Every finding on record at Trailpoint Village

Based on observation, record review and interviews, the facility failed to updated/revise a comprehensive person-centered care plan for nutritional needs related to continued weight loss (Resident B), for 1 of 21 residents reviewed for care plans.Finding includes:During an interview, with Resident B's daughter, she indicated she had a concern regarding her mother's ongoing weight loss.On 4/10/2026 at 9:01 A.M., Resident B's medical record was reviewed. Diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease, depression, anxiety, and osteoporosis.A Quarterly Minimum Data Set (MDS) assessment, dated 3/18/2026, indicated Resident B had severe cognitive impairment, required set up assistance for eating and had experienced a weight loss of 5% or more in the past month and 10% or more in the past 6 months.Resident B weighed 130 pounds on October 1, 2025. However, by November 18, 2025 she had lost weight and only weighted 120 pounds which resulted in an over 7.5% weight loss in a little over a month. A Care Plan initiated, on 12/20/2024 and updated on 6/19/2026, indicated Resident B was at nutritional risk related to her diagnoses. Resident B's goal was to maintain her (UBWR) usual body weight range of 135-140 pounds but was noted to have had a significant weight loss in December 2025. Interventions, initiated on 11/06/2025, included but were not limited to high calorie house milk shakes at lunch and ice cream at dinner.A Follow Up Nutrition Review, completed by the Corporate Dietary Manager, dated 3/26/2026, indicated Resident B's current weight of 118 pounds, indicated the resident had experienced a weight loss of 5% or more in the last month and a 10% or more weight loss in the last 6 months. Current diet orders/interventions included, but were not limited to regular diet, high calorie shakes at lunch, ice cream at dinner. Resident B's average meal intake indicated the following: breakfast 39%, lunch 54% and dinner 54%. Acceptance of extra items provided to help maintain/improve nutrition indicated the interventions had been refused.An Interdisciplinary Team (IDT) Progress Note, dated 3/26/2026 at 12:01 P.M., indicated Resident B's current weight was 116 pounds. A root cause for the weight change/nutrition concerns indicated Resident B was a picky eater. New recommendation/interventions indicated to re-evaluate food choices/preferences and to update the Care Plan. However, a care plan was not updated related to food choices and preferences.A policy was provided by the executive director on 4/13/2026 10:15 A.M., The policy dated 10/2025, titled IDT Comprehensive Care Plan Policy, indicated, . Procedures: . care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically.This federal tag is related to Intake 2806507.3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to initiate a recommended restorative program after therapy for 1 of 1 resident reviewed for rehabilitation. (Resident 14)Finding includes:During an interview, on 4/8/2026 at 1:45 P.M., Resident 14 indicated she was able to walk prior to surgery, had received rehabilitation, but the insurance company had cut her therapy. Resident 14 indicated she could now only walk a few steps to get to the toilet, and the therapy department have been planning to start a restorative program for ambulation. A record review for Resident 14 was completed on 4/9/2026 at 11:00 A.M. Diagnoses included, but were not limited to: chronic pain constipation, conversion disorder with seizures or convulsions and chronic obstructive pulmonary disease (COPD). An Annual Minimum Data Set (MDS) assessment, dated 3/23/2026, indicated Resident 14 was cognitively intact, had no extremity impairment, required partial/moderate assistance for walking 10 feet and walking 50 feet was not attempted due to her medical condition and/or safety. A Physician's Order, dated 1/10/2026 and discontinued on 2/19/2026, indicated Resident 14 was to have received physical therapy five times weekly for five weeks for therapeutic activity, therapeutic exercises, gait training, moist heat, Bio freeze as needed and group therapy as indicated. A Physical Therapy Discharge Note, dated 2/19/2026, indicated Resident 14 had shown excellent progress since the start of therapy. Resident 14 was able to walk 50-60 feet, four times, with a four-wheeled walker and contact guard assistance. The note indicated Resident 14 was to continue with restorative services to maintain her current level of functioning. During an interview, on 4/13/2026 at 11:52 A.M., the Director of Therapy indicated Resident 14 should have received restorative therapy, but the therapy department had been down a restorative aide due to a staff members hospitalization. The Director of Therapy indicated Resident 14 was at the top of the list to receive restorative services within the next week. A policy was provided by the Executive Director, on 4/13/2026 at 1:25 P.M. The policy titled, Restorative Nursing Program, indicate, .To provide a nursing program for residents who no longer need skilled therapy but still have functional goals to be met or maintained through practice and repetition.Process.Programs may also be initiated following cessation of skilled therapy. 16.2-3.1-38(a)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, related to the omission of prescribed doses and medications for 4 of 31 medications observed during medication administration. These medication errors resulted in an error rate of 7.75% (Residents 39 & 112). Findings include:1. During a medication administration observation, on 4/10/2026 at 8:34 A.M., RN 3 prepared medications for Resident 39. She prepared the following medications:-bupropion hydrochloride 300 milligrams one tablet-calcium-Vitamin D3 600 milligram-10 microgram one tablet- ferrous fumarate 325 milligrams one tablet- fluoxetine 20 milligrams one tablet- magnesium oxide 400 milligrams one tablet- omeprazole 20 milligrams one capsule- multivitamin one tablet- liquid protein 30 milliliters- pregabalin 100 milligrams one capsule A record review for Resident 39 was completed on 4/10/2026 at 9:02 A.M. Resident 39 had orders for lactobacillus acidophilus 10 billion cell 1 tablet. The medication had not been administered during the medication pass observation. 2. During a medication administration observation, on 4/10/2026 at 8:04 A.M., RN 3 prepared the following medications for Resident 112. -amlodipine 10 milligrams one tablet-buprenorphine-naloxone 8-2 milligrams buccal strip one strip-clopidogrel 75 milligrams one tablet-vitamin B12 1 milligram one tablet-docusate sodium 100 milligrams one tablet-ezetimibe 10 milligrams one tablet-famotidine 20 milligrams one tablet-ferrous sulfate 325 milligrams one tablet-furosemide 20 milligrams one tablet-metoprolol tartrate 25 milligrams one tablet-pantoprazole 40 milligrams one tablet-gabapentin 300 milligrams one capsule A record review for Resident 112 was completed on 4/10/2026 at 9:42 A.M. Resident 112 had orders for venlafaxine 37.5 milligrams two tablets, isosorbide mononitrate 60 milligrams one tablet and buprenorphine-naloxone 8-2 milligrams buccal strip two strips. During an interview, on 4/10/2026 at 10:00 A.M., RN 3 indicated she gave all scheduled medications ordered during the observation period. At 4/10/2026 at 10:05 A.M., the Executive Director and the Regional Director of Clinical Services were informed of the medication errors observed during the medication pass. During an interview, on 4/10/2026 at 10:39 A.M., the Executive Director indicated Resident 39's the lactobacillus acidophilus had been moved to a noon time administration because the medication had contributed to nausea and the buprenorphine-naloxone had been ordered incorrectly to the pharmacy by the physician as one strip instead of two strips. The Executive Director indicated Resident 112's isosorbide mononitrate was on hold due or had been place on hold due to the pharmacy had not delivered the medication. However, RN 3 the lactobacillus acidophilus order was written for a morning dose (an evening dose) and had not been rewritten for a noon time dose, and buprenorphine-naloxone was ordered for 2 strips and not one strip as indicated on the packaging. In addition, there was not a hold order or notification to hold the isosorbide mononitrate. During an interview, on 4/10/2026 at 10:51 A.M., the Executive Director indicated the facility did not have a policy on medication administration, but instead utilized a skills check-off. A Skills Competency for Medication Administration was provided by the Executive Director, on 1/13/2026 at 1:50 P.M. The competency indicated, .2. The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right Time. 16.2-3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for abuse was free from abuse, when a previous staff member verbally abused the resident while exiting the facility following her resignation, (Resident C). Finding includes: On 8/14/25 at 12:00 P.M., Resident C's clinical record was reviewed. Diagnoses included but were not limited to osteomyelitis, type 2 diabetes with diabetic polyneuropathy, and spinal stenosis. Resident C's Care Plans included but were not limited to, Resident displays verbal aggression towards others when feeling frustrated with them, initiated on 7/30/25. Review of a facility Incident Number 668, reported to the State Agency on 8/8/25, indicated on 8/8/25 at 4:01 P.M., Resident C reported that the previous Unit Manager, Licensed Practical Nurse (LPN) 5, went up to him on her way out of the facility and spoke rudely to him after telling him she had quit. The staff member had resigned and was terminated from the system when an investigation was initiated. All appropriate parties were notified. Staff and residents were interviewed regarding the potential abuse with negative findings. Upon investigation, the facility follow-up, dated 8/13/25, indicated other staff and resident were interviewed and indicated they had heard an interaction between LPN 5 and Resident C, but were not able to make out what was said. The resident had suffered no psychosocial distress. During an interview on 8/14/25 at 1:20 P.M., Resident C indicated LPN 5 was not a good nurse and had failed to order pain medications in a timely manner on two occasions and had also failed to arrange for transportation to an appointment for him. The resident indicated he was able to use Tylenol for pain and staff had transported him to his appointment. Resident C indicated that LPN 5 had to apologize to him, per the administration's direction, which upset her and so was unhappy with him. Resident C indicated LPN 5 was in the facility on 8/8/25 to hand in her resignation and as she was leaving the building, went to the 400 Hall Nurse's Station where he was seated in his wheelchair, approached the resident and told him he was a piece of shit. During an interview on 8/15/25 at 10:00 A.M., the Administrator indicated on 8/8/25, LPN 5 came to the facility to resign her position. As she was leaving the facility, LPN 5 had gone to Resident C, who was near the Nurse's Station, and had spoken rudely to him. The Administrator indicated she was made aware of the incident after Resident C reported it to the staff. The Administrator indicated she went to the resident immediately and initiated an investigation and reported the incident to the State Agency. The Administrator indicated it was inappropriate for LPN 5 to speak to the resident in a rude manor. On 8/15/25 at 12:30 P.M., the Administrator provided the policy, Abuse Prohibition, Reporting, and Investigation, dated 6/23, and indicated it was the current facility policy. The policy indicated, .It is the policy of [facility] to provide each resident with an environment that is free from abuse.This includes but is not limited to verbal abuse.[facility] will not permit resident to be subjected to abuse by anyone, including employees.friends, or other individuals.Verbal Abuse- The use of oral.language that willfully includes disparaging and derogatory terms to residents. This citation relates to Intake 25884363.1-27(a)(b)

Based on record review and interview, the facility failed to ensure a CNA (Certified Nurse Assistant) followed the resident's comprehensive care plan and the facility's Mechanical Lift/Hoyer Lift Safety procedure during a transfer from the resident's wheelchair to bed. This resulted in the resident falling to the floor and sustaining multiple fractures and requiring hospitalization. (Resident B) The Immediate Jeopardy began on 5/29/25 at 4:28 P.M., when a CNA failed to follow a resident's comprehensive care plan and transferred a resident, via a Hoyer lift, from a wheelchair to the bed, without assistance. This deficient practice resulted in a fall, from a Hoyer sling, to the ground, in which the resident sustained multiple fractures and requiring hospitalization. The Administrator, the Director of Nursing and Regional [NAME] President were notified of the Immediate Jeopardy on 6/13/25 at 11:36 A.M. The deficient practice was corrected on 6/6/25, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 6/12/25 at 1:28 P.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: chronic respiratory failure with dependence on ventilator, artificial opening of gastrointestinal tract-gastrojejunostomy tub (G-tube), cerebral palsy, paraplegia, and an anxiety disorder. An Activities of Daily Living (ADL) care plan, dated 12/26/23 and revised on 3/27/25, indicated the resident required assistance with ADLs which included bed mobility and transfers related to a diagnosis of cerebral palsy. Interventions included but were not limited to: assist with transfers, then on 3/12/24, an intervention of transfers with 2 person assist with a Hoyer lift was added. A Fall care plan, dated 12/26/23 and revised on 3/27/25, indicated the resident was at risk for falls due to impaired mobility. There were no specific interventions related to the resident's needs for transfers on the plan. A Minimum Date Set (MDS) annual assessment, dated 3/24/25, indicated Resident B was dependent on staff for transfer assistance and had had no falls since his admission. A Fall Risk assessment, dated 3/20/25, indicated the resident was had a moderate risk for falls. A Fall Event form, dated 5/29/25 at 5:10 P.M., indicated CNA 3 reported the resident had fallen out of the side of the Hoyer pad during a transfer. CNA 3 reported she had used her body to guide the resident's fall to the floor. The Respiratory Manager had assisted CNA 3, immediately after the fall, with getting the Hoyer pad back underneath the resident and then CNA 3 had transferred Resident B back into his bed. The form indicated the Immediate intervention was that CNA 3 was instructed on Hoyer (mechanical lift) use with 2 persons. A Nursing Progress Note, dated 5/29/25 at 5:19 P.M., indicated CNA 3 had reported the resident had fallen while she was transferring him from the wheelchair to his bed. The note indicated the following: .CNA states that she used her body to guide resident fall to floor, but left forehead hit the floor, RT [Respiratory] manager present with CNA and assisted getting resident on hoyer pad and into bed. Dime sized Hematoma present above left eyebrow, ice in place A Nursing Progress Note, dated 5/29/25 at 8:55 P.M., indicated Resident B had fallen and had hit his head earlier in the afternoon. Resident B had later demonstrated neurological changes and appeared cold and clammy., The resident's vital signs were documented as the following: Blood pressure 80/53, Pulse 123 and respirations were 42. At 8:23 P.M., 911 was called to transfer the resident to the hospital for an evaluation for a possible intracranial pressure/bleeding. The paramedics had arrived at 8:38 P.M. and the resident was taken to a local hospital. A typed form, titled Fall Incident Timeline: Hoyer Lift Transfer with injury indicated the following: -Date of incident: 5/29/25 -At 2:00 P.M., RN 2 had spoken with CNA 3 to ensure her if she needed assistance with transferring Resident B, with a Hoyer, to let her know and she would help CNA 3. CNA 4 also had told CNA 3 he would assist her when she needed assistance. -At 2:35 P.M., CNA 3 had attempted to transfer Resident from his wheelchair to his bed using the facility approved Hoyer lift. During the transfer, the resident had slid out of the sling and fell to the ground. -At 2:45 PM The nurse was promptly notified. An initial assessment was conducted, revealing only a small hematoma above the Resident's left eyebrow. Vital signs were stable -At 8:30 P.M., the resident demonstrated a change of condition, which prompted an immediate re-assessment. The decision was made to have the resident transported to a local emergency department for an evaluation. -On 5/30/25 at 10:30 A.M., the hospital records confirmed the resident had sustained multiple fractures from the fall and the incident was reported to the Indiana State Health Department. -The typed form indicated additional facts: CNA 3 had been trained on the proper Hoyer techniques, on 11/6/24 and signed a Mechanical Lift/Hoyer Lift Safety attestation on 11/6/24. A copy of the attestation indicated .1. I understand that all mechanical lifts, including hoyer lifts require the use of 2 people to operate safely .I understand that if I operate a mechanical lift by myself, I am subject to disciplinary action up to and including termination In addition, a skills competency form regarding Hoyer transfer techniques had been completed by CNA 3 in July 2024. The Conclusion indicated the following: .Investigation shows the root cause of the fall was that the care plan was not followed during the transfer. The employee received the proper training prior to the incident and staff were available for assistance at the time of the incident but were not notified to assist A typed statement/interview, dated 5/29/25 (no time), indicated RN 2 had told CNA 3 she would assist her with any transfers on 5/29/2025 prior to the resident's fall. A typed statement/interview from CNA 3, undated (no time), indicated she had transferred Resident B and he slipped out of the Hoyer sling. The Administrator indicated she had interviewed CNA 3 on 5/30/25 and the only explanation provided had been the resident's buttock was possibly not positioned correctly in the sling prior to the transfer. A typed statement by the Respiratory Manager, undated (no time), indicated CNA 3 had came to Respiratory Manager searching for RN 2. CNA 3 indicated she needed assistance with Resident B and she had followed CNA 3 into Resident B's room. The Hoyer lift was still elevated with the Hoyer sling/pad attached to the Hoyer lift machine. The resident was located on the floor laying on his left side, with his body between the legs of the Hoyer. CNA 3 told the Respiratory Manager the resident had fell off the Hoyer. The Respiratory Manager indicated she had then assisted CNA 3 to position the sling underneath the resident. She indicated CNA 3 then lifted Resident B up from the floor onto his bed with the Hoyer lift. A Hospital History and Physical, dated 5/29/25 at 11:55 P.M., indicated the resident presented to the emergency room (ER) with hypoxia (low levels of oxygen in the body tissue) after a fall earlier in the afternoon. In the ER the resident had profuse vomiting and there were concerns regarding a potential G-tube displacement. A CT (Computerized Tomography) of the abdomen and pelvis was conducted which revealed the G-tube was present with tip of the catheter located within the stomach, however, there were acute bilateral femoral (hip) fractures, a right superior pubic ramus (lower pelvis) fracture, a left iliac wing (upper pelvis) fracture and a left sacral (bones at the base of the spine ) fracture. A facility self-reported incident, dated 5/30/25 at 9:01 A.M., indicated the resident had experienced a fall while being transferred, using a Hoyer lift and had sustained multiple fractures. .Root cause of fall was that the care plan was not followed during transfer An Employee Communication Form for CNA 3, dated 6/2/25 indicated .Employee demonstrated gross disregard of resident safety by failing to follow established procedures for transferring residents. Specifically, the staff member attempted to use a Hoyer lift without the required second staff member, resulting in a fall and injury to the resident. This action demonstrates as serious violation of safety protocols and placed the resident at significant risk, warranting immediate termination On 6/13/25 at 9:30 A.M., the Administrator provided a skills competency form titled, Mechanical Lift, dated 8/2023 which indicated .Two (2) staff is required at all times when using a mechanical lift During an interview, on 6/13/25 at 2:01 P.M., the Administrator indicated the resident had been in the hospital since the day of his fall and would possibly return to the facility on 6/13/2025. She indicated the incident report had been filed the next day as the facility had not received a report from the hospital regarding the resident's injuries until 5/30/25. She indicated CNA 3 had been suspended on 5/30/25, until further investigation. During an interview, on 6/16/25 at 10:57 A.M., the Respiratory Manager indicated CNA 3 had asked for help and when she entered Resident B's room he was located on the floor and the Hoyer lift was over him. She indicated she had only assisted the CNA with positioning the resident onto the Hoyer sling. Then CNA 3 lifted the resident, via the Hoyer lift and lowered the resident onto his bed. During an interview, on 6/16/25 at 11:00 A.M., RN 2 indicated CNA 3 came to her and told her Resident B had fallen. When she entered the room, the resident was tucked in bed and the Hoyer lift was in the hallway. She indicated CNA 3 should have not moved the resident until she had assessed him for injuries. On 6/13/25 at 9:30 A.M., the Administrator provided a policy titled, Fall Management Policy, dated 8/2022 and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of [name of the facility] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Facilities must implement comprehensive, resident-centered fall prevention care plans for each resident at risk for falls The Past Noncompliance Immediate Jeopardy began on 5/30/2025. The Immediate Jeopardy was removed and corrected by 6/6/25 after the facility implemented a systemic plan of correction that included the following actions: all nursing staff were re-educated on Hoyer use and the need for 2 persons to perform a transfer via a Hoyer lift, return demonstration/skills check off on Hoyer transfers were conducted with all nursing staff, resident care plans were reviewed to ensure their transfer care plans were updated with the correct number of staff needed for their transfer needs, staff were educated regarding the notification of the a Charge Nurse following a fall for an assessment of possible injuries, a daily observation/audit of resident transfers was initiated on 6/2/25 and was ongoing and the QAPI (Quality Assurance and Performance Improvement) to review audit tool ongoing. This citation relates to Complaint IN00460600. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to prevent the misappropriation of narcotics for 1 of 4 residents receiving narcotics reviewed. (Resident C) Finding includes: On 6/12/25 at 12:16 P.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but were not limited to: respiratory failure with hypoxia-tracheostomy, diabetic neuropathy, dysphagia (difficulty swallowing), diabetes and chronic kidney disease. A current Care plan for pain, initiated on 4/28/25, indicated the resident was at risk for pain related to impaired mobility and diabetic neuropathy. The interventions included, but were not limited to: notify physician if pain is unrelieved and/or worsening, assist with positioning to comfort, administer medications as ordered and document effectiveness of pain medications. A Nursing Progress Note, dated 5/15/25 at 7:56 A.M., indicated the previous shift had reported the resident's narcotics had been held since 2:00 P.M. on 5/14/25. In addition, they had reported the resident had slept most of the previous shift. After the nursing staff had relayed their converns to Director of Nursing, it was decided to send the resident to a local hospital for an evaluation and treatment. A facility census event for Resident C indicated on 5/15/25 at 8:25 A.M., the resident had a Hospital Leave/ER Visit. On 6/2/25 at 5:40 P.M., the census indicated the resident had a Return from Hospital Leave. The Medication Administration Record for May 2025 for Resident C, indicated the resident had an order for Oxycodone (narcotic pain medication) 10 milligrams every 8 hours (6:00 A.M., 2:00 P.M. 10:00 P.M.). The last dose of Ocycodone had been administered to Resident C on 5/14//25 at 2:00 P.M. with no doses given at 10:00 P.M. The MAR indicated there had been no narcotic medication administered to Resident C through the month of May. A facility self-reported incident, dated 5/23/25 at 12:01 P.M., indicated .Facility noted 5 missing Oxycodone pills were missing during an audit. The count was correct prior to [name of LPN 7] shift LPN 7 was suspended pending the investigation. Resident C had been in the hospital during the time the medication was noted to be missing. A follow up to incident report, on 5/28/25 indicated .a discrepancy was identified during a narcotic audit, prompting an internal investigation. [name of LPN 7] was identified as having access to the medication in question. When approached, the staff member was asked to complete a drug screen and provide a written statement. She refused both requests and subsequently left the building. Police report was filed. The staffing agency responsible for the employee was also notified of the incident and investigation findings .Consumer complaint was filed on staff member A typed statement by RN 8, dated 5/23/25, indicated RN 8 had been doing her assigned narcotic audit and requested the cart keys from LPN 7. RN 8 noted Resident C's narcotic cards had been repositioned towards the back of the other cards. RN 8 asked LPN 7 why were Resident C's cards out of order to which LPN 7 replied she had placed them there because the drawer was stuffed. RN 8 noticed there were 5 Oxycodone missing. RN 8 questioned LPN 7 where the Ocycodone had gone and who did she get report from and the LPN did not respond. RN 8 took Resident C's narcotic medication cards to the Director of Nursing to report the drug diversion. A typed statement by the Director of Nursing (DON), dated 5/23/25 at 11:05 A.M., indicated RN 8 had informed the DON of the missing Oxycodone for Resident C during her cart/narcotic audit. The DON had verified there were 5 Oxycodone missing from Resident C's narcotic card. The DON was instructed by Human Resources to have a drug test completed on LPN 7, as directed by the facility's policy. LPN 7 refused to be drug tested, threw the cart keys towards the nurses station, grabbed her things and headed towards the exit. DON and 2 other nurse managers walked along with LPN 7 until they reached the front lobby. At that time, LPN 7 pushed past the nurse managers and exited the building. A hand written statement by RN 2, on 5/23/25, indicated when she had counted the narcotics with LPN 7 (prior to the start of LPN 7's shift) the narcotic count had been correct. A picture of the narcotic cards and the Controlled Substance Record were observed on 6/12/25 for Resident C, which revealed the last dose of Oxycodone was removed from the card, on 5/14/25 at 2:00 P.M., with a count at 75 tablets, however the Ocycodone card only had 70 Oxycodone left on the card. During an interview, on 6/12/25 at 11:29 A.M., the DON indicated Resident C had been discharged a couple of days prior to the discovery of his narcotics missing. The DON indicated LPN 7 had been an agency nurse and was unaware there was an ongoing audit of narcotics being conducted throughout facility. The DON indicated LPN 7 had been suspended but there had been no contact with LPN 7 since her departure. On 6/12/25 at 9:54 A.M., the Administrator provided a policy titled, Abuse Prohibition, Reporting, and Investigation, dated June/2023 and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation .Misappropriation of Resident Funds or Property - Deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent 3.1-28(a)

Based on interview and record review the facility failed to ensure staff members acted competently and followed facility protocol regarding notification and assessment of a licensed nurse after a resident experienced a fall prior to moving the resident for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: On 6/12/25 at 1:28 P.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: chronic respiratory failure with dependence on ventilator, artificial opening of gastrointestinal tract-gastrojejunostomy tub (G-tube), cerebral palsy, paraplegia, and an anxiety disorder. A Fall Event form, dated 5/29/25 at 5:10 P.M., indicated CNA 3 reported the resident had fallen out of the side of the Hoyer pad during a transfer. CNA 3 reported she had used her body to guide the resident's fall to the floor. The Respiratory Manager had assisted CNA 3, immediately after the fall, with positioning the Hoyer pad back underneath the resident and then assisted to transfer Resident B back into his bed. The form indicated the Immediate intervention was that CNA 3 was instructed on Hoyer use with 2 persons. A Nursing Progress Note, dated 5/29/25 at 5:19 P.M., indicated CNA 3 had reported the resident fell while she was transferring him from the wheelchair to his bed. The note indicated the following: .CNA states that she used her body to guide resident fall to floor, but left forehead hit the floor, RT [Respiratory] manager present with CNA and assisted getting resident on hoyer pad and into bed. Dime sized Hematoma present above left eyebrow, ice in place A typed statement by the Respiratory Manager, undated (no time), indicated CNA 3 had came to Respiratory Manager searching for RN 2. CNA indicated she needed assistance with Resident B and she had followed CNA 3 into Resident B's room. The Hoyer lift was still elevated with the Hoyer sling/pad attached to the Hoyer lift machine. The resident was located on the floor laying on his left side, with his body between the legs of the Hoyer. CNA 3 told the Respiratory Manager the resident had fell off the Hoyer. The Respiratory Manager indicated she had then assisted CNA 3 to position the sling underneath the resident. She indicated CNA 3 then lifted Resident B up from the floor onto his bed with the Hoyer lift. An Employee Communication Form, signed on 6/2/25, by the Respiratory Manager and the Administrator, indicated the following: .Staff member was educated on residents who have experienced a fall must be assessed by a nurse before any attempt is made to move or assist them. This ensures that potential injuries are properly evaluated and that the resident's safety is not compromised. Assisting a resident up before nursing assessment can lead to further harm and violates facility protocol. Please ensure that all falls are immediately reported to the nurse and that no movement occurs until the resident has been assessed During an interview, on 6/13/25 at 2:01 P.M. the Administrator indicated CNA 3 and the Respiratory Manager should have notified the nurse of the resident's fall prior to moving him. She indicated the Respiratory Manager was new and had been instructed on the facility's protocol since the incident. During an interview, on 6/16/25 at 10:57 A.M., the Respiratory Manager indicated CNA 3 had asked for help and when she entered Resident B's room he was located on the floor, and Hoyer lift was over him. She indicated she had only assisted the CNA with positioning the resident onto the Hoyer sling. She indicated CNA 3 had then proceeded to lift the resident, via the Hoyer lift and lowered the resident onto his bed. Since the incident, the Respiratory Manager indicated she had been instructed to never move a resident after a fall but to obtain a nurse to assess the situation and the resident. During an interview, on 6/16/25 at 11:00 A.M., RN 2 indicated CNA 3 came to her and told her Resident B had fallen. When she entered the room, the resident was tucked in bed and the Hoyer lift was in the hallway. She indicated CNA 3 should have not moved the resident until she had assessed him for injuries. On 6/13/25 at 9:30 A.M., the Administrator provided a policy titled, Fall Management Policy, dated 8/2022 and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of [name of the facility] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Post fall 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided The Administrator indicated this was the only policy regarding post fall protocol. This citation relates to Complaint IN 00460600. 3.1-14(i)

Based on observation, interview and record review, the facility failed to ensure medications were labels and stored according to professional priniciples on 3 of 4 medication carts observed. (Memory Care, 100 Hall & 400 Hall) Findings include: 1. On 2/27/2025 at 9:30 A.M., a medication storage observation was completed with RN 2 on the Memory Care cart, the following was observed: An opened, undated and unlabeled bottle of calcium magnesium with zinc capsules. In addition, there was a bottle of One a Day Men 50 + vitamin supplement with only a resident's first name written on the lid of the bottle. During an interview on 2/27/2025 at 9:40 A.M., RN 2 indicated a family member had brought them in and the bottles should have had labesl and an opened date on them. 2. On 2/27/2025 at 10:47 A.M., a medication storage observation was completed with RN 3 on the 100 Hall cart and the following was observed: Three bottles of prescirption eye drops were stored the same drawer as oral medications. One of three bottles of eye drops was not labeled with complete instructions regarding which eyes were to have drops administered. During an interview on 2/27/2025 at 11:00 A.M., RN 3 indicated she was not aware eye drops could not be stored next to oral medications, but she had been instructed by the DON that the eye drop bottles needed to be stored upright in the cart. She indicated the bottle of eye drops with incomplete instructions should have indicated the drops were to be instilled in the resident's right eye. 3. On 2/27/2025 at 1112 A.M., a medication observation was completed with the Unit Manager on the 400 Hall cart and the following was observed: An opened and undated bottle of nasal spray. An opened and undated bottle of eye drops. During an interview on 2/27/2025 at 11:33 A.M., the Unit Manager indicated the bottles should have had an opened date. On 2/27/2025 at 11:41 A.M., the Regional Nurse Consultant provided a policy titled, Medication Storage and Expiration Policy, dated 11/2024, and indicated the policy was the one currently used by the facility. The policy indicated . 2. Internal (oral) medications should be stored separately from external (not taken orally) mediations 9. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler). On 2/28/2025 at 2:45 P.M., the Regional Nurse Consultant provided a policy titled, Over-The -Counter (OTC) Medications, dated 2022, and indicated the policy was the one currently used by the facility. The policy indicated . Order: Ensure prescriber order is in place for all OTC medications and Label patient-specific OTC's per facility policy (e.g., first initial, last name, room #) . On 2/28/2025 at 2:52 P.M., the Administrator provided a policy titled, Medication Brought Into the Facility, dated 12/1/2017, and indicated the policy was the one currently used by the facility. The policy indicated Facility staff should not administer medications, including over-the-counter mediations, naturally occurring substances, and physician/perscriber medication samples, brought to the facility by a resident, a resident's responsible party, or a resident's physician/prescriber without a physician/perscriber order . 3.1-25(l)(1) 3.1-25(l)(2) 3.1-25(l)(3) 3.1-25(l)(4) 3.1-25(l)(5)

Based on record review and interview, the facility failed to ensure advanced directives were coordinated with hospice for 1 of 2 residents reviewed for hospice services. (Resident 28) Finding includes A record review for Resident 28 was completed on 2/26/2025 at 9:45 A.M. Diagnosis included, but were not limited to occlusion and stenosis of right posterior cerebral artery, metabolic encephalopathy, dementia, schizoaffective, borderline personality, bipolar, and aortic stenosis. A Physicians Order dated 11/25/2024, indicated the resident was a full code. Resident 28's care plan, initiated on 11/26/2024, indicated the resident and/or the resident's legal representative preferred a full code status. A Physician's Order dated 2/11/2025 indicated an order for hospice for Resident 28 for end of life care. Review of the hospice initial plan of care, dated 2/10/2025, indicated an advanced directives of Do Not Resuscitate (DNR) code status. A Physician Orders for Scope of Treatment (POST) form, signed on 2/10/2025 indicated Resident 28's code status was now a DNR. The facility was not notified by the hospice provider of the change until 2/28/2025. During an interview with the Administrator on 2/28/2025 at 11:40 A.M., she indicated when someone transitioned to Hospice care, the hospice provider was responsible to write orders for any changes being made. She indicated the hospice provided had not communicated to the facility any changes for code status for Resident 28. The administrator indicated she had called the Hospice administrator on 2/28/2025 and verified there was a POST form for Resident 28 indicating a change in the advance directives/code status to a DNR. On 2/28/2025 at 1:30 P.M., the Administrator provided a policy titled, Advanced Directives and indicated the policy was the one currently used by the facility. The policy indicated The DNR status will be reviewed with resident/representative during the quarterly care plan conference and/or during significant changes in condition There was no policy provided regarding communication between the hospice providers and the faclity to ensure all new orders were updated timely. 3.1-37(a)

Based observation and interview the facility failed to ensure food preparation areas and equipment was clean and that food was stored in a sanitary manner. The facility failed to ensure employees utilized hygienic practices when handling food delivery items, and washed their hands after handling the trash receptacle. This had the potential to affect all residents receiving food from the kitchen. Findings include: 1. During an initial observation of the kitchen with the Dietary Manager (DM), on 2/26/2024 at 9:45 A.M., the handwashing sink was dirty. Vents in the ceiling were dirty with dust collected in the slats. Pans used in the steam table were stacked together wet. The oven had a burnt substance on the bottom. The sneeze guard on the steam table was dirty with food substances dripping down. During an interview, on 2/26/2024 at 10:00 A.M., the DM indicated the handwashing sink, oven, and sneeze guard should have been clean, the vents in the ceiling were going to be replaced, and the pans should have been dry before stacking. 2. During an observation of the kitchen with the DM, on 2/28/2024 at 11:57 A.M., the steam table had a whitish substance dripping down the sides and dirt and food spills were noted on the lower shelf. During an interview, on 2/28/2024 at 12:08 P.M., the DM indicated the steam table should have been clean. A current policy dated 5/23/2023, provided by the Executive Director on 2/29/2024 at 9:45 A.M., indicated .Equipment should be cleaned and sanitized after use and more frequently as needed. In general, follow these steps .b. Remove food and soil present on, under, and around the equipment 3. During an observation, on 2/28/2024 at 11:58 A.M., Dietary Aide 11 was leaning her arm on clean trays that were meant to transport resident's meals. Cooks 3, 4, and 5 each handled the lid on a trash can, and did not wash their hands before returning to the food preparation area. During an interview, on 2/28/2024 at 12:11 P.M., the Dietary Manager indicated staff should not be leaning on food trays and should wash hands after handling the trash can lid and before returning to the food preparation area. A current policy, dated 5/23/2023, provided by the Executive Director on 2/29/2024 at 9:45 A.M., indicated, .To provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure medication storage areas were free from loose pills, failed to date medications when opened, and failed to ensure a medication refrigerator was free from ice buildup, for 4 of 6 medication storage areas observed. (#1 & #2 400 Hall medication carts, 100 Hall medication cart, & medication room) Findings include: 1. A medication storage observation on the #1 400 hall medication cart was completed on 2/27/2024 at 2:36 P.M., with LPN 7. There were 2 loose pills in the cart. During an interview, on 2/27/2024 at 2: 39 P.M., LPN 7 indicated the loose pills should not be in the drawer. 2. During a medication storage observation, on 2/27/2024 at 2:45 P.M., on the #2 400 hall medication cart with RN 8, the following was observed: - An opened and undated bottle of guaifenesin. - An opened and undated bottle of Robitussin. During an interview, on 2/27/2024 at 2:52 P.M., RN 8 indicated the medications should be dated when opened. 3. A medication storage observation on the 100 hall medication cart was completed on 2/27/2024 at 3:16 P.M., with LPN 2. There were 2 loose pills in the cart During an interview, on 2/27/2024 at 3:18 P.M., LPN 2 indicated the loose pills should not be in the drawer. 4. During a medication storage observation, on 2/27/2024 at 3:19 P.M., in the 100 Hall medication room with LPN 2, a large amount of ice build up was observed in the freezer section of the fridge. During an interview, on 2/27/2024 at 3:20 P.M., LPN 2 indicated the fridge should have been defrosted. On 2/29/2024 at 8:57 A.M., the Administrator provided the policy titled, Storage and Expiration Dating of Medications, Biological's, dated 7/21/2022, and indicated the policy was the one currently used by the facility. The policy indicated .5. Once any medication or biological is opened, Facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 11. Facility should monitor refrigerated storage for evidence of moisture and condensation 3.1-25(j) 3.1-25(m)

Based on interview and record review, the facility failed to provide adequate supervision to prevent a resident from falling out of bed during care, for 1 of 4 residents reviewed for accidents. (Resident 34) Finding includes: During an interview, on 2/27/2024 at 8:58 A.M., Resident 34 indicated he had fallen out of bed about two months ago during care, and was sent to the hospital. A record review for Resident 34 was completed on 2/28/2024 at 3:16 P.M. Diagnoses included, but were not limited to: morbid obesity, chronic respiratory failure, dependence on a ventilator, and chronic kidney disease. A Significant Change MDS (Minimum Data Set) assessment, dated 12/10/2023, indicated the resident required extensive physical assistance from two staff members for bed mobility and toilet use, required supervision with set-up help for eating, and transferring occurred 1-2 times with 2 or more staff assist. An Admission MDS assessment, dated 1/25/2024, indicated the resident was cognitively intact. A Care Plan, dated 6/5/2019, indicated the resident required the assist of 2 staff members for bed mobility, transfer with a Hoyer lift with assist of 2-4 staff members, and transfers occurred once or twice with the extensive physical assistance of at least 2 staff members. A Fall Risk Assessment, dated 12/5/2023, indicated the resident was a moderate fall risk. A Functional Assessment Form, dated 12/6/2023, indicated the resident was dependent for mobility to roll left and right, and the helper did all the effort, with the resident doing none of the effort to complete activity, or the assistance of 2 or more helpers was required for the resident to complete the activity. A Progress Note, dated 12/18/2023, indicated the resident had been assisted with care, rolled to the left side of the bed, and then rolled off the bed. Resident 34 was on a ventilator, landed on his chest, and required hospital evaluation. An IDT (Interdisciplinary Team) Progress note, dated 12/19/2023, indicated the root cause of Resident 34's fall was only one person was assisting the resident with bed mobility during care. A Fall Risk Assessment, dated 1/19/2024, indicated the resident was a high fall risk. During an interview, on 2/29/2024 at 8:52 A.M., the resident indicated when he fell out of bed, only one CNA had been assisting him with care at that time, he rolled off the side of the bed, and landed on the floor. During an interview on 2/29/2024 at 1:20 P.M., CNA 1 indicated the least number of staff members used to assist Resident 34 for bed mobility was 2 staff members. Prior to his fall, he also required 2 staff members for assistance with bed mobility. During an interview, on 2/29/2024 at 1:45 P.M., LPN 2 indicated the resident had been able to help with bed mobility more prior to his fall than now, and he required 2-4 staff members for bed mobility prior to his fall. During an interview, on 2/29/2024 at 2:17 P.M., the DON (Director of Nursing) indicated the resident required 1-2 person assist for bed mobility, and it depended on the day how much resident could help at the time of care. A policy, titled Fall Management, with a revision date of 1/2022, was provided as current by the DON on 2/29/2024 at 3:15 P.M. The policy indicated, .It is the policy .to ensure residents residing with the community has adequate assistance to prevent injury related falls .A Fall refers to unintentionally coming to rest on the ground, floor, or other lower level 3.1-45(a)

Based on observation, record review, and interview, the facility failed to properly store a BIPAP mask to prevent contamination, for 1 of 5 residents reviewed for respiratory care. (Resident 56) Finding includes: During an observation, on 2/27/24 at 10:43 A.M., Resident 56's oxygen mask was laying on her bedside table outside of a bag, and the mask appeared dirty with an oily substance noted around the seal. During an observation, on 2/29/24 at 2:31 P.M., Resident 56's BIPAP mask was laying on the table and not in a bag. The mask had a dirty substance around the seal. During an observation, on 3/1/2024 at 9:11 A.M., Resident 56's BIPAP mask was laying on the bedside table and not in a bag. The mask remained dirty around the seal. A record review for Resident 56 was completed on 2/28/24 at 2:43 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, type 2 diabetes, dementia, quadriplegia, and hypertension. A Quarterly MDS (Minimum Data Set) assessment, dated 12/19/23, indicated Resident 56 had moderate memory impairment. A Physician's Order, dated 1/3/23, indicated to clean the BiPAP/CPAP mask/unit with soap/water daily. During an interview, on 3/1/24 at 10:39 A.M., the DON (Director of Nursing) indicated the BIPAP mask should have been stored in a bag. On 3/1/24 at 10:49 A.M., the Director of Nursing provided the policy titled, CPAP Therapy as current. The policy indicated . Purpose: Continuous Positive Airway Pressure is used to treat sleep apnea. The goals of this therapy include; improve ventilation, improve quality of sleep, decrease hospitalization s, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance. Procedure: Cleaning and Maintenance; J. With a soft cloth, gently wash the mask or pillows with a solution of warm water, and a mild clear liquid detergent; K. Rinse thoroughly. If the mask still feels oily, repeat step C; N. Clean and inspect all components regularly : 3.1-18(b)

Based on interview and record review, the facility failed to ensure a clean, safe, and sanitary environment for 1 of 3 resident reviewed environment. (Resident B) Findings include: On 8/25/23 at 1:00 P.M., the clinical record for Resident B was reviewed. The resident's Face Sheet, indicated he was most recently admitted to the facility on [DATE], with diagnoses that included pneumonia, stroke, gastrostomy, chronic obstructive pulmonary disease, and chronic respiratory failure. Resident B's Admission Minimum Data Set (MDS) assessment, dated 6/21/23, indicated the resident was admitted to room [ROOM NUMBER] on 6/15/23. On 8/28/23 at 11:08 A.M., a facility grievance dated 6/15/23 at 3:00 P.M., was provided by the Administrator and indicated, Resident B's wife complained that room [ROOM NUMBER] was filthy and there were bugs everywhere. The grievance indicated the Director of Marketing and Admissions looked at room [ROOM NUMBER] and found garbage in the trash and floors were dirty and bugs were in the room and the bathroom, and that the room had not been cleaned before Resident B arrived. The grievance further indicated the Director of Marketing cleaned the room and bathroom and apologized. On 6/28/23 at 11:30 A.M., the Administrator provided the [Local pest control company] Sighting/Evidence Log dated 6/08/23 - 8/07/23, that indicated on 6/08/23, room [ROOM NUMBER] was treated for ants, and on 6/14/23, room [ROOM NUMBER] was treated for flying ants in the room and bathroom. On 8/28/23 at 11:47 A.M., during an interview with the Administrator, he indicated when Resident B was admitted to the facility on [DATE], he was placed in room [ROOM NUMBER], which had been treated for ants the previous week and the previous day of the admission. The Administrator indicated the dead ants had not been cleaned from the room before Resident B was admitted to the room and that the room should have been cleaned before the resident was admitted to the room. On 8/29/23 at 2:00 P.M., during an interview with the Director of Nursing, she indicated that Resident B was admitted to room [ROOM NUMBER] on 6/15/23, and was unaware at the time of the admission that the room had not been cleaned, and that the resident should not have been admitted into a dirty room. This Federal tag relates to complaint IN00415532. 3.1-19

Based on interview and record review the facility failed to monitor and follow physician orders for 1 of 3 residents who had a peripherally inserted central catheter (PICC). (Resident C) Finding includes: On 1/30/23 at 11:05 A.M., a review of the clinical record for Resident C was conducted. The record indicated the resident was admitted on [DATE] from a local hospital for intravenous (IV) antibiotic administration. The resident's diagnoses included, but were not limited to: diabetes, Cerebrovascular Accident (CVA), diabetic foot ulcer with gangrene and left below the knee amputation. The Minimum Data Set (MDS) Admission Assessment, dated 11/28/22, indicated the resident was receiving an IV antibiotic. A Care Plan indicated the resident had IV access and was at risk for infection/complications. The interventions included, but were not limited to: administer as ordered, assess for complications from IV every shift, discontinue IV at 1st sign of inflammation or localized infection, monitor IV site for swelling, tenderness, redness and warmth. The Physician Orders, dated 11/22/22 indicated the resident was to be administered cefazolin 2 grams in a 100 milliliters of solution every 8 hours and infuse per RUA (right upper arm) PICC line via pump for osteomyelitis of the right foot. The start date was 11/22/22 with an end date of 12/16/22. There were orders of special instructions The Medication Administration Record (MAR) had the following Physician Orders/Nursing Measures: observed and document on the PICC line for signs and symptoms of infection every shift, change PICC line dressing every 7 days and measure PICC length & arm circumference and to flush the PICC line before and after antibiotic to maintain patency. A Progress Note, dated 11/23/22 at 2:50 P.M., indicated the resident had a vascular access devices-double lumen (PICC line) in the right upper arm with zero redness or warmth. The MAR indicated the PICC was to be discontinued on 12/16/22, however there was no documentation of procedure occurring. The MAR's last documentation of nurse assessing the PICC site was on 12/16/22 on the 1st shift (6:00 AM-2:00 PM). The MAR indicated the PICC line was to have a dressing change every 7 days, which would have been on 11/29/22, 12/6/22, 12/13/22 and 12/20/22. There was documentation the resident refused on 12/6/22, was completed on 12/12/22 with measurements therefore the next dressing change should have been on 12/19/22 however there was no documentation the procedure was completed as ordered The MAR indicated the last time the PICC line was flushed was on 12/16/22 at 12:00 P.M. A Progress Note, dated 12/10/22 at 5:58 A.M., was provided by the Regional Nurse which indicated the PICC dressing had been changed, flushed and measured as ordered, however this was not documented on the MAR and she deducted that may be why it was completed again on 12/12/22. An Infectious Disease Office/Clinic Note, dated 12/15/22, indicated the resident presented, to the clinic, for a follow up for her right foot osteomyelitis. Cultures from the surgery grew MSSA (Methicillin-susceptible Staphylococcus aureus-infection caused by a type of bacteria) and finegodia (a Gram-positive bacteria). She was started on a planned 6 week course of IV antibiotics with cefazolin, which was due to end on 12/16/22. The Note indicated to stop current antibiotics on the planned end date of 12/16/22 and PICC can be removed after the last dose of the antibiotic. A Facility Hospital-Transfer Form, dated 12/21/22 at 2:42 P.M., indicated reason for transfer to hospital was shortness of breath, chest congestion and had a PICC line. A Hospital emergency room Note, dated, 12/21/22, indicated the resident was evaluated for shortness of breath. She was admitted in November for a non-healing diabetic foot wound that required prolonged antibiotic use. She was discharge to nursing facility for further care. Review of the infection disease notes indicate the patient would have stopped her antibiotics on 12/16/22 and had PICC removed at that time. PICC line is still in place in the right upper extremity and patient states they were to remove it today. PICC confirmed by X-ray and was drawn from the PICC line. A Progress Note, dated 12/23/22 at 10:05 A.M., written by the previous Director of Nursing, indicated .Spoke to hospital regarding PICC line removal. This writer informed hospital that IV [intravenous] ABT [antibiotic] ended on 12/16 and resident had follow up appointment. This writer informed hospital about PICC line plan and removal plan During an interview, on 1/30/23 at 4:35 P.M. a representative from the hospital indicated the Resident C came to the hospital, 12/21/22 a Wednesday, with a PICC line that was to be discontinued, on 12/16/22. The hospital Unit Manager had contacted the facility to find out why it had not been discontinued, as ordered, by the infectious disease physician. The physician had reported to the hospital Unit Manager he was unhappy the PICC had not been removed as directed. The facility's Director of Nursing (DON) reported to the hospital Unit Manager there were no nurses working the on the 16th to pull the PICC line and would investigate as to why it wasn't pulled the next time an RN worked. The complainant indicated there was concern for possible endocarditis but the family refused to have the PICC line tested . And there was no indication the PICC line was infected. The hospital representative indicated the resident went home from the hospital with hospice, which was the plan. Staffing schedules indicated an RN work in the facility on the following days: 12/16, 12/17, 12/18, 12/19,/12/20 and 12/21. During an interview on 1/31/23 at 9:30 A.M. the Regional Nurse indicated the PICC line had not been removed and there had been a discussion with the previous DON regarding as to why the PICC line had not been discontinued. The Regional Nurse indicated the previous DON and ADON (Assistant Director of Nursing) were both RNs and they could of removed the PICC line themselves. Also the order to flush and assess the PICC line dropped off the MAR, due to the fact the resident's PICC was to be removed 12/16/22. On 1/31/23 at 11:36 A.M., the Regional Nurse provided a policy titled, Peripherally Inserted Central Catheter (PICC) Management Guidelines, dated 9/2012 and reviewed on 7/2016 and indicated the policy was the one currently used by the facility. The policy indicated .3. Physician order is required for PICC placement and removal .5. Dressing and securement device is to be changed every 7 days or PRN [as needed] using sterile technique .8. PICC insertion site should be assessed every shift for signs of redness, edema, pain, drainage or venous cord (red or hard outline of vein tracing upward on upper arm) This Federal tag relates to complaint IN00399580. 3.1-47(a)(2)

Based on interview, observation, and record review, the facility failed to provide preferences and choices for bathing for 3 of 3 residents reviewed for self-determination. (Resident 69, 58, and 29) Findings include: 1. During an initial interview with Resident 69 on 12/27/2022 at 2:58 P.M., Resident 69 indicated she gets a bed bath, but every so often is placed on a cart, taken to another room, and gets a shower with her hair washed. She indicated her hair was fine and the hair gets greasy looking. She would like to have her hair washed weekly to every 10 days. A clinical record review for Resident 69 was completed on 12/30/2022 at 8:39 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, functional quadriplegia, and anemia. A Significant Change MDS (Minimum Data Set) Assessment on 12/4/2022 indicated, Resident 69 had moderate cognitive impairment. She was dependent for bathing and needed two or more staff members to complete bathing. She indicated that it was very important to choose between a tub bath, shower, bed bath, or sponge bath. A Care Plan initiated on 5/14/2021 and revised on 10/20/2022 indicated, Resident 69 needs assistance with ADL's (Activities of Daily Living). An intervention on 5/14/2021, indicated to assist with bathing as needed per resident preference, and to offer showers two times per week, and a partial bath in-between. A Preferences for Customary Routine and Activities Assessment was completed on 3/29/2022. Resident 69 indicated, it was very important to choose between tub bath, shower, bed bath/sponge bath. She had no preference as to what time or how often bathed. She indicated her type of bathing she was used to was showering. A review of the CNA electronic documentation, in the past two months, Resident 69 received a shower on 11/18/2022 and 12/21/2022. During an interview on 1/3/2023 at 9:15 A.M., Resident 69 indicated her hair could use some soap and water. On 1/3/2023 at 3:23 P.M., Shower Sheet documentation was reviewed for the past two months. A Shower Sheet that indicated a shampoo was completed was found for 11/14/2022, 12/5/2022, and 12/21/2022. There is an undated shower sheet that indicated Resident 69 refused a shower after three attempts. 2. An initial interview on 12/27/2022 at 3:51 P.M., Resident 58 indicated she gets shower when the staff are free and have time. She indicated her scheduled shower days are on Sunday and Wednesday in the afternoon, and would prefer to have the shower in the morning. A clinical record review was completed on 1/3/2023 at 9:49 A.M. Diagnoses included, but were not limited to: cerebral vascular accident with left hemiplegia, morbid obesity, and osteoarthritis. An Annual Minimum Data Set (MDS) Assessment on 10/12/2022 indicated Resident 58 was cognitively intact. She required extensive assistance with two or more staff members for bathing. Resident 58 indicated it was very important to choose between a tub bath, shower, bed bath, or sponge bath. A Care Plan initiated on 1/3/2020 and revised on 11/9/2022 indicated Resident 58 required assistance with ADL's. An intervention on 8/4/2020, indicated to assist with bathing as needed per resident preference, to offer showers two times per week, and partial bath in between. A Preferences for Customary Routine and Activities Assessment was completed on 10/12/2021. Resident 58 indicated, it was very important to choose between tub bath, shower, bed bath/sponge bath. She had no preference as to what time or how often bathed. She indicated her type of bathing she was used to was showering. A review of the CNA electronic documentation, in the past two months, Resident 69 received a shower on 11/2/2022, 11/20/2022, 12/11/2022, 12/14/2022, and 12/21/2022 On 1/3/2023 at 3:23 P.M., Shower Sheet documentation was reviewed for the past two months. The Shower Sheets indicated that a shower was received on 11/20/2022, 12/11/2022, 12/14/2022, 12/21/2022, 12/28/2022. A Shower Sheet on 11/16/2022 indicated Resident 58 refused a shower on 11/16/2022. 3. During an initial interview on 12/29/2022 at 9:38 P.M., Resident 29 that half of the time the facility does not have the staff to provide showers. She indicated she refuses to have male staff provide a shower, and on 12/26/2022 no one would answer the call light to determine who would give her a shower, and she indicated she stunk. She indicated the lack of showers happens frequently A clinical record review of Resident 29 was completed on 1/3/2023 at 8:55 A.M. Diagnoses included, but were not limited to: Osteomyelitis of vertebra, Paraplegia, diabetes mellitus type 2, and major depressive disorder. A Quarterly Minimum Data Set (MDS) Assessment on 12/6/2022 indicated Resident 29 was cognitively intact. She was dependent with the assistance of two or more staff members for bathing. A Significant Change MDS Assessment on 9/13/2022 indicated it was very important to choose between a tub bath, shower, bed bath, or sponge bath. A Care Plan initiated on 8/4/2022 and revised on 12/12/2022 indicated Resident 29 required assistance with ADL's. An intervention on 8/4/2020, indicated to assist with bathing as needed per resident preference, to offer showers two times per week, and partial bath in between. On 11/8/2022, a Care Plan indicated Resident 29 has a preference of two showers a week on Tuesday and Thursday. An intervention included to honor Resident 29's preferences through the next review. A Preferences for Customary Routine and Activities Assessment was completed on 9/17/2022. Resident 29 indicated, it was very important to choose between tub bath, shower, bed bath/sponge bath. She had no preference as to what time or how often bathed. She indicated her type of bathing she was used to was showering. A review of the CNA electronic documentation for the past two months indicated, Resident 29 received a shower on 11/21/2022, 12/2/2022, 12/14/2022, 12/28/2022. Resident 29 refused a shower on 12/31/2022. On 1/3/2023 at 3:23 P.M., Shower Sheet documentation was reviewed for the past two months. The Shower Sheets indicated that a shower was received on 11/3/2022, 11/17/2022, 11/21/2022, 11/28/2022, 12/2/2022, 12/11/2022, 12/14/2022, 12/18/2022, 12/23/2022, 12/28/2022. Shower Sheets on 11/23/2022, 12/21/2022, 12/26/2022 (male caregiver), and 12/31/2022 indicated Resident 29 refused showers. On 1/3/2023 at 2:04 P.M., during an interview, a Regional Support employee indicated the Preferences for Customary Routine and Activities Assessment should be completed quarterly. If a resident answers a question as very important of somewhat important, that response will be care planned. On 1/3/2023 at 2:50 P.M., the Director of Nursing (DON) indicated the shower schedule was rearranged 6 months ago. The Shower Aide encouraged all residents to take a shower, and if the resident refuses a bed bath will be completed. The DON indicated a bed bath or shower should be done twice weekly or per the resident's preference. The DON indicated if a resident refused a shower, the Shower Aide needs to let the nurse know. The Shower Aide will document on the Shower Sheet of a refusal. On 1/4/2023 at 9:26 A.M., CNA 14 working as a Shower Aide provided the units shower schedule. The schedule indicated Resident 69 was to receive bathing on Mondays and Fridays in the evening. She indicated, if the resident was oriented, she will ask the resident what type of bathing they prefer since no preferences are provided. CNA 14 indicated if a resident refused to be bathed, she would inform the nurse on the unit. She indicated a Shower Sheet would be completed to indicate the refusal. On 1/4/2023 at 12:32 P.M., the Director of Nursing (DON) provided a policy titled, Preferences for Daily Routine. The policy indicated, .1. Activity Director or designee will complete the Preferences for Daily Customary Routines worksheet upon admission of a new resident, quarterly and upon significant change of a resident. The interview will be conducted with the resident unless they are not able to be understood. 2. The information on the worksheet will be used to complete section F of the MDS when applicable. 3. The information from the worksheet will be shared with the interdisciplinary team so that each department can address the resident's preferences 3.1-3(u)

Based on observation, interview and record review, the facility failed to ensure the walls in resident rooms were maintained in good repair. Findings include: During the initial tour of the facility, conducted on 12/28/2022 at 9:20 A.M., an alert and oriented resident indicated the walls in his/her room needed repaired. The resident pointed out an approximately 1 1/2 foot section of the wall above his roommate's bed with a missing chair rail, the wall underneath the missing chair rail was crumbling and had exposed plaster and drywall. During the environmental tour of the facility, conducted with the Maintenance Supervisor on 1/3/2023 at 1:15 P.M. - 1:30 P.M., the following was noted: The wall on the corner between the bathroom and bed 1 in room [ROOM NUMBER] had crumbled, the covebase was missing and the underneath drywall and framing was noted. There was a section of marred wallpaper and a missing chair rail noted in room [ROOM NUMBER] above bed 2. There was an approximately 1 1/2 foot section of missing chair rail and exposed dry wall on the wall in room [ROOM NUMBER] above Bed 1, underneath the overbed light and above the wooden wainscoting panel. In addition, the corner of the wall between the bathroom and Bed 1 was crumbled, missing the covebase and had the drywall and metal framing exposed. During an interview with the Maintenance Director, conducted on 1/3/2023 at 1:30 P.M., indicated he had not received any Tells, the electronic work order system utilized by the facility, for any of the noted room. He also indicated he had conducted a full house sweep of the facility and made a note of all of the repairs needed. He indicated he had also been waiting on an airgun tool to nail the chair rail back onto the walls. Review of the full house sweep documentation, conducted in early December by the Maintenance Director indicated the areas in room [ROOM NUMBER], 421 and 505 were all noted in the sweep. During an interview with the Administrator, on 1/4/2023 at 11:40 A.M., she indicated the Maintenance Director had conducted an audit of all the room repairs needed and the plan was to repair two resident rooms per week. She indicated the Regional Maintenance staff was going to assist the Maintenance Director with the repairs. 3.1-19(a)(4)

Based on record review and interviews, the facility failed to provide a notice of discharge for 1 of 2 residents reviewed for transfers/discharge. (Resident 100) Finding includes: The closed clinical record for Resident 100 was reviewed on 12/29/2022 at 2:30 P.M. Resident 100 was admitted to the facility on [DATE] with diagnoses, including but not limited to, non displace fracture of the lateral condyle of the left tibia, status post orthopedic surgery, chronic obstructive pulmonary disease, anoxic brain damage secondary to cardiac arrest, chronic viral hepatitis C, Wernicke's encephalopathy and bipolar disorder. Nursing Notes, dated 10/08/2022 at 8:33 P.M,. indicated the following: Resident arrived via stretcher tri county. Resident refused assessment. Resident states he wants leave AMA (Against Medical Advice)DNS (Director of Nursing Services) called to room. DNS spoke to resident regarding AMA. [NAME] NP (Nurse Practioner) informed of wishes to leave AMA. Provider aware of AMA. Resident currently trying to find ride home. Resident called uber and taxi services for ride home. A subsequent nursing noted, dated 10/08/2022 at 8:40 P.M. indicated the following: AMA paperwork printed and delivered to resident to sign resident states he will stay for only 3 days. Provider notified of resident changed mind. The nursing note the following day, dated 10/09/2022 at 11:26 A.M., indicated the resident had called 911 himself because he wanted to go to the hospital because he thought his leg was infected. The noted indicated the following: Executive director notified of resident wish to go to the hospital and he asked this writer to tell resident that,'since he called 911 on his own wish, til (sic) him,that he will not be coming back to this facility. Resident was made aware of this condition and was okay with it. The note indicated the resident left the building with the paramedics at 11:24 P.M. There were no discharge forms, bed hold forms or transfer forms completed for Resident 100. The last nursing progress note, dated 10/9/2022 at 12:36 P.M. indicated the following: Report called out to ER (emergency room ) at Memorial hospital. Spoke to EJ at the ER He was made aware of resident calling 911 and his wish to go to the hospital. Also told that the facility would not want him to come back because he was smoking in his room even after being told that this is a non smoking facility, he continued to facility notified. (sic) During an interview, with the Director of Nursing Services (DNS) on 1/3/2023 at 11:35 A.M., she indicated a bed hold and transfer forms were not given to the resident because he called 911 himself and discharged himself. She indicated the resident was not readmitted due to his issues with smoking in his room. The facility discharge, bed hold and readmission policy was requested on 1/4/2023 at 11:40 A.M. Review of the facility policy and procedure, titled Nursing Admission/Return Admission Policy and Procedure, provided by the Director of Nursing services (DNS) on 1/4/2023 at 11:50 A.M. indicated there were no specific information on what forms were required when a resident was transferred to an acute care facility and/or discharged from the facility. Review of the Emergency Department documentation from the Acute Care Center for Resident 100, dated 10/9/2022 indicated the following: This patient is a (age of patient) male with a medical history significant for discharge from the hospital yesterday with left lower extremity pain and eczema and what appears to be a popliteal cyst rupture discharged to (Name of Long Term Care Facility) Patient has been discharged from (Name of LTC Facility) due to poor behavior and smoking in his room Review of the facility policy and procedure, titled Bed Hold provided by the Business Office Manager on 12/29/2022 at 2:00 P.M. included the following: Medicare/Medicaid Assistance and Managed Care Resident - If Resident is receiving Medicare or Medicaid assistance, has been deemed eligible for such assistance, or was admitted under a Managed Care policy, and resident leaves the facility for hospitalization , ,medical therapeutic leave, the resident's bed will be reserved unless Resident provides written notice to the Community of his or her intention to not reserve his or her bed. If written notice is not provided and following a hospitalization or therapeutic leave, Resident requires the services provided by the Community the Resident ,Amy return to the Community and to the room where he/she previously resided: .2. The resident will be provided the bed hold policy at the time of thee hospital transfer or therapeutic leave 3.1-12(a)(6)(C)(9)

Based on record review and interviews, the facility failed to provide a notice of discharge for 1 of 2 residents reviewed for transfers/discharge. (Resident 100) Finding includes: The closed clinical record for Resident 100 was reviewed on 12/29/2022 at 2:30 P.M. Resident 100 was admitted to the facility on [DATE] with diagnoses, including but not limited to, non displace fracture of the lateral condyle of the left tibia, status post orthopedic surgery, chronic obstructive pulmonary disease, anoxic brain damage secondary to cardiac arrest, chronic viral hepatitis C, Wernicke's encephalopathy and bipolar disorder. Nursing Notes, dated 10/08/2022 at 8:33 P.M. indicated the following: Resident arrived via stretcher tri county. Resident refused assessment. Resident states he wants leave AMA (Against Medical Advice) . DNS (Director of Nursing Services) called to room. DNS spoke to resident regarding AMA. [NAME] NP (Nurse Practitioner) informed of wishes to leave AMA. Provider aware of AMA. Resident currently trying to find ride home. Resident called uber and taxi services for ride home. A subsequent nursing noted, dated 10/08/2022 at 8:40 P.M. indicated the following: AMA paperwork printed and delivered to resident to sign resident states he will stay for only 3 days. Provider notified of resident changed mind. The nursing note the following day, dated 10/09/2022 at 11:26 A.M. indicated the resident had called 911 himself because he wanted to go to the hospital because he thought his leg was infected. The noted indicated the following: Executive director notified of resident wish to go to the hospital and he asked this writer to tell resident that,'since he called 911 on his own wish, til (sic) him,that he will not be coming back to this facility. Resident was made aware of this condition and was okay with it. The note indicated the resident left the building with the paramedics at 11:24 P.M. There were no discharge forms, bed hold forms or transfer forms completed for Resident 100. The last nursing progress note, dated 10/9/2022 at 12:36 P.M. indicated the following: Report called out to ER (emergency room ) at Memorial hospital. Spoke to EJ at the ER He was made aware of resident calling 911 and his wish to go to the hospital. Also told that the facility would not want him to come back because he was smoking in his room even after being told that this is a non smoking facility, he continued to facility notified. (sic) During an interview with the Director of Nursing Services (DNS) on 1/3/2023 at 11:35 A.M., she indicated a bed hold and transfer forms were not given to the resident because he called 911 himself and discharged himself. She indicated the resident was not readmitted due to his issues with smoking in his room. The facility discharge, bed hold and readmission policy was requested on 1/4/2023 at 11:40 A.M. Review of the facility policy and procedure, titled Nursing Admission/Return Admission Policy and Procedure, provided by the Director of Nursing services (DNS) on 1/4/2023 at 11:50 A.M. indicated there were no specific information on what forms were required when a resident was transferred to an acute care facility and/or discharged from the facility. Review of the facility policy and procedure, titled Bed Hold provided by the Business Office Manager on 12/29/2022 at 2:00 P.M. included the following: Medicare/Medicaid Assistance and Managed Care Resident - If Resident is receiving Medicare or Medicaid assistance, has been deemed eligible for such assistance, or was admitted under a Managed Care policy, and resident leaves the facility for hospitalization , ,medical therapeutic leave, the resident's bed will be reserved unless Resident provides written notice to the Community of his or her intention to not reserve his or her bed. If written notice is not provided and following a hospitalization or therapeutic leave, Resident requires the services provided by the Community the Resident ,Amy return to the Community and to the room where he/she previously resided: .2. The resident will be provided the bed hold policy at the time of thee hospital transfer or therapeutic leave 3.1-12(a)(26)

Based on interview and record review, the facility failed to provide a written summary of the base line care plan to the resident and resident representative within 48 hours of admission for 2 out of 2 newly admitted residents reviewed for base line care plans. (Resident 201 & 97) Findings include: 1. The clinical record for Resident 201 was reviewed on 12/29/2022 at 2:42 P.M. The diagnoses included but not limited to, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, acute bronchitis, chronic respiratory failure, embolism and thrombosis of superficial veins of right lower extremity, gout, obstructive sleep apnea, morbid (severe) obesity due to excess calories. The resident was admitted on [DATE]. During an interview, on 12/30/2022 at 8:59 A.M., Resident 201 indicated no one came in to see him within 2 days after he admitted to talk about his care plan nor provided a written summary. During an interview, on 12/29/2022 at 3:00 P.M., the Social Worker Director indicated that they do a road to recovery care plan within 72 hours, his is scheduled for 12/30/2022. He did not have a baseline care plan within 48 hours and he should have had. 2. The clinical record for Resident 97 was reviewed on 12/20/2022 at 1:32 P.M. Diagnoses included but not limited to, acute transverse myelitis demyelinating disease of central nervous system, cerebral infarction due to occlusion or stenosis of small artery, and neuromyelitis optica. The resident was admitted on [DATE]. During an interview, on 1/3/2022 at 3:21 P.M., Resident 97 indicated he did not recall meeting with any one or receive any written information of his plan of care 2 days after being admitted . During an interview, on 1/3/2022 at 2:39 P.M., the Social Service Assistant indicated that his road to recovery was done on 12/2/2022. He did not have a base line care plan with a written summary provided 48 hours after admission and he should have had. On 12/29/2022 at 3:05 P.M., the Social Service Director provided a paper titled, Road to Recovery, undated, and indicated that this is what she is currently following in the facility. It indicated .Purpose: The purpose of the Road to Recovery meeting is to meet with resident/representative/IDT members shortly after their admission to establish expectations and answer questions about the SNF stay as well as gather information as an Interdisciplinary Team to begin to establish a discharge plan. Agenda: The Road to recovery meeting is to be held no later than 72 hours after admission. Best practice includes a standard time daily which attendees have slotted; new admissions would then have R2R the next business day at that time On 12/29/2022 at 3:06 P.M., the MDS Assistant provided a policy titled, IDT Baseline Care Plan, revised 4/2018, and indicated the policy was the one currently used by the facility. The policy indicated .Resident and/or resident's representative will participate in the development of the resident-centered Baseline Care Plan to the extent possible. A summary of the Baseline Care Plan will be provided to and reviewed with the resident and/or representative during the Road to Recovery, or other scheduled IDT meeting following admission to the facility

Based on observation, interview and record review, the facility failed to ensure 3 of 3 residents were free from sexual and mental abuse. (Resident B, Resident C and Resident D) The immediate jeopardy began, on 9/24/2020, when the first sexually inappropriate text message was received by Resident D, from facility's staff member/Certified Nurse Aide (CNA) 4. The Administrator was notified of the immediate jeopardy on 8/18/2021 at 1:18 P.M. The immediate jeopardy was removed, and the deficient practice corrected, on 6/25/2021, prior to the start of the survey and was therefore Past Noncompliance. Findings include: 1. On 8/17/21 at 2:15 P.M., a review of the clinical record for Resident D was conducted. The record indicated the resident was admitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, dated 7/21/21, indicated the residents BIMS (Brief Interview for Mental Status) score was 15-normal cognition. The resident required the supervision of 1 person for transfers and toileting. She weighed 468 pounds, received oxygen, [CONDITION(S)] care and respirator. An Incident Report #487, dated 6/30/21, indicated Resident D reported she was exchanging text messages with CNA 4. Resident D reported CNA 4 had given her his phone number. An investigative narrative/timeline indicated the following: -On 6/30/21 at 9:45 A.M., Resident D had reported to CNA 5 that she had lied, to Social Services, last week during the interviews, regarding a staff member. Resident explained to CNA 5, something had happened between her and CNA 4. Their relationship had started in August of 2020 and continued until recently. The resident provided the CNA 5 with text message exchanges between herself and CNA 4. The text messages contained similar verbiage sent to Resident C. In addition, there were explicit images sent from CNA 4 to Resident D. -At 2:00 P.M., a police interview was conducted. A statement from Resident D, undated but timed at 11:00 A.M., indicated the relationship between the Resident D and CNA 4 had been ongoing since August of 2020. The CNA had approached her and stated she was beautiful. The resident's statement indicated . intimate encounters they had, one encounter being that she performed oral sex on [name of CNA 4] and that he has fondled her breast and she fondled his genitals, which wasn't forced, all consensual Resident was very tearful and stated that she .really liked him and the attention that she was receiving from him and that's why she was afraid to come forth with this information A review of the copied text messages, indicated the first message sent by CNA 4 was on 8/1/20 and stated .Hey beautiful its [name of CNA 4] The following were text messages between CNA 4 and Resident D: -On 9/24/20 at 3:16 P.M., CNA 4 sent a photo of himself in a T-shirt and the T-shirt stated A** MAN. At 3:28 P.M., CNA 4 states he likes big butts and at 3:50 P.M., he indicated .Love big butts, especially yours At 3:57 P.M., Resident D replies and states .I miss you period. With or without kisses. I miss your touches well at least I get to see you soon -On 9/27/20 at 9:46 P.M., a photo was sent of CNA 4's buttock, in his underwear. Resident replies she wasn't expecting that, makes her blush and asks him .Why you taking pictures of yourself lol [laugh out loud] Been a while is all. I said I feel like a virgin again. Shyness all over again. At 10:57 P.M., CNA 4 sends a picture of his exposed genitalia and states .Maybe this will take away your shyness, hahaha -On 9/28/20 at 3:04 P.M., the resident indicates she can't believe she let him touch her breasts. -On 10/4/20 at 1:39 P.M., CNA 4 sends a picture of himself at a gym. -On 10/6/20 at 8:43 P.M., CNA 4 sends a picture of himself without a shirt. -On 10/13/20 at 4:58 P.M., CNA 4 sends a picture of his exposed genitalia again. Resident D replies, that doesn't look like a football game. CNA 4 replies .Wish you was sucking that since brag about your mouth having so many talents -On 11/22/20 at 8:42 P.M., CNA 4 resends the same picture of his exposed genitalia that was sent on 10/13/20. At 9:01 P.M., CNA 4 states .I love you so much -On 12/11/20 at 3:12 P.M., CNA 4 indicates he loved her talented mouth, Resident D responds she liked it when he nibbled while he sucked on her bottom lip. -On 1/24/21 at 6:36 P.M., CNA 4 sends four pictures of himself shirtless. -On 1/29/21 at 1:20 P.M., CNA 4 indicated he complained to the Executive Director he would quit if he was changed to a different unit. -On 2/8/21 at 8:12 A.M., CNA 4 sends a picture of himself in a sweatshirt. -On 3/23/21 at 4:24 P.M., CNA 4 sends 4 pictures of himself, after that there are no more available copies of text message between CNA 4 and Resident D. An Investigation statement, given by CNA 5, on 6/30/21 at 2:44 P.M., indicated the resident had something to tell her. The statement indicated the resident had told her .she and [name of CNA 4] had kissed, hugged, texted and 'other things' .there were texts for some time .there were pictures .Text messages began 8/1/20 and went till 4/10/21. In the texts were pictures of him, him at the gym, him with his shirt off and 3 of his genitalia. [Resident D's name] stated that they would kiss and hug, and there were a few times they were almost caught by Nurse/staff. She stated that he had touched her breast, would touch her breast, she had touched his penis, he touched/rubbed above his pants at her and there were 2 encounters where oral sex was started, she performed, after kissing and he had told her/showed her, this is what you do to me A Psychotherapy Progress Note, dated 6/30/21, indicated the following: .Symptom Description and Subjective Report Patient was seen individually in follow-up to address symptoms of depression and anxiety, and binge eating behavior. Patient seen sooner than previously scheduled at the urgent request of facility staff. Patient had reported that she and a male aide had been engaged in a romantic/sexual relationship for the past eight months, and was being interviewed by the police. Patient was tearful as she talked about the events. Objective Content: Patient and I talked about her fear that this provider will not trust her or think badly of her, given she did not disclose the relationship she had with the aide. We discussed the fact that this was not her fault, and that he crossed boundaries inappropriately. Patient insisted that the relationship was mutual and that she understood it needed to be kept secret so that he would not get in trouble. Patient stated I was enjoying the attention, even though I knew it was wrong. Patient talked about the fact that she came forward after he was suddenly no longer working there. Patient and I processed the ramifications of these events, and that she will need to let things sink in before she will know how it is affecting her Psychiatry Note, dated 7/12/21, indicated the resident .Recently admitted to being involved in a romantic/sexual relationship with a male staff member who has since been fired. Patient is only beginning to process her emotions with the psychologist. Did state she knew if was wrong but enjoyed the attention .Staff reports no other mood or behavior concerns During an interview, on 8/17/21 at 4:20 P.M., Resident D indicated she had been exchanging text messages, with CNA 4, since last August of 2020. She indicated, at the time, it felt good to receive the attention of the CNA 4. She indicated he was good with his words, a sweet talker. She indicated she had provided the facility with a copy of the text messages and some of the text messages included, pictures of the CNA 4's genitalia. She stated she never asked for those pictures and when they were sent she tried to change the subject. She indicated CNA 4 texted her while he was working at the facility and when he was at home. She didn't tell anyone at first, but then found out he had done something to someone else and it bothered her. She indicated she felt so stupid to fall for him and was trying to protect him. She confessed she had touched his genitals, but it was only to try to please him. She is working through her feeling with a therapist, but has concerns CNA 4 will go to another facility and victimize others, by taking advantage of them. Resident was observed to wring hands and frequently look down as she was interviewed. During an interview, on 8/18/21 at 2:23 P.M., CNA 5 indicated she was giving the resident a bed bath, when the resident started asking questions about CNA 4, such as where he was and what's going on with him. She only told the resident CNA 4 was not at the facility. She continued to ask questions about him and CNA 5 kept telling Resident D she wasn't sure. She told the resident she could confide in her if she wanted to and she wanted the resident to feel safe in her home. The Resident opened up and told CNA 5 she had a relationship with CNA 4 and provided some text messages. CNA 5 told the resident she needed to report this to the Administrator. She indicated, the resident had asked her to be present when she explained what had happened to her with Social Service Director, the Administrator and the police. CNA 5 indicated the resident cried during one of the interviews. 2. On 8/18/21 at 2:00 P.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE] and discharged on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, dated 6/25/21, indicated the residents BIMS (Brief Interview for Mental Status) score was 13 - intact cognition. The resident required extensive assistance with dressing, toileting and personal hygiene. A Progress Note, dated 7/1/21 at 11:47 P.M., indicated the following: .Resident expressed the incident with attempted inappropriate contact with staff occurred months ago. Resident expressed that she did not tell anyone, but that she didn't want that staff member to care for her and he had not. Resident expressed she is not afraid or bothered by the situation. Psych services notified and will follow up with resident as well A Psychiatry Progress Note, dated 7/12/21, indicated resident was resting in bed, appeared in no distress or discomfort and continued to voice feelings of depression and anxiety. Remains reclusive to her bed. Sleeps off and on most of the day. Shared with psychologist she had several family issues that contribute to her emotional state. Patient continues to process those with the psychologist and reports no other mood or behavior concerns. There was no indication the psychiatrist questioned the resident regarding the inappropriate staff contact. A facility investigative narrative/timeline indicated on 6/30/21 at 11:00 A.M., Resident B came forth and reported CNA 4 .would come into the room and try to rub her shoulders and back and try to hug her. He talked dirty to me [could not recall what kind of things] He gave me his number, but I threw it away. I would not let him come in my room anymore Resident B's statement/interview was conducted by RN 6, on 6/30/21 at 5:18 P.M., and resident revealed .He was very creepy and that he would talk dirty to me On 8/17/21 at 4:45 P.M., Resident B was observed in bed in her room but indicated she did not want to be interviewed. On 8/18/21 at 4:56 P.M., facility staff indicated Resident B should be awake as she had just received a bath. Resident B was observed in her bed, refused to answer any questions and placed her blankets over her head. 3. On 8/17/21 at 3:15 P.M., a review of the clinical record for Resident C was conducted. The record indicated the resident was admitted on [DATE] to room [ROOM NUMBER] and had a room change on 6/8/21 to 506 A. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, dated 4/12/21, indicated the residents BIMS (Brief Interview for Mental Status) score was 13 - intact cognition. The resident required extensive assistance of 2 persons with transfers dressing, toileting and personal hygiene. An Incident Report #484 and investigation, dated 6/24/21, indicated Resident C reported, to a staff member, she was receiving text messages from CNA 4. CNA 4 was immediately suspended pending the investigation. The report indicated .The allegation was substantiated. The staff member was identified as [name of CNA 4] CNA 4 admitted he was sending and receiving text messages from Resident C. CNA 4 . resigned his position as a result of violating the facilities policy of Professional Boundaries in Nursing. Social Services and psych services will continue to follow up with [name of Resident C] Resident C willingly let the Administrator take pictures of some of the text messages. The undated messages indicated the following: Resident C states I am fighting depression I will message you later have a good night. CNA 4 replies Ok beautiful love you so much Another text Resident C asks You do, why, what's so special about me, but thank you, I like you a lot too. CNA 4's response .It's your kind loving caring and very beautiful looks, I love older, thick, white, women Text from Resident C, .do you work tomorrow hopefully come by and say hi or give me a big hug are you still up do you work this weekend let me know, May 14, 4:03 A.M Resident C's statement, taken by Assistant Director of Nursing and the Administrator, dated 6/24/21 at 12:00 P.M., indicated the resident provided a thread of text message exchanges with CNA 4. Resident told them she had fallen in love with CNA 4 and their relationship had started sometime in May 2021. The resident indicated the two of them had kissed and hugged on numerous occasions. CNA 4 had come into her room and slammed the door and confronted her, regarding her questioning, other employees, who he was sleeping with. CNA 4 grabbed her by the face and kissed her. Resident was tearful and anxious, stating how hurt she was about the incident and wanted to talk to a professional psychologist to get more medicine to deal with the trauma. An Investigation Narrative/timeline was received from the Administrator and indicated the following: -On 6/24/21 at 8:50 AM, CNA 4 was called into the office to be interviewed by the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS). CNA 4 admitted to texting the resident. The DNS indicated the behavior was not appropriate, unprofessional and against the facility's Code of Conduct. He was instructed to stop contacting the resident immediately and CNA 4 reported he had already blocked her number because she was texting and calling him all night. -At 12:00 P.M. the Administrator and ADNS went to interview the resident. The resident opened her phone and allowed the Administrator to observe the text messages she had received from CNA. Text message details mentioned Resident C and CNA 4 had hugged and kissed 2 days prior. -At 1:15 P.M., CNA 4 was suspended for a violation of accusation of abuse. -At 3:00 P.M. staff and resident interviews were initiated. -At 10:56 P.M., Resident C was assessed and had bruises to her right inner thigh, but could not recall how she obtained them. -On 6/25/21 staff education was initiated, and Police were notified and came to the facility to begin the investigation-case number 21- . -On 6/25/21 at 4:30 P.M., DNS and ADNS went to CNA 4's home for a written statement, as he did not have transportation to come to the facility and again he was informed he could not return to work until the investigation was completed. -On 6/28/21 at 9:05 A.M., CNA 4 text messaged the DNS indicating he had resigned. A Progress Note, dated 6/25/21 at 2:02 P.M., indicated the Social Service Director (SSD) witnessed the resident in room talking with her son. SSD listened to resident and offered validations. Resident mood/behavior was stable and resident had no signs/symptoms/ of distress. The resident was to be followed by psych services. A Progress Note, dated 6/28/21 at 10:28 A.M., indicated the resident had no noted behaviors in the last 24 hours but was expressing anxiety. Psych services increased [MEDICATION(S)] (anti-anxiety medication) to 10 mg for anxiety. A Psychotherapy Note, dated 5/3/21, indicated the resident was seen for symptoms of depression and anxiety. Staff report she is getting her tracheotomy removed this afternoon and is having a lot of anxiety related to the procedure. Resident reports high anxiety and depression. Resident also reports feeling lonely and isolated. She was tearful at times today. A Psychotherapy Note dated, 6/14/21, indicated .patient and I discussed why she feels like the nursing home isn't a good place for her to be currently and what she can do to make things better for herself currently. She reports she doesn't want to make things better, she only wants to return home. We identified healthy coping skills to help decrease depression and anxiety. She reports she has been using deep breathing exercises to help calm herself down A Psychotherapy Note, dated 6/28/21, indicated the resident reports continued depression, anxiety and panic attacks, but no more than last week. She also reports being emotional and tearful. A Psychotherapy Note, dated 7/4/21, indicated the provider had been asked to see the resident due to concerns with anxiety.Patient reported periods of increased anxiety due to issues with staff and being discharged and having to go to her ex-husband's home to live with him and her son During an interview, on 8/17/21 at 3:03 P.M., LPN 3-Unit Manager indicated when she arrived, at the facility, on 6/24/21, CNA 2 reported to her Resident C had been upset most of the night and telling her a male CNA was texting her. LPN 3 indicated Resident C's new room allowed her to observe the parking lot and the resident was mad because male CNA 4 was being observed, by Resident C with CNA 7. During an interview, on 8/18/21 at 1:58 P.M., CNA 2 indicated she was fairly new at the facility, and she was the one who Resident C confided in, regarding her relationship with CNA 4. The resident showed her some text messages from CNA 4 but his name was not on the messages. She then asked another staff member if she knew whose number it was and she identified the phone number of CNA 4. She indicated the resident was upset and crying and she checked on her often throughout the night. The resident shared with her that CNA 4 had came into her room and was upset with her, questioning her about why she was asking other staff members about his relationships. CNA 2 reported her findings to her unit manager. On 8/17/21 at 11:16 A.M., the Administrator provided a current policy titled, Abuse Prohibition, Reporting, and Investigation, dated February 2010 and last revised on February of 2020. The policy indicated .It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but in not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .[name of facility] will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents, consultants, volunteers, staff or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals .Sexual Abuse - Nonconsensual sexual contact of any type. Examples may include but not be limited to fondling, touching, rubbing, exposing, licking, kissing, gestures, sharing pornography, assault, rape, harassment, deduction, coercion, graphing a resi photo dent's rectal [photographing a resident's rectal], genital, or breast areas, and /or exhibitionism .Mental Abuse - Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. This includes any episode of staff to resident; and resident to resident, if it appears to be willfully directed to a specific resident .Exploitation - The unfair treatment or use of a resident or the taking of a selfish or unfair advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion .Romantic relationship between staff and resident that does not involve physical intimacy (such as a relationship that is an abuse of power and position and is professionally unethical) The past noncompliance immediate jeopardy began on 9/24/20. The immediate jeopardy was removed and the deficient practice corrected by 6/25/21, after the facility implemented a systemic plan of action which included, but was not limited to: removing CNA 4 from the building and away from all residents, conducting an all staff in-services regarding abuse & professional boundaries, letter to residents-requesting them not to share their phone numbers with staff members, complete/thorough investigations, an immediate resident council meeting to review resident rights and discussed relationships between staff and residents should remain professional. This Federal tag relates to complaint IN 114. 3.1-27(a)(1)

Based on record review and interview, the facility failed to provide adequate supervision to a COVID-19 positive resident who required supervision to keep his oxygen on, as a result the resident was able to remove oxygen and leave the building where he was found unresponsive a short time later and subsequently passed away. This affected 1 of 3 residents reviewed for accidents and supervision. (Resident B) Finding includes: During an interview, conducted with the Director of Nurses (DON), on 10/6/2020 at 12:30 P.M., the DON indicated on 10/2/2020 sometime after 5:30 P.M., Resident B who was diagnosed with [REDACTED]. He was found in a neighboring lawn and transported to the hospital where he passed away. A (Name of local Fire Department) Run Report, dated 10/2/2020 at 6:15 P.M., indicated .Assessment time: 17:50 (5:50 P.M.) 911 Priority 2 response to address for an unknown medical .Upon arrival on the scene, (local fire department) personnel were continuing resuscitative efforts. Patient was laying supine in the front yard of a business. Patient was unresponsive and apneic with no palpable pulse. Personnel advised that pulses were regained upon (local fire department). While moving patient, staff from (nursing home) who stated that he was patient of theirs on the locked COVID UNIT. The staff then stated that the patient was COVID positive and not sure why he was outside. (Local fire department) personnel then loaded patient into (ambulance) to continue resuscitative efforts .During pulse checks, no carotid or femoral pulses felt. Monitor/pads showed a bradycardic rhythm with no mechanical capture. It was noted by initial medic that patient's eyes were dilated more than before and fixed. Third EPI ([MEDICATION NAME]) was administered followed by NS (Normal Saline) bolus. Last pulse checked revealed no carotid or femoral pulses, monitor/pads still showed bradycardic rhythm but still no mechanical capture (PEA) (Pulseless Electrical Activity). Auscultation of the heart by (local fire department) revealed no heart tones. Efforts were continued while (local fire department) called (local hospital) All resuscitative efforts were ceased, at 1815 (6:15 P.M.), per the order at (local hospital) On 10/6/2020 at 1:30 P.M., the clinical record for Resident B was reviewed. Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A Minimum Data Set assessment (MDS), dated [DATE], indicated Resident B had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment, Section E of the MDS did not indicate that Resident B had any presence or frequency of wandering. An Elopement risk assessment dated , 9/7/2020 indicated Resident B was an elopement risk related to being able to move about freely and easily and for having a [DIAGNOSES REDACTED]. The clinical record indicated Resident B tested positive for COVID-19 on 9/21/2020. During a second interview, on 10/6/2020 at 1:25P.M., the DON indicated she had taken care of him on the day shift but was not at the facility when he left the facility. She had been having trouble with him not wanting to wear his non rebreather (NRB) oxygen mask, he would take it off and place it on his forehead. She bribed him with a soda and other things to get him to put it back on. She indicated his oxygen saturation levels would drop when he took off his NRB. She came up with the idea to take him to the day room so he could get some sun on his face. Resident B, was known to be independent before his COVID-19 [DIAGNOSES REDACTED]. On the afternoon of 10/2/2020 he was sitting in the day room when laundry came to deliver supplies, Resident B wanted to let her in, but he could not understand why she couldn't come in. It was upsetting to him to not be able to let her in. DON tried to explain that they had a disease and the lady could not come inside because she might get sick, but he wanted to let her in. The DON told the staff member to leave, she then assisted the resident back to his chair where she placed his oxygen and a blanket and resumed her duties. DON did not believe this was an exit seeking behavior as he could not understand why the laundry lady could not come inside the unit but did state that the resident had pushed on the door during the incident. A Progress Note, dated 10/2/2020, at 3:30 P.M., indicated .Resident alert per baseline lungs congested upper and diminished lower (name of physician) visited today see note. Resident sats (saturation levels) maintain at 91 with 02 non rebreather on. (Resident) takes off 02 frequently, sats at 80-85% when 02 saturation is off. (Staff ) continue to encourage resident to keep resident on the nonrebreather mask, resident states if he can sit in the dining room he will keep mask on, continued reassurance on importance of oxygen and keeping oxygen on A Progress Note, dated 10/2/2020, at 4:50 P.M., indicated .Resident found with O2 off. SpO2 (measurement of oxygen in the blood) 68%, non-rebreather (delivery mask) replaced SpO2 increased to 91% During an interview, conducted with NA 1 (Nurse Aide), on 10/6/2020 at 2:42 P.M., she indicated she had worked that day and she was sitting near Resident B when she was assisting another resident to eat. She did not see Resident B display any exit seeking behavior. She did not indicate whether Resident B was wearing his oxygen at that time. She then went to assist Resident B's roommate, in their room a short time later she heard the door alarm go off and was told it was the laundry department. She went back into assist Resident B's roommate when she heard a 'CODE SILVER' being called. There was no one in the hallway so she stayed on the unit until people started coming back to the unit. NA 1 estimated the time the incident occurred was between 5:15 P.M. and 5:25P.M. During an interview, conducted with CNA 2 on 10/6/2020 at 2:50 P.M., CNA 2 indicated that on 10/2/2020 around supper time the staff were passing trays out and assisting others to eat. He could not recall the exact time. The door alarm started going off and he went to the door to look around. Another resident, Resident C, was near the door, he redirected her, she walked down the hall and he resumed passing trays until the alarm for a CODE SILVER was announced and then the staff went out and started looking for Resident B. He indicated the cops were there before he got there and Resident B was found lying on the grass of a business next door. During an interview, conducted with the Interim Executive Director (ED), on 10/6/2020 at 3:00 P.M., he indicated that Resident B was not known to be exit seeking. As he understood the incident of the day, Resident B was trying to assist staff to come into the building from the outside earlier in the day. He indicated he had video footage that does not show the resident exhibiting exit seeking behavior. He believed what happened was that Resident B punched in the code for the door to unlock it, and exited the building. He provided this surveyor the following timeline of events: .10/2/2020 at approximately 5:00 pm-- DNS (Director Nursing Services) spoke with resident prior to leaving her shift. Resident was sitting in the day room on 400 hall with oxygen in place .10/2/2020 at 5:27pm-Resident walking down hallway towards dietary turned right and then to the left towards exit door .Resident does not return to facility after going out of camera view .10-2-2020 at 5:29pm-Culinary staff looking into 400 unit. Culinary did see (Resident C) at the dietary door. No alarms sounds noted. There was nobody else in the hallway at this time .5:30pm-(Resident C) moved out of camera view towards the door (Resident B) exited through for a minute .5:31pm-Staff heard an alarm. CNA 2 looked outside door and did not see anyone, resident, or staff. CNA walking towards door and passed (Resident C) as she was leaving the area of the alarming door. CNA proceeded to turn alarm off .10/2/2020 around 5:40pm-employee saw resident outside of facility and reported to front desk. 911 notified, Code Silver initiated. Video footage #1, indicated that on 10/2/2020 at 3:49 P.M., Resident B was seen at the door, with facility staff sitting behind the desk working. There is a bad glare towards the window and the laundry staff was not visualized but the DON is seen running to the door and assisting Resident B back to his chair and placing a blanket on him. Video footage #2, indicated that on 10/2/2020 at 5:25 P.M., the resident was sitting in his chair by the nurse's station. There were 4 staff in the area where Resident B was sitting, they were seen with trays in their hands. The resident is visualized getting up from a chair and walking down the hall. He is not visualized going out a door but he is seen ambulating independently down the hallway. He is known to live in the hallway he was ambulating in. He did not have oxygen on. Video footage #3, indicated that on 10/2/2020 at 5:27 P.M., Resident B is observed walking down the 400 hall toward the dietary doors, earlier in the footage a culinary staff member is seen looking inside the door of the unit, then they close the door, afterward Resident B walked up to the door then turned to the right, he then came back and ambulated to the left and did not return. There is a resident, (Resident C) who is observed wandering up and down the hall holding her hospital gown. Later in the footage she is observed ambulating in the same direction Resident B had gone a very short time earlier, she also turned first to the right where Resident B had gone. Later in the footage CNA 2 is observed going down the hall turning to the right and then coming back with Resident C who was ambulating while holding her gown. Video footage # 4, indicated that on 10/2/2020 at approximately 5:35 P.M., Resident B was ambulating just outside the door of the COVID UNIT in the parking lot away from the building. The culinary staff member was unavailable for interview, it is unknown what time the trays were brought to the COVID UNIT. In touring the facility, each door of the facility has a code you must enter. It is placed on the code pad with white tape and it labeled M (month) / Y (year). During an interview, conducted with Dietary Aide 3, on 10/6/2020, he indicated he was an employee of the facility and was driving home from his second job between 5:35 P.M., and 5:40 P.M., he saw Resident B lying in the grass on his stomach at the adjacent business and ran to the facility to notify staff to call 911. He indicated Resident B was breathing when he went to notify the facility but when he came back the police were working on him so he got into his car and went home. During an interview, conducted with the Interim ED on 10/7/2020 at 12:47 P.M., he indicated a call was placed to 911 Emergency Services at 5:41 P.M. on 10/2/2020. An Elopement Prevention and Response Program policy, with a revised date of 10/17, indicated .Policy: It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action is taken This Federal tag is related to Complaint IN 865. 3.1-45(a)(2)

Based on interview and record review, the facility failed to have a system in place to determine code status and failed to perform Cardiopulmonary Resuscitation on a resident who was a full code. (Resident #33) The facility also failed to ensure advanced directive/code status was clearly documented for 4 of 23 residents reviewed of the total census of 99 residents. (Residents #73, #146, #77, #9) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE], when staff failed to ensure the code status of a resident was correctly documented and to perform Cardiopulmonary Resuscitation. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 2:43 P.M. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower level scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On [DATE] at 3:58 P.M., the clinical record for Resident #33 was reviewed. Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED].acute urinary tract infection, acute kidney injury, acute osteomylitis, [MEDICAL CONDITIONS], chronic wound of extremity and respiratory acidosis A facility form titled, Admission Acceptance Information, inquiry date [DATE], indicated, . Name: (resident name) . Diagnosis: [REDACTED].Contact Person: (Resident's sister) .Inquiry Date: [DATE] Clinical Status/Needs: Guardian A form titled, (Name of local hospital) Patient Transfer Nurse Assessment- Extended Care, dated [DATE], indicated, .Nurse Discharge Summary/Current Problem: S.O. (significant other) obtained guardianship today-pt.(patient) deemed incompetent A form titled, (Name of local hospital) PHYSICIAN SUMMARY & TRANSFER ORDERS TO ECF (extended care facility), dated [DATE] and [DATE], indicated, .CODE STATUS: Yes Code . Physician Signature (physician's signature) A facility form titled, ADVANCED DIRECTIVES POLICY AND RECORD, indicated, .GUARDIANSHIP . Guardian of Person/Medical Decision Name of Guardian: (name of guardian) .DOCUMENTS RECEIVED .Date [DATE] .Initials (initials of facility staff) A facility form titled, Social Services Admission/Discharge Evaluation-Long Stay, dated [DATE], indicated under the Advanced Care Planning the Resident is own person. A document titled, ORDER APPOINTING TEMPORARY GUARDIAN FOR INCAPACITATED PERSON, dated [DATE], indicated the Court appointed a Temporary Guardian for Resident #33. A facility form titled, PHYSICIAN'S MEDICATION ORDERS, dated ,[DATE], indicated .admitted :[DATE] .ADVANCED DIRECTIVES .CODE STATUS: Full Code A facility form titled, (CPR) CARDIOPULMONARY RESUSCITATION CONSENT, indicated, NO RESUSCITATION (No Cardiopulmonary Resuscitation or External Defibrillation). The a signature was on the form and appeared to be the resident's signature. This form was not dated. There was no guardian signature or witness signature on the form. A nurses note, dated [DATE] at 3:10 P.M., indicated resident had experienced a [MEDICAL CONDITION] at 2:10 P.M. POA (name of guardian) called and notified of all the above A nurses note, dated [DATE] at 10:00 A.M., indicated resident had been transported to (name of local hospital) for a blood transfusion. POA (name of guardian) also called and informed of resident blood transfusion to be done at (name of local hospital) A nurses note, dated [DATE] at 3:30 A.M., indicated has had no [MEDICAL CONDITION] activity noted this shift A nurses note, dated [DATE] at 12:30 A.M., indicated Gave [MEDICATION NAME] PRN (as needed) for L (left) leg pain CNA (certified nurses assistant) got her some ice for her soda, she was pleasant et (and) talking (and) smiling. Took her updraft (breathing treatment) without problems et (and) Biox was 95% with O2 (oxygen) @ (at) 3L/nc (3 liters per nasal canula) A nurses note, dated [DATE] at 1:30 A.M., indicated Res. (resident) resting peacefully with eyes closed @ this time. O2 (oxygen) in place A nurses note, dated [DATE] at 2 A.M., indicated Incontinent of sm. (small) amt (amount) urine, changed (sic) et (and) voices no complaints. O2 (oxygen) in place et has had no [MEDICAL CONDITION] activity noted A nurses note, dated [DATE] at 3:00 A.M., indicated Looked in on res. as was passing room, O2 in place et resting peacefully A nurses note, dated [DATE] at 5:00 A.M., indicated Was preparing to take updraft to res.(resident) room. CNA (certified nurses assistant) requests to please come check on her. Found her cool to touch with no B/P (blood pressure) or Pulse A nurses note, dated [DATE] at 5:15 A.M., indicated Left msg. (message) for her sister (name of sister) to please call facility, called POA (name of guardian) et notified him. States he will try to find a ride up here before calling funeral home A nurses note, dated [DATE] at 5:30 A.M., indicated Obtained order from (name of physician) to release res body to funeral home of family choice. Left msg. for DON (Director of Nurses) On [DATE] at 5:22 P.M., an interview was conducted with the Social Worker. The Social Worker indicated the nursing department was responsible for the code status care plan. The Social Worker further indicated, . I guess we (social services) don't do code status care plans. Nursing has the resident sign the CPR form, it should be done within 24 hours of admission On [DATE] at 5:26 P.M., an interview was conducted with the Director of Nurses. The Director of Nurses indicated, . the nursing department does not do Advance Directive careplans .if a resident is admitted without guardian paperwork and the resident is alert and oriented the facility has the resident sign the paperwork .the nurse would look at the chart Advanced Directives to determine if a resident is full code or no code .I would look at the CPR consent, but it should have a date .the nurse should have obtained an order from the doctor that matched the CPR consent form that was signed. If the husband/boyfriend wanted her (Resident #33) to be a DNR (do not resuscitate) it would be his decision if she is deemed incompetent The current facility policy entitled, Cardiopulmonary Resuscitation (CPR)-Basic Life Support (BLS), dated [DATE], received from the Director of Nurses on [DATE] at 5:30 P.M., indicated, .Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or a unwitnessed cardiopulmonary arrest while in the center On [DATE] at 12:20 P.M., an interview was conducted with the Administrator and the Director of Nurses. The Director of Nurses indicated that, .When a resident comes into the facility the nursing department is responsible to get the CPR form signed by the resident if they are alert and oriented. The code status is then placed on the POS (Physician order [REDACTED].#33 and guardianship the Director of Nurses indicated she did not recall a guardian but she did recall that she was in the facility about 3 weeks and something about a boyfriend coming up. When discussing a system of monitoring code status of resident's, the Director of Nurses indicated that when a resident comes into the facility, the IDT (Interdisciplinary Team) a chart was taken to IDT for 3 days and reviewed. She indicated there was a check off list for medical records and a check off for nursing. IDT reviewed all new orders or changes in condition. Code status is talked about during care plan meetings. If the resident had a guardian, the admissions person would tell you. Sometimes the paperwork goes through the business office and it doesn't get communicated On this one, admitting orders said full code, CPR consent said No Code, I would say it (signing of CPR consent form) was done upon admission. The nurse should have put a date on it. The nurse should have initiated CPR (cardiopulmonary resuscitation) A interdisciplinary team note for Resident #33, dated [DATE], indicated . IDT met day 1 for admission to this facility on [DATE]. Medication and treatment orders reviewed. Follow up appointments arrange with transportation and lab orders reviewed A interdisciplinary team note for Resident #33, dated [DATE], indicated .IDT met day 2 of admission & new orders for lab due to [MEDICAL CONDITION] activity & sent to ER (emergency room ) if resident develops Temp > (greater than) 101 or continues to have [MEDICAL CONDITION] A interdisciplinary team note for Resident #33, dated [DATE], indicated .IDT met day 3 of admission & order to receive 2 units of PRBC (packed red blood cells) due to critical hemoglobin 7.2 There was no documentation related to Advanced Directives/Code Status on the IDT notes. 2. On [DATE] at 9:52 A.M., record review for Resident #73 was conducted. No CPR Consent form was present on chart. Physicians orders, dated and signed [DATE] and [DATE], indicated that a code status was not established. 3. On [DATE] at 10:00 A.M., record review for Resident # 146 was conducted. A Letter of Guardianship, dated [DATE], was included in the record. A CPR Consent form indicated, No Resuscitation. The document was undated and unsigned by the Resident's Authorized Representative. 4. On [DATE] at 11:00 A.M., record review for Resident #77 was conducted. The CPR Consent form indicated, Resuscitation dated [DATE]. The Physician orders, dated and signed [DATE], indicated, DNR. 5. On [DATE] at 11:05 A.M., record review for Resident #9 was conducted. No CPR consent form was found on chart. The Physicians orders, dated and signed [DATE], indicated that a code status was not established. On [DATE] at 11:12 A.M., LPN #2 indicated, . they (facility staff) look for the CPR form first, but it isn't always there, sometimes the family does not come in and sign it so we would look for a physician order [REDACTED].>On [DATE] at 5:42 P.M., the Director of Nursing provided the procedure titled Cardiopulmonary Resuscitation (CPR) - Basic Life Support (BLS), and indicated the procedure was the one currently being used by the facility. The procedure indicated, Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center. The Immediate Jeopardy that began on [DATE] was removed on [DATE], with an effective date of [DATE], when through record reviews and interviews, staff had completed education regarding the facility policy and procedure related to CPR. The facility had also reviewed all records to ensure advanced directives/code status was correct for each resident. Even though the facility's corrective action removed the Immediate Jeopardy the facility remained out of compliance at a reduced scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy because of on-going monitoring to ensure the staff were knowledgeable and the resident's advanced directive/code status was documented correctly. 3.1-f(5)

Based on observation, interview and record review, the facility failed to ensure residents were protected from falls resulting in fractures for 2 residents, and for 1 resident who received a 4 cm (centimeter) hematoma (raised bruising) to her forehead. This deficient practice affected 3 of 5 residents with falls in a sample of 5. (Residents # D, #B and #F) Findings include: 1. During initial tour on 1/5/12 at 9:15 am of the 500 hall, accompanied by LPN # 6, Resident # D was observed resting in bed with her eyes closed. During an interview with LPN # 6 at this time, she indicated Resident # D sustained a fall with a fracture to her right hip. She indicated the resident transferred with a mechanical lift (Hoyer) with two person assistance. Residents # D's record was reviewed on 1/5/12 at 12:15 p.m. The resident's record indicated [DIAGNOSES REDACTED]. Resident #D's significant change MDS (minimum data set) assessment dated [DATE], indicated the resident had problems with her cognition. The resident needed total assistance with transfers with 2 staff assisting and extensive assistance with eating, dressing and bathing. physician's orders [REDACTED]." Review of the "Nursing Assistant Worksheet" on 1/5/12 at 1:00 p.m. indicated Resident #D transferred with a Hoyer lift with two staff. Nurse note dated 12/13/11 at 7:30 p.m. indicated "incident in shower room, and resident lowered to floor, no apparent injuries noted...." A statement written by LPN # 8 dated 12/13/11 at 7:30 p.m. indicated " "...last night (Resident #D) fell out of the Hoyer lift with (CNA # 2) transferring her by herself...." A form titled "Witness Investigations Statement" dated 12/13/11 at 7:30 p.m. written by (CNA # 2), indicated "after the resident was seated in the chair, I took the hooks off and noticed she was on the edge of the chair not seated that good. She proceeded to slide off. I couldn't pull the resident so I lowered her to the floor and called for help to help me with the resident." A "Witness Investigation Statement" dated 12/13/11 at 7:30 p.m., indicated: "Resident told this nurse that after shower CNA was pushing machine and she fell off of machine onto floor. No other staff member present." The nurse who wrote the statement was not able to be identified. A "Witness Investigation Statement" written by an unidentified LPN dated 12/13/11 at 7:30 p.m., indicated "... when (CNA # 2) was asked why she didn't have that second person during transfer, (CNA # 2) stated: 'q (every) body was busy but (CNA #3) looked in on me.'" Nurse note dated 12/14/11 at 2:38 a.m., indicated "...upon assessment resident with complaints of increased pain to (R) (right) hip, during ROM (Range of Motion) resident yelling out in pain. (Doctor name) paged with return call, updated on change in condition, N.O. (new order) received to X-ray (R) hip...." Nurse note dated 12/14/11 at 8:30 a.m. indicated "PRN (as needed) Tylenol (a medication given to relieve pain) given due to complaints right hip discomfort rated "7"... Right hip fracture... N.O. direct admit to (hospital name)...." The resident's record indicated the pain scale was from 1-10 with 10 indicating severe pain. A form titled "Discharge Summary" dated 12/16/11 indicated ..." Right hip reveals evidence of an old fracture with questionable acute new fracture." "HOSPITAL COURSE: The patient was admitted ... She was on a Hoyer lift and they dropped her. I would prefer not to do that again. I will discharge her to the care of the home, follow her there, see how she does and hopefully make this resolved in regards to further hospitalization and hopefully she will not fall again...." During an interview with the Director of Nursing on 1/5/12 at 12:40 p.m., she indicated all residents who are transferred with Hoyer lifts are to have two person assistance during transfers. 2. Resident # B's record was reviewed on 1/5/12 at 12:30 p.m. The resident's record indicated [DIAGNOSES REDACTED]. The resident's significant change MDS (minimum data set) assessment dated [DATE] indicated the resident's cognition was severely impaired, she transferred with assistance of 1 staff and needed extensive assistance with dressing and bathing with assistance of 1 staff. The resident's record indicated the resident had fallen on the following dates: 11/10/11, 11/21/11, 11/25/11,12/16/11, 12/21/11 and 12/25/11. The resident's plan of care, dated as last updated on 12/19/11, failed to indicate interventions had been put into place to prevent the falls. Nurses note dated 12/25/11 at 5:30 p.m. indicated "This nurse heard res (resident) yell out 'help' from her room. Came to res's room found her on the floor on her side beside the bed. Helped res to wc (wheelchair). Found 4 cm hematoma to (R) (right) side of forehead)...." During an interview with the Director of Nursing on 1/5/12 at 12:40 p.m., regarding a fall risk assessment, she indicated the care plan is used. Nurse note dated 12/26/11 at 2:15 p.m. indicated "F/U (follow-up) fall with neuro (neurological checks) cont (continue)...(R) (right) forehead/ eye remains bruised...." Nurse note dated 12/27/11 10:00 a.m. "...continues to have facial bruising, especially to eye area...." 3. Resident F's record was reviewed on 1/5/12 at 3:00 p.m. The resident's record indicated [DIAGNOSES REDACTED]. Nurses note dated 9/2/11 at 10:00 p.m. indicated "...CNA leaving unit noted res on floor next to a chair. Had been sleeping in bed was wearing socks, floor was dry." Nurse note dated 9/2/11 at 10:45 p.m. indicated "...Res left on gurney 11 p (p.m.) with (ambulance service name), complains of pain with paramedic's assessment...." Nurse note dated 9/3/11 2:30 a.m. indicated "...Res admitted with rt (right) hip fx (fracture)...." A physician's form titled " History & Physical" dated 9/3/11 indicated "... she did have a ground level fall and right hip pain...we are going to admit her...her x-ray does confirm a fractured right femoral neck with mild varus angulation...." The nurse notes indicated the resident had a fall in July 2011. The note indicated on 7/31/11 staff notified the physician of a fall. The resident's plan of care for falls failed to indicate an intervention had been put into place to prevent another fall from occurring. The facility's policy titled "Falls and Injuries"...Policy: Supervision, refers to an intervention and means of mitigation the risk of an accident. Centers are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment. Supervision may vary resident to resident and time to time for the same resident. The use of tools or items such as personal alarms can help monitor resident's activities but does not eliminate the need for staff vigilance and are not to be utilized in lieu of supervision...." This Federal tag relates to Complaint IN 816. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure staff safely transferred a resident using a Hoyer lift with the required 2 staff assistance. This deficient practice resulted in a resident sustaining a fall and fracture resulting in hospitalization for 1 of 2 residents reviewed with Hoyer transfers in a sample of 5. (Resident # D) Findings Include: During initial tour on 1/5/12 at 9:15 a.m. of the 500 hall, accompanied by LPN # 6, Resident # D was observed resting in bed with her eyes closed. During an interview with LPN # 6 at this time, she indicated Resident # D sustained a fall with a fracture to her right hip. She indicated the resident transferred with a mechanical lift (Hoyer) with two person assistance. Residents # D's record was reviewed on 1/5/12 at 12:15 p.m. The resident's record indicated [DIAGNOSES REDACTED]. physician's orders [REDACTED]." Review of the "Nursing Assistant Worksheet" on 1/5/12 at 1:00 p.m. indicated Resident #D transferred with a Hoyer lift with two staff. Nurse note dated 12/13/11 at 7:30 p.m. indicated "incident in shower room, and resident lowered to floor, no apparent injuries noted...." A statement written by LPN # 8 dated 12/13/11 at 7:30 p.m., indicated, "...last night (Resident #D) fell out of the Hoyer lift with (CNA # 2) transferring her by herself...." A form titled "Witness Investigations Statement" dated 12/13/11 at 7:30 p.m., written by CNA # 2, indicated "after the resident was seated in the chair, I took the hooks off and noticed she was on the edge of the chair not seated that good. She proceeded to slide off. I couldn't pull the resident so I lowered her to the floor and called for help to help me with the resident." A "Witness Investigation Statement" dated 12/13/11 at 7:30 p.m., indicated: "Resident told this nurse that after shower CNA was pushing machine and she fell off of machine onto floor. No other staff member present." The nurse who wrote the statement was not able to be identified. A "Witness Investigation Statement" written by an unidentified LPN, dated 12/13/11 at 7:30 p.m., indicated "...when (CNA # 2) was asked why she didn't have that second person during transfer, (CNA # 2) stated: 'q (every) body was busy but (CNA #3) looked in on me.'" Nurse note dated 12/14/11 at 2:38 a.m. indicated "...upon assessment resident with complaints of increased pain to (R) (right) hip, during ROM (Range of Motion) resident yelling out in pain. (Doctor name) paged with return call, updated on change in condition, N.O. (new order) received to X-ray (R) hip...." Nurse note dated 12/14/11 at 8:30 a.m. indicated "PRN (as needed) Tylenol (a medication given to relieve pain) given due to complaints right hip discomfort rated "7"... Right [MEDICAL CONDITION] N.O. direct admit to (hospital name)...." The resident's record indicated the pain scale was from 1-10 with 10 indicating severe pain. A form titled "Discharge Summary" dated 12/16/11, indicated "...Right hip reveals evidence of an old fracture with questionable acute new fracture." "HOSPITAL COURSE: The patient was admitted ... She was on a Hoyer lift and they dropped her. I would prefer not to do that again. I will discharge her to the care of the home, follow her there, see how she does and hopefully make this resolved in regards to further hospitalization and hopefully she will not fall again...." During an interview with the Director of Nursing on 1/5/12 at 12:40 p.m., she indicated all residents who are transferred with Hoyer lifts are to have two person assistance during transfers. CNA #2 was hired to facility on 8/16/11. CNA #2 was trained on Hoyer use and technique. Review of form titled "SKILLS CHECK OFF/RETURN DEMONSTRATION INVACARE 450/600 TOTAL LIFT" dated 8/18/11, indicated to use the number of staff required for the procedure. The skills check off/demonstration form was signed by CNA #2 on 8/18/11. This federal tag relates to Complaint IN 816. 3.1-14(i)

Based on interview and record review, the facility failed to ensure a resident experiencing pain received pain medication that was available in the emergency drug kit to relieve her pain, which subsequently caused her to be transferred to the emergency room for pain relief for 1 of 5 residents reviewed for pain in a sample of 5. Resident # B Findings include: Resident # B's record was reviewed on 12/5/11 at 12:00 p.m. The resident's record indicated [DIAGNOSES REDACTED]. The record indicated Resident # B was admitted to the facility on [DATE]. Review of the following nurses notes dated 10/7/11 and 10/8/11 indicated the following: 10/7/11 at 11:12 p.m. "...picc (peripherally inserted central catheter) line drsg (dressing) to (L) (left) upper arm, pt (patient) c/o (complains of) pain to lower extrem (extremities) bliat (bilaterally) and doesn't like air mattress states "it makes my feet hot" , HOB (head of bed) up and call light in reach, vs (vital signs) T (temperature) 99.1...P (pulse) 115." The resident's record lacked documentation to indicate her pain was assessed or treated. 10/7/11 10:30 p.m. (notes out of sequence in record for time) " ...P 114...c/o feet "hot" stated "I do not like this bed." Requested to deflate bed, informed her that cannot be done...cont (continue) to c/o feet being "hot" supervisor (name) notified and went to see resident and adjusted bed. Cont to c/o "feet hot" and (R) (right) arm pain at this time." 10/7/11 11:20 p.m. "This writer entered room and readjusted resident in bed, removed compressor from foot of bed r/t (related to) feet "feel hot" per resident request father contacted, (father's name) stated "she gets medication for that." Pharmacy contacted r/t medication delivery, pharmacy unable to give eta (estimated time of arrival) for RX's (medications). (Name of nurse practitioner) notified order received to administer 1st doses of medication upon availability and if pain increases and RX has not arrived may send to ER (emergency room ) for eval (evaluation). 10/7/11 11:55 p.m." Resident's father (name) at bedside." 10/8/11 12:25 a.m. "...HR (heart rate) [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (for [MEDICAL CONDITION]), [MEDICATION NAME] (for appetite), [MEDICATION NAME] (for blood pressure) and [MEDICATION NAME] ([MEDICATION NAME]) administered, awaiting [MEDICATION NAME](narcotic pain medication) delivery. Resident POA (power of attorney) becoming upset, asked me to call Administrator, Admin notified." 10/8/11 1:30 a.m. "Resident c/o increased pain, POA with request to send to ER, prompt (ambulance) notified for transport." A physician's orders [REDACTED]." The resident's record failed to include a pain assessment at the time the resident was experiencing pain. The resident went from 10/7/11 at 11:12 p.m. until 10/8/11 1:30 a.m. in pain without her pain medication to relieve her pain. During an interview with the Director of Nursing on 12/5/11 at 1:00 p.m.. regarding the availability of pain medications for new admissions, she indicated the facility has those medications available in the EDK (emergency drug kit). She indicated the [MEDICATION NAME] have been available for the resident. A care plan dated 10/10/11 indicated, "Problem: Alteration in comfort related to pain secondary to: Lupus, s/s (signs and symptoms) brain shunt,...contractures of fingers (R) hand,...contrax (contractures) R hand and wrist, s/s of shunt placement, Lupus, leg weakness and pain. Intervention: Administer pain medication as ordered...." This federal tag relates to Complaint # IN 241. 3.1-37(a)