 had to pull them apart. CRCA 6 assisted Resident D back into her wheelchair, and assisted Resident H out of Resident D's room. Resident H responded by saying, Call the police. They're taking me away. Staff tried to keep them away from each other, and we eye them, but Resident D wanted to be around Resident H. I had never seen anything like this before. CRCA informed RN 5 of what she observed. RN 5 instructed CRCA to assist Resident H to bed, while RN 5 called the ADHS (Assistant Director of Health Services.) CRCA 6 was unsure what RN 5 reported to the ADHS. CRCA 6 was not told to do anything more than keep them apart. I know that's a reportable. The ED (Executive Director) was gone last week, and CRCA 6 was not sure where he was. CRCA 6 was the only staff member to witness the interaction between Resident D and Resident H. CRCA 6 informed RN 5 and the CRCA, who relieved her on the next shift, of what she observed. CRCA 6 informed the oncoming CRCA to keep Resident D and Resident H away from each other, because they were touching each other. CRCA 6 did not report this to the ED, because he did not usually answer his phone, so she did not try to call him. CRCA 6 received abuse training annually, and she knew this was reportable, because she'd been an aide for seven years. CRCA 6 was not instructed to keep Resident D and Resident H away from each other until after the incident on 6/6/25. No one from management ever asked her about the incident afterwards, or asked her to write a statement, or interviewed her about it. An interview was conducted with RN 5 on 6/11/25 at 1:36 p.m. She indicated CRCA 6 found Resident D and Resident H together in Resident D's room the evening of 6/6/25. CRCA 6 was called to another hallway for a while that night. While RN 5 was passing medications, CRCA 6 noticed Resident D and Resident H were no longer sitting in the common area by the nurse's station, so CRCA 6 went into Resident D's room and there they both were. CRCA 6 informed RN 5 that Resident H had one hand on Resident D's shoulder, and the other on her leg. CRCA 6 did not inform her that Resident H was touching Resident D's breast, but did say chest area. CRCA 6 was upset when she came out of Resident D's room. I can't remember if she said chest or not, sorry. Then RN 5 called the ADHS, because she wasn't sure if it was a reportable incident. The ADHS had RN 5 look up both residents most recent cognitive assessments and informed her to make sure to keep them separated on the hall. Both cognitive assessments showed severe deficit. The ADHS called corporate, informed them, and was instructed to enter a note into each resident's medical record. RN 5 entered her notes, based on what she heard and what CRCA 6 said. RN 5 did not inform the ED, because he was out of town, so she started with the ADHS. RN 5 was not involved in physically separating Residents D and H that evening. By the time she came on the scene, both residents were each in their own rooms and had on regular attire. Resident D had the ability to put on and take off her own pants. CRCA 6 did not inform her that Resident D's pants were off. That would have been a whole situation My note would not have read like that had I known. An interview was conducted with the ADHS on 6/11/25 at 2:41 p.m. She indicated RN 5 called her the night of 6/6/25 and informed her that Resident H had his hands on Resident D's shoulder and leg, while conversing. RN 5 informed her they were fully clothed, and the encounter did not seem sexual in nature, just chatting, and that was it. The ADHS did not recall if she was informed of who actually found the residents together in Resident D's room. She normally clarified who witnessed an incident and talked to that person. The ADHS called corporate and informed them. An interview was conducted with the DHS, AIT (Administrator in Training,) Clinical Support, and MDS (Minimum Data Set) Support on 6/11/25 at 2:05 p.m. The DHS indicated Resident D and Resident H were close friends, who congregated in the common area. She looked into the 6/6/25 occurrence between Resident D and Resident H. Resident D would touch Resident H, and Resident H would touch back, but she thought it was just friendly. Resident D was very friendly. Resident H would put his hand on her (DHS) when he talked to her. To the DHS's knowledge, it was RN 5 who found Resident D and Resident H together in Resident D's room. The DHS did not speak with CRCA 6 about it, as she was unaware CRCA 6 was the one who found them, and she did not know Resident D's pants were not on at the time. The DHS read RN 5's note the following day and called RN 5 about it. CRCA 6 should have called her, the AIT, or the ED. The AIT, Clinical Support, and the MDS Support all indicated they were unaware Resident D's pants were off and that Resident H was touching Resident D's breast. The IDOH reportable incidents for the past six months were provided by Clinical Support on 6/11/25 at 9:30 a.m. There were no reportable incidents regarding the 6/6/25 occurrence between Resident D and Resident H. The Abuse, Neglect, and Exploitation Procedural Guidelines policy was provided by Clinical Support on 6/10/25 at 12:30 p.m. It indicated, Identification .Any person with knowledge of or suspicion of suspected violations shall report immediately, without fear of reprisal The Shift Supervisor or Manager is identified as responsible for initiating and/or continuing the reporting process, as follows: iv. IMMEDIATELY notify the Executive Director. If the Executive Director is absent, they may appoint a designee. i. The Executive Director or designee must notify the resident(s)' physician(s) and family/resident representative. ii. The Executive Director is responsible for: 1. Notification to the State Department of Health (per State guidelines) and other agencies, which include the ombudsman, Adult Protective Services and/or local law enforcement agencies, as indicated Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This citation relates to Complaint IN00461220. 3.1-28(c)

Based on interview and record review, the facility failed to timely transmit a Quarterly Minimum Data Set (MDS) assessment for 1 of 9 residents reviewed for MDS Assessments. (Resident 21) Findings include: The clinical record for Resident 21 was reviewed on 6/16/2025 at 11:40 a.m. The diagnosis included, but was not limited to, dementia. A Quarterly MDS assessment, had an assessment reference date (ARD) of 5/9/2025. This assessment was completed on 5/22/2025. An MDS transmission report, provided on 6/16/2025 at 2:20 p.m., indicated the Quarterly MDS assessment for Resident 21 with an ARD of 5/9/2025 was transmitted on 6/13/2025. During an interview, on 6/16/2025 at 1:35 p.m., MDS Support indicated they utilize the RAI (Resident Assessment Instrument) Manual for guidance on timeliness of MDS Assessments. For Quarterly assessments, they have 14 days to transmit the completed assessments, but this was not done because she was busy with end of month activities.

3. The clinical record for Resident Q was reviewed on 6/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, overactive bladder and urinary tract infection. An interview and observation were conducted with Family Member 7 on 6/11/25 at 11:05 a.m. She indicated Resident Q had a history of UTIs (urinary tract infections.) During her most recent care plan meeting a couple of weeks ago, they discussed Resident Q having a possible allergy to Bactrim, an antibiotic medication used to treat UTIs. The staff at the care plan meeting said they would chart it, but she wasn't sure what happened, because she was just prescribed it again a couple of days ago, and Resident Q's lips swelled up, like they did in April 2025, when she was prescribed it. At this time, Family Member 7 displayed two photographs on her cell phone. One, dated 4/13/25 at 11:38 a.m., was Resident Q with a very red, swollen, bottom lip. Family Member 7 indicated Resident Q had to have a cream applied to her lips for it. The other photograph, dated 6/9/25 at 7:44 p.m., was of Resident Q with a red, swollen, bottom lip, that was not quite as swollen as the 4/13/25 photograph. Family Member 7 indicated Resident Q received a dose of Bactrim earlier that day, on 6/9/25. The 5/27/25 Resident First Meeting Minutes (care plan meeting) observation did not reference discussing an allergy to Bactrim. It indicated the SSD (Social Services Director,) and DHS (Director of Health Services) were present at the meeting. An interview was conducted with the SSD on 6/12/25 at 1:06 p.m. She indicated she was at Resident Q's 5/27/25 care plan meeting, along with the DHS and Family Member 7. Someone mentioned Resident Q having a sensitivity to some type of medication, that she had a hive type reaction to it, but they didn't say it was a true allergy. She could not recall the name of the medication or what it was used for, just that Resident Q had an adverse reaction to it. As far as taking notes during the meeting, any of the staff could do it. The SSD reviewed her notes and indicated she didn't have any notes from the meeting, so she didn't think she took any for this particular meeting. She did not usually document any notes into a care plan meeting observation for long term care residents, only for residents who are in the facility for rehabilitation. An interview was conducted with the DHS on 6/12/25 at 2:20 p.m. She indicated she was present at Resident Q's 5/27/25 care plan meeting. She did not recall family discussing an allergy or sensitivity to Bactrim. If something like that were discussed, it would normally be handwritten, and she would inform the ADHS (Assistant Director of Health Services) to address it. The 4/7/25 nurse's note indicated, NP [Nurse Practitioner] starting resident on Bactrim DS 800-160 mg BID x [twice daily time] 7 days for UTI; daughter aware of new medication being started vs Macrobid. The 6/9/25 physician's note indicated, .Aphthous ulcer [also known as canker sores] 4/14/25: acute onset. Per nursing staff, resident with mouth pain. On exam, resident noted to have ulcer inside bottom lip. Treat with orajel bid x7 days. No other open areas noted. No signs of thrush on exam. Lips noted to be dry on exam, continue with moisturizing chap stick to lips 6/9/25: acute onset dysuria. Per staff, resident with complaints of dysuria. Hx [History] of chronic UTIs. Resident currently prescribed prophylactic Fosfomycin per Urology. Pleasantly confused on exam, this is baseline. UACS/CBC/CMP [urinalysis/culture and sensitivity/complete blood count/ complete metabolic panel] ordered. Obtain urine via in and out cath [catheter.] Due to history of chronic UTIs and urosepsis will go ahead and start bactrim ds 800/160mg bid x7 days. Adjust once final urine culture results. Hold fosfomycin while on ATB The June 2025 MAR (medication administration record) indicated the first dose of Bactrim DS was administered on 6/9/25. The second dose on 6/9/25 was not given due to family wants different atb [antibiotic] . The third dose was not administered, as it was discontinued due to the family refused her taking it. The 6/10/25, 8:19 a.m. nurse's note indicated to discontinue Bactrim per the nurse practitioner. The CCD (Continuing Care Document) listed Bactrim DS as an allergy with a rash reaction, starting 6/10/25. The Resident First Meeting Guidelines policy was provided by the Clinical Support on 6/13/25 at 10:50 a.m. It indicated, Director of Social Services will open the observation Trilogy Resident First Meeting Minutes prior to the scheduled meeting Director of Social Service will follow up on missing documentation and escalate to ED [Executive Director] if not completed timely At the meeting: .Solicit input from the resident and/or representative regarding care choices and changes to their routine. d. Add any input from the resident and/or representative into the narrative notes sections on the observation form The Resident First Meeting is a time to communicate information related to care needs and medical condition and seek input from the resident or representative A record of the meeting should be documented within the electronic health record by completing the Resident First Observation with each meeting. The observation will be the supportive documentation of the meeting. This citation relates to Complaint IN00461161, IN00461220, IN00460769, IN00461614, and IN00461308. 3.1-37(a) Based on interview and record review, the facility failed complete treatments as ordered (Resident M and Resident N) and failed to timely address a medication allergy (Resident Q) for 3 of 4 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident N was reviewed on 6/17/2025 at 11:20 a.m. The diagnoses included, but were not limited to, diabetes and debility. An admission assessment, dated 6/12/2025, indicated Resident N had skin impairments upon admission and was cognitively intact. A skin care plan, dated 6/16/2025, indicated to complete Resident N's skin treatments as ordered. A physician's order, dated 6/12/2025, indicated for Resident N to have a foam dressing applied to the left buttocks every Monday, Wednesday, Friday, and as needed. The June 2025 Treatment Administration Record for Resident N indicated the treatment was not completed on 6/13/2025 with a reason of Not enough time. During an interview, on 6/16/2025 at 12:53 p.m., Registered Nurse (RN) 16 indicated she did not have enough time to get everything done in her shift. Specifically, on 6/13/2025, the day shift nurse did not have time to do the treatments for residents on her assignment, and she attempted to do as much as she could, but she couldn't get to Resident N's treatment. 2. The clinical record for Resident M was reviewed on 6/16/25 at 1:35 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia and chronic pulmonary edema. During an interview with Registered Nurse (RN) 2 on 6/16/25 at 12:53 p.m., she indicated the day shift nurse on 6/13/25 was unable to do wound care/dressing changes on the 300 Hall, so these tasks were pushed off for her to complete on evening shift, and she was not able to do them because she just did not have the time. The physician's order, dated 6/10/25, indicated to apply Profore two step to bilateral lower extremities (BLE) due to edema and change every Tuesday and Friday. The Treatment Administration Record (TAR) for June 2025, indicated Resident M was scheduled for the Profore two step dressing change to the BLE on 6/13/25, and was charted as not completed by RN 2 with comments documented as not enough time/staff. During an interview with Resident M on 6/16/25 at 1:25 p.m., he indicated his leg dressings were changed yesterday, on 6/15/25. The admission Minimum Data Set (MDS) assessment, dated 4/14/25, indicated Resident M was cognitively intact. During an interview with RN 3 on 6/16/25 at 2:30 p.m., she indicated she did not know why Resident M's leg dressings were not changed on Friday as ordered. RN 3 indicated she went in yesterday (Sunday) and saw Resident M's leg dressings rolled down. She indicated finding out that they were not changed on Friday made sense to her after seeing the dressings rolled down. RN 3 indicated floor staff were responsible for doing treatments that were ordered and as needed. The Dressing Changes policy was provided by Clinical Support on 6/17/25 at 9:55 a.m. It indicated, .11. Follow doctor's recommendations for treatment .

Based on interview, observation, and record review, the facility failed to ensure a resident's catheter drainage bag and tubing were free of contact with the floor for 1 of 2 residents reviewed for catheters. (Resident E) Findings include: The clinical record for Resident E was reviewed on 6/16/2025 at 1:20 p.m. The diagnoses included, but were not limited to, urinary tract infection and depression. A Minimum Data Set Assessment, dated 5/14/2025, indicated Resident E was cognitively intact, utilized an indwelling urinary catheter, and needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. A care guide care plan, initiated on 6/27/2024 and revised 6/13/2025, indicated to ensure Resident E's indwelling catheter did not touch the floor. A physician's order, dated 3/20/2025, indicated Resident E utilized an indwelling urinary catheter for neurogenic bladder. During an interview and observation, on 6/10/2025 at 1:59 p.m., Resident E was sitting in his wheelchair. The urinary catheter drainage bag and tubing were contacting the floor. Resident E indicated his catheter bag often drags the floor and has gotten caught under his wheelchair wheel before. During an observation, on 6/11/2025 at 1:05 p.m., Resident E was propelling himself in his wheelchair after lunch. Resident E's urinary catheter tubing noted to be looped down and contacting the floor. A policy, entitled Urinary Catheter Care, was provided by MDS Support on 6/16/2025 at 2:10 p.m. The policy indicated, .Be sure the catheter tubing and drainage bag are kept off of the floor . 3.1-41(a)(2)

Based on interview and record review, the facility failed to follow hospital discharge orders to discontinue medication upon readmission for 1 of 4 residents reviewed for quality of care. (Resident J) The clinical record for Resident J was reviewed on 6/12/25 at 10:04 a.m. The diagnoses included, but were not limited to, anemia and atrial fibrillation. During an interview with Resident J on 6/11/25 at 12:51 p.m., Resident J indicated she had just returned from the hospital yesterday after having blood loss and thought she had been told they were going to hold all of her blood thinners for a while. The admission Minimum Data Set (MDS) assessment, dated 5/9/25, indicated Resident J was cognitively intact. The hospital Discharge summary, dated [DATE], was provided by MDS Support on 6/12/25 at 12:57 p.m. It indicated Resident J had a discharge diagnosis of acute blood loss anemia and discontinue aspirin 81 mg po (by mouth) daily. The Medication Administration Record (MAR) for June 2025, indicated aspirin 81 mg po was given 6/11/25. A plan of care for Resident J, dated 5/13/25, indicated the resident was at risk for excessive bleeding and bruising related to medications. The intervention included, but was not limited to, administering medication as per the current physician's orders. A plan of care for Resident J, dated 5/26/25, indicated the resident had potential for experiencing symptoms of fatigue, weakness, and confusion related to anemia. The intervention included, but was not limited to, administering medications as ordered. During an interview with the Director of Health Services (DHS) on 6/12/25 at 10:52 a.m., she indicated she did not know why Resident J received her aspirin. The DHS indicated when the resident went to the hospital her orders were not discontinued in the computer system, so when she returned all of her previous orders showed up on her MAR. The DHS indicated that when a resident returns from the hospital, they have an admission checklist to go over for any new orders or discontinued orders and two nurses are to check them. The Guidelines for admission Nursing Assessment and Data Collection policy was provided by MDS support on 6/12/25 at 12:57 p.m. It indicated, .3. The observation and data collection shall include identification of risk factors through assessment, observation, and review of pertinent documentation that may contribute to additional complications, medical decline or safety concerns . 3.1-25(b)

Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for call light accessibility. (Resident 218) Findings include: During an observation and interview with Resident 218 on 6/11/25 at 9:59 a.m., Resident 218 was sitting in a wheelchair in the middle of her room. The call light was on the other side of the room on the floor beside her bed. Resident 218 indicated when staff would get her up during the day, she could never reach her call light and had no way of contacting staff when she needed help. She indicated every night she would get anxious before bed because staff would shut her door and she's not sure if she would have her call light or not, and if not, she had no way of contacting staff and had to yell out for help. During an observation and interview with Resident 218 on 6/12/25 at 10:15 a.m., Resident 218 was sitting in her wheelchair in the middle of her room. The call light was on the opposite side of the bed across the room. Resident 218 indicated she was glad someone came into her room because she needed to use the restroom but had no way to get a hold of anyone for help. The clinical record for Resident 218 was reviewed on 6/12/25 at 10:34 p.m. The diagnoses included, but were not limited to, dementia, orthostatic hypotension, and muscle weakness. The Brief Interview for Mental Status (BIMS) Evaluation, dated 6/7/25, indicated Resident 218 was cognitively intact. A Minimum Data Set (MDS) Functional Abilities Assessment, dated 6/10/25, indicated Resident 218 was dependent for toileting hygiene, and required substantial/maximal assistance with sitting to lying, lying to sitting on side of bed, sit to stand, toilet transfers, and utilized a wheelchair. The plan of care for Resident 218, dated 6/10/25, indicated the resident was at risk for falling related to weakness, medications, and incontinence. The interventions included, but were not limited to, keep the call light in reach. During an interview with Registered Nurse (RN) 3 on 6/12/25 at 10:17 a.m., she indicated it was any staff member's job who may enter the resident's room to ensure the call light was available and within reach for the resident. A Guidelines for Answering Call Lights policy was provided by MDS Support on 6/12/25 at 12:57 p.m. It indicated, .2. Ensure the call light is plugged in securely to the outlet and in reach of the resident . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to promote a resident's dignity by telling Resident H to utilize an incontinence brief instead of a bedpan, and a staff member cursed within hearing distance of Resident F. This affected 2 of 3 residents reviewed for dignity. Findings include: 1. Resident F's record was reviewed on 4/26/24 at 11:03 a.m. The record indicated Resident F had diagnoses that included, but were not limited to, metabolic encephalopathy, heart disease, atrial fibrillation, type 2 diabetes, violent behavior, speech disturbances, and vascular dementia, severe, with psychotic disturbance. An Admission Minimum Data Set assessment, dated 1/19/24, indicated Resident F was severely cognitively impaired, is sometimes understood, rarely/never understood, had physical behavior symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Had other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days. did not reject care, did not wander, was frequently incontinent of bowel and bladder, and was dependent on staff for toileting, hygiene, showers, and most activities of daily living. A State reportable incident, dated 3/14/24, indicated a brief description of incident: At approximately 4:30 pm an allegation was reported to the Executive Director that the employee was cursing while providing care to the resident. The employee has been suspended pending an investigation. Type of Injury: No injuries noted. Immediate Action Taken: Allegation reported to Executive Director, employee suspended, investigation, and the resident was assessed for potential injury, no injuries noted, and/or emotional distress noted. the resident's physician and responsible party were notified. Type of preventative measures added: This investigation is ongoing, employee will remain suspended during investigation, [resident] will be monitored for signs and symptoms of emotional distress. Follow Up: 3/20/24: Investigation concluded with no findings that CRCA (Certified Resident Care Assistant) [CRCA's initials] was verbally inappropriate while providing care to resident [resident's initials]. Employee may return to work. Resident [resident's initials] will continue to be followed by Social Services, family/POA has no requests for the facility at time of conclusion of this investigation. On 4/26/24, at 11:40 a.m., CRCA 3 indicated she usually didn't have any difficulty with Resident F's care. He would be agitated or aggressive at times, but would usually just let them take care of him, mainly when he was incontinent, and needed to go to the bathroom. He would refuse care, they would wait a few minutes and re-approach. She said she has not observed or been told that any staff had cursed at Resident F, nor became agitated with him. The investigative notes of the interviews were reviewed, as provided by the Administrator, on 4/26/24 at 1:35 p.m., as follows: A. The payroll coordinator, on 3/14/24, indicated I was assisting a resident back to their room and observed [CRCA 3] assisting the resident. The resident was sitting in the common area by the nurse's station and the employee was picking up pieces to an activity table. CRCA 3 reported the resident had pushed her causing her to fall onto the activity table to break. CRCA 3 stated 'I was attempting to assist him to his room to change his brief and clothes.' I heard CRCA 3 cursing in front of the resident. B. CRCA/CNA [3], on 3/14/24, indicated: I had just returned from break and observed the resident, [F], walking unassisted in the common area by the nurse's station. I attempted to redirect the resident to sit down. The resident then pushed me, causing me to fall onto his activity table resulting in the table breaking. At this time the resident had sat back down in his wheelchair, and I walked away to assist another resident. Once I had finished assisting the other resident, I returned to the common area and noticed the resident was attempting to stand and walk unassisted. I re-approached the resident and noticed the resident pooped. At this time, I attempted to redirect the resident to his wheelchair, explain to him that he had pooped and that I needed to change him. I said to the nurse, This man needs changed and needs his medicine. I do not remember if I had cussed but I would not cuss at a resident. I was frustrated but that is why I walked away to assist other residents and attempted to re-approach [Resident F]. C. Director of Nursing, on 3/19/24: I arrived at 1500 (3:00 p.m.). There was no aid at that time, she was on break. 3:45 she returned. [Resident F] was continuing to stand up. [CRCA 3] returned and assisted [Resident F] to his chair. It looked like [Resident F] shoved [CRCA 3] and she fell backwards onto the table and broke it into multiple pieces. Later on, [Resident F] was repeatedly trying to stand up. [CRCA 3] was asking [Resident F] to sit. [Payroll Coordinator] was present and [CRCA 3] was with [Resident F]. I didn't hear anything or see any forceful motions. They all disappeared and then the ED came down to talk to [CRCA 3]. During an interview, with the AP/Payroll Coordinator, on 4/26/24, at 2:31 p.m., she indicated she was taking a resident back to her room, as she was walking by, she saw CRCA 3, and heard her mumbling and grumbling while she was picking stuff off the floor. She asked CRCA 3 what was going on, and she said the resident had pushed her and she had fallen back. CRCA 3 said some curse words in front of the resident but not to the resident, she did not see the interactions, he was sitting on the couch and didn't act bothered at all. The CRCA had broken a table, and she said f***ing poop, but it wasn't directed toward the resident. Resident F was incontinent at the time, it was about a month before he passed. She said she did not feel it was abusive, it was not directed toward him. He didn't seem to notice anything. He acted like he could care less. No other residents or staff were present. A nurse was at the medication cart and might have heard, but the nurse heard her addressing it. The CRCA was talking in her normal voice and she has a loud personality. She said she saw it happened and reported it to her business office manager, and her BOM went to the Executive Director or the Director of Nursing about it, and the Executive Director talked to her before she left for the day. On 4/30/24, at 11:39 a.m., the Business Office Manager (BOM) indicated she had heard about it but did not see it, that the AP/Payroll Coordinator had reported it also, after it was reported the employee was suspended for investigation and said they knew to report it right away. 45291 2. The clinical record for Resident H was reviewed on 4/25/2024 at 1:55 p.m. The medical diagnosis included depression. No minimum data set assessment was available for Resident H. A baseline care plan, dated 4/19/2024, indicated to provide assistance to Resident H with toileting as needed. An interview with Resident H on 4/23/2024 at 1:52 p.m., indicated that she is continent of her bladder, but she had an ostomy from a complications from a procedure. Since she had been admitted to the facility, she utilized a bedpan due to not being able to transfer to the toilet. She indicated that there is often spillage, or she overfills the bedpan, resulting in a need to have her linens changed. This caused her to be upset at times due to her history with incontinence and the importance of her to be continent after the complications of her previous history that resulted in her having an ostomy for her bowel. An interview with CNA 3 on 4/26/2024 at 11:42 a.m., indicated she had cared for Resident H. Resident H was continent of her bladder and utilized a bedpan for toileting needs due to having a recent procedure to her foot and being non weight bearing. The morning on 4/25/2024, Resident H disclosed to her that the night shift nurse had instructed her to use her brief instead of a bedpan. An interview with LPN 4 on 4/26/2024 at 1:45 p.m., indicated that Resident H disclosed to her the night shift nurse had told her to use her brief instead of the bedpan because she was going to have to change her anyway. Resident H appeared upset when she was talking about the interaction to LPN 4. LPN 4 indicated that Resident H was continent of her bladder and utilized a bed pan, but the bed pan was too small for Resident H so she would have spillage and need a linen change with peri-care after toileting. An interview with Resident H on 4/26/2024 at 3:15 p.m., indicated that early on the morning on 4/25/2024 she had requested to use the bedpan. The night shift nurse responded to her request with, Just go in your brief, I'm going to have to change you anyway. Resident H recalled that she told the nurse she was not going to do that, and they went back and forth for a few minutes before the nurse finally put her on the bedpan. The interaction made Resident H upset, frustrated, and disrespected. A policy, entitled Resident Rights Guidelines, was provided by the Executive Direction on 4/29/2024 at 2:49 p.m. the policy indicated, .Our residents have the right to .Be treated with dignity and respect .Be treated fairly, courteously and with respect by all staff This Federal tag relates to Complaint IN00431921. 3.1-3(t)

Based on interview, and record review, the facility failed to provide showers as scheduled for 2 of 4 residents reviewed for activities of daily living. (Residents K and B) Findings include: 1. On 4/23/24, at 2:39 p.m., Resident K indicated she doesn't get her showers like she is supposed to, that she doesn't get her showers twice a week; staff will come in at 9 p.m. and she doesn't want one then. She is supposed to get showers on Wednesday and Saturday after 6 p.m. Resident K's record was reviewed, on 4/25/24, at 1:19. The record indicated Resident K was admitted with diagnoses that included, but were not limited to, metabolic encephalopathy, severe sepsis with septic shock, acute respiratory failure with hypoxia, acute kidney failure, chronic obstructive pulmonary disease, osteoarthritis, low heart rate, and high blood pressure. An Admission Minimum Data Set assessment, dated 2/20/24, indicated Resident K was cognitively intact, required substantial/maximal assistance for shower or bathing, and it was very important for her to choose between a tub bath, shower, bed bath or sponge bath. A care plan, with a start date of 3/01/2024, indicated a problem of Resident requires staff assistance to complete self-care and mobility functional tasks completely and safely. Goal: Resident will have functional needs met safely by staff Shower sheets, for 3/1/24 through 4/17/2024, were provided by the Director of Nursing, on 4/19/24 at 10:00 a.m., and indicated she had a shower on the following days: 3/9/24, 3/20/24, 3/23/24, 3/30/24, 4/6/24, 4/10/24, 4/13/24, 4/17/24. Resident K should have received 9 showers in March. 45291 2. The clinical record for Resident B was reviewed on 4/30/2024 on 11:20 a.m. The medical diagnosis included stroke. Resident B was admitted on [DATE], had a hospital stay from 8/27/2023 to 8/29/2023, and discharged on [DATE]. An Admission Minimum Data Set Assessment, dated 8/20/2023, indicated that Resident B was mildly cognitively impaired, did not reject care, and was dependent on staff for bathing. A care plan, dated 8/17/2023, indicated that Resident B would receive showers on Mondays and Thursdays. During a confidential interview on 4/29/2024 at 1:11 p.m., it was indicated in the two months that Resident B was at the facility that he had only received four showers. Shower documentation for Resident B indicated he had a complete bed bath or shower on the following dates: 8/21/2023 - Shower 9/4/2023 - Complete bed bath 9/15/2023 - Complete bed bath 9/22/2023 - Shower 10/13/2023 - Shower 10/17/2023 - Shower A policy entitled, Guidelines for Bathing Preferences, was provided by the Nursing Support Services on 4/30/2024 at 1:50 p.m. The policy indicated, .Bathing shall occur at least twice a week unless resident preference states otherwise . This Federal tag relates to Complaint IN00419594. 3.1-38(a)(2)(A) 3.1-38(b)(1)

Based on interview and record review, the facility failed to provide Resident 207 with a Notification of Medicare Non-Coverage (NOMNC) at least two calendar days prior to discharge from Medicare Part A services for 1 of 3 beneficiary notices reviewed. Findings include: The clinical record for Resident 207 was reviewed on 2/23/2023 at 1:15 p.m. Resident 207 started Medicare Part A services on 11/29/2022 and the last covered day of Part A services was 1/3/2023. A NOMNC with a last covered day of Medicare Part A services was dated for 1/3/2023 and was signed by Resident 207 on 1/3/2023. An interview with the Executive Director on 2/24/2023 at 3:57 p.m., indicated the facility was unable to provide a notice that Resident 207 was aware of Medicare Part A services to be discontinued prior to the NOMNC and he was unable to explain why Resident 207 was not given the NOMNC sooner. A policy entitled, NOMNC Completion SOP [Standard Operating Procedure], was provided by the Clinical Support on 2/24/2023 at 11:05 a.m. The policy indicated, .For residents being notified of discontinuation of their Medicare coverage, the NOMNC is requested to be issues 2 calendar days prior to the actual discharge from Medicare . 3.1-12(a)(15)

Based on record review and interview, the facility failed to provide written bed hold information for 1 of 2 residents reviewed for hospitalization . (Resident 15) Findings include: Resident 15's record was reviewed on 2/22/23 at 1:23 p.m. The record indicated Resident 15 had diagnoses that included, but were not limited to, liver disease, type 2 diabetes mellitus, urinary tract infection, heart failure, heart disease, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 1/4/2023, indicated Resident 15 was cognitively intact. Progress notes, dated 12/26/22 at 12:33 a.m., indicated Resident 15 was transported to a local hospital. Census documentation indicated the resident was sent to the hospital on 12/26/22 and returned on 12/30/22. There was no documentation in the clinical record that indicated a bed hold notice was provided to the resident or family upon discharge to the hospital. During an interview, on 2/24/23 at 2:45 p.m., the Director of Health Services indicated she could not find any documentation that a bed hold notice had been issued. A policy for Bed Hold Notification was provided by the Director of Health Services on 2/24/23 at 3:00 p.m. The policy included, but was not limited to, Overview: Residents and Responsible Parties have a right to be notified verbally and in writing on reserve bed payment policy per the state plan when someone goes out to the hospital or on a therapeutic leave. Before a nursing facility transfers a resident to a hospital or the resident goes on a therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies the duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; the reserve bed payment policy in the state plan if any; the nursing facility's policies regarding bed-hold periods permitting a resident to return. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed hold policy 3.1-12(a)(6)(A)

Based on interview and record review the facility failed to complete a care plan meeting for 1 of 1 resident's reviewed for care plan meetings (Resident 43). Finding include: During an interview with Resident 43 on 2/20/23 at 2:04 p.m., indicated he had not had care plan meeting where the facility talked to him about his goals and needs. Review of the record of Resident 43 on 2/23/23 at 11:20 a.m., indicated the resident's diagnoses included, but were not limited to, severe sepsis with septic shock, acute kidney failure, pulmonary fibrosis, Parkinson disease, hypertension, type two diabetes mellitus, low back pain, right and left knee contractures, prostate cancer, chronic pain, insomnia, muscle weakness and urinary retention. The Annual Minimum Data Set (MDS) assessment for Resident 43, dated 11/11/22, indicated the resident was cognitively intact for daily decision making. During an interview with the Director Of Health Services (DHS) on 2/23/23 at 11:55 a.m., indicated Resident 43 had not had a care plan meeting since April 2022. The DHS indicated she was unsure how the resident's care plan meeting got missed and the standard of the facility was resident's were suppose to have a care plan meeting quarterly. The resident first meeting guidelines provided by Clinical Support on 2/23/23 at 1:30 p.m., indicated the purpose was to facilitate communication and participation regarding the resident's plan of care, medical condition and care needs between the resident, family, resident representative and care givers. Resident first meetings should be conducted at a minimum of quarterly. 3.1-35(C)(2)(B)

Based on observation, interview and record review the facility failed to provide showers as scheduled for dependent residents for 2 of 2 reviewed for Activities Of Daily Living (ADL) ( Resident 30 and Resident 9). Findings include: 1.) During an interview with Resident 30 on 2/20/23 at 11:46 a.m., the resident indicated she was not receiving two showers a week like she was suppose to. The resident indicated she used wipes to clean herself the best she could. The resident indicated she had not had her hair washed for seven days. During an interview with Resident 30 on 2/23/23 at 1:58 p.m., the resident indicated when she was home she took at least three showers a week. The resident indicated she would be glad when she was able to give herself a shower so she wasn't a burden on the staff. I did get a shower on Monday. Review of the record of Resident 30 on 2/23/23 at 2:10 p.m., indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease, occlusion of arteries, peripheral vascular disease, chronic obstructive pulmonary disease, lack of coordination, unspecified fall, pain in right knee, muscle weakness, age related osteoporosis and left femur fracture. The profile care guide for Resident 30, dated 1/19/23, indicated the resident was to receive a shower two times a week on Mondays and Thursday. The Admission Minimum Data Set (MDS) assessment for Resident 30, dated 1/23/23, indicated the resident was cognitively intact for daily decision making. The resident required extensive assistance of one person for dressing. The resident was totally dependent of one person for bathing. It was very important to the resident to receive her preference of a shower. Review of the showers/bathing for Resident 30 indicated in the last 37 days the resident had received 4 showers. 2.) During an observation on 2/21/23 at 11:02 a.m., Resident 9 was sitting in her wheelchair. The resident's hair was greasy and dirty. The resident's fingernails were long and jagged. During an observation on 2/23/23 at 11:10 a.m., Resident 9 was sitting in her wheelchair in the dining room. The resident's hair was greasy and dirty. The resident's fingernails were long and jagged. Review of the record of Resident 9 on 2/22/23 at 11:56 a.m., indicated the resident's diagnoses included, but were not limited to, dementia, depression, anxiety, difficulty walking, abnormal posture, repeated falls, lack of coordination, muscle weakness and chronic pain. The Quarterly Minimum Data Set (MDS) assessment for Resident 9, dated 11/17/22, indicated the resident was severely cognitively impaired for daily decision making. The resident had no behaviors of rejecting care. The resident had no behaviors of physical aggression or verbal aggression. The resident required extensive assistance of two people for personal hygiene and total dependent for bathing. The profile care guide for Resident 9, dated 3/17/22, indicated the resident was to receive a shower twice a week. Review of the shower/bathing for Resident 9, dated 11/22/23 to 2/22/23, the resident received two showers and two complete bed baths in the past three months. During an interview with the Director Of Health Services (DHS) on 2/23/23 at 11:50 a.m., indicated it was the responsibility of the CNA to provide residents with their showers/baths, if the resident refuses then the protocol was to reproach at a later time and if the resident continues to refuse the CNA was to report it to the nurse and the nurse would attempt to provide the resident with a shower. The bathing policy provided by the DHS on 2/24/23 at 11:15 a.m., indicated the bathing shall occur at least twice a week. 3.1-38(a)(2)(A)

Based on observation, interview, and record review the facility failed to ensure collaboration with a hospice provider regarding coordination of care related to laboratory work, medication form changes, wound assessments, and Registered Dietitian (RD) recommendations for 1 of 1 resident reviewed for hospice services (Resident 17), 1 of 5 residents reviewed for pressure ulcers (Resident 22), and 1 of 1 resident reviewed for nutrition (Resident 26). The facility also failed to ensure a device was in place, per physician orders, in regard to limited range of motion (ROM) for 1 of 1 resident reviewed for impaired mobility (Resident 22). Findings include: 1a. The clinical record for Resident 17 was reviewed on 2/24/23 at 11:26 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety disorder, chronic kidney disease, and unspecified convulsions. A safety care plan, revised 2/17/23, indicated Resident 17 was at risk for seizures related to diagnosis of unspecified convulsions. The approach was listed to do any laboratory work per physician orders and give medication per physician orders. A fall care plan, revised 2/17/23, indicated Resident 17 was at risk for falls due to history of falls, tremors, decreased mobility, increased weakness, and assistance needed with activities of daily living. A physician order, dated 3/18/22, was noted for Keppra (antiseizure medication/anticonvulsant medication) A fall event, dated 2/1/23, indicated Resident 17 was sitting in her broda chair and appeared agitated. Resident 17 slid assisted from the broda chair. The root cause was listed as Resident 17 having a history of being cold and shivering. The intervention was to offer a blanket when up in broda chair and due to reported seizure-like activity, the facility was to inquire with hospice about obtaining a Keppra level to ensure therapeutic level. There was no previous physician order for February 2023 for a Keppra level for Resident 17 in the clinical record. 1b. A progress note, dated 2/15/23, indicated the following, .Hospice in to see resident .also medications discussed to change resident to liquid meds [medications]; resident does not take whole medications and tends to spit or not take meds when they are crushed; per hospice nurse will have MD [Medical Director] review medications and see about changing meds to liquids due to resident taking liquids better than solids hospice nurse will call and discuss with daughter; daughter in earlier and this nurse had spoke with daughter as well; daughter stated that liquid meds would be fine with her There was no follow up in the clinical record in regard to changing Resident 17's medications from pills/capsules to liquid. The medication list for Resident 17, dated 2/14/23 at 11:28 a.m., indicated orders for medications by mouth that were not liquid. These medications included docusate sodium capsule, Keppra tablet, nitrofurantoin capsule (antibiotic), buspirone tablet (anxiety medication), hydroxyzine tablet (antihistamine), acetaminophen capsule, and Ativan (anxiety medication) tablet. An interview conducted with the Director of Health Services (DHS), on 2/24/23 at 12:18 p.m., indicated the facility requested another Keppra level. The previous one taken, in 2022, was within normal limits. The DHS had made a call out to hospice and waiting to hear back from one of the case managers about the request for a Keppra level. She also reached out about the request for liquid medication. The floor nurse was supposed to contact hospice and obtain an order for the Keppra level as well as a request for the liquid medication. 2a. The clinical record for Resident 22 was reviewed on 2/22/23 at 11:23 a.m. The diagnoses included, but were not limited to, dementia, contracture to right hand, dysphagia, and pain. The Wound Management Detail Report, dated 2/24/23, indicated that Resident 22 had a pressure ulcer to her right big toe that was identified on 12/22/22 and her coccyx that was identified on 12/6/22. Weekly wound assessments were conducted, per the Wound Management Detail Report, but there appeared to be a gap with a delay in obtaining weekly wound assessments from 12/27/22 to 1/24/23. An interview conducted with the DHS, on 2/24/23 at 2:40 p.m., indicated she had reached out to hospice to inquire about the weekly wound measurements for the weeks that appear to be missing from the Wound Management Detail Report due to the Assistant Director of Health Services (ADHS) being ill during that time period. 2b. A physician order, dated 10/14/22, indicated for Resident 22 to utilize a carrot in right hand at all times, except for hygiene or if causing pain/discomfort, as tolerated. A care plan for ROM, revised 12/29/22, indicated Resident 22 had limited ROM to the right hand. The approach was to utilize a carrot device to the rand hand per orders and as tolerated. The following observations were conducted to where Resident 22 did not have a carrot or device to her right hand: 2/22/23 at 11:06 a.m., 2/22/23 at 11:36 a.m., 2/22/23 at 2:30 p.m., & 2/22/23 at 3:36 p.m. An interview conducted with the DHS, on 2/24/23 at 12:40 p.m., indicated the expectations are for staff to following physician orders and the residents care plans as written. 3. The clinical record for Resident 26 was reviewed on 2/22/23 at 12:44 p.m. The diagnoses included, but were not limited to, history of COVID-19, history of pneumonia, congestive heart failure (CHF), dysphagia, anemia, and cerebrovascular disease. A care plan for nutritional status, revised 2/18/23, indicated Resident 26 was malnourished and/or at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands. The approach was to have the Dietitian to re-evaluate as indicated and provide diet, supplements, medications, and adaptive equipment as ordered. A Registered Dietitian (RD) note, dated 2/21/23 at 3:26 p.m., indicated the following, .Noted COVID+ [positive] on 2/6/23 with decline. Noted significant weight loss since 2/6/23 with poor meal intake. Noted new impairments to coccyx and bilateral buttocks on 2/20/23. Dxs [diagnoses]: CHF, CKD 3 [chronic kidney disease; stage 3], dysphagia, lymphedema. Noted recent weight history: 2/21/23: 165.8 lbs, 2/20/23: 167.2 lbs, 2/19/23: 169.2 lbs, 2/18/23: 170.2 lbs, 2/6/23: 182.2 lbs, 2/1/23: 186 lbs, IBW: 136 lbs, BMI: 26.76. Weighed daily per order. Continues Lasix 40 mg qday [daily] with no changes since 1/4/23. Receiving regular diet with food preferences honored as requested. Ordered protein drink qday and ProStat AWC Sugar Free TID [three times a day]. Will recommend d/c [discontinue] protein drink and giving Ensure supplement TID between meals and fortified shakes at meals. Will recommend MVI [multivitamin] with minerals 1 po[by mouth] qday[every day] to aid in skin integrity. Careplan initiated [sic] As of 2/24/23 at 11:11 a.m., there were no physician order for an Ensure supplement in Resident 26's clinical record. An interview conducted with the DHS, on 2/24/23 at 2:40 p.m., indicated she was going to follow up with hospice in regard to the RD recommendation. A policy titled Guidelines for Weight Tracking, revised 1/16/21, was provided by Clinical Support on 2/24/23 at 2:57 p.m. The policy indicated the facility dietitian or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted. It also stated residents with a significant weight change can be added to Clinically At Risk. A Hospice Services Agreement, dated 6/12/17, was provided by the DHS on 2/24/23 at 3:20 p.m. The document indicated the following, .Plan of Care [POC]: a written individualized Plan of Care and services necessary to meet the patient-specific needs. It includes all patient care physician orders, and planned interventions for problems identified during patient assessments, to ensure that care and services are appropriate to the severity level of each patient and family needs .TERMS AND CONDITIONS .1.2 Plan of Care .The Plan of Care will be written in collaboration with the Hospice IDT [interdisciplinary team], the Facility Staff, the Hospice Patient or the Hospice Patient's Representative and the physician, based on the needs of the Hospice Patient. Any change in the POC will be discussed with the Hospice Patient or the Hospice Patient's representative, and the Facility representatives, and must be approved by Hospice before implementation 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure weekly measurements were conducted of pressure ulcers, provide treatment as ordered by the physician, and ensure a resident with a history of pressure ulcers didn't stay in the same position for an extended period of time for 2 of 5 residents reviewed for pressure ulcers. (Resident 17 and Resident 22) Findings include: 1. The clinical record for Resident 17 was reviewed on 2/22/23 at 10:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, unspecified protein-calorie malnutrition, anxiety disorder, and unspecified convulsions. A progress note, dated 2/15/23 at 3:44 p.m., indicated Resident 17 had an area to the left hip that appears to look like an old scar. A new red blanchable area was noted on her right hip. Resident was very thin and has multiple bony prominences noted. The hospice nurse was present and verbalized to continue to change position. A care plan for skin integrity, revised 2/21/23, indicated Resident 17 was at risk for pressure ulcers related to decreased mobility and incontinent of bowel and bladder. The approach was to conduct a systematic skin inspection by nurse weekly, keep bony prominences from direct contact with one another, and turn and reposition frequency. An observation conducted on 2/22/23 at 11:12 a.m. of Resident 17 sitting in her broda chair with the head lowered with appearance of sleep. An observation conducted on 2/22/23 at 2:35 p.m. of Resident 17 sitting in the same position in her broda chair. She appeared to be attempting to move herself to slide down in her broda chair. An observation conducted on 2/22/23 at 3:35 p.m. of Resident 17 still in the same position in her broda chair. Her eyes were closed, and she appeared to be sleeping. An interview conducted with the Director of Health Services (DHS), on 2/24/23 at 12:40 p.m., indicated her expectations are for staff to follow the plan of care and follow physician orders as written. 2a. The clinical record for Resident 22 was reviewed on 2/22/23 at 11:23 a.m. The diagnoses included, but was not limited to, dementia, contracture of right hand, anxiety disorder, dysphagia, and muscle weakness. A care plan for pressure, dated 12/6/22, indicated she had a pressure ulcer to her coccyx. The approach was to assess the wound, include measurement and observation of the pressure ulcer, record such, and provide treatment as ordered. A physician order, dated 1/24/23, indicated to cleanse coccyx with normal saline or wound cleanser, pat dry, apply Medihoney to area, and cover with foam dressing. Change every 5 days and PRN (as needed) for soilage. The special instructions for the physician order was to be changed by hospice nurse 1 day a week and facility nurse x 6 days a week. The order was discontinued on 2/20/23. The electronic medication administration record (EMAR) for January of 2023 and February of 2023 indicated the physician order for Medihoney to Resident 22's coccyx was signed off, as administered, on the following day(s): 1/24/23, 1/29/23, 2/3/23, 2/8/23, 2/13/23, and 2/18/23. A physician order, dated 2/20/23, indicated the use of Medihoney to coccyx, cover with foam, and change every 3 days. 2b. The Wound Management Detail Report for Resident 22's coccyx indicated there were no measurements from the assessment on 12/27/22 until 1/31/23. An interview conducted with the Director of Health Services (DHS), on 2/24/23 at 2:40 p.m., indicated she was following up with hospice on weekly wound assessments due to the Assistant Director of Health Services (ADHS) being ill during the time period of late December to late January. The hospice nurse was conducting wound rounds during that time period. A policy titled Guidelines for General Wound and Skin Care, dated 12/31/22, was provided by Clinical Support on 2/23/23 at 1:30 p.m. The policy indicated the following, .PROCEDURE .2. Turn/reposition residents who are immobile according to their care plan requirements .14. Perform the wound treatment .Reevaluate the wound's response to the prescribed treatment .20. Document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flowsheet 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place per the care plan and ensure a fall follow-up included completed neurological checks for 3 of 4 residents reviewed for accidents. (Resident 17, 31, and 9) Findings include: 1a. The clinical record for Resident 17 was reviewed on 2/22/23 at 10:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, malnutrition, anxiety disorder, and unspecified convulsions. A fall care plan, revised 2/17/23, indicated Resident 17 was at risk for falling with the approach to provide resident with a blanket while up in broda chair and staff to recline broda chair after meals. An observation conducted, on 2/23/23 at 12:35 p.m., of Resident 17 being assisted by a staff member in her broda chair and set her in her broda chair in the common area on the hallway where she resided in front of the television. The broda chair was not positioned in a recline position and Resident 17 was sitting upwards. An observation conducted, on 2/24/23 at 10:00 a.m., of Resident 17 up in her broda chair, reclined back, but no blanket nor cover was in place while she was up in her broda chair. 1b. A fall event, dated 12/26/22, indicated Resident 17 fell out of her chair and onto floor in common area. The fall was unwitnessed. There were no neurological checks conducted for two 15-minute follow ups, four 30-minute follow ups, four 1 hour follow ups, and three 4 hour follow ups after the fall event. 2. The clinical record for Resident 31 was reviewed on 2/23/23 at 11:48 a.m. The diagnoses included, but were not limited to, dementia, heart disease, atrial fibrillation, anemia, and major depressive disorder. A fall care plan, revised 2/20/23, indicated Resident 31 was at risk for falling with the approach to place resident in recliner after meals. An observation conducted of Resident 31, on 2/23/23 at 2:50 p.m. of him sitting up in his wheelchair with appearance of sleep. An observation conducted of Resident 31, on 2/23/23 at 3:50 p.m., of him sitting up in his wheelchair. 25054 3.) Review of the record of Resident 9 on 2/22/23 at 11:56 a.m., indicated the resident's diagnoses included, but were not limited to, dementia, depression, anxiety, difficulty walking, abnormal posture, repeated falls, lack of coordination, muscle weakness and chronic pain. The Quarterly Minimum Data Set (MDS) assessment for Resident 9, dated 11/17/22, indicated the resident was severely cognitively impaired for daily decision making. The resident has had one fall with injury since the last assessment. The fall event for Resident 9, dated 11/2/22, indicated the resident had an unwitnessed fall in the bathroom. The resident had an moderate amount of pain in her right knee. The resident's neurological checks were not complete for the last 4 neurological checks required. The fall event for Resident 9, dated 12/27/22, indicated the resident had an unwitnessed fall out of her bed. The resident only received on neurological check after the fall. The fall event for Resident 9, dated 2/6/23, indicated the resident had an unwitnessed fall from her wheelchair in the dining room. The resident had right hip pain. The resident only received one neurological check after the fall. An interview conducted with the Director of Health Services (DHS), on 2/24/23 at 12:40 p.m., indicated her expectations are for staff to follow the care plan and/or physician orders as written. A policy titled Falls Management Program Guidelines, review date of 3/16/22, was provided by Clinical Support on 2/23/23 at 1:30 p.m. The policy indicated the following, .4. Any orders received from the physician should be noted and carried out .5. The resident care plan should be updated to reflect any new change in interventions .6. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours A policy titled Guidelines for Neurological Checks, review date of 12/31/22, was provided by the DHS on 2/24/23 at 12:17 p.m. The policy indicated the following, .PURPOSE .To evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that may alert staff for potential for head injury or seizure activity .PROCEDURES .3. Neuro-checks for 24 hours should be completed within the Fall Event Form 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer and to promote healing that resulted in an unstageable pressure ulcer after admission to the facility that required surgical debridement during hospitalization for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/24/17 at 10:29 a.m. The [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The Initial Minimum Data Set (MDS), dated [DATE], indicated Resident B was an extensive assist with 2 staff person for transfers, bed mobility and personal hygiene. There was No marked under the presence of pressure ulcers and Yes marked under being at risk for pressure ulcers. The clinical record did not have any care plans for pressure ulcers, documentation of alterations in skin integrity, and/or any wound assessments completed for Resident B. An interview was conducted with Family Member 8 on 7/24/17 at 2:04 p.m. She indicated Resident B had a temperature of 102.7 on 7/9/17. The nursing staff gave her a suppository for her fever and when she assisted her to her side she noticed a very bad open area to Resident B's buttocks. When the nursing staff and Family Member 2 were turning Resident B to administer a suppository she was yelling out in pain. There was no treatment or dressing applied to Resident B's buttocks after the pressure ulcer was noted. She was then sent out to the hospital on [DATE] without a dressing or treatment completed. When Resident B discharged from the hospital and to the facility on [DATE] there was no areas noted on her buttocks. A progress note, dated 7/2/17 at 7:14 p.m., indicated the following, .resident has two bruises on abd (abdomen): one on left lower quadrant measuring 7 cm (centimeters) x 4 cm and fading blue, and one on the right lower quadrant measuring 4 cm x 3 cm and red/purple (sic), both from insulin injections. resident also has two small bruises, one on upper lt (left) arm measuring 1 cm x 1.5 cm dark purple (sic) and one on inner lt (left) fa (forearm) measuring 1 cm x 1 cm dark purple (sic). will continue to monitor for changes The progress note was signed by LPN (Licensed Practical Nurse) 12. There was no indication of a pressure ulcer being present when Resident B was admitted to the facility on [DATE]. An interview was conducted with LPN 12 on 7/24/17 at 1:31 p.m. She indicated when she performed a skin assessment on Resident B, upon admission, there was bruising noted to her abdomen and upper extremities. There was no pressure ulcers present on the initial skin observation done on 7/2/17. A progress note, dated 7/9/17 at 10:28 p.m., indicated the following, .while assisting resident with peri-care (perineal care) this nurse noticed about a quarter sized opened pressure ulcer to resident coccyx and an irritated reddened area to the inner right gluteal fold .resident's daughter stated irritated area to residents gluteal fold has been there The progress note was completed by LPN 10. The progress note was also recorded as a late entry that was completed on 7/11/17 at 12:35 p.m. There was no assessment of the wound documented that included measurements, color, odor, etc. for the pressure ulcer to Resident B's coccyx. There was no documentation of Resident B having any pressure ulcers from 7/2/17 to 7/9/17. An interview was conducted with LPN 10 on 7/24/17 at 2:50 p.m. She indicated she was performing perineal care for Resident B and noticed a pressure ulcer to her coccyx. There were no measurements taken due to Resident B being to weak to stand up. She indicated the resident needed to be standing up for measurements to be obtained. She notified the Assistant Director of Health Services (ADHS) about the pressure ulcer and that is the only person notified. There was no notification of the Physician or the Nurse Practitioner of the pressure ulcer. LPN 10 indicated there was no treatment ordered or applied to the pressure ulcer then evening of 7/9/17 when it was discovered. The progress note about the pressure ulcer was not completed until 7/11/17 because LPN 10 was busy and didn't have time to document in the progress notes about Resident B's pressure ulcer. There were no treatment orders or interventions documented in the clinical record for Resident B's pressure ulcer. An interview was conducted with Certified Resident Care Assistant (CRCA) 6 on 7/24/17 at 3:02 p.m. She indicated she cared for Resident B previously and she noted an open area to her buttocks when she worked on Thursday, 7/6/17, and told the nurse on duty. She worked on Sunday, 7/9/17, and the open area was bigger and looked red at that time. The nurse working that day took a look at it. A hospital document, dated 7/12/17, titled Problem List indicated the following, .(2) Decubitus ulcer of sacral region, unstageable .Will debride in the a.m. and then likely changed to Santyl (prescription ointment that cleans wounds to clear the way for healthy tissue) A hospital document titled Operative Report indicated the following, .Procedure Note .Laceration/Wound Repair .Buttock .Wound Length (cm): 6 .Wound Debrided: 100% .Comments: .Wound cleaned with wound cleanser. 1% [MEDICATION NAME] applied. Excisional debridement of 100% of eschar to subcutaneous bleeding tissue The document was dated for 7/13/17. An interview was conducted with the Executive Director (ED) on 7/24/17 at 5:00 p.m. She indicated she spoke with a family member of Resident B and she was made aware of a concern regarding an open area to Resident B's buttocks. When the nursing staff and she looked into the situation they noticed there was no documentation in the progress notes about an open area. So, we called that nurse in (LPN 12) and she documented in the progress notes as a Late Entry. The expectations are for the documentation to be accurate and completed in a timely manner. If there is care being provided it should be documented shortly thereafter. An interview was conducted with the Director of Health Services (DHS) on 7/25/17 at 11:44 a.m. She indicated she never observed Resident B's skin. During the admission assessment they will open an event for a skin issue and we will follow-up within 24 hours to assess and provide treatment and/or interventions for the skin issue. The nursing staff are expected to complete the measurements and chart under the event that was created for the pressure ulcer. The Physician should be made aware and obtain orders for the treatment of [REDACTED]. A policy titled Pressure/Stasis/Diabetic Wound Guidelines, revised 5/10/16, was provided by the ED on 7/25/17 at 8:55 a.m. The policy indicated the following, .Procedures .1. Appropriate skin Event is completed by a RN/LPN in EHR (electronic health record) .a. Complete event for each impaired area .b. All measurements are recorded in centimeters .2. Document description of wound using: .a. Length .b. Width .c. Depth .d. Exudates .e. Color .f. Odor .g. Wound margins .h. Surrounding tissue .i. Tunneling and/or undermining if applicable This federal tag relates to Complaint IN 306. 3.1-40(a)(2) 3.1-40(a)(3)