Every finding on record at Transcendent Healthcare of Boonville

Based on observation, interview, and record review, the facility failed to ensure the plan of care was revised for 1 of 3 residents reviewed for incontinence. The care plan interventions were not updated as a resident's incontinence increased and need for assistance changed. (Resident F)Finding includes: Record review on 8/13/26 at 10:20 A.M., Resident F's diagnoses included but were not limited to dementia and muscle weakness.The most recent quarterly Minimum Data Set (MDS) assessment, dated 6/6/26 indicated the resident had moderate cognitive impairment, required supervision for toileting, and had occasional incontinence. The care plan included but was not limited to resident requires variable assist with late lossADLs due to weakness and resident has potential for bladder incontinence due to history of incontinence and impaired mobility (revised 3/9/26). Interventions included Toileting - Please assist resident as needed - occasionally incontinent, and ensure the resident has an unobstructed path to the bathroom (initiated 3/2/26).Nurse's notes included but were not limited to:5/31/26 at 8:27 P.M. - Resident was told of wet pants. Refused to change clothing.6/19/26 at 11:09 P.M. - Resident observed with wet clothing but refused to change until he had a soda and snack. 6/24/26 at 3:15 P.M.- Resident in hall going to lobby with wet pants. Staff asked him to go get cleaned up, he called them names and refused.6/25/26 at 6:07 A.M.- Resident is soiled and bed soaked and refuses to change.6/26/26 at 12:35 A.M.- Resident clothing soaked in urine. Refuses to go back to room and change. 7/19/26 at 12:10 A.M. - Resident wet and returned to room, refusing activity of daily living (ADL) care.7/28/26 at 2:19 P.M. - Resident receiving shower due to incontinence. Called nurse to shower room to see large area of right lower back, right buttock and right upper thigh covered with diaper rash type rash. 8/8/26 at 2:22 A.M. - Resident observed with wet clothing, refused to change. Observation on 8/13/26 at 11:00 A.M., Resident F was standing up in his bedroom. The resident walked self to bathroom and stood at bathroom doorway but did not go in. Resident stood looking into bathroom until CNA 6 knocked on the door and asked if she could assist him. The resident replied that she could assist him. CNA 6 then changed the resident's brief. An interview on 8/13/26 at 11:10 A.M., CNA 6 indicated Resident F can at times help himself with toileting but he does get confused. He often does not ask for help so staff have to check on him. An interview on 8/13/26 at 12:45 P.M., OT (occupation therapist) 2 indicated he as worked with Resident F regarding his toileting and incontinence. OT 2 indicated the resident had recently returned from the hospital and has seemed to be less motivated to care for himself. OT 2 indicated Resident F had potential to improve his ability for self care and toileting but did require encouragement and some assistance. An interview on 8/13/26 at 2:10 P.M., the Director of Nursing (DON) indicated a sign had been hung in Resident F's room to remind him and staff to encourage frequent toileting and to praise the resident for his efforts. On 8/13/26 at 2:15 P.M., the DON supplied an undated facility policy titled, Goals and Objectives, Care Plan. The policy included, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly .This citation relates to intake 3092774.410 IAC 16.2-3.1-35(e)

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with food safety standards to maintain a sanitary environment and prevent foodborne illness during 2 of 2 kitchen observations. Food preparation areas contained a buildup of dust, the walk-in freezer contained a build-up of ice, milk cartons were stored in crates resting on the floor, and the dry food storage room contained canned goods on the floor and a buildup of dust and debris under storage shelving. Finding includes: Kitchen observation on 6/1/26 at 10:20 A.M., the walk in refrigerator contained three milk crates with milk cartons resting directly on the refrigerator floor. The walk-in freezer unit at the back of the freezer had a buildup of ice hanging from under the fans/unit. A buildup of ice had formed on two bread boxes stored under the freezer fans/unit. The dry food storage room contained a buildup of dust and debris under the storage shelving. Two cans of soup were on their sides on the floor under the shelving. The ceiling and smoke detector above a food preparation table contained a buildup of dust. Kitchen observation on 6/2/26 at 9:22 A.M., the walk-in freezer unit at the back of the freezer had a buildup of ice hanging from under the fans/unit. A buildup of ice had formed on two bread boxes stored under the freezer fans/unit. The dry food storage room contained a buildup of dust and debris under the storage shelving. Two cans of soup and a can of dumplings were on the floor under the shelving. The ceiling and smoke detector above a food preparation table contained a buildup of dust. Interview on 6/2/26 at 9:45 A.M., the Dietary Manager (DM) indicated the kitchen will clean the ceiling and overhead vents if they notice they need cleaned but that was not part of their routine cleaning schedule. The milk delivery truck came on Thursdays, and the last milk delivery was the previous Thursday (5/28/26). Crates of milk should not be stored directly on the refrigerator floor. The DM indicated the bread boxes would be moved from under the walk-in freezer unit. Staff cleaned the dry food storage room routinely.Review of the daily and nightly kitchen cleaning task schedule on 6/2/26 at 10:20 A.M., the morning cook task for Mondays included, Organize freezer and remove any ice buildup . The night cook cleaning checklist included sweep/mop all kitchen areas including dry stock and under all equipment and shelves. This citation relates to intake 3016372. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for wandering and/or elopement. A care plan intervention to indicate which residents were at risk for elopement was not in place for a resident who had demonstrated increased exit seeking behaviors. (Resident F)Finding includes: Record review on 6/1/26 at 10:20 A.M., diagnoses included but were not limited to neurocognitive disorder, unspecified psychosis, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 3/20/26 indicated the resident had severe cognitive impairment, utilized a walker and required supervision during mobility. An elopement assessment dated [DATE] indicated the resident was at high risk for elopement. The care plan included but was not limited to resident is at risk for elopement (initiated 6/24/25). An intervention included resident will wear a white band on his wrist to identify to staff that he is high risk for elopement (initiated 1/15/26).Nurse's notes included but were not limited to:5/27/2026 at 2:21 P.M. - Resident is more restless today. Noted increased confusion and wondering more. Becomes easily upset with staff reminding to use walker. Resident seems more restless. Will continue to monitor.5/31/2026 3:43 A.M. - Resident has been up pacing this nightshift. Has been redirected numerous time but continues to come out and pace in sitting area. Have given drinks and snacks but is still hard to redirect. Unable to get resident to use his walker when walking. Observation on 6/1/26 at 10:50 A.M., Resident F was sitting in a wheelchair in the dining room. The resident was not wearing a white band on either wrist. Observation on 6/1/26 at at 12:00 P.M., Resident F was wheeling self in a wheelchair near the front hall nurse's station. The resident had no white band on either wrist. Interview on 6/1/26 at 1:00 P.M. QMA 4 indicated Resident F did wander and, at times, was exit seeking. QMA 4 indicated staff could request a list of residents who are at risk for elopement if they wanted to know who is at risk. Interview on 6/1/26 at 2:15 P.M., the MDS nurse and Social Service Director nurse indicated the resident had been recently been demonstrating exit seeking behaviors and that the Social Service Direct came in on 5/27/26 to assist with Resident F's increased behavior. The MDS nurse indicated residents who were assessed to be a high risk for elopement should be wearing a white bracelet. Interview on 6/2/26 at 10:35 A.M., the Director of Nursing (DON) indicated Resident F's white bracelet had been removed about a week prior to his increased wandering and exit seeking behaviors due to a skin condition. The DON indicated there was no documentation made of when the wrist band was removed or how staff monitor the placement of the white wrist band for at risk residents. On 6/2/26 at 11:52 A.M., the Facility Administrator supplied a facility policy titled Wandering/Unsafe Resident, dated 11/2010. The policy included, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The residents care plan will indicate the resident is at risk for elopement or other safety issues . Interventions to try to maintain safety will be included in the resident's care plan .This citation relates to intake 3028911.410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure proper sanitation to prevent foodborne illness during during 2 of 2 observations of the kitchen. The high temperature dishwasher did not reach a rinse temperature of 180 degrees Fahrenheit, hands were washed with seven and ten second lather, and a suction cup was placed on the cart and then on clean plates used to serve food to the residents. (Kitchen)Finding includes:1. On 3/9/26 at 6:30 A.M., the dishwasher was observed to run. Of three consecutive runs, the dishwasher did not reach a final rinse temperature of greater than 73 degrees Fahrenheit. On 3/12/26 at 10:25 A.M., the Kitchen Manager indicated the dishwasher had not gotten above 180 degrees Fahrenheit during the first observation because the staff had just gotten there that morning. She indicated maintenance had looked at it and said it was working fine, but that the heating element may be going out. He indicated if the red light on the machine was on, to flip the switch off and back on. At that time, the dishwasher was observed to run and the rinse temperature was 169 degrees Fahrenheit. After resetting the red light that was observed to be on, the dishwasher was ran again with a rinse temperature of 171 degrees Fahrenheit. The dishwasher was then ran a third time with a rinse temperature of 169 degrees Fahrenheit. The Kitchen Manager indicated she had spoken with the kitchen staff about the importance of watching for the dishwasher temperature to rise up to the appropriate temperature before washing the dishes. She indicated the staff were not watching the temperature and just documenting a temperature so she was unsure how long it had not been up to the correct rinsing temperature. 2. During an observation on 3/12/26 at 11:29 A.M., the following was observed: Cook 2 performed handwashing with a 10 second lather. Dietary Manager performed handwashing with a 7 second lather. Dietary Manager used a suction cup to pick up clean plates and set them on the bottom plate warmer. After the plate was placed on the plate warmer, she placed the suction cup (part that touched clean plates down) on the plate holder cart rather than on the next clean plate. Food was served on these plates. During an interview on 3/12/26 at 1:14 P.M., the Infection Preventionist indicated staff should lather (rubbing hands together) their hands for at least 20 seconds during handwashing. During an interview on 3/12/26 at 1:29 P.M., the Dietary Manager indicated the bottom of the suction cup used for picking up clean plates should go on the next clean plate instead of on the cart. On 3/13/26 at 9:20 A.M., a current non dated Prevent Foodborne Illness Policy was provided by the Administrator and indicated, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness . On 3/13/26 at 12:51 P.M., the Administrator provided a current non-dated dishwasher users manual that indicated a minimum and recommended rinse temperature of 180 degrees Fahrenheit. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2) 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications for 8 residents during a random observation of the medication carts. Medications, including narcotics, had been pre-prepared and held in medication cups in the medication cart prior to administration. Loose pills were observed in the medication cart. (Resident 40, Resident 43, Resident 2, Resident 3, Resident 10, Resident 30, Resident 54, Resident 47)Findings include:1. On 3/9/26 at 6:10 A.M., the medication cart for [NAME] Hall was observed. Registered Nurse (RN) 7 opened the top drawer and multiple medication cups were observed with pills in them. At that time, RN 7 indicated he had the medication cups set up for his 6:00 A.M. medication pass. The cups had the resident's first names on them and included the following:- Resident 40's cup contained the following narcotic- Buprenorphine HCl (a medication used to treat opiod use disorder) Sublingual Tablet 8 mg (milligrams) - Resident 43 contained the following narcotic- Norco (opioid pain medication) 5 mg-325 mg - Resident 2 contained the following narcotics- clonazepam (anti-anxiety) 0.5 mg, Norco 7.5 mg-325 mg - Resident 3 contained the following narcotic- Norco 5 mg-325 mg - Resident 10 contained the following narcotic- Oxycodone (opioid pain medication) 7.5 mg-325 mg - Resident 30 contained the following narcotic- Norco 7.5 mg-325 mg - Resident 54 contained the following narcotics- Norco 5 mg-325 mg, Lorazepam (anti-anxiety medication) 1 mg - Resident 47 contained the following narcotic- Lorazepam 0.5 mg 2. Three loose pills were observed in the [NAME] Hall medication cart. The pills were as follows:Amlodipine/olmesartan (blood pressure medication) 10mg-40mg Risperidone (anti-psychotic medication) 0.25 mgRisperidone 2 mg During an interview on 3/12/26 at 10:41 A.M., the Director of Nursing (DON) indicated narcotics had to be double locked in the locked narcotic box until given. During an interview on 3/13/26 at 8:27 A.M., Licensed Practical Nurse (LPN) 9 indicated loose pills should not be in the medication carts. If loose pills were found, they should be destroyed in drug buster liquid. On 3/13/26 at 9:20 A.M., the Administrator provided a non-dated Medication Labeling and Storage policy which indicated, Policy Interpretation and Implementation Medication Storage 1. Medication and biologicals are stored in packaging, containers or other dispensing systems in which they are received. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.7. Controlled substances (listed as Schedule II-V of the Comprehensive Dug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(m)410 IAC 16.2-3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure care and services were provided to a resident at risk to prevent pressure ulcers and promote the healing of existing pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. Skin assessments were not completed as ordered, specific care plans were not developed for pressure ulcers, and pressure ulcer healing interventions were not in place. (Resident 4)Findings include:On 3/11/26 at 8:36 A.M., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, debility and heart failure. The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/27/26, indicated no cognitive impairment, partial to moderate assistance (staff performs less than half the effort) needed for bed mobility, and was totally dependent on staff with toileting, showering, and transfers. The MDS assessment indicated three facility acquired stage 2 pressure ulcers. A current pressure ulcer care plan indicated:I have pressure ulcers to bilateral heels and potential for further pressure ulcer development, last revised 2/23/26. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Current physician orders included, but were not limited to: Right Heel: Paint with betadine. Float every day shift for wound care, dated 3/4/26. Left heel: Paint with betadine. Float every shift for prevention, dated 2/12/26. Weekly skin assessment every night shift every Monday, dated 8/4/25. The following Braden scale for predicting pressure ulcer risk evaluations were completed from 3/19/25 through 2/27/26 which indicate the resident was at high risk for pressure ulcers. Resident 4's Medication Administration Record (MAR) indicated, but was not limited to, the following weekly skin assessments: 8/18/25 existing area, intact (at that time, there were no documented skin areas and no dressings) 8/25/25 existing area, intact (at that time, there were no documented skin areas and no dressings) 9/15/25 not intact, new area (at that time, there was no documentation of a new skin area, but the resident did have a dressing to an area) 9/22/25 not intact (at that time, the resident did have a dressing to an area) 10/27/25 no weekly skin assessment completed 11/3/25 existing area (at that time, there were no documented skin areas) 11/10/25 no weekly skin assessment completed 11/17/25 existing area (at that time, there were no documented skin areas) 12/8/25 no existing area, intact (at that time, the resident had an unstageable pressure ulcer to the left heel with a dressing) 12/15/25 not intact (at that time, the resident did have a dressing to an area) 12/22/25 not intact (at that time, the resident did have a dressing to an area) 12/29/25 no weekly skin assessment completed 1/5/26 no existing area, intact (at that time, the resident had an unstageable pressure ulcer to the left heel with a dressing) 1/19/26 not intact (at that time, the resident did have a dressing to an area) 1/26/26 not intact (at that time, the resident did have a dressing to an area) 2/2/26 not intact (at that time, the resident did have a dressing to an area) 2/9/26 not intact (at that time, the resident did have a dressing to an area) 2/16/26 not intact (at that time, the resident did have a dressing to an area) 2/23/26 not intact, new area (at that time, the resident did have a dressing to an area, but no documentation of a new skin area) 3/2/26 not intact (at that time, the resident did have a dressing to an area) 3/9/26 not intact (at that time, the resident did have a dressing to an area) Pressure wound assessments included, but were not limited to, the following pressure ulcers: #1 Right HeelA right heel stage 2 pressure ulcer was identified on 8/29/25. A care plan for the right heel pressure ulcer was not developed. The area was healed on 9/30/25. The stage 2 right heel pressure ulcer developed again on 1/14/26. A care plan for bilateral heel pressure ulcers was developed on 1/15/26. A specific care plan for the right heel was not developed. The right heel had not been healed and was current. #2 Left HeelA left unstageable pressure ulcer was identified on 9/24/25 and healed on 9/30/25. A care plan for the left heel was not developed at that time. The unstageable left heel pressure ulcer developed again on 12/3/25. A care plan was developed for the left heel on 12/10/25. The area was healed on 2/3/26. The left heel pressure ulcer was developed again on 2/12/26, but no assessment on the area was completed until 2/18/26 and it was identified as a stage 2 pressure ulcer. The area was documented as not healed and current. On 3/11/26 at 10:04 A.M., Licensed Practical Nurse (LPN) 9 indicated Resident 4's left heel pressure ulcer had been healed the previous night, but not documented yet. At that time, Resident 4 was observed lying on his back in bed with a pillow under his calves with both heels hanging off of the pillow resting on the bed. The right heel pressure ulcer was observed to be open to air and was scabbed with surrounding redness, measuring 1cm (centimeter) x 0.8cm. There was no drainage. After observing the area, LPN 9 replaced the right heel on the mattress and did not adjust the pillow. At that time, LPN 9 indicated all nurses were responsible for doing the weekly skin assessments. She indicated there were three questions on each skin assessment that included existing, intact, and new. Existing was to be marked yes if there were any current skin areas including pressure ulcers, skin tears, bruising, etc. Intact was referring to any current dressings, and new would be marked yes if the nurse identified any new skin areas not previously identified. On 3/11/26 at 12:35 P.M., Resident 4 was observed lying in bed with a pillow under his right calf. The right heel was hanging off of the pillow and resting on the bed. At that time, LPN 9 lifted the right foot and then placed it back resting on the bed. The left leg was not elevated with leg and heel resting on the bed. On 3/12/26 at 1:59 P.M., the Director of Nursing (DON) indicated there was some confusion among staff as to what the intact meant on the resident MARs for the weekly skin assessments. Some thought it was referencing skin intact, and others were documenting if the dressing was intact. She also indicated that pressure ulcers in the same areas were placed on the same care plan, for example left and right heels, and was unaware that each area would need its own care plan. On 3/13/26 at 9:20 A.M., the Administrator provided a current non-dated Prevention of Pressure Injuries policy that indicated Monitor regularly for comfort and signs of pressure-related injury . Review the interventions and strategies for effectiveness on an ongoing basis On 3/13/26 at 9:20 A.M., the Administrator provided a current non-dated Pressure Ulcers/Skin Breakdown policy that indicated The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff used proper hand hygiene and wound care to help prevent the development and transmission of communicable diseases and infections for 1 of 2 observations of wound care and 1 of 1 observations of incontinence care. While packing a wound, the packing touched the incontinence pad under the resident. During hand washing, the lather time was 5-12 seconds. (Resident 30, Resident 5, CNA 2, LPN 3)Findings include:1. On 3/12/26 at 9:44 A.M., incontinence care performed by CNA 2 (assisted by CNA 16) was observed on Resident 5. CNA 2 washed her hands with a ten second lather and put on gloves. The resident had a bowel movement. She removed her soiled gloves and washed her hands with a seven second lather and put gloves on. She proceeded to perform care on the resident's buttocks. She removed her soiled gloves and washed her hands with a 12 second lather. She put gloves on and put a clean brief on the resident. CNA 2 removed her gloves after care was completed and washed her hands with a six second lather. 2. On 3/11/26 at 1:56 P.M., Licensed Practical Nurse (LPN) 3 changed the dressing on Resident 30's coccyx. LPN 3 knocked on Resident 30's door. Upon entering, she put on a gown and gloves and placed a clean trash bag on the bed. She had requested supplies from another staff member. She removed her gown and gloves to go get the supplies when the staff member knocked on the door with the supplies. She washed her hands and put on a clean gown and gloves. She placed a towel on the bedside table and placed supplies on the towel. The dressing had fallen off the wound. LPN 3 cleaned the area with wound cleaner and patted dry. She cut packing and placed it in a medicine cup. While using a cotton tipped swab to place the packing inside the wound, the end of the packing was touching the clean blue incontinence pad under the resident. After the packing was in the wound, the area was covered with a Telfa island dressing. LPN 3 removed the gown and gloves, removed the trash bag from the bed and tied it shut. She went into the bathroom to wash her hands and only lathered with soap for 5 seconds. During an interview on 3/12/26 at 2:14 P.M., the Infection Preventionist (IP) indicated staff should lather (rub hands together) for at least 20 seconds during handwashing and wound packing should not touch the bedding prior to being put into a wound. On 3/13/26 at 9:30 A.M., the Administrator provided an undated Handwashing/Hand Hygiene policy which indicated, Washing Hands .2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. 410 IAC 16.2-3.1-18(b)(1) 410 IAC 16.2-3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing forms were posted daily with the actual working hours of nursing staff during the survey for 5 of 5 days reviewed during the survey. The posted nurse staffing form was not updated over the weekend and the actual working hours of staff was not included on the form. (3/9/26, 3/10/26, 3/11/26, 3/12/26, 3/13/26) Finding includes:On 3/9/26 at 5:45 A.M., the posted nurse staffing form was observed at the nurse's station dated 3/7/26 and lacked the actual working hours of the nursing staff. During an interview on 3/13/26 at 9:42 A.M., the Scheduler indicated the posted nurse staffing should be put up by the nursing staff on the weekends, and they should do it around midnight for the day. She was not aware the actual working hours for nursing staff should be included on the posted nurse staffing form.On 3/13/26 at 11:42 A.M., the Administrator provided the posted nurse staffing forms for 3/9/26 through 3/13/26. At that time, the forms were reviewed and lacked the actual working hours of the nursing staff.On 3/13/26 at 10:42 A.M., a current non dated Posting Direct Care Daily Staffing Policy was provided by the Administrator and indicated, . Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location . The information recorded on the form shall include the following: g. The actual time worked during that shift for each category and type of nursing staff .

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 2 of 3 resident halls observed. Resident areas contained uneven floors, the main dining room contained an odor of cigarette smoke, resident rooms and restrooms were unkept, hall closet doorknobs were missing or were in disrepair, and duct tape was used to repair coved base and door trim. (East Hall, [NAME] Hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Resident B, Resident C, Resident D, Resident F, and Resident G)Findings include:1. During an observation on 12/9/25 at 10:30 A.M., Resident B was standing at the foot of the bed in room [ROOM NUMBER]. Resident B leaned over onto a bedside table and the table slid out from under him and caused the resident to lose his balance. A soft spot on the floor was observed at the foot of the bed which caused the floor to be uneven.During an observation on 12/9/25 at 10:40 A.M., a dip in the [NAME] Hall floor outside of room [ROOM NUMBER] caused the floor to be uneven. During an observation on 12/9/25 at 12:34 P.M. a dip in the East Hall floor outside of rooms [ROOM NUMBERS] caused the floor to be uneven. room [ROOM NUMBER] appeared to have a hump and then a dip in floor near the room door which caused the flooring to be coming up. room [ROOM NUMBER] contained an uneven floor with visible indentions in the floor where the floor was uneven. room [ROOM NUMBER] contained a dip in the flooring near the room door that caused the floor to be uneven. 2. During an observation on 12/9/25 at 12:30 P.M., multiple residents were smoking in a designated area just outside a set of double-doors that exited the main dining room. Light could be seen between and under the double-doors due to a gap and lack of weather stripping. The main dining area smelled strongly of cigarette smoke. During an observation on 12/11/25 at 11:10 A.M., Residents were smoking in the designated area just outside a set of double-doors that exited the main dining room. Light could be seen between and under the double-doors due to a gap and lack of weather stripping. The main dining area smelled of cigarette smoke. During an interview on 12/11/25 at 10:55 A.M., Resident C indicated the main dining room smells of cigarette smoke when the smokers are out smoking. 3. During an observation and interview on 12/9/25 at 2:00 P.M., Resident D was lying in bed in room [ROOM NUMBER]. A cup and lid were on next to the bed on the floor with a dark orange colored food or drink that had dried. Resident D indicated the spill was from her breakfast that morning and that staff had come into her room to remove her food tray but did not clean the spill. Resident D's shared restroom contained an uncovered specimen collection hat that was resting on the floor adjacent to the commode. During an interview on 12/10/25 at 12:10 P.M., Resident F indicated the shared restroom in room [ROOM NUMBER] was not cleaned well. During an interview on 12/11/25 at 9:50 A.M., Resident G indicated the resident restrooms are not cleaned well. 4. During an observation on 12/10/25 at 1:00 P.M. the [NAME] Hall linen closets near the far end of the hall was missing a doorknob that appeared to have been broken off. The [NAME] Hall activity closet door handle was bent downward and was in disrepair. The [NAME] Hall linen closet door near the nurse's station contained a doorknob that was loose and hanging away from the door. 5. During an observation on 12/11/25 at 9:20 A.M., room [ROOM NUMBER] on the [NAME] Hall had a small hole on the outside of the shared restroom. Two overhead lights contained a build-up of debris and dead insects trapped in the light cover. 6. During an observation and interview on 12/11/25 at 10:30 A.M., the coved base behind the room refrigerator in room [ROOM NUMBER] was duct taped to the wall. Resident H indicated there was a hole behind the cove base and mice were coming into the room over this past summer. Duct tape was then placed over the coved base to keep it sealed. During an observation on 12/11/25 at 10:45 A.M., the door trim around the restroom door was loose toward the base of the trim. A piece of duct tape was holding the base of the trim to the wall and was taped the door jamb.During an interview on 12/11/25 at 12:20 P.M., the Maintenance and Housekeeping Director indicated cove base for resident rooms had been ordered and that an outside source would be working on the uneven flooring. A resident had been known to break into the linen closets on the [NAME] Hall to retrieve towels but was no longer in the facility. During an interview on 12/11/25 at 12:40 P.M., the Facility Administrator indicated not having a policy related to the physical environment. A record review on 12/11/25 at 1:00 P.M. included an order update and shipping confirmation dated 12/20/25 indicated coved base was ordered on 12/9/25. This citation relates to intakes 2613157, 2615101, and 2627530.3.1-19(a)(4)3.1-19(f)(5)

Based on the interview and record review, the facility failed to update or revise the care plan for 1 of 3 residents reviewed for advance directives. A resident's code status was not updated in the plan of care. (Resident B)Finding includes:During record review on [DATE] at 10:05 A.M., Resident B's Advance Directive Form, dated [DATE], indicated the resident chose Do Not Attempt Resuscitation (DNR) should the resident have no pulse and stop breathing.Resident B's care plan included, but was not limited to, Resident is a Full Code - Attempt Cardiopulmonary Resuscitation (CPR) (initiated [DATE] and revised and canceled on [DATE]) with the goal; if the resident's heart/breathing stops, please start CPR through the target date [DATE] (Cancelled [DATE]).Resident B's nurses' progress notes included, but were not limited to: [DATE] at 2:37 P.M. - Resident B's date of death [DATE]. Time of death 2:37 P.M.During an interview on [DATE] at 11:00 A.M., the Social Service Director (SSD) indicated a change of code status should be uploaded into the resident's record and the plan of care should be updated at that time. On [DATE] at 11:15 A.M., the Director of Nursing (DON) supplied an undated facility policy titled, Advanced Directives. The policy included, .If the Resident Has an Advanced Directive . 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . 8. Changes or revocations of a directive must be submitted in writing to the administrator . The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan .This citation relates to Intake 2618600.3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and ensure residents were free from accident hazards for 1 of 3 resident reviewed for smoking. Resident areas contained a cigarette smoke odor and a resident indicated smoking in his room without supervision and against facility policy. (West Hall, Resident C) Finding includes:During an observation on 10/6/25 at 12:00 P.M., the back of [NAME] Hall contained an odor of cigarette smoke. During an observation on 10/7/25 at 9:35 A.M., the back of [NAME] Hall contained an odor of cigarette smoke. During a confidential interview, a resident indicated being aggravated that Resident C did not adhere to the facility's smoking rules and smoked in his room. During an observation and interview on 10/7/25 at 9:40 A.M., Resident C was sitting up on his bed in his room. Resident B indicated that Resident C had smoked cigarettes in his room the night prior. During an interview on 10/7/25 at 9:45 A.M., QMA 4 indicated residents were not allowed to smoke in the facility and that residents should not have cigarettes or a lighter in their possession. Smokers are given their cigarettes during designated smoking times in the smoking area while they are supervised by a staff member. During record review on 10/7/25 at 10:00 A.M., Resident C's diagnoses included but were not limited to tobacco use, nicotine dependence, chronic obstructive pulmonary disease (COPD), polyneuropathy, and unspecified mental disorder. Resident C's most recent quarterly minimum data set (MDS) assessment, dated 9/4/25, indicated the resident had no cognitive impairment. Resident C's most recent smoking safety assessment, dated 8/26/25, indicated the resident used tobacco and the resident had burn marks on his skin/clothing/or furniture. The smoking assessment indicated supervision, designated smoking areas, and smoking times were determined by facility policy. Resident C's nurses' progress notes included, but were not limited to:9/10/25 at 8:16 A.M. - Resident smoking in his bathroom. The resident had taken cigarette butts from the ashtray outside. 9/11/25 at 11:47 A.M. - Resident again with smoking items and smoking in the facility. On 10/7/25 at 11:15 A.M., the Director of Nursing (DON) supplied an undated facility policy titled Smoking Policy - Residents. The policy included, This facility has established and maintains safe resident smoking practices . 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building . Smoking is not allowed inside the facility under any circumstances . 12. All smoking materials are to be kept at the nurse's station and will be distributed at each designated smoke time .This citation relates to intake 2618600.3.1-45(a)(1)

Based on interview and record review, the facility failed to implement ordered treatment for a rectal fissure for 1 of 3 residents reviewed for skincare. This deficient practice resulted in the resident being hospitalized with severe sepsis and a necrotizing soft tissue infection. (Resident C)Finding includes:During record review on 8/13/25 at 10:00 A.M., Resident C's diagnoses included, but were not limited to, type II diabetes, irritable bowel syndrome with constipation, and overactive bladder. Resident C's most recent annual Minimal Data Set (MDS) assessment, dated 4/29/25, indicated the resident had no cognitive impairment, was always incontinent of bowel and bladder, and required substantial assistance with toileting hygiene. Resident C's physician orders included but were not limited to; 2-BAD Cream Baclofen/Diltiazem/Amitriptyline topical: apply to hemorrhoids twice a day to reduce inflammation/pain related to rectal fissure (started 3/20/25 and discontinued 7/28/25). (Diltiazem ointment is used to promote the healing of anal fissures by relaxing the anal sphincter muscle, reducing pressure, and increasing blood flow to the affected area, facilitating healing and pain relief.)Resident C's nurse's progress notes included but were not limited to;6/9/225 at 1:40 P.M. - Received a call from pharmacy stating Baclofen for the 2-BAD cream is on back order and would not be available until 7/26/25. Call placed to physician's office to inform and request further treatment orders. Office nurse to confer with on call physician as resident's physician is on vacation. 6/20/25 at 8:55 A.M. - Call placed to surgical facility related to 2-BAD cream on hold due to Baclofen being on back order until 7/26/25. Requesting a potential substitute.Resident C's Medication Administration Record/ Treatment Administration Record (MAR/TAR) for the months of June and July, 2025 indicated the resident did not receive the prescribed 2-BAD cream and no new treatment orders were obtained to treat the rectal fissure. A bowel and bladder program assessment completed 7/27/25 indicated the resident was always bladder and was incontinent of bowel daily. The skin of the genital, perineal, and buttocks showed no redness and other predisposing factors were present but treatable and under control. Resident C's hospital admission history and physical, dated 7/29/25 at 1:36 P.M., indicated the resident's reason for admission included, Left perianal abscess/possible Fournier's gangrene with sepsis.A skin assessment indicated, Erythema (redness) around the sacrum with tracking lesion.Findings suspicious for Fournier's gangrene possibly related to a left perianal abscess.Hospital provider notes dated 7/29/25 at 1:53 P.M., indicated a genitourinary assessment during a physical exam included a rectal exam with small opening above anus with purulent bloody drainage expressed, dusky appearing tissue over gluteal cleft without visible perineal extension. A final impression included severe sepsis and necrotizing soft tissue infection. During an interview on 8/14/25 at 11:45 A.M., LPN 9 indicated if a prescribed treatment was unavailable from the pharmacy, the physician should be notified to obtain a substitute treatment. During an interview the Director of Nursing on 8/14/25 at 11:55 A.M., indicated if a physician did not return a call for a requesting order, she would continue attempting to reach the physician until an order was obtained and would document all attempts to contact the physician. On 8/14/25 at 12:35 P.M., the Facility Administrator supplied an undated facility policy, titled Administering Medications. The policy included, .2. The director of nursing services supervised and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders. 24. Topical mediations use in treatments are recorded on the resident's treatment record (TAR). A facility policy titled, Non-Control Medication Order Requirements, dated 1/26/24 was also supplied. The policy included, Medications are dispensed from the pharmacy only upon the clear, complete, and signed telephone order by the nurse receiving or on behalf of the prescriber. E. The prescriber (or nurse on duty) is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available.This citation relates to complaints 2576910 and 2575830. 3.1-35(g)(1)3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine treatments for 1 of 3 residents reviewed for pharmaceutical services. A facility did not have a treatment on hand and could not provide proof that the treatment (ointment) had been delivered by the pharmacy. (Resident C) Finding include: During an interview on 5/21/25 at 12:50 P.M., Resident C indicated that he typically received his ordered medications, however he had not been receiving a routine hemorrhoid cream and had asked for multiple times. During record review, Resident C's diagnoses included, but were not limited to, anxiety, irritable bowel syndrome, and hypertension. Resident C's physician orders included but were not limited to; 2-BAD Cream Baclofen/Diltiazem/Amitriptyline topical: apply to hemorrhoids twice a day to reduce inflammation/pain related to rectal fissure (started 3/20/25). During an interview on on 5/21/25 at 1:00 P.M., the Assistant Director of Nursing (ADON) indicated Resident C's hemorrhoid cream was not in the medication cart but should be in the treatment cart on the front hall of the building. The ADON indicated that she had not administered the resident's routine dose yet that shift. The ADON then searched the treatment cart and could not locate the resident's hemorrhoid cream. During an interview on 5/21/25 at 1:45 P.M., the Director of Nursing (DON) indicated she was unable to locate a pharmacy delivery receipt for Resident C's ordered hemorrhoid cream. On 5/21//25 at 1:25 P.M., the Facility Administrator supplied an undated facility policy titled, Medication and Treatment Orders. The policy included, .11. Drugs and biologicals that are required to refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available . This citation relates to complaint IN00459395. 3.1-25(a)

Based on interview and record review, the facility failed to ensure residents were free from misappropriation for 1 of 1 residents reviewed for misappropriation. A resident's debit card was taken without consent and used by staff to make multiple unauthorized purchases. (Resident D) Finding includes: During a review of facility reported incidents on 5/21/25 at 11:15 A.M., an incident dated 5/2/25, indicated Resident D contacted local police to report a stolen debit card. Resident D identified on a bank statement several unauthorized transactions. The local police reviewed surveillance footage from the locations where the unauthorized purchases were made that showed CNA 13 had been responsible for the transactions. CNA 13 was placed on suspension during an investigation. During a review of the facility's investigation into the incident on 5/21/25 at 11:30 A.M., a facility grievance form, dated 4/30/25, indicated Resident D had a bank statement with unknown charges. Resident D claimed someone used her debit card without her permission. An undated and unsigned, typed, note in the facility investigation indicated on 5/1/25 at approximately 7:00 P.M., Resident D stated she was missing her entire wallet, however a few a items from the wallet were located on her bed. The local police department were called and arrived to the facility. On 5/5/25, a local police detective indicated that CNA 13 was observed on camera with Resident D's debit card. During record review on 5/21/25 at 11:50 A.M., Resident D's diagnoses included, but were not limited to, dementia, anxiety, depression, and psychotic disorder. Resident D's most recent quarterly minimum data set (MDS) assessment, dated 4/8/25, indicated the resident had moderate cognitive impairment. During an interview on 5/21/25 at 12:35 P.M., Resident D indicated she had placed her purse at the foot of her bed and fell asleep, when she woke, her wallet and debit card was missing. Resident D indicted she called the local police to report the stolen wallet. She later reviewed a bank statement and noticed several unauthorized purchases made with her debit card. Resident D was unable to determine the total sum of fraudulent purchases, but indicated there were multiple transactions at a local gas station and a paid phone bill that was not hers. During an interview on 5/21/25 at 11:40 A.M., the Facility Administrator indicated the facility did not have a written policy related to shopping or making purchases for residents. The Facility Administrator indicated the CNA's and nursing staff were not permitted to make purchases for residents, and that only department heads or the facility Activity Director could make purchases on a resident's behalf, with the resident's permission. On 5/19/25 at 11:55 A.M., the Facility Administrator supplied an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. The policy included, All reports of . theft/misappropriation of resident property are reported to local, state and federal agencies . 3.1-28(a)

Based on interview, and record review, the facility failed to ensure the physicans orders were thoroughly followed and documented when completed for 2 of 3 residents reviewed for nursing services related to wound care. Routine dressing changes and skin assessments were not completed per the physician's orders. (Resident F, Resident G) Findings include: 1. During record review on 5/21/25 at 9:15 A.M., Resident F's diagnoses included, but were not limited to peripheral vascular disease, morbid obesity, and lymphedema. Resident F's most recent admission MDS (Minimum Data Set) dated 3/12/25, indicated the resident had one unhealed venous ulcer. Resident F's physician orders included, but were not limited to, Right dorsal lateral foot: Cleanse with wound cleanser and pat dry, Apply collagen moistened with sodium chloride to wound bed. Cover with bordered foam dressing and apply three layer compression wrap every day shift, Monday, Wednesday, and Friday (started 5/9/25 and discontinued on 5/15/25), Right dorsal lateral foot: Cleanse with wound cleanser. Place collagen dressing as filler to wound bed. cover with alginate dressing. Cover with abdominal pad. Cover with absorbent wound dressing. Wrap with Kerlix (medical gauze). Apply medical tape, then wrap with four layer compression wrap. Wear post-operative shoe for offloading of wound. To bed done three times a week every day shift, every Monday, Wednesday, and Friday (started 5/15/25), Right medial foot: Cleanse area and peri-wound with wound cleanser, apply alginate border dressing every Monday, Wednesday, and Friday (discontinued 5/15/25), Right dorsal mid-foot: Cleanse area with wound cleanser, cover with Mepilex Transfer (wound dressing), cover with gauze, cover with abdominal pad, wrap with Kerlix and apply medical tape. Wrap with four layer compression wrap. Wound to be offloaded with post operative shoe. Three times a week, every Monday, Wednesday, and Friday (started 5/16/25), and weekly skin assessment every day shift, every Thursday. Resident F's care plan included, but was not limited to, resident has surgical wound on top/dorsal side of foot (initiated 4/19/25) with an intervention of; provide treatment as ordered. Resident F's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2025 lacked documentation indicating the resident received the following orders on the following dates and times: Right dorsal lateral foot: Cleanse with wound cleanser and pat dry, Apply collagen moistened with sodium chloride to wound bed. Cover with bordered foam dressing and apply three layer compression wrap every day shift, Monday, Wednesday, and Friday (started 5/9/25 and discontinued on 5/15/25) - not completed Monday 5/12/25. Right dorsal lateral foot: cleanse with wound cleanser. Place collagen dressing as filler to wound bed. cover with alginate dressing. Cover with abdominal pad. Cover with absorbent wound dressing. Wrap with Kerlix (medical gauze). Apply medical tape, then wrap with four layer compression wrap. Wear post-operative shoe for offloading of wound. To bed done three times a week every day shift, every Monday, Wednesday, and Friday (started 5/15/25) - not completed Monday 5/19/25. Right medial foot: Cleanse area and peri-wound with wound cleanser, apply alginate border dressing every Monday, Wednesday, and Friday (discontinued 5/15/25) - not completed Friday 5/2/25 and Monday 5/12/25. Right dorsal mid-foot: Cleanse area with wound cleanser, cover with Mepilex Transfer (wound dressing), cover with gauze, cover with abdominal pad, wrap with Kerlix and apply medical tape. Wrap with four layer compression wrap. Wound to be offloaded with post operative shoe. Three times a week, every Monday, Wednesday, and Friday (started 5/16/25) - not completed Monday 5/19/25. Weekly skin assessment every day shift, every Thursday - not completed Thursday 5/8/25. 2. During record review on 5/21/25 at 10:00 A.M., Resident G's diagnoses included, but were not limited to pressure ulcer to right heel, type II diabetes, and edema. Resident G's most recent admission MDS (Minimum Data Set) dated 4/11/25, indicated the resident admitted to the facility with one unhealed stage IV pressure wound. Resident G's physician orders included, but were not limited to; Right Heel: Cleanse with wound cleanser, pat dry. Cover with bordered gauze dressing, initial and date every day shift for wound care (started 4/11/25 and discontinued 4/19/25), Right Heel: Cleanse with wound cleanser, pat dry. Cover with bordered gauze dressing. Initial and date every day shift for wound care (started 4/20/25 and discontinued 5/20/25), and Check placement of dressing to right heel every shift and replace if not present every shift (started 4/19/25). Resident G's care plan included, but was not limited to; resident has ulcer of the right foot/heel (initiated 4/16/25). Interventions included, but were not limited to, monitor placement of dressing every shift. Replace if soiled/dislodged, and provide treatment as ordered. Resident G's MAR/TAR for April and May 2025 lacked documentation that indicated the resident received the following orders on the following dates: Right Heel: Cleanse with wound cleanser, pat dry. Cover with bordered gauze dressing, initial and date every day shift for wound care (started 4/11/25 and discontinued 4/19/25) - not completed 4/11/25, 4/15/25, and 4/19/25. Right Heel: Cleanse with wound cleanser, pat dry. Cover with bordered gauze dressing. Initial and date every day shift for wound care (started 4/20/25 and discontinued 5/20/25) - not completed 4/20/25, 4/21/25, 4/29/25, 4/30/25, 5/4/25, 5/12/25, and 5/18/25. Check placement of dressing to right heel every shift and replace if not present every shift (started 4/19/25) - 4/20/25 (day shift), 4/21/25 (day shift), 4/29/25 (day shift), 4/30/25 (day shift), 5/4/25 (day shift), 5/12/25 (day shift), 5/14/25 (nightshift), and 5/18/25 (day shift). During an interview on 5/21/25 at 12:30 P.M., the Director of Nursing (DON) indicated some of the uncompleted treatment orders were due to the resident having an order completed by an outside source, however could not provide a rational for not providing all treatment orders. During an interview on 5/21/25 at 1:20 P.M., LPN 4 indicated a residents routine treatment orders should be documented as completed in the resident's record or if the treatment was not provided, a reason should be documented. On 5/21/25 at 1:25 P.M., the Facility Administrator provided an undated facility policy titled, Medication and Treatment Orders. The policy included, Orders for medications and treatments will be consistent with principles of safe and effective order writing. This Federal tag relates to complaint IN00458151. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision, and a secure environment was provided to prevent a resident with dementia from exiting the facility and leaving the property for 1 of 3 residents reviewed for elopement risk. This deficient practice resulted in an elopement that occurred during the early morning hours on 3/15/25 after being last seen by facility staff at approximately 2:00 A.M. A resident exited the facility through an unsecured window and was not realized to be missing until approximately 5:00 A.M. The resident was located by local law enforcement at approximately 6:00 A.M. in a field near the facility wet and shivering and required hospitalization . (Resident C) Finding includes: During record review on 3/26/25 at 9:10 A.M., Resident C's diagnoses included, but were not limited to dementia, anxiety disorder, schizoaffective disorder, and heart failure. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/17/25, indicated the resident had severe cognitive impairment, could walk 10 feet with partial to moderate assistance, and could walk 50 feet with substantial to maximal assistance. A risk for elopement assessment, completed 1/15/25, indicated Resident C was not at risk for elopement. Resident C's care plan included but was not limited to, resident had late loss Activity of Daily Living (ADL) self-care performance deficit due to dementia (initiated 10/17/24) with an intervention of resident required assistance with bed mobility. Resident C had impaired cognitive function/thought processes related to dementia (initiated 2/25/25) with an intervention of cue, reorient, and supervise as needed. Resident at risk for elopement (initiated 3/24/25). Resident C's physician orders included, but were not limited to, turn and reposition every two hours for prevention every shift (started 10/10/24). Resident C's progress notes included, but were not limited to: (A previous note was dated 3/12/25 with no other documentation made prior to the note on 3/15/25 at 6:36 A.M. in the resident's record.) 3/15/25 at 6:36 A.M. - Resident sent out to hospital for evaluation and treatment. 3/15/25 at 11:29 A.M. - Resident admitted to the hospital with altered mental status. 3/21/25 at 3:13 P.M. - Resident was admitted to hospital (on 3/15/25) with altered mental status and urinary tract infection (UTI). Facility to pick up from hospital around 4:00 P.M. During an observation on 3/26/25 at 9:30 A.M., Resident C was sitting on the couch in a common area near the back hall nurse's station watching television. During an interview on 3/26/25 at 9:40 A.M., CNA 2 indicated Resident C could walk without assistance but was not always steady. Resident C often kept to himself and had not displayed any behaviors of wandering or exit seeking that she was aware of. During an interview on 3/26/25 at 9:55 A.M., Police Sergeant 4 indicated that Resident C had exited the facility during the morning hours of 3/15/25. Resident C had apparently slipped out of a window of the facility, crossed a ditch on the facility property and then fell and was found by police lying on the ground near a neighboring middle school, in the rain. During an interview on 3/26/25 at 10:10 A.M., LPN 6 indicate that she worked the morning of 3/15/25 but was late arriving to work due to the bad weather during the morning hours of 3/15/25. LPN 6 indicated that she had received a report from Resident C's night shift nurse and was told the resident had been sent to the hospital for altered mental status. LPN 6 indicated she was not aware of anything unusual that occurred during the night shift morning hours of 3/15/25 and that Resident C did not have any history of exit seeking or elopements. During an interview on 3/26/25 at 10:25 A.M., Police Sergeant 4 indicated that Emergency Medical Services (EMS) was called to the scene the morning of 3/15/25, after Resident C was located in the rain, shivering. A local police report, dated 3/15/25 at 5:57 A.M., indicated an officer was dispatched in reference to a person down in the grass. An officer arrived at the scene to find Resident C with his clothes completely wet. The facility called and indicated that Resident C was a resident at the facility. EMS was called due to the unknown timeframe of which the resident was outside, cold and wet. The facility staff indicated that Resident C was last seen during a 2:00 A.M. bed check. Staff then noticed the resident was missing around 5:00 A.M. Staff never called for police on a missing person. A local weather search indicated, at 3:00 A.M., the area received heavy rain and wind gusts from 14 to 23 miles per hour. During an interview on 3/26/25 at 10:55 A.M., the Facility Administrator indicated that she was notified by the night shift nurse on 3/15/25 that Resident C was missing and then had been found by local police outside of the facility. The Facility Administrator indicated that Resident C was found on facility property and that the night nurse had called the local police department after being unable to locate the resident in or around the facility. Resident C was then sent to the hospital for a change in mental status. The resident had been able to slip out of a bedroom window after construction crews had removed the screws that secured the windows while doing repairs in the facility to vent the facility during the construction. It was not known that the bedroom window was unsecured. During a review of Resident C's Emergency Department Medical Doctor (MD) exam, dated 3/15/25 at 7:06 A.M., indicated Resident C presented via EMS. Resident C apparently eloped from a nursing facility and was found lying in a football field in the rain. During an interview on 3/27/25 at 8:25 A.M., RN 10 indicated that Resident C had eloped from the facility on the morning of 3/15/25 and was found by local police. Resident C was last seen by staff around 2:00 A.M. during a bed check. RN 10 could not recall the exact time but being notified that the resident was not in his room, a search was initiated inside and outside of the facility. RN 10 notified the Facility Administrator and was told to call the local police department. RN 10 indicated he called the police to report the missing resident, and the police called the facility shortly after to alert them that the resident was found outside of the building. During an interview on 3/27/25 at 8:50 A.M., CNA 8 indicated she was the staff member that realized Resident C was not in his room during the early morning hours of 3/15/25. CNA 8 indicated Resident C was observed in his room during the 2:00 A.M. bed check. During a bed check at around 5:00 A.M., CNA 8 observed that Resident C's room had been rearranged, and the resident was not in his room. CNA 8 indicated a window in the room was opened, but was not completely open and it was not obvious at the time that the resident may have gone out the window. CNA 8 immediately notified the nurse, and staff began checking all rooms and closets on the unit. Staff then searched in and around the entire building until the local police notified them that the resident had been found. During an interview on 3/27/25 at 9:30 A.M., the Facility Administer indicated she was called by RN 10 at 5:46 A.M. and notified that Resident C was missing. The Facility Administrator instructed RN 10 to call the local police. At 6:12 A.M., RN 10 called to notify the Facility Administrator that Resident C had been located by the local police. On 3/26/25 at 2:05 P.M., the Facility Administrator supplied an undated facility policy titled Wandering and Elopements. The policy included, .3. If a resident is missing, initiate the elopement/missing resident emergency procedure: .b. initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials . f. document relevant information in the resident's medical record. This citation relates to complaint IN00456171. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 of 3 residents reviewed for elopement risks. Resident records contained no documentation of an elopement event, and the Medication Administration Records (MAR) was documented inaccurately. (Resident C) Findings includes: 1. During record review on 3/26/25 at 9:10 A.M., Resident C's diagnoses included, but were not limited to dementia, anxiety disorder, schizoaffective disorder, and heart failure. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/17/25, indicated the resident had severe cognitive impairment, could walk 10 feet with partial to moderate assistance, and could walk 50 feet with substantial to maximal assistance. A risk for elopement assessment completed 1/15/25 indicated Resident C was not at risk for elopement. Resident C's care plan included but was not limited to, resident at risk for elopement (initiated 3/24/25). Resident C's progress notes included, but were not limited to: (A previous note was dated 3/12/25 with no other documentation made prior to the note on 3/15/25 at 6:36 A.M. in the resident's record.) 3/15/25 at 6:36 A.M. - Resident sent out to hospital for evaluation and treatment. During an interview on 3/26/25 at 10:55 A.M., the Facility Administrator indicated that she was notified by the night shift nurse on 3/15/25 that Resident C was missing and then had been found by local police outside of the facility. The Facility Administrator indicated that Resident C was found on facility property and that the night nurse had called the local police department after being unable to locate the resident in or around the facility. Resident C was then sent to the hospital for a change in mental status. During an interview on 3/27/25 at 8:25 A.M., RN 10 indicated that Resident C had eloped from the facility on the morning of 3/15/25 and was found by local police. Resident C was last seen by staff around 2:00 A.M. during a bed check. RN 10 could not recall the exact time but being notified that the resident was not in his room, a search was initiated inside and out of the facility. RN 10 notified the Facility Administrator and was told to call the local police department. RN 10 indicated he called the police to report the missing resident, and the police called the facility shortly after to alert them that the resident was found outside of the building. RN 10 indicated no documentation was made in the record regarding the elopement or notification to the police department. On 3/26/25 at 2:05 P.M., the Facility Administrator supplied an undated facility policy titled Wandering and Elopements. The policy included, .3. If a resident is missing, initiate the elopement/missing resident emergency procedure: .f. document relevant information in the resident's medical record. 2. During an interview on 3/26/25 at 11:15 A.M., QMA 14 indicated she had worked the day of 3/15/25 and had received a report from RN 10 that Resident C had been sent out to the hospital during the night shift. During record review on 3/26/25 at 2:30 P.M., Resident C's Medication Administration Record (MAR) for the month of March, 2025, documentation indicated that Resident C received the following medications during the 7:00 A.M., medication pass, signed by QMA 14: Aspirin 81 milligrams (mg) (started 10/11/24) documented as administered on 3/15/25 at 7:00 A.M. Depakote Sprinkles 125 mg (started 10/10/24) documented as administered on 3/15/25 at 7:00 A.M. Famotidine 20 mg (started 10/11/24) documented as administered on 3/15/25 at 7:00 A.M. GlycoLax oral powder 17 grams (started 2/10/25) documented as administered on 3/15/25 at 7:00 A.M. Metoprolol succinate extended release 25 mg (started 10/11/24) documented as administered on 3/15/25 at 7:00 A.M. Quetiapine fumarate 125 mg (started 2/19/25) documented as administered on 3/15/25 at 7:00 A.M. Senna-docusate sodium 8.6-50 mg (started 10/11/24) documented as administered on 3/15/25 at 7:00 A.M. Seroquel 25 mg (started 2/20/25) documented as administered on 3/15/25 at 7:00 A.M. During an interview on 3/27/25 at 11:35 A.M., QMA 10 indicated that Resident C was not in the building on 3/15/25 at 7:00 A.M., and that the medications had been documented as administered in error. QMA 10 indicated she would correct the record to show the resident was in the hospital at that time. This citation relates to complaint IN00456171. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure development and implementation of a comprehensive person-centered care plan for each resident for 4 of 17 residents reviewed for care plans. A resident lacked a care plan for antidepressant use, and current care plan interventions were not followed. (Resident 4, Resident 54, Resident 23) Findings include: 1. On 1/22/25 at 1:20 P.M., Resident 4 was observed lying in bed. A call light was observed lying on the floor just under the bed, out of the resident's reach. On 1/23/25 at 9:13 A.M., Resident 4 was observed lying in bed. A call light was observed lying on the floor beside the bed, out of the resident's reach. On 1/23/25 at 12:19 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, depression and schizophrenia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/12/25, indicated no cognitive impairment and no behaviors. Resident 4 required staff supervision with eating, bed mobility, and transfers. A current risk for falls care plan, dated 10/14/24, indicated an intervention to keep call light and frequently used personal items within reach , last revised 10/14/24. On 1/29/25 at 9:57 A.M., Certified Nurse Aide (CNA) 9 indicated Resident 4's call light should have been in reach at all times as the resident did use it. 46416 2. On 1/27/25 at 1:49 P.M., Resident 54's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, and depression. The most recent Admission Minimum Data Set (MDS), dated [DATE], indicated Resident 54's cognition was severely impaired and received an antidepressant. Current physician's orders included, but were not limited to, the following: mirtazapine (antidepressant) 7.5 milligram tablet, take one tablet by mouth at bed time for mood stabilization, ordered 12/25/24 Resident 54's clinical record lacked a care plan related to taking an antidepressant. During an interview on 1/29/25 at 9:21 A.M., the MDS Coordinator indicated she was responsible for developing resident care plans for medications received except for antipsychotics. She indicated if a resident was on a medication they should have a care plan for that medication. 46882 3. On 1/27/25 at 10:53 A.M., Resident 23 was observed to be out of the room, the bed was in the middle of her side of the room, had wheels on it, and no fall mat was observed in the room. On 1/28/25 at 10:01 A.M., Resident 23's bed was not next to the wall, wheels were on bed, and no landing mat was observed in the room. On 1/23/25 at 10:33 A.M., Resident 23's clinical records were reviewed. Diagnoses included, but were not limited to chronic obstructive pulmonary disease, Parkinson's disease with dyskinesia, vascular dementia with other behavioral disturbance, and fracture of right wrist and hand. The most current Quarterly Minimum Data Set (MDS) assessment, dated 11/27/24, indicated Resident 23 had moderate cognitive impairment, required supervision or touching assistance for eating, bed mobility, and transfers, and partial/moderate assistance for toilet use. Current care plans included, but were not limited to: Risk for falls due to medication usage, need for assistance with adls (activities of daily living), variable need for assistive device when ambulating, Parkinson's Disease, she had poor safety awareness and was impulsive, revised 1/23/2025. Interventions included, but were not limited to the following: Keep wheel chair next to bed, initiated 1/14/25 Assistive device rolling walker as needed, initiated 12/24/24 Bed in lowest position, initiated 1/2/25 Encourage to allow staff to assist with toileting needs, initiated 12/24/24 Encouraged to allow staff to assist with clothing and not put it up herself, initiated 12/24/2024 Landing mat at bedside, initiated 1/2/25 Occupational therapy to evaluate for wheelchair positioning. Pommel cushion added, initiated 1/2/25 Remove wheels from bed to lower bed for ease of transfers, initiated 12/24/24 On 1/28/25 at 2:00 P.M., Licensed Practical Nurse (LPN) 5 indicated Resident 23's bed should have been against the wall, the head of the bed should have been against the wall at the top and the left side. She indicated she was unsure if the wheels were supposed to be on the bed, but that when the resident moved rooms, the bed was probably not moved with her. LPN 5 indicated they were supposed to move the fall interventions with the resident when they moved rooms. On 1/29/25 2:10 P.M., the Director of Nursing (DON) provided an undated Care Plans, Comprehensive Person-Centered policy which indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 3.1-35(a) 3.1-35(b)(1) 3.1-35(c)(1) 3.1-35(g)(2)

Based on interview and record review, the facility failed to facilitate care plan meetings with the resident and/or resident representatives for 5 of 6 random clinical records reviewed for care plan conferences and 1 of 5 residents reviewed for unnecessary medications. A newly admitted resident did not have an initial care plan conference and other residents care plan conferences were not held quarterly. (Resident 260, Resident 11, Resident 35, Resident 26, Resident 3, Resident 30) Findings include: 1. On 1/28/25 at 8:09 A.M., Resident 260's clinical record was reviewed. Resident 260 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), schizophrenia, and alcohol dependence with alcohol induced persisting dementia. Resident 260's clinical record lacked a care plan conference since admission. 2. On 1/27/25 at 1:11 P.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, COPD, dementia with behaviors, schizophrenia, Parkinson's disease, and mild intellectual disorder. Resident 11's clinical record indicated the most recent care plan conference was 8/2/24. 3. On 1/27/25 at 8:19 A.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, COPD, and dementia with behaviors. Resident 35's clinical record indicated the most recent care plan conference was 8/6/24. 46882 4. On 1/27/25 at 11:15 A.M., Resident 3's clinical record was reviewed. Resident 3 was admitted on [DATE]. Diagnoses included, but were not limited to acute on chronic systolic (congestive) heart failure, fracture of unspecified lumbar vertebra, chronic kidney disease stage 3B, retention of urine, Type 2 diabetes mellitus without complications. Resident 3's clinical record indicated the most recent care plan conference was 7/26/24. 5. On 1/22/25 at 1:16 P.M., Resident 26's clinical records were reviewed. Resident 26 was admitted on [DATE]. Diagnoses included, but were not limited to disorder of bone density and structure, hereditary and idiopathic neuropathy, spinal stenosis, lumbar region with neurogenic claudication, achondroplasia, and neuromuscular dysfunction of bladder. Resident 26's clinical record indicated the most recent care plan conference was 8/2/24. 6. On 1/27/25 at 9:06 A.M., Resident 30's clinical records were reviewed. Resident 30 was admitted on [DATE]. Diagnoses included, but were not limited to schizophrenia, obstructive sleep apnea, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, severe, with psychotic features, and dementia, severe, with psychotic disturbance. Resident 30's clinical record indicated the most recent care plan conference was 7/26/24. During an interview on 1/29/25 at 9:01 A.M., the Social Services Director (SSD) indicated she was responsible for scheduling care plan conferences and they should have been done quarterly. On 1/29/25 at 1:10 P.M., the Director of Nursing (DON) provided a current undated Care Plans, Comprehensive Person-Centered policy which indicated .12. The interdisciplinary team reviews and updates the care plan: .d. at least quarterly, in conjunction with the required quarterly MDS assessment . 3.1-3(n)(3) 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure accuracy of assessments for 6 of 17 resident records reviewed during the survey. Minimum Data Set (MDS) assessments did not accurately reflect resident status. (Resident 31, Resident 20, Resident 6, Resident 23, Resident 30, Resident 40) Findings include: 1. On 1/23/25 at 9:25 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, depression and anxiety. The most recent Quarterly MDS assessment, dated 12/9/24, indicated no cognitive impairment and diuretic use. The assessment indicated Resident 31 had not received an opioid or an antiplatelet. Current physician orders included, but were not limited to: Aspirin (an antiplatelet) 81mg (milligrams) once a day, dated 8/20/24. Oxycodone-Acetaminophen (an opioid) 7.5-325mg every 12 hours as needed for pain, dated 8/18/24. Resident 31's Medication Administration Record (MAR) for December 2024 indicated during the MDS look back period, a diuretic had not been given, aspirin was administered daily, and oxycodone-acetaminophen was administered once on 12/6/24 at 10:02 A.M. 2. On 1/23/25 at 8:15 A.M., Resident 20's clinical record was reviewed. Diagnosis included but was not limited to, intellectual disability. The most recent Annual MDS assessment, dated 8/7/24, indicated a level 2 Preadmission Screening and Resident Review (PASARR) had not been completed for Resident 20. A level 2 PASARR was completed on 7/25/23. 3. On 1/23/25 at 8:27 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, major neurocognitive due to Parkinson's and Bipolar disorder. The most recent Admission MDS assessment, dated 7/8/24, indicated a level 2 Preadmission Screening and Resident Review (PASARR) had not been completed for Resident 6. A level 2 PASARR was completed on 12/20/23. 4. On 1/23/25 at 8:36 A.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, major depression and psychotic disorder. The most recent Annual MDS assessment, dated 1/27/24, indicated a level 2 Preadmission Screening and Resident Review (PASARR) had not been completed for Resident 23. A level 2 PASARR was completed on 9/23/21. 5. On 1/23/25 at 8:42 A.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, Bipolar disorder, Schizophrenic disorder, and adjustment disorder. The most recent Annual MDS assessment, dated 5/28/24, indicated a level 2 Preadmission Screening and Resident Review (PASARR) had not been completed for Resident 30. A level 2 PASARR was completed on 8/22/22. 46882 6. On 1/23/25 at 8:38 A.M., Resident 40's clinical records were reviewed. Diagnoses included, but were not limited to fracture of neck of right femur, and subsequent encounter for closed fracture with routine healing. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 11/16/24, indicated Resident 40 had moderate cognitive impairment, and had received one injection. Review of the Medical Administration Record (MAR) from 11/10/24 thru 11/16/24 (MDS lookback period) indicated an injection had not been administered during that time. On 1/23/25 at 12:30 P.M., the MDS Coordinator indicated she had swapped the antiplatelet and diuretic, marking the wrong one had been given, and missed the opioid on Resident 31's MDS assessment. Residents 20, 6, 23, and 30 should have been marked yes for having a level 2 PASARR on their MDS assessments. She further indicated Resident 40 had not received an injection and was unsure why it had been marked but should not have been. At that time, she indicated the Resident Assessment Instrument (RAI) manual was used to enter information into the MDS and was used as a facility policy.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a resident with dementia and a history of elopement from exiting the facility and leaving the property for 1 of 4 residents reviewed for elopement and risk for wandering. This deficient practice resulted in an elopement that occurred during the night of 5/14/24 and early morning hours of 5/15/24, after being last seen by facility staff around 10:00 P.M. on 5/14/24, a resident exited the facility and was not realized to be missing until approximately 1:00 A.M. on 5/15/24. The resident was located by local law enforcement at a previous residence approximately 22 miles from the facility. (Resident C) This Immediate Jeopardy began on 5/15/24 when the facility failed to ensure Resident C did not exit the facility through a window in the resident's room. Following a search in and around the facility property, local law enforcement was notified and located the resident. The resident was admitted to a local hospital for monitoring due to having had an APS (Adult Protective Services) court order filed on 4/11/24 for placement in a healthcare facility. The Facility Administrator and DON (Director of Nursing) was notified of the Immediate Jeopardy on 5/31/24 at 10:20 A.M. The Immediate Jeopardy was removed on 5/31/24, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During a review of facility reported incidents on 5/30/24 at 9:55 A.M., an IDOH (Indiana Department of Health) Reportable Incident form completed by the facility administrator, with an incident dated 5/15/24 at 1:30 A.M., indicated that Resident C had a history of mental health complications related to dementia and delusional disorder. At 2:16 A.M., the Facility Administrator was notified by facility staff that Resident C was not in his room and could not be located within the parameters of the facility. Staff reported that Resident C was last seen in his bed during a medication pass at 10:00 P.M. Upon entering Resident C's room, staff observed the room window to be open and the screen to the window had been cut. The local police department was notified and came to the facility. A neighboring police department located Resident C at his previous address. Resident C was admitted to a local hospital for evaluation and treatment. During record review on 5/30/24 at 10:10 A.M., a court emergency protective services order, filed 4/11/24, indicated that Resident C was an endangered adult and in need of the proposed emergency protective services. The objectives of the emergency protective order were to secure the safety and well-being of Resident C. That a medical provider delivers the least restrictive protective services necessary to attain the objective of the adult protective services protective order. The medical provider shall place the endangered adult, Resident C, in a medical facility with 24-hour care for the duration of 45 days or until the order is terminated by the petitioner. Resident C's diagnoses included, but were not limited to dementia, delusional disorder, and mood disorder. Resident C's most recent admission MDS (Minimum Data Set) assessment, dated 5/15/24, indicated the resident had moderate cognitive impairment and that his wandering placed him at significant risk of getting to a potentially dangerous place. A risk for wandering assessment completed 5/3/24 indicated Resident C was at high risk for wandering. Resident C's initial baseline care plan included, but was not limited to, resident has an ADL (Activities of Daily Living) self-care performance deficit due to activity intolerance, dementia, fatigue, and impaired balance (initiated 5/3/24), resident anticipates long term care as he is unable to provide his own personal care (initiated 5/4/24), and resident has a potential of psychosocial well-being concern related to new placement in healthcare nursing facility (initiated 5/4/24). Resident C's initial baseline care plan did not reference Resident C's high risk for wandering or include interventions to minimize or prevent wandering. A social service note, dated 5/4/24, indicated that Resident C refused to answer questions for assessments. When the Social Service Director (SSD) asked if they could return later to complete the assessments, Resident C stated, doesn't matter, I won't be here later. A behavior note, dated 5/5/24, indicated that Resident C went out with the smokers for a breath of fresh air. During the smoke break, Resident C took off through a break in the fence. A staff member initially gave chase to stop Resident C but slipped in water and could not catch up to the resident. Other staff members gave chase in their personal vehicles. An ambulance was called, and the resident was eventually detained on the property located next to the facility. Resident C was taken to a local hospital where he was admitted . Resident C stated that if he was brought back, he would try to escape until he succeeded. An admission note, dated 5/9/24, indicated that Resident C had readmitted to the facility following discharge from the local hospital. A risk for wandering assessment completed 5/9/24 indicated Resident C was at high risk for wandering. Following Resident C's return to the facility on [DATE], no interventions were added to prevent or minimize the residents wandering risk and ensure safety or to prevent another elopement attempt. A nurse's alert note, dated 5/15/24, indicated at 2:16 A.M., the Facility Administrator was notified by facility staff that Resident C was not in his room and could not be located within the parameters of the facility. Staff reported that Resident C was last seen in his bed during a medication pass at 10:00 P.M. Upon entering Resident C's room, staff observed the room window to be open and the screen to the window had been cut. The local police department was notified and came to the facility. A neighboring police department located Resident C at his previous address. Resident C was admitted to a local hospital for evaluation and treatment. During an observation and interview on 5/30/24 at 9:25 A.M., Resident C and Resident D's names were listed outside of room [ROOM NUMBER]. Resident D indicated that Resident C had been his roommate, but that he had escaped by breaking through their room window. Resident D indicated he had witnessed Resident C going out the window around 10:00 to 11:00 P.M. and did not notify staff. The mesh wire of the window screen in the resident room appeared to have been torn apart and contained a large hole. During an interview on 5/30/24 at 10:00 A.M., the Facility Administrator indicated that Resident C had used a taxi service to return to his previous address after exiting the building on 5/15/24. During an observation and interview on 5/30/24 at 1:30 P.M., Maintenance 4 indicated that window stops were on all windows to prevent them from fully opening as that would be an elopement risk to have window that fully opened. Screws were observed in the window frames that prevented the windows from fully opening as well as in the window latches to prevent the windows from tilting open. Maintenance 4 then demonstrated how Resident C was able to get out of his room window by grabbing the top portion of the bottom double-hung window and pulling it inward. Maintenance 4 indicated that Resident C was able to break the window latches which allowed the window to fall forward. Resident C was then able to break through the window screen and exit the facility. During an interview on 5/31/24 at 1:00 P.M. the MDS nurse indicated that an interim 48-hour care plan should be completed for all new admissions by using completed assessments, the resident's history if available, and what the nurse initially observed from the resident. If a resident demonstrated a new behavior after the interim 48-hour care plan was completed, the care plan should be updated to address the new behavior. The MDS nurse indicated that Resident C's care plan should have been updated following his readmission to the facility on [DATE]. On 5/31/24 at 12:15 P.M., the Facility Administrator supplied an undated facility policy titled Wandering and Elopements. The policy included, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . An undated Care Plans - Baseline policy was also provided, and included, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care . 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan . The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. The Immediate Jeopardy, that began on 5/15/24, was removed on 5/31/24 when the facility in-serviced the staff on elopement prevention and ensured all windows were secured with latches and window stops but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, the facility continues to monitor residents at risk for elopement, continued staff education and elopement drills. This citation relates to complaint IN00434692. 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide supervision to prevent multiple falls, resulting in multiple injuries including a nasal fracture, for 1 of 3 residents reviewed for falls (Resident N). Findings include: The closed clinical record of Resident N was reviewed on 10/13/21 at 11:00 A.M. Diagnoses included, but were not limited to, dementia and Alzheimer's disease. An annual Minimum Data Set (MDS) assessment, dated 7/23/21, indicated Resident N had severely impaired cognition, required supervision for walking in room and corridor. Resident N had fallen previously. A Care Plan, initially dated 7/24/20 and updated 9/10/21, indicated: Focus: I am at risk for falls due to diagnoses of Alzheimer's, dementia, aging, medication usage, use of rx [prescription] glasses at times, and need for assistance with ADLs [activities of daily living including .transfers and toileting .I have episodes where I will see staff and almost run to reach them. The Interventions included: 7/24/20 Fall prevention interventions: to assist with ADLs as needed. Keep frequently used personal items including call light within reach. Non skid footwear at all times. Transfer assist as needed. 4/16/21 Resident is to be observed during meal times and assist when meals are finished with ambulation back to common area or room. Resident's door is to be closed when out in the hallways to encourage resident to seek assistance with getting into bed from staff. 8/31/21 Reduce stimulation during times of increase [sic] anxiousness. Offer to seat in recliner in lobby to watch television. 9/1/21 Offer to lay down post meals for rest period. Documentation indicated the resident resided on the secured Alzheimer's unit until 7/7/21, and was transferred to a regular unit when the Alzheimer's unit closed. An Initial fall incident report, dated 7/31/21 at 6:46 P.M., indicated the resident fell at 6:00 P.M. The resident was running down the hall and tripped, and had an injury of a small cut to upper lip. The resident was ambulating in the hall. The immediate intervention put in place to prevent further falls indicated, resient [sic] put to bed. A Fall Risk Assessment, dated 7/31/21 at 6:52 P.M., indicated Resident N was disoriented to person, place, and time; had 3 or more falls in the previous 3 months, was ambulatory, had a balance problem while standing and walking, had decreased muscular coordination and jerking movement, and had a score of 18. A score of 10 or more represents high risk for falls. An Initial fall incident report, dated 8/3/21 at 1:15 P.M., indicated the resident fell at 1:15 P.M. The Resident was walking in room with rubber soled shoes on, tripped and fell . The resident had an injury of abrasion to left outer eye and cheek below eye .new red/purple area to left outer knee. Painful to touch. The resident was ambulating in the room. The fall was not witnessed. The resident's shoes were removed and gripper socks applied. Nurses Notes included the following notations: 8/4/21 at 1:43 P.M.: IDT [interdisciplinary team] note: Reviewed fall, resident sliding feet instead of picking them up which is causing her to trip, intervention to remove shoes, and have resident ware [sic] non skip socks, staff to monitor for effectiveness, assist as needed, care plan updated. Will follow up as needed. 8/9/21 at 1:30 P.M.: Res [resident] remains very anxious since room move. Following staff, runs after them. Sad, fearful expression .Restless and pacing. has had few fall [sic] r/t [related to] moving fast to catch staff. Will continue to monitor An Initial fall incident report, dated 8/10/21 at 11:12 A.M., indicated the resident fell at 7:00 A.M. The Resident was ambulating down the hall with QMA when her legs gave out and she set in the floor .No injuries noted .Continue to assist resident with ambulating. Nurses Notes continued: 8/12/21 at 4:11 P.M. Resident had fall in west common room, lost balance and fell when ambulating unassisted. MD notified and order for x-ray of left knee obtained d/t [due to] pain and bruising. An Initial fall incident report, dated 8/12/21 at 4:16 P.M., indicated: Resident was ambulating in common area on west unit, lost balance and fell .Assist resident ambulate [sic] as possible. Nurses Notes continued: 8/12/21 at 6:47 P.M.: .Resident approached east nurses station .bright red abrasion to right forehead and bridge of nose noted. No other falls witnessed but these injuries were not present with fall at 1545 [3:45 P.M.] and resident did not hit her head or face with that fall which was witnessed 8/12/21 at 7:30 P.M.: .nose now swollen and slightly deviated to right. Front upper tooth dangling from socket and was removed easily to prevent choking hazard. Ice applied to bridge of nose x 20 minutes. An Initial fall incident report, dated 8/18/21 at 4:39 A.M. indicated the resident fell at 4:00 A.M. The resident was found on floor in room, and sustained a sm [small] cut behind left ear. The resident was barefoot, and was not witnessed. The immediate intervention to prevent further falls was to place the resident in bed. An Initial fall incident report, dated 8/18/21 at 5:22 A.M. indicated the resident fell at 5:00 A.M. The resident was found under roommate bed. The nose appears bruised and right knee red. The resident was barefoot, and the fall was not witnessed. The immediate intervention to prevent further falls was to place the resident in bed. Nurses Notes continued: 8/19/21 at 1:27 P.M.: IDT note: Review of falls appear r/t anxiety and being tired as res is in constant movement with high anxiety. Med list sent to MD .for review. Staff trying to reassure res and give frequent attention to help alleviate anxiety only effective while giving attention. 8/30/21 at 12:59 P.M.: IDT note: .Upon reivew [sic] of incidence, there [sic] resident is described to be walking quickly or running toward staff. This is felt to be an anxious behavior needing reassurance of staff .Staff is assisting resident to a seat position if observed up or ambulation An Initial fall incident report, dated 8/31/21 at 11:49 A.M. indicated the resident fell at 11:00 A.M. The staff heard fall seen res on floor next to chair in common room. look [sic] like she missed chair when trying to sit. The resident's back and buttocks were observed to be red and blanchable. The fall was not witnessed. The res has been very restless since transfer from secured unit. Res moves quick and is unsteady. Nurses Notes continued: 9/1/21 at 11:02 A.M.: IDT note: Review of incident documente [sic] on 08/31/21. Resident was observed to be sitting on her buttocks in front of recliner in the lounge on the west hall. Resident is unable to tell staff what she was doing at the time of the incident .There were no reliable witnesses to the incident .Staff to lay down post meal for period of rest An Initial fall incident report, dated 9/5/21 at 8:15 A.M. indicated the resident fell at 8:00 A.M. The resident lost her balance and fell into the doorframe of her room. The resident had a possible fracture to nose and a skin tear on her right hand. The resident was transferred to the emergency room (ER) on 9/5/21 at 9:01 A.M. Nurses Notes continued: 9/5/21 at 12:13 P.M.: [Name of hospital] ER phoned to say res is returning to the facility [with] nose fx [fracture]. States res is not a good [NAME] [sic] for surgery et [and] to follow up [with] an ENT [ear, nose throat physician]. 9/8/21 at 11:44 A.M.: IDT note: Review of incident documented on 09/05/21. Resident was observed walking through her doorway to her room, loose [sic] her balance and fall to the floor. She was assessed for injury and sent to hospital ER for evaluation. Upon return, resident was noted to have a fx nose .She is disoriented to surroundings and unable to interpret surroundings and safety situations. Resident is ambulatory with general supervision. Resident is unable to seek/request assistance with ambulation related to cognition IDT review indicates that resident requires increase assistance with ambulation On 10/15/21 at 9:20 A.M., during an interview with the Administrator and Corporate Nurse, the Corporate Nurse indicated she had reviewed Resident N's frequent falls. The resident would frequently cross her legs, then stand up and fall. The resident would run after staff, and the facility could not prevent that. On 10/15/21 at 11:00 A.M., the Administrator provided the current facility policy, Falls and Fall Risk, Managing, dated 3/28/21. The policy included: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant This Federal tag relates to Complaint IN 115. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prevent the development of pressure areas and/or ensure residents with pressure areas received necessary treatment to promote the healing of pressure areas for 2 of 3 residents reviewed for pressure ulcers. Resident E did not receive catheter care that resulted in the development of an infected unstageable pressure area resulting in a hospital visit and antibiotic treatment given IM (Intramuscular) for 5 days. (Resident E, Resident D) Findings include: 1. During record review on 5/18/21 at 1:45 P.M., Resident E's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident E's most recent quarterly MDS (Minimum Data Set), dated 4/20/21, indicated the resident had an indwelling urinary catheter, required extensive assistance with mobility, transfers, and toileting, was frequently incontinent of bowels, did not have any unhealed pressure ulcers, and was not at risk for developing pressure ulcers. Resident E's care plan included, but was not limited to, at risk of skin breakdown related to: decreased circulation, decreased mobility, decreased nutritional intake, incontinence of bowel and/or bladder. Interventions included but were not limited to, assess for incontinent frequently to keep skin free from moisture (revised 5/7/21). Resident has ADL (Activities of Daily Living) self-care performance deficit with interventions including, but not limited to, toilet us - able to toilet with extensive assistance, bed mobility - able to turn and reposition with extensive assistance of two staff members (revised 5/7/21). Resident E's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 4/13/21 included, Resident E returned from hospital . Foley Catheter patent draining yellow urine. A progress note dated 4/30/21 included, Resident E complains of pain from catheter. The tip of penis looks red, he would like it to be taken out. Physician was notified. A progress note dated 5/3/21 included, Resident E's physician was faxed regarding small black area at tip of penis and penile [CONDITION(S)] at head and foreskin. Awaiting reply. A physician notification dated 5/3/21 included, Resident E, has an area at the tip of his penis that is black, Foley Catheter remains intact. Head of penis is swollen (and) reddened. Foreskin is edematous as well. Appears that foreskin was not pulled back over penis (during) cleaning. Foul odor present. A progress note dated 5/3/21 1:25 P.M. included, Resident E's physician indicated Resident E was to be sent to the emergency for evaluation. A progress note dated 5/4/21 included, Resident E returned from hospital on 5/3/21 at approximately 8:30 P.M., with new orders to apply [MEDICATION(S)] to area on penis every shift. A progress note dated 5/5/21 included, CNA asked nurse to assess Resident E due to open area found on buttocks during pericare. Area was assessed and noted in assessments. Cleanse with wound cleanser and [MEDICATION(S)] (dressing) placed. CNA had reported a large amount of clear liquid leaking from anus . Resident E indicated buttocks and penis really hurts. A physician notification for Resident E, dated 5/5/21, included, Resident has a new pressure injury to (right) buttocks - 4.2 cm (centimeters) x 3.7 cm 10% epithelial tissue, 50% granulation and 40% hard necrotic area in center - 1.6 cm x 0.8 cm . Resident has 2 area on tip of penis. (Left) side 1.8 cm x 1 cm 100% slightly loose necrotic tissue. Appears to be pressure from (Foley Catheter). (Right) side abrasion 1.5 cm x 0.8 cm granulation tissue . Can we (discontinue) the (Foley Catheter)? A doctor visit note dated 5/6/21 included, Resident E was seen due to area on penis. Orders for [MEDICATION(S)] (ceftriaxone) (antibiotic) IM (intramuscular injection) reconstituted with [MEDICATION(S)] (Xylocaine) daily for 5 days. A progress note dated 5/7/21 included, Resident E's Foley Catheter was removed as ordered due to penis infection. Wound assessments include: 5/5/21 - Penis wound - date acquired 5/5/21 - unstageable pressure with necrotic tissue present, small amounts of serous drainage present. Measures 1.8 cm (length) x 1.0 cm (width) x 0.1 cm (depth) - Area around penis is reddened. End of penis is swollen and reddened - Cleanse around wound with cleanser every shift and as needed. Ensure catheter lock is on at all times. 5/5/21 - Right buttock wound - date acquired 5/5/21 - unstageable pressure with granulation tissue and necrotic tissue present - scant amounts of serous drainage present - Measures 4.2 cm x 3.7 cm x 0.1 cm 5/11/21 - Penis wound - unstageable pressure with necrotic tissue - small amounts of serous drainage present - Measures 1.5 cm x 1.0 cm x 0.1 cm 5/11/21 - Right buttock wound - unstageable pressure with granulation and necrotic tissue present, scant amounts of serous drainage present - Measures 4.0 cm x 3.1 cm x 0.1 cm During an observation on 5/19/21 at 9:30 A.M., PT 17 (physical therapist) was providing an ultra-sound treatment to Resident E's right buttock wound. The wound had 2 open areas, one larger area and one smaller area. The areas appeared to be well approximated in covered in slough tissue. The surround skin was pink in color. PT 17 indicated the area was improving since the day prior. During an interview on 5/19/21 at 9:41 A.M., PT 17 indicated that Resident E had returned from the hospital with a Foley Catheter that had since been discontinued and that Physical therapy did not provide any wound treatments to Resident E's penis. During an interview on 5/20/21 at 10:20 A.M., CNA 19 indicated that Resident D did not have a Foley catheter before returning from the hospital on 4/13/21. CNA 19 indicated anytime a resident has a catheter, the CNA's should provide catheter care every shift and document the care along with the output from the catheter. During an interview on 5/20/21 at 1:24 P.M., the Facility Administrator indicated that a care plan for Resident E's Foley Catheter was not developed following his return from the hospital on 4/13/21 and that there was no documentation of catheter care for Resident E. On 5/20/21 at 10:31 A.M., the Facility Administrator provided a facility policy, titled Catheter Care, Urinary, dated 3/28/21. The policy included, .The following information should be recorded in the resident's medical record: Initial the MAR (Medication Administration Record) on the date and shift that the catheter care was provided. All assessment data obtained when giving catheter care. Character of urine such as color . and odor. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, pain . If the resident refuses the procedure, the reason(s) why and the intervention taken.Notify the supervisor if the resident refuses the procedure . 2. During record review on 5/18/21 at 10:25 A.M., Resident D's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed), noncompliance with other medical treatment and regimen, and lung cancer. Resident D's most recent quarterly MDS, dated [DATE] indicated the resident required extensive assist with bed mobility and transfers and had an unhealed stage II pressure area (the National Pressure Injury Advisory Panel defines a Stage II pressure injury as a, Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present). Resident D care plan included, but was not limited to, unstageable pressure injury to right hip. Interventions included, but were not limited to treatment as ordered per MD (Doctor of Medicine), initiated on 3/2/21 and revised on 5/13/21. Resident D's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/20/21 at 10:32 A.M., LPN 15 was performing wound care for Resident D. LPN 15 removed a bordered foam dressing dated 5/19/21 and exposed the pressure injury. LPN 15 indicated that was the incorrect dressing for the treatment. The pressure wound was located on a bony prominence of the right hip on the right buttock. The wound bed was covered in slough, the wound was well approximated and the surrounding skin was pink/purple in color. LPN 15 cleaned the wound, applied Santyl (Collagenase) to the wound bed, placed calcium alginate over the wound and covered with a bordered gauze dressing. During an interview on 5/20/21 at 11:40 A.M., LPN 15 indicated that they did not see any border foam dressings in the medical supply room but had also wrote the treatment order down incorrectly before performing Resident D's treatment. LPN 15 indicated that a bordered gauze dressing was incorrectly applied the Resident D's pressure area and bordered foam dressing should have been applied. LPN 15 indicated the treatment would be corrected. On 5/20/21 at 10:31 A.M., the Facility Administrator supplied a facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 3/28/21. The policy included, The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to prevent the development of urinary catheter related infections for 2 of 2 residents reviewed for catheter care. Resident D with a suprapubic catheter developed a urinary tract infection (UTI) that led to hospitalization and required IV (intravenous) antibiotics, and Resident E with a Foley catheter developed catheter related unstagable wound that became infected and required a hospital visit, IM (intramuscular) antibiotics for 5 days due to a lack of or improper catheter care. (Resident D and Resident E) Findings include: 1. During record review on 5/18/21 at 10:25 A.M., Resident D's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's most recent quarterly MDS, dated [DATE] indicated the resident required extensive assistance with toileting and personal hygiene, and had an indwelling catheter. Resident D care plan, revised 7/2021, included, but was not limited to, resident has a suprapubic catheter, with interventions that included, but were not limited to, observe/record/report signs and symptoms of UTI. Resident D's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's MAR (Medication Administration Record) and TAR (Treatment Administration Record) included: Flush suprapubic catheter every shift was not documented as completed on: 4/1/21 - Day shift 4/1/21 - Night shift 4/8/21 - Night shift 5/6/21 - Night shift 5/14/21 - Night shift 5/15/21 - Night shift 5/17/21 - Night shift 5/18/21 - Day shift 5/18/21 - Night shift Change suprapubic catheter dressing every day was not documented as completed on 5/9/21, 5/10/21, and 5/18/21. A progress for Resident D, dated 4/11/21, included, While changing resident noticed that his urine was bloody. Turned resident on his side to change sheets (due to) being wet and noticed large (amount) of bleeding from penis, bright red. MD (Doctor of Medicine) notified and order received to send to resident to (hospital) . A progress note for Resident D, dated 4/16/21, included, Resident returned from hospital. Resident has suprapubic catheter and Foley catheter in place both draining yellow urine. A hospital discharge note for Resident D, dated 4/16/21, included Discharge orders for [MEDICATION(S)] IV antibiotic and [MEDICATION(S)] IV antibiotic. Resident D had a discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note for Resident D, dated 4/20/21, included, .(suprapubic catheter) and (Foley catheter) patent (draining) yellow urine, no blood noted. Denies pain/(discomfort). Continues on IV (antibiotics) for urinary [CONDITION(S)]. A progress note for Resident D, dated 4/23/21, included, Continues with IV (antibiotics) for urinary. A progress note for Resident D, dated 4/26/21, included, Continues on (antibiotic) for urinary infection. During an observation on 5/16/21 at 9:40 A.M., Resident D was lying in bed with a catheter bag clipped to the side of the bed and resting on the floor. During an observation on 5/17/21 at 8:38 A.M., Resident D was lying in bed with a catheter bag clipped to the side of the bed and resting on the floor. During an observation on 5/18/21 at 1:18 P.M., Resident D was lying in bed with a catheter bag clipped to the side of the bed and resting on the floor. During an interview on 5/19/21 at 11:14 A.M., QMA 12 (Qualified Medication Aide) indicated a urinary catheter bag should never be on the floor. On 5/20/21 at 10:31 A.M., the Facility Administrator supplied a facility policy titled, Catheter Care, Urinary, dated 3/28/21. The policy included, Infection Control . Be sure the catheter tubing and drainage bag are kept off the floor. 2. During record review on 5/18/21 at 1:45 P.M., Resident E's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident E's most recent quarterly MDS (Minimum Data Set), dated 4/20/21, indicated the resident had an indwelling urinary catheter, required extensive assistance with mobility, transfers, and toileting, was frequently incontinent of bowels. Resident E's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 4/13/21 included, Resident E returned from hospital . Foley Catheter patent draining yellow urine. A progress note dated 4/30/21 included, Resident E complains of pain from catheter. The tip of penis looks red, he would like it to be taken out. Physician was notified. A progress note dated 5/3/21 included, Resident E's physician was faxed regarding small black area at tip of penis and penile [CONDITION(S)] at head and foreskin. Awaiting reply. A physician notification dated 5/3/21 included, Resident E, has an area at the tip of his penis that is black, Foley Catheter remains intact. Head of penis is swollen (and) reddened. Foreskin is edematous as well. Appears that foreskin was not pulled back over penis (during) cleaning. Foul odor present. A progress note dated 5/3/21 included, Resident E's physician indicated Resident E was to be sent to the emergency room for evaluation. A progress note dated 5/4/21 included, Resident E returned from hospital on 5/3/21 at approximately 8:30 P.M., with new orders to apply [MEDICATION(S)] to area on penis every shift. A progress note dated 5/5/21 included, CNA asked nurse to assess Resident E . Resident E indicated buttocks and penis really hurts. A physician notification for Resident E, dated 5/5/21, included, .Resident has 2 areas on tip of penis. (Left) side 1.8 cm x 1 cm 100% slightly loose necrotic tissue. Appears to be pressure from (Foley Catheter). (Right) side abrasion 1.5 cm x 0.8 cm granulation tissue . Can we (discontinue) the (Foley Catheter)? A doctor visit note dated 5/6/21 included, Resident E was seen due to area on penis. Orders for [MEDICATION(S)] ([MEDICATION(S)]) (antibiotic) IM (intramuscular injection) reconstituted with [MEDICATION(S)] (Xylocaine) daily for 5 days. A progress noted dated 5/7/21 included, Resident E's Foley Catheter was removed as ordered due to penis infection. During an interview on 5/20/21 at 10:20 A.M., CNA 19 indicated that anytime a resident has a catheter, the CNA's should provide catheter care every shift and document the care along with the output from the catheter. During an interview on 5/20/21 at 1:24 P.M., the Facility Administrator indicated that a care plan for Resident E's Foley Catheter was not developed and that there was no documentation of catheter care for Resident E. On 5/20/21 at 10:31 A.M., the Facility Administrator provided a facility policy, titled Catheter Care, Urinary, dated 3/28/21. The policy included, .The following information should be recorded in the resident's medical record: Initial the MAR (Medication Administration Record) on the date and shift that the catheter care was provided. All assessment data obtained when giving catheter care. Character of urine such as color . and odor. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, pain . If the resident refuses the procedure, the reason(s) why and the intervention taken.Notify the supervisor if the resident refuses the procedure . 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to implement specific interventions for 1 of 3 residents who were at risk for pressure ulcers. Resident B had a Stage III ( subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed) sacral pressure ulcer. (Resident B) Findings include: During a review of Resident B's closed clinical record it indicated Resident B's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was severely cognitively impaired. The Discharge MDS (Minimum Data Set Assessment), dated 10/10/20, indicated she did not have pressure ulcers or skin conditions. Resident B required supervision with bed mobility, limited assist x 1 with transfers, end extensive assist x 1 with hygiene, eating, and toileting. Resident B required total dependence bathing. Resident B's care plans indicated, but were not limited to, A care plan with a start date of 5/10/20, with no revisions noted, indicated, Self -care deficits related to need for variable assistance with ADLs, incontinency of bowel and bladder, and dementia. Interventions included, but were not limited to, assist and encourage resident to reposition self in bed, staff to assist with turning, repositioning and bed mobility as needed, observe for changes/decline in ability to complete ADLs, notify MD and therapy of any changes, resident needs assist/reminders to toilet upon rising, before/after meals, at bedtime an as needed. Staff to assist resident with transfers to toilet and toileting hygiene as needed, does not use an assistive device, needs variable assistance with transfers, staff to assist with transfers as needed. Resident B lacked a specific care plan related to pressure ulcers. 5/1/20 Braden skin assessment Score: 20 No risk Scale: NO RISK 19-23 MILD RISK 15-18 MODERATE RISK 13-14 HIGH RISK 10-12 VERY HIGH RISK 9 or below 7/8/20 Braden skin assessment Score: 19, No risk 7/15/20 Braden skin assessment Score: 16, at risk The progress notes indicated, but were not limited to, 9/8/2020 7:55 a.m.- Weekly skin assessment. No new areas noted at this time. Will continue to monitor weekly. 9/15/2020 5:00 p.m.- Weekly skin assessment. No new areas noted at this time. Will continue to monitor weekly. No new areas noted at this time. Will continue to monitor weekly. 9/22/2020 7:26 a.m.- Administration note. Weekly skin assessment. No new areas noted. 10/10/2020 3:44 p.m.- Transfer/Discharge Information. discharged from Season's unit to local hospital. Reason for transfer: recent fall, steady decline, low saturations (79% room air), non responsive. MD notified. No answer from POA. Voicemail left. Clinical documents provided for continuity of care. 10/10/2020 4:55 p.m.- Left facility via ambulance to local hospital. Resident fell approximately 2 weeks ago. She has had a steady decline in her mental/physical status since the fall. During a review of Resident B's hospital records, provided by the local hospital on 4/14/21 at 10:51 a.m., they indicated but were not limited to, Resident B was admitted to the emergency roiagnom on [DATE] at 5:36 p.m. Resident B presented to the emergency room with complaints of a change in mental status. Resident B had no fever, no rashes. Resident B was confused and had memory loss. Skin had good color, was warm and dry with normal turgor. Musculoskeletal system: warm, well perfused, no [CONDITION(S)], distal pulses 2+. Quarter sized ulcer in the middle of the sacrum with a necrotic (death of tissue) base, no obvious swelling or [CONDITION(S)]. Resident B was admitted as stable to the hospital from the emergency department on 10/10/20 at 7:08 p.m. with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was seen by the wound team on 10/12/20 for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The sacral region had areas that are superficially open and draining and other areas that appear to be DTI (deep tissue injury). Patient would benefit from mist therapy to area to promote healing. Heels with intact blisters without signs of constant pressure and seem to be responding to offloading. Wound 1- sacral area, central/left sided. Peeling epithelial with pink dermis visible, deep tissue injury in areas. 11 cm (centimeters) x 6.5 cm x 0.1 cm depth. Surface area 71.5 cm. Pressure. Stage II with areas of suspected deep tissue injury. Very minimal wound drainage, serosanguineous (thin, pink, watery) drainage. No odor. Peri wound tissue: blanching, [CONDITION(S)]. Resident B was discharged from the hospital to a different Long Term Care facility on 10/14/20 at 3:30 p.m. Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Non-ambulatory, difficulty bathing/dressing, difficulty performing independent ADLs. High risk for falls, oriented to self only. During an interview on 4/13/21 at 12:53 p.m. with the new Long Term Care facility, the Administrator indicated the resident was discharged from the hospital into their care on 10/14/20. Resident B was alert only to self and was an total assist at time of admission with all ADLs. She was incontinent of bowel and bladder and was non-ambulatory. She presented with an unstageable coccyx wound and black heels. During an interview on 4/14/21 at 10:07 a.m. with the Seasons Memory Care Director (locked dementia unit) at the prior Long Term Care facility, she indicated if a resident has a pressure ulcer they attempt to keep the resident off of that area. For example, float a resident's heels. The management staff holds morning meetings daily and go through all documentation to ensure all information is there and discuss any new falls, wounds, or other concerns with residents. She is in charge of MDS assessments for the Seasons unit and for updating their care plans, but it is a new plan that was just put in place, so it is a work in progress. During an interview with QMA 1 on 4/14/21 at 10:09 a.m., she indicated staff is required to report new skin issues to the nurse or DON. Residents should be turned and repositioned at least every 2 hours and [MEDICATION(S)] should be applied after every incontinent episode. They are to answer call lights timely and to keep residents dry. During an interview with the Administrator on 4/14/21 at 10:57 a.m., she indicated she had noted concerns with the care plans not being updated and interventions not being put in place. She noted concerns with assessments of falls and wounds. She indicated she has a new management team and they are currently implementing new tools to ensure staff is available to assess residents and implement interventions. During a review of the current policy, Pressure Ulcers/Skin Breakdown, revised 4/14/21, provided by the Administrator on 4/14/21 at 10:47 a.m., indicated, The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcers .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wound develop despite existing interventions. This Federal tag relates to Complaint IN 378. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control practices for COVID-19 were followed during the pandemic to prevent the spread of [MEDICAL CONDITION] for residents with potential exposure from COVID-19 positive staff members and 3 COVID-19 positive residents (Resident 6, Resident 7, and Resident 17) on the West unit. The 3 roommates (Resident 1, Resident 2, Resident 13) of the 3 positive residents, as well as the other residents on the unit, including Resident 5 who developed COVID-19 symptoms, were not placed in transmission-based precautions. Staff were observed not using all recommended PPE, resident room doors were open, and residents were observed outside of their rooms. This potentially affected all 41 residents who resided on the West unit as of [DATE]. The Immediate Jeopardy began on [DATE], when the facility failed to initiate transmission based precautions (TBP) for residents exposed to a COVID-19 positive staff member and again failed to initiate TBP after 3 residents tested positive on [DATE]. The positive staff member worked on the West unit and 3 residents resided on the West unit with roommates. On [DATE], 12 additional residents and one additional staff member tested positive for COVID-19 on the West unit, and 7 residents tested positive on the East unit. On [DATE] and [DATE], staff were observed not using all recommended PPE, resident room doors were open, and residents were observed outside of their rooms. The Administrator and Regional RN were notified of the Immediate Jeopardy on [DATE] at 10:51 A.M. The Immediate Jeopardy was removed on [DATE] at 2:47 P.M., but noncompliance remained at the lower scope and severity level of patten, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview on [DATE] at 9:30 A.M., the Administrator indicated on [DATE] four staff members had tested positive for COVID-19 during routine staff testing. The Administrator indicated the Business Office Manager (BOM), Director of Maintenance, QMA 1, and Housekeeper 1 had tested positive for COVID-19. The Administrator indicated the BOM and the Director of Maintenance had not had direct contact with any residents. The Administrator indicated QMA 1 had worked the Season's unit (locked dementia unit) on [DATE]. The Administrator indicated Housekeeper 1 had limited contact with residents residing on the West unit on [DATE]. The Administrator indicated in response to the positive staff members, all residents were tested for COVID-19 on [DATE] and had negative [MEDICATION NAME] test results. The Administrator indicated on [DATE] the hospital notified the facility that Resident 6, Resident 7, and Resident 17, who had been admitted to the hospital, were positive for COVID 19. The Administrator indicated all three residents resided on the West Unit. The Administrator indicated on [DATE] Resident 1, Resident 2, and Resident 13 were retested for COVID 19 because they were roommates to Resident 6, Resident 7, and Resident 17, and all three retested residents had negative [MEDICATION NAME] test results. The Administrator indicated that no residents in the facility were on any isolation precautions. On [DATE] at 10:20 A.M., the door to Resident 1's room was closed. No signs were posted on Resident 1's door to indicate the resident was in droplet isolation. No isolation supplies were located at the resident's door. On [DATE] at 10:21 A.M., the door to Resident 2's room was open, and the resident was sitting in his wheelchair in the door way. Resident 2 was not wearing a mask at that time. No signs were posted on Resident 2's door to indicate the resident was in droplet isolation or any other transmission based precautions. No isolation supplies were located at the resident's door. On [DATE] at 10:22 A.M., the door to Resident 13's room was open, and the resident was lying in bed with her eyes closed. No signs were posted on Resident 13's door to indicate the resident was in droplet isolation or any other transmission based precautions. No isolation supplies were located outside the resident's door. On [DATE] at 10:30 A.M., CNA 1 indicated no residents on the West Hall were assigned isolation precautions. CNA 1 indicated Resident 13's roommate was in the hospital for COVID-19, but Resident 13 had no orders for precautions. CNA 1 said, We treat her just like everyone else on this hall. The door is always open. CNA 1 said she did not have safety glasses or a face shield to wear while providing care for the residents. CNA 1 indicated she did not know where safety glasses and face shields were located. On [DATE] at 10:45 A.M., LPN 2, indicated there were no residents currently residing on the West Hall who were assigned isolation precautions. LPN 2 indicated she was unsure where PPE supplies were located if needed. LPN 2 indicated she needed to ask the Administrator or Director of Nursing for the location of the supplies. On [DATE] at 10:45 A.M., Resident 5's call light was lit above his door. CNA 1 entered his room and asked what he wanted. He said he wanted a lemonade and indicated at that time he didn't feel well. He was taking short, shallow breaths, and said he had been very tired for days. CNA 1 departed the resident's room and left the door open. On [DATE] at 11:05 A.M., LPN 2, who was wearing a surgical mask, entered Resident 5's room and asked him if he wanted a breathing treatment. Resident 5 was taking short, shallow breaths and appeared to be short of breath. Resident 5 said he did not want a breathing treatment at that time. He told LPN 2 he had been very fatigued and had body aches over the weekend, but thought maybe he felt a little better today. Resident 5's temperature was 100.8. Oxygen saturation was 96. Heart rate was 116. LPN 2 told the resident she would return with [MEDICATION NAME]. LPN 2 departed the resident's room, leaving the door open. LPN 2, who was wearing a surgical mask, returned to the resident's room at 11:20 A.M. and administered an [MEDICATION NAME]. On [DATE] at 9:30 A.M., the Administrator indicated residents had been tested for COVID-19 Monday evening ([DATE]), and Resident 5 had tested COVID positive. On [DATE] at 10:30 A.M., Resident 5's clinical record was reviewed. The Progress Notes included, but were not limited to: [DATE] at 9:38 A.M., [MEDICATION NAME] tablet (anti-pyretic medication), give 800 milligrams by mouth every six hours, as needed for pain-temperature 100.8 degrees Fahrenheit. [DATE] at 11:39 A.M., follow up temperature 97.4. [DATE] at 4:26 P.M., Resident this morning had temperature of 100.8 degrees Fahrenheit and weak. Has [MEDICATION NAME] as needed which was given and effective. Patient states feels better now. MD notified. New order for rapid COVID-19 test. Results were negative. Resident 5's record indicated the facility did not initiate transmission based precautions as soon as the resident began exhibiting symptoms of COVID-19 on [DATE] at 10:45 a.m. On [DATE] at 11:32 A.M., the Administrator indicated Resident 1, Resident 2, and Resident 13 were in quarantine because their roommates had tested positive for COVID-19. The Administrator indicated the residents were to stay in their rooms and standard precautions were utilized. The Administrator indicated that Resident 1, Resident 2, and Resident 13 were not on full transmission based precautions. At that time, the Administrator and Corporate Nurse indicated that Resident 1, Resident 2, Resident 13 and perhaps the entire West Unit should be placed on full transmission based precautions for COVID-19. On [DATE] at 11:35 A.M., Resident 2's door was open and the resident was sitting in the doorway saying he had a right to be out of his room. LPN 2 told the resident his roommate had tested positive for COVID-19 and therefore he needed to stay inside his room. Wearing only a surgical mask, LPN 2 entered the resident's room to administer medications, but the resident refused the medications. On [DATE] at 11:39 A.M., the Nurse Practitioner (NP) approached LPN 2 and asked if Resident 2 needed a new prescription. LPN 2 told the NP that Resident 2 was in 14 day quarantine now and was very upset about being restricted to his room. Wearing only a mask and no other protective gear, the NP entered the resident's room and started talking with the resident. On [DATE] at 12:57 P.M., Resident 1's clinical record was reviewed. The clinical record lacked an order for [REDACTED]. [DATE] at 4:44 P.M., Rapid COVID-19 test completed in house, negative. MD notified. On [DATE] at 1:00 P.M., Resident 6's clinical record was reviewed. The Progress Notes included, but were not limited to: [DATE] at 4:24 P.M., COVID-19 Point of Care test, one time for surveillance [DATE] at 1:39 A.M., Resident discharged to hospital for temperature of 103.4, decreased oxygen saturation, and lethargy. [DATE] at 4:28 P.M., Received word that resident tested positive for COVID-19. We will continue precautions. On [DATE] at 1:05 P.M., Resident 13's clinical record was reviewed. The clinical record lacked an order for [REDACTED]. [DATE] at 4:49 P.M., Received word that resident roommate tested positive for COVID-19. We tested her again today after obtaining an order from MD. She had a rapid test in house and was negative. On [DATE] at 1:15 P.M., Resident 2's clinical record was reviewed. The clinical record lacked an order for [REDACTED]. [DATE] at 4:55 P.M., MD notified that resident's roommate tested positive for COVID-19. MD gave order for COVID testing. COVID testing conducted and resident results negative. On [DATE] at 1:42 P.M., Resident 6's clinical record was reviewed. The Progress Notes included, but were not limited to: [DATE] at 3:51 P.M., Resident has had a change in status. Resident has increased drowsiness. Resident not as alert and oriented as normal. He has not been up out of bed. [DATE] at 4:43 P.M., (Name of X-ray Company) here to do chest x-ray. [DATE] at 4:46 P.M., lab called again for stat lab notification [DATE] at 10:55 A.M., Lab called and notified we need the stat labs sent. Labs sent and reviewed by physician. New order to send to hospital of choice. [DATE] at 11:14 A.M., Resident discharged to hospital for critical labs and change in condition. No further notes were documented related to Resident 6's COVID-19 status. On [DATE] at 2:53 P.M., Resident 2 was observed sitting in his wheelchair in the nurses' lounge. He said he did not want to stay in his room. Resident 2 had his mask pulled down to his chin while talking. CNA 1 redirected Resident 2 as she returned the resident to his room. CNA 1 walked out of the resident's room and left the door open. No hand hygiene was observed. No disinfecting around the area was observed at that time. On [DATE] at 2:55 P.M., the door to Resident 13's room was open and the resident was lying in bed with her eyes closed. The were no signs posted on Resident 13's door to indicate the resident was in droplet isolation or any other transmission based precautions. No isolation supplies were located outside the resident's door. On [DATE] at 2:56 P.M., Resident 11's door was closed, but no signs were posted which indicated isolation precautions were assigned and no isolation station was observed outside the door. On [DATE] at 9:28 A.M., the Administrator indicated that on the evening of [DATE] all residents were retested for COVID-19. The Administrator indicated 19 additional residents had tested positive on [DATE]. The Administrator indicated 7 residents resided on the East Unit and 12 residents resided on the West Unit. The Administrator indicated that one additional staff member, LPN 5, had tested positive for COVID-19 as well. The Administrator indicated that LPN 5 worked the West Unit. The Administrator indicated the West Long Hall was now the active COVID-19 red unit. The Administrator indicated that Resident 2 (roommate of original positive resident) was now positive for COVID-19. On [DATE] at 9:40 A.M., on the West unit, the following residents' doors were open: Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24 and Resident 25. On [DATE] at 9:57 A.M., the Administrator indicated that all other residents in the facility were considered on droplet precautions, except the Season's Unit (locked dementia unit). The Administrator indicated that residents were on droplet precautions, not droplet isolation and were not restricted to their rooms. The Administrator indicated that facility staff was utilizing face shields, gloves, masks and the residents were not restricted to their rooms. On [DATE] at 11:30 A.M., the Administrator provided the current Isolation-Initiating Transmission-Based Precautions policy, revised [DATE]. At that time the policy was reviewed and included, but was not limited to: Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease . On [DATE] at 10:00 A.M., the Administrator indicated that Resident 1 and Resident 13 (both roommates of the original positive residents) had tested positive for Covid 19 on that morning ([DATE]). On [DATE] at 9:45 A.M., the Administrator indicated that 30 residents had tested positive for Covid 19: Four were hospitalized , one resident had died , and 25 residents were still in the facility. The Administrator indicated 10 staff members had tested positive for Covid 19. Review of CDC guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, Considerations for the Public Health Response to COVID-19 in Nursing Homes, dated as updated [DATE], included the following: Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. Exposed HCP should be assessed for risk and need for work exclusion. If testing is available, asymptomatic residents and HCP who were exposed to HCP with COVID-19 should be considered for testing .If testing identifies infections among additional HCP, further evaluation for infections among residents and HCP exposed to those individuals should be performed as described above. Resident with new-onset suspected or confirmed COVID-19 Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible,should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Counsel all residents to restrict themselves to their room to the extent possible. HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. Maintain all interventions while assessing for new clinical cases (symptomatic residents): Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions. If testing is available, asymptomatic residents and HCP who were exposed to the resident with COVID-19 (e.g., on the same unit) should be considered for testing Review of CDC guidance, Considerations for Use of [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Testing in Nursing Homes, [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Testing in Nursing Homes, dated as updated Aug. 27, 2020, included the following: This document provides a summary of considerations for use of [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19) [MEDICATION NAME] testing in nursing homes and is intended for nursing home providers and state and local public health departments. [MEDICATION NAME] tests are available as point-of-care (POC) diagnostics for [DIAGNOSES REDACTED]-CoV-2. They have a rapid turnaround time, which is critical to the identification of [DIAGNOSES REDACTED]-CoV-2 infection and rapid implementation of infection prevention and control strategies. These tests can augment other testing efforts, especially in settings where RT-PCR testing capacity is limited or testing results are delayed (e.g., >48 hours) .As the sensitivity of [MEDICATION NAME] tests is generally lower than RT-PCR, FDA recommends that negative POC [MEDICATION NAME] tests be considered presumptive. Clinical staff in nursing homes should consider when confirmatory RT-PCR testing might be needed prior to making clinical decisions, cohorting residents, or excluding HCP from work. When interpreting the results of [MEDICATION NAME] tests, test characteristics and probability of infection should be considered. This document guides the interpretation of results when [MEDICATION NAME] tests are used in the following circumstances: Testing of asymptomatic residents and HCP in facilities as part of a COVID-19 outbreak response, and testing of asymptomatic HCP in facilities without a COVID-19 outbreak as required by CMS recommendations. [MEDICATION NAME] tests should not be utilized to determine the duration of Transmission-Based Precautions nor when HCP can return to work. Test-based strategies are not generally recommended to determine duration of transmission-based precautions, nor to determine when HCP may return to work. If used, test-based strategies should rely only on RT-PCR. Testing of asymptomatic residents or HCP in nursing homes as part of an outbreak response* If an [MEDICATION NAME] test is positive, no confirmatory test is necessary. Residents should be placed in transmission-based precautions, and HCP should be excluded from work. If an [MEDICATION NAME] test is presumptive negative, residents should be placed in appropriate precautions for facilities with an outbreak. HCP should be allowed to continue to work with continued symptom monitoring. The facility should continue serial [MEDICAL CONDITION] testing ([MEDICATION NAME] or RT-PCR) every ,[DATE] days until no new cases are identified for a 14-day period. *A COVID-19 outbreak response in a nursing home is triggered when a resident or HCP tests positive for [DIAGNOSES REDACTED]-CoV-2. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility educated staff about transmission based precautions and the proper use of PPE. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated about transmission based precautions (TBP) and proper use of PPE. Staff and resident monitoring was continued for the proper implementation of TBP, observations and assessments were ongoing to ensure the health and safety of the residents. 3XXX,[DATE](a)

Based on observation, interview, and record review, the facility failed to prevent sexual abuse from occurring when a male staff member had anal intercourse with a male resident for 1 of 3 abuse allegations reviewed. The state agency received videos and picture evidence of two males, one identified as a male employee and the other identified as a resident. (Resident B, CNA 7). This Immediate Jeopardy began on March 6, 2020, when the facility failed to prevent sexual abuse from occurring when a male staff member had anal intercourse with a male resident. The Administrator, DON (Director of Nursing), and MDS Coordinator were notified of the Immediate Jeopardy on March 6, 2020 at 9:00 P.M. The Immediate Jeopardy was removed on 3/9/20 at 3:24 P.M., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On 3/6/20 at 12:29 P.M., the Indiana State Department of Health received videos and a picture. The videos depicted a staff member wearing royal blue scrubs, having anal intercourse with another individual in a teal colored T-shirt. The picture depicted a penis of an individual wearing a teal colored T-shirt and a staff member in royal blue scrubs with multiple bracelets on the left wrist. The wrist with the bracelets appeared to be up close and directly underneath the testicles of the individual in the teal colored T-shirt. On 3/6/20 at 6:15 P.M., and on 3/8/20 at 9:10 A.M., an observation of Resident B's former room included, but was not limited to: Valances and additional sheer drapes as seen in the videos Ceiling fire detector, light fixture, and sprinkler head as seen in the videos A side chair, with a brown metal frame as seen in the videos White clothes basket with Resident B's name On 3/6/20 at 3:25 P.M., Resident B's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 12/1/19, indicated Resident B was cognitively intact and had a [DIAGNOSES REDACTED]. The Care Plans included, but were not limited to: I have behavioral issues and frequently make false truths, initiated 6/28/19. The intervention included, staff to go in room of resident with two staff members at all times, initiated 6/28/19. The Progress Notes included, but were not limited to: 3/3/20 at 8:00 A.M., Updated resident that (name of aging council) would be here to interview him today. Resident voiced understanding. 3/4/19 at 7:00 P.M., Returned from LOA. meds (medications) given and went to bed. 3/4/20 at 8:33 P.M., Resident came to nurses (sic) desk to speak to this nurse. Resident visibly shaking. Asked if he was cold, resident state no that he has been like this since returning because being here makes him anxious. Making statements to staff presenting as being very paranoid. Making statements that staff is accusing resident of several different behaviors. States that he is going to be arrested tomorrow because of what staff is accusing. Reassurance given but resident remains paranoid & anxious. 3/4/20 at 10:42 P.M., Resident pacing between units. Remains paranoid & (and) anxious. Continues to make paranoid statements regarding staff making accusations about him. 3/5/20 at 12:08 A.M., Upset left the building. 3/5/19 at 9:05 A.M., ED and DNS (Director of Nursing Services) were both contacted by floor nurse about resident and his increased behaviors. It was reported resident was anxious and showing increased signs of paranoia. ED instructed floor nurse to educate resident on leaving AMA (Against Medical Advice) if that was his wishes and have him sign them. Res (resident) did sign them and left the building. 3/6/20 at 2:36 P.M., Resident has texted the ED (Executive Director) multiple times in the last three days. It started with needing to come back for an appointment with (Name of aging council) for a continued level of care after leaving on LOA (leave of absence). These text messages were increased in paranoia and accusatory towards staff. When staff was interview (sic) about accusations, staff knew nothing about it. It was discovered the resident had told staff members different stories than he would tell the ED and management. Resident had been close to a preacher the entire time here. When resident missed his appointment, the ED called the preacher to see if he had known where he was. Upon talking with him, it was discovered the information the resident had been telling the ED was different then (sic) the information he had been telling the preacher. Today, the resident had continued to text the ED accusatory statements. ED informed management and floor staff if resident comes on to the property to immediately call her. During an interview on 3/6/20 at 3:17 P.M., the Administrator indicated there was one other abuse reportable involving Resident B. The Administrator provided the abuse allegation from 7/4/19. During an interview on 3/6/20 at 4:40 P.M., QMA 8 indicated on the night of 3/4/20 she was in the facility visiting a coworker. CNA 7 told QMA 8 she should go check on Resident B. QMA 8 indicated Resident B was anxious and rambling about being in trouble for stealing medications from the facility. QMA 8 indicated Resident B's paranoia was worse on the night of 3/4/20. QMA 8 indicated Resident B and CNA 7 were close. QMA 8 indicated CNA 7 would bring his dog in to visit Resident B. During a telephone interview on 3/6/20 at 4:56 P.M., Resident B indicated he was the resident in the video provided to the Indiana State Department of Health and CNA 7 was the staff member. Resident B indicated the sexual abuse had been ongoing from November 2019 until approximately one week prior to that date (3/6/20). Resident B indicated he had attempted to tell the Administrator multiple times but was told he was being dramatic. Resident B indicated that was the reason he left AMA (Against Medical Advice) on 3/4/20. During the telephone interview, Resident B indicated he had electronic messages where had indicated to several staff members he was being abused. On 3/6/20 at 5:39 P.M., Resident B forwarded electronic messages he had shared with facility staff members regarding the abuse. From 2/11/20 to 3/2/20 Resident B shared electronic messages with RN 11 and CNA 12. On three occasions Resident B alleged abuse and on two occasions included that he had videos and pictures to prove the abuse occurred. The information shared with RN 11 and CNA 12 was not shared with facility administration or addressed in the clinical record. On one occasion time stamped 2/17/20, Resident B electronically messaged the Social Service Director, regarding bloody stools and bloody vomit. Resident B listed the names of four employees working who knew he was sick, RN 13, LPN 14, CNA 14, and CNA 12. There was no assessment or notification included in the clinical record. During an interview on 3/6/20 at 6:22 P.M., LPN 9 indicated she was working on the night of 3/4/20. LPN 9 indicated Resident B had come to the nursing station on the West unit and was visibly shaking. LPN 9 indicated she asked Resident B if he was okay, to which Resident B replied it was his nerves. LPN 9 indicated Resident B was rambling about staff talking about him and the police being called because he was stealing drugs. LPN 9 indicated this behavior was unusual for Resident B and was very concerning. During an interview on 3/6/20 at 6:52 P.M., a photo was shown of the arm with bracelets, edited to exclude the male genitalia. CNA 10 indicated the bracelets in the picture were familiar but could not say which employee wore the bracelets. During an interview on 3/6/20 at 7:06 P.M., CNA 7 came to the facility and indicated he had met Resident B on a phone sex application prior to becoming employed with the facility. CNA 7 indicated Resident B had been to his apartment prior to CNA 7 working at the facility where they had hooked up. CNA 7 indicated he had not had sexual contact with Resident B since he began working at the facility on 11/7/19. CNA 7 indicated those were his bracelets in the photo of the arm with bracelets. (Edited to exclude the male genitalia) During an interview on 3/7/20 at 11:06 A.M., Resident J indicated that Resident B and CNA 7 were close. Resident J indicated that at one time, Resident B and CNA 7 had dated but was unsure if it had occurred after CNA 7 had begun working at the facility. Resident J indicated CNA 7 would take Resident B out of the facility for lunch, as friends. Resident J indicated CNA 7 had terminated his friendship with Resident B recently. On 3/6/20 at 4:00 P.M., the DON provided the current Reporting Abuse to Facility Management policy, revised 1/1/19. The policy was reviewed at that time and included, but was not limited to: Our facility does not condone resident abuse by anyone, including staff members. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. On 3/8/20 at 2:00 P.M., Facility Owner provided the current Employee Handbook, undated. The Employee Handbook included, but was not limited to: The selected colors and styles of acceptable uniforms will be the same for all facilities and are as follows: Certified Nursing Assistants, Royal blue scrub tops and pants. The Immediate Jeopardy that began on 3/6/20 was removed on 3/9/20 when the facility educated staff about abuse, reporting abuse, and social media policies. The Immediate Jeopardy was removed on 3/9/20, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated about abuse, reporting abuse, and social media policies and monitoring implemented and observations made to ensure the safety of the residents. This Federal tag relates to Complaint IN 823. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to report allegations of abuse for 3 of 3 abuse allegations reviewed. Allegations of abuse were not immediately reported to the Administrator and state survey agency. Resident B's allegations were not reported timely, leading to further abuse. (Resident C) This Immediate Jeopardy began on February 11, 2020, when the facility failed to ensure allegations of abuse were immediately reported to the Administrator resulting in a male staff member having anal intercourse with a male resident. The Administrator, DON (Director of Nursing), and Facility Owner were notified of the Immediate Jeopardy on March 9, 2020 at 3:52 P.M. The Immediate Jeopardy was removed on 3/9/20 at 4:24 P.M., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. On 3/6/20 at 12:29 P.M., the Indiana State Department of Health received videos and a picture. The videos depicted a staff member wearing royal blue scrubs, having anal intercourse with another individual in a teal colored T-shirt. The picture depicted a penis of an individual wearing a teal colored T-shirt and a staff member in royal blue scrubs with multiple bracelets on the left wrist. The wrist with the bracelets appeared to be up close and directly underneath the testicles of the individual in the teal colored T-shirt. On 3/6/20 at 6:15 P.M., and on 3/8/20 at 9:10 A.M., an observation of Resident B's former room included, but was not limited to: Valances and additional sheer drapes as seen in the videos Ceiling fire detector, light fixture, and sprinkler head as seen in the videos A side chair, with a brown metal frame as seen in the videos White clothes basket with Resident B's name On 3/6/20 at 3:25 P.M., Resident B's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 12/1/19, indicated Resident B was cognitively intact and had a [DIAGNOSES REDACTED]. The Progress Notes included, but were not limited to: 3/6/20 at 2:36 P.M., Resident has texted the ED (Executive Director) multiple times in the last three days. It started with needing to come back for an appointment with (council on aging) for a continued level of care after leaving on LOA (leave of absence). These text messages were increased in paranoia and accusatory towards staff. When staff was interview (sic) about accusations, staff knew nothing about it. It was discovered the resident had told staff members different stories than he would tell the ED and management. Resident had been close to a preacher the entire time here. When resident missed his appointment, the ED called the preacher to see if he had known where he was. Upon talking with him, it was discovered the information the resident had been telling the ED was different then (sic) the information he had been telling the preacher. Today, the resident had continued to text the ED accusatory statements. ED informed management and floor staff if resident comes on to the property to immediately call her. During a telephone interview on 3/6/20 at 4:56 P.M., Resident B indicated he was the resident in the video that was provided to the Indiana State Department of Health and CNA 7 was the staff member. Resident B indicated the sexual abuse had been ongoing from November 2019 until approximately one week prior to that date (3/6/20). Resident B indicated he had attempted to tell the Administrator multiple times but was told he was being dramatic. Resident B indicated that was the reason he left AMA (Against Medical Advice) on 3/4/20. During the telephone interview, Resident B indicated he had electronic messages where he had indicated to several staff members he was being abused. On 3/6/20 at 5:39 P.M., Resident B forwarded electronic messages he had shared with facility staff members regarding the abuse. From 2/11/20 to 3/2/20 Resident B shared electronic messages with RN 11 and CNA 12. On three occasions Resident B alleged abuse and on two occasions included that he had videos and pictures to prove the abuse occurred. The information shared with RN 11 and CNA 12 was not shared with facility administration or addressed in the clinical record. On one occasion time stamped 2/17/20, Resident B electronically messaged the Social Service Director, regarding bloody stools and bloody vomit. During an interview on 3/9/20 at 2:15 P.M., RN 11 was shown a copy of electronic messages provided to the state survey agency, which included, but was not limited to: Just done with the bull**** here and the [MEDICATION NAME] out abuse and nothing gets done I can't do it no more. RN 11 indicated those were electronic messages between her and Resident B. RN 11 indicated she did not report the allegation of abuse because it was crap. RN 11 indicated she had called the facility to check on residents but had not notified the Administrator of the allegation of abuse. During an interview on 3/9/20 at 4:50 P.M., RN 11 indicated she had to look on her phone for the time and date of the following electronic message, Just done with the bull**** here and the [MEDICATION NAME] out abuse and nothing gets done I can't do it no more. RN 11 walked back to the medication cart, picked up her phone, and scrolled thru her messages and said, The date is February 11 at 7:00 P.M. During an interview on 3/6/20 at 6:22 P.M., LPN 9 indicated she was working on the night of 3/4/20. LPN 9 indicated Resident B had come to the nursing station on the West unit and was visibly shaking. LPN 9 indicated she asked Resident B if he was okay, to which Resident B replied it was his nerves. LPN 9 indicated Resident B was rambling about staff talking about him and the police being called because he was stealing drugs. LPN 9 indicated this behavior was unusual for Resident B and was very concerning. This was not reported to the ED. During an interview on 3/6/20 at 7:06 P.M., CNA 7 came to the facility and indicated he had met Resident B on a phone sex application prior to becoming employed with the facility. CNA 7 indicated Resident B had been to his apartment prior to CNA 7 working at the facility where they had hooked up. CNA 7 indicated he had not had sexual contact with Resident B since he began working at the facility on 11/7/19. CNA 7 indicated those were his bracelets in the photo of the arm with bracelets. (Edited to exclude the male genitalia) During an interview on 3/6/20 at 3:17 P.M., the Administrator indicated there was one other abuse reportable involving Resident B. The Administrator indicated the incident was not reported to the state survey agency because other staff members had witnessed the incident and it was not abuse. On 3/6/20 at 3:30 P.M., the Administrator provided the abuse allegation from 7/4/19 involving Resident B. The incident investigation included, but was not limited to: Resident B, current BIMS (Brief Interview for Mental Status) score of 9 (moderate cognitive impairment). Description of alleged incident: Resident reported that he was in the hallway in front of his room. The resident asked the employee, How's it going. The employee responded, I hate this f****** place and f*******hate the people who work here. CNA 30's statement included, but was not limited to, (Name of Employee 1) came onto Season's (locked dementia unit) telling (Name of Employee 2) that (Name of QMA 8) was sending her home and called her mommy (name of Administrator) using profanity and the f-word and bull**** (Name of employee 2) agreed and said that it was f****** bull****. 2. During an interview on 3/6/20 at 3:35 P.M., Resident C indicated RN 13 had been verbally abusive to her a couple of weeks ago. Resident C indicated that when RN 13 came into her room, she (Resident C) had asked him (RN 13) to turn her TV on. Resident C said, RN 13 said, 'Do it yourself that's not my problem' . Resident C indicated she told RN 13, Go to h----. Resident C indicated RN 13 motioned with his hands up in the air, Come on baby, bring it on. Resident C indicated she told RN 13 to get out of her room. Resident C said, I told a nurse about it later. I don't know her name, but she had brown hair. Resident C indicated no one had come to talk to her about the incident. Resident C indicated the interview was not confidential and could be reported to the administrator using her name. During an interview on 3/6/20 at 4:00 P.M., the Administrator was notified of an allegation of verbal abuse by Resident C. The Administrator indicated that no allegations of verbal abuse had been reported to her in the last 2 weeks. The clinical record for Resident C was reviewed on 3/6/20 at 11:11 A.M. The record indicated Resident C was admitted to the facility on [DATE]. Resident C's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident C experienced mild cognitive impairment. The assessment further indicated Resident C required the assistance of two staff for bed mobility, toileting and transfers and was only able to stabilize with staff assistance. During an interview on 3/8/20 at 10:21 A.M., The Housekeeping Supervisor (HK 1) indicated that, whenever a Resident complained of abuse, the allegation should be reported immediately to the Administrator. Even if staff members heard about an abuse allegation of a resident at the facility when staff members were off work, HK 1 indicated staff members should still contact the facility and report the abuse allegation to the Administrator. On 3/9/20 at 4:02 P.M., the Administrator provided the current Reporting Abuse to Facility Management policy, revised 3/7/20. At that time the policy was reviewed and included, but was not limited to: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse. All personnel are required to report incidents of resident abuse or suspected incidents of abuse. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. The Executive Director is responsible for immediately notifying all appropriate state agencies of any allegation of abuse. Notification shall be made to the Indiana State Department of Health, local law enforcement, and Adult Protective Services The Immediate Jeopardy that began on 2/11/20 was removed on 3/9/20 when the facility educated staff about abuse, reporting abuse, and social media policies. The Immediate Jeopardy was removed on 3/9/20, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated about abuse, reporting abuse, and social media policies. This Federal tag relates to Complaint IN 823. 3.1-28(c)

Based on interview and record review, the facility failed to ensure the pressure ulcer treatment was consistently performed as ordered by the wound care physician, resulting in a worsening of a pressure wound with resulting hospitalization for infection and exposed tendon, for 1 of 3 residents reviewed with pressure ulcers, in a sample of 14. (Resident N) Findings include: The clinical record of Resident N was reviewed on 1/15/19 at 10:50 A.M. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 9/28/18, indicated the resident had a memory impairment, required extensive assistance of two+ staff for bed mobility and transfer, and did not have any pressure areas. Progress Notes included the following notations: 11/1/18 at 8:40 P.M.: Returned from appt .pressure redistribution boots due to wound to left heel & refer to (name) wound clinic for left heel wound 11/5/18 at 9:00 A.M.: Assessed wound to L (left) heel. See skin assessment this date. Received n.o. (new order) fro treatment A Pressure Wound Observation Tool, dated 11/5/18, included: L (left) heel, Acquired, Pressure, STDI (suspected tissue deep injury) .Current treatment plan: [REDACTED] Nursing Progress Notes continued: 11/7/18 at 12:17 P.M.: .patient is noncompliant with diet. Has snacks and coca cola at bedside 11/19/18 at 1:27 P.M.: Pt (patient) out to apt (sic) at wound care clinic with POA. A Wound Care Clinic physician's orders [REDACTED]. The ulcer measures 1.6 cm (centimeters) x 1.1 cm x 0.1 cm. Remove old dressing. Cleanse with wound cleanser. Use Santyl/[MEDICATION NAME] Transfer as the primary dressing. Use 4 x 4 gauze as the secondary gauze. This order to be carried out daily for one week Non-weight bearing on left foot. Passive movements only with PT (physical therapy). Nursing Notes continued: 11/19/18 at 5:44 P.M.: Pt came back with new wound orders. Forwarding orders to our wound MD and awaiting to hear back. 11/21/18 at 3:05 P.M.: Wound MD would like to continue with skin prep to heal (sic) daily A Weekly Pressure Wound Observation Tool, dated 11/27/18, indicated, Overall Impression: Improving. Length 1.5 cm x 2.0 cm x 0 cm .Skin prep area twice a day. Nursing Progress Notes continued: 12/5/18 at 1:56 P.M.: Pressure wound to left heel now open and draining. See wound assessment. Treatment plan changed to [MEDICATION NAME] dressing change Mondays and Thursdays .Will continue pressure relieving boots and elevating heels. A Wound Care Clinic note, dated 12/17/18, indicated: Ulcer: Left lateral posterior heel. The ulcer measures 2.1 cm x 1.6 cm x 0.2 cm .(Dressing change) to be carried out every other day for one week .Pressure ulcer of left heel, stage 3. Patient to be toe-touch weight-bearing to left foot to offload heel ulcer Nursing Notes continued: 12/17/18 at 2:24 P.M.: New order from wound clinic - Left Heal (sic) - cleanse with wound cleanser spray, use calcium alginate as primary dressing, cover with ABD pad and secure with Kerlix (dressing), change every other day. Use off loading boots while in bed 12/19/18 at 4:06 P.M.: Pt continually tucks left foot under right leg putting pressure on wound, encouraging pt not to do this and educate why .noncompliant wearing boots. Will cont to monitor. A Wound Care Clinic note, dated 12/26/18, indicated: Ulcer: Left lateral posterior heel. The ulcer measures 2 cm x 1.6 cm x 0.2 cm .(Dressing change) to be carried out every other day for one week. A Pressure Wound Observation Tool, dated 12/26/18, indicated, Length 1.5 cm x 2 cm x 0.1 cm .Treatment: Cleanse with wound cleanser and pat dry then apply calcium alginate to wound .and wrap with kerlix daily. Nursing Progress Notes continued: 12/26/18 at 4:41 P.M.: [MEDICATION NAME] Tablet 100 mg (an antibiotic), Give 1 tablet by mouth two times a day for osteo[DIAGNOSES REDACTED] for 10 days. Order received from (name) wound clinic .osteo[DIAGNOSES REDACTED] (bone infection). 12/27/18 at 7:45 A.M.: Received orders from wound care clinic. Dressing to Left heel are the same .Change dressing every other day 12/31/18 at 4:30 P.M.: .Dressing changes as ordered. Heel boots on but resident can be noncompliant with keeping them in place A Pressure Wound Observation Tool, dated 1/2/19, indicated, Length 1.5 cm x 2 cm x 0.1 cm .Treatment: Cleanse with wound cleanser and pat dry then apply calcium alginate to wound .and wrap with kerlix daily. Nursing Progress Notes continued: 1/3/19 at 3:29 P.M.: Wound care clinic ordered for resident to take [MEDICATION NAME] an additional five more days .Dressing to L heel changed per order. Continuous reminders to keep heel boots on and in place .Continue to monitor. 1/3/19 at 4:01 P.M.: Friend (name) called wound care clinic and stated residents (sic) heel looked worse. Resident now has appt. there tomorrow A Wound Care Clinic Physician's note, dated 1/4/19, indicated: Patient's left heel ulcer is much larger today. There is surrounding purple discoloration suggestive of deep tissue injury and there is loose necrotic (dead) tissue over purple discolored regions. There is exposed tendon, which is directly above the bone .ulcer was selectively debrided just to remove the very loose necrotic tissue .Unfortunately, at previous visits and today patient keeps putting his foot down on the bed or a pillow, directly on the ulcer and rubbing it. This is worsening the ulcer site. Discussed if the ulcer continues to worsen, patient needs to go to ER .Patient has Alzheimer's, has some times of clarity .Patient did have wound dressed this week by (facility) staff. He has not been getting up with physical therapy over the past week . Included on dressing change orders to apply [MEDICATION NAME] foam (a protective dressing) to dorsal foot d/t (due to) potential for breakdown. Care coordinated with (name of facility). 1/4/19 at 7:46 P.M.: Late Entry 1/14/19. Pt returned from wound care clinic. No new orders, continue to change every other day, cleanse with would (sic) cleanser, pat dry, cover with calcium alginate, then abd pad and secure with kerlix, continue to use off loading boots while in bed. Will cont to monitor. The documentation did not indicate the facility was to start using [MEDICATION NAME] foam on the resident. 1/8/19 at 1:13 P.M.: Wound assessment done. Resident lying with left leg tucked and pressure on left heel wound. Resident repositioned to right side and left heel floated .Education done regarding pressure wound and osteo[DIAGNOSES REDACTED] and that he risks losing his foot if he is not compliant. Resident continues to be non compliant. A Pressure Wound Observation Tool, dated 1/8/19, indicated, Length 4 cm x 4.2 cm x 0.1 cm .Infection suspected .Treatment: skin prep bid and cover with island [MEDICATION NAME] dressing. 1/8/19 at 2:12 P.M.: Late Entry. 1/14/19 at 2:12 P.M. (after survey entrance). Resident wound is stable. The size indicates it is bigger but has no open areas just black eschar. Scan (sic) drainage. MD notified. He is following with wound clinic on the 10th. 1/9/18 at 10:50 A.M.: Late Entry 1/14/19 Skin prep left heel bid (twice daily) and cover with [MEDICATION NAME] island dressing .Start Date: 1/8/2019. 1/10/19 at 12:30 P.M.: Res (resident) loa (leave of absence) with POA (name) to go to Dr. Appt. A Wound Care Clinic note, dated 1/10/19, included: .He presents today with no dressings in place to the left heel ulcer, had nonskid socks on only .The ulcer measures 4.6 cm x 3.4 cm x 0.2 cm. It has increased in size from its original measurement of 2 cm x 1.6 cm x 0.2 cm .There is a moderate amount of serosanguineous exudate (drainage) draining from the ulcer .The ulcer bed has exposed subcutaneous, tendon and bone tissue. The skin around the ulcer is [DIAGNOSES REDACTED]tous (red and swollen) The resident was admitted to the hospital on [DATE], and remained in the hospital during the survey. A Plan of Care, initially dated 4/20/18 and updated 1/10/19, indicated, I am risk for skin impairment r/t (related to) having fragile skin and being diabetic. The Interventions included: Assist with T/R (turn/reposition) q2h (every 2 hours) and PRN (as needed). Follow facility protocols for treatment of [REDACTED]. An additional Plan of Care, initially dated 11/7/18 and updated 1/14/19, after survey entrance, indicated, I have a stage 3 ulcer on my left heel and I am non compliant with keeping my feet elevated when I am in bed. The Interventions included: Bilateral bunny boots. Treatment as ordered. The resident's Treatment Administration Record (TAR), dated (MONTH) (YEAR), indicated the resident received skin prep to his L heel 4 times from 12/1/18-12/7/18. The resident had a border foam dressing applied on 12/10 and 12/13. The next treatment recorded was on 12/21, which was Calcium Alginate. The resident received a dressing change on 12/21/18, and that was the last time in (MONTH) a treatment was performed. The resident's TAR, dated (MONTH) 2019, indicated the resident received daily dressing changes, with calcium alginate, covering with an ABD pad and wrapped with Kerlix, from 1/1/19-1/8/19. There were no dressing changes documented after 1/8/19. There was no documentation a skin prep was used on the resident's pressure ulcer. On 1/16/19 at 9:45 A.M., the Program Director at the Wound Care Clinic was interviewed. She indicated Resident N had been coming to their clinic, but that they were concerned that our orders were not being followed. She indicated the Wound Care Clinic's physician would order a treatment, and then the facility's wound doctor, (MD 1) would overwrite the orders. The Program Director indicated she had spoken to the Director of Nursing (DON), either in late (MONTH) or early December, regarding the clinic's concerns. She indicated the resident, resident's POA, and the resident's surgeon requested that the Wound Care Clinic resume seeing the resident, and they resumed services on 12/17/18. She indicated the resident would come to the clinic with no dressings on his wound, and would report therapy was having him stand on his foot when he was to be non weight bearing. She indicated on 1/4/19, the medical director at the clinic, referred the resident to a podiatrist. She indicated the podiatrist saw the resident on 1/10/19, and directly admitted him to the hospital with a [DIAGNOSES REDACTED]. She indicated skin prep would not have been an appropriate treatment for [REDACTED]. On 1/16/19 at 10:35 A.M., RN 1 was interviewed. She indicated she and the DON would look at the wound 1-2 x weekly. She indicated the POA wanted the resident to go to the Wound Care Clinic, so he went there once a week. She indicated the facility also had their own wound doctor, MD 1, and they would have a teleconference with him to get his advice and recommendations. She indicated on 1/9/19, the wound was no longer draining, and so they called the physician. and got the treatment order changed to skin prep. She indicated she did not know which physician they called, but thought it may have been the primary physician. RN 1 then explained the TAR discrepancy between the orders for the treatment every other day, but was signed as completed every day. She indicated, We may have moved it to every day because of increased drainage. She indicated she did not know if a physician was notified. She indicated the order for the skin prep may have not been transferred to the TAR, but that the staff would have passed it on in report. On 1/16/19 at 10:55 A.M., the Administrator was interviewed. She indicated she would have teleconference with MD 1 and he would give advice. She indicated, What the wound care clinic was doing was not helping him get better. She indicated she had informed MD 1 on 1/9/19 that the resident's wound was no longer draining, and he suggested the skin prep. The Administrator indicated the resident's POA did not have a problem with using MD 1. The Administrator indicated Resident N was non compliant with his care, as well as the POA. The Administrator indicated she did not know why the treatment record did not accurately document the treatments the resident received. The STAGES OF PRESSURE ULCERS, AMDA - 2008, included: Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence .Note: This area may be painful, firm, soft, warmer or cooler compared to adjacent skin. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. (MONTH) also present as an intact or open/ruptured serum filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. Note: The depth of a Stage III or IV varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the ulcer bed. Note: Until enough slough or eschar is removed to expose the base of the ulcer, the true depth and therefore stage, cannot be determined. On 1/16/19 at 4:35 P.M., RN 2 provided the current facility policy, Prevention of Pressure Ulcers, dated 11/1/17. The policy included: The facility has a system/procedure to assure assessments are timely, appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed This Federal tag relates to Complaints IN 202 and IN 440. 3.1-40(a)

Based on interview and record review, the facility failed to correctly assess a resident at risk for falls, and failed to develop and implement a plan to prevent falls, resulting in a fall and a [MEDICAL CONDITION]; and utilized alarms in place of supervision, for 2 of 3 residents reviewed with falls, in a sample of 11. (Resident C, Resident F) Findings include: 1. On 1/18/18 at 9:50 A.M., the Administrator provided CNA assignment sheets. The sheets included the facility's 78 residents, and the care they required. The assignment sheets indicated 12 residents were on some type of alarm for fall prevention. The closed clinical record of Resident C was reviewed on 1/1818 at 10:35 A.M. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Notes from the resident's previous facility included: 1/3/18 (untimed): .Pt (patient) cont (continues) confused much of the time and lethargic. She very often forgets she is not to get out of bed without alerting staff and sets off bed alarm. Reminded repeatedly 1/3/18 (untimed): .She appeared to be wide awake when I said her name, but soon began talking nonsense and falling asleep during the visit .Patient was alert and disoriented during the visit when she wasn't falling asleep A faxed Patient Information form, dated 1/4/18 at 11:36 A.M., included: Safety: bed rails and bed alarm A facility Progress Note, dated 1/4/18 at 6:30 P.M., included, Resident arrived via cab with daughter. Resident walks with rolling walker. She has portable oxygen. Resident is alert and oriented x 2 and confused at times A Progress Note, dated 1/4/18 at 8:57 P.M., included, Upon entering room, noted resident's pain pump in the floor. Pump no longer connected to resident's port. Resident confused & saying that call light was part of the pump An Admission Assessment, dated 1/4/18 at 10:09 P.M., included: Bed Mobility: self-performance, Supervision, Transfer: self-performance, Supervision .L(NAME) (level of consciousness), Alert .is confused at times .Mobility/Safety: Walk in room: self-performance, Supervision, Walk in corridor: self-performance, Limited assistance .Walker .Interim Care Plan: .Walk in room: support provided: One person physical assist .Cognitive status, Cognitively intact .Safety Risks: Does resident have a history of falls? No .Does resident use alarms? No Progress Notes included the following notations: 1/5/18 at 6:03 A.M.: Resident has been restless most of the night. Staff has to untangle pump line from bed remote, O2 (oxygen) tubing & call light. Reminders given to resident to be very careful with pump so to not disconnect again. Expresses understanding but continues to fiddle with pump. 1/5/18 at 7:33 P.M.: Fall Documentation .Location of Fall/Unit: (Resident C's room). Date/Time/day of week of incident: 1-5-18 @ 1845 (6:45 P.M.)/Friday .Unwitnessed .Resident observed lying on the floor in room on her back .Oxygen concentrator pulled away from the side of her bed and was observed in the middle of the room, resident had O2 tubing in mouth. Legs bent up with feet flat on floor. Resident sated she was going to go close her door .Location and Type of injury: Right hip pain 10/10 .Sent to (name of hospital) ER for Eval and TX (evaluate and treat) 1/6/18 at 1:43 A.M.: .Res (resident) returned from hospital and it was reported she had fx (fracture) of femur (hip) .R/T (related to) cancer and current condition surgery is not an option .Returned and assisted to bed 1/6/18 at 5:04 P.M.: Res resting comfortably. Confused and disoriented 1/8/18 at 10:35 P.M.: .Location of Fall/Unit: (Resident C's room). Date/Time/day of week of Incident .2220 (10:20 P.M.) .Unwitnessed .Alarm sounded, staff entered room. Resident on floor on R (right) side of bed. Resident stated she needed to get up to go to the door and fell alarm in place et (and) functioning properly. A Care Plan, dated 1/5/18, included: I am at risk for falls r/t my confusion, Gait/balance problems, Incontinence, Psychoactive drug use, being Unaware of my safety needs and muscle weakness . The Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .Bed alarm On 1/22/18 at 9:40 A.M., during an interview with the Director of Nursing (DON), she indicated Resident C was alert and oriented, and ambulatory when she was first admitted . She indicated the resident did not have an alarm when she was first admitted , because she was alert. She indicated they added a bed alarm after the first fall, because the resident kept getting herself tangled in all of her tubing. On 1/22/18 at 10:00 A.M., the DON was interviewed regarding the resident's previous facility's notes which indicated the resident was confused, and required a bed alarm. She indicated she was unaware of the documentation which indicated the confusion and bed alarm. 2. On 1/18/18 at 2:00 P.M., the clinical record of Resident F was reviewed. [DIAGNOSES REDACTED]. Progress Notes included the following notations: 12/29/17 at 7:12 P.M.: Resident arrived .Assist x 2 to bed. Resident alert but confused An Admission Assessment, dated 12/29/17 at 8:08 P.M., included: .Very confused .Transfer: self-performance Extensive assistance .Mobility: Walk in room: self-performance, Extensive assistance .Wheelchair. Poor trunk control A Fall Risk Assessment, dated 12/29/18, indicated the resident scored 16, which was a high risk for falls. An Interim Care Plan, dated 12/29/18, included: Transfer: support provided, Two + persons physical assist. Safety Risks: Does resident have a history of falls? Yes .Specify fall during the last month prior to admission: 12/20/17 .pressure pad alarm bed and w/c (wheelchair). Progress Notes continued: 1/1/18 at 6:08 P.M.: Location of Fall/Unit: Lobby on East Unit, Date/Time/day of week of incident: 1/1/18 @ 1735 (5:35 P.M.), Monday. Unwitnessed .Alarm sounded followed by a large thud. Resident observed laying on Left side. Immediate intervention to ensure resident stafety (sic): Resident evaluated for injury. V.S. (vital signs) obtained. ROM (range of motion) performed. Resident assisted to standing by 2 staff members with use of gait belt. Location and Type of injury: Resident has abrasion under Left eye and an abrasion above Left eyebrow .Clip alarm on and functioning. 1/2/18 at 4:00 P.M.: (Recorded on 1/15/18 at 4:00 P.M.) Medication review and lab work. 1/4/18 at 6:06 P.M.: Location of Fall/Unit: Dining room, Date/Time/day of week of incident: 1/4/18 @ 1745 (5:45 P.M.), Thursday. Unwitnessed .Alarm sounded followed by a thud alerting staff. Resident observed sitting on floor of dining room, right leg in front of body, left leg bent . Immediate intervention to ensure resident stafety (sic): Resident evaluated for injury. V/S (vital signs) obtained. Resident assist up by 3 staff members with use of gait belt. Location and Type of injury: 3 cm superficial laceration to side of right of eyebrow 1/5/18 at 3:45 P.M.: (Recorded on 1/15/18 at 3:45 P.M.) Medication review. On 1/22/18 at 9:40 A.M., the DON was interviewed regarding Resident F's falls. She indicated the resident had multiple falls in the hospital prior to being admitted to the facility. She stated, We do have a lot of alarms right now, but we are trying to get rid of them as soon as our psych doctor looks at those residents. She also stated that she thought the resident's falls were witnessed by staff. The DON added that the resident was currently receiving close supervision. On 1/22/18 at 1:10 P.M., the DON provided the current facility policy, Falls and Fall Risk, Managing, revised 9/24/17. The policy included: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .The staff must implement a new intervention immediately following any fall in an attempt to prevent future falls This Federal tag relates to Complaint IN 651. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to identify an area of impaired skin integrity, and failed to ensure a staff member did not scratch at an area of impaired skin integrity, causing the resident distress, for 1 of 3 residents reviewed for care during skin assessments, in a sample of 28. (Resident J) Findings include: On 10/3/17 at 8:55 A.M., during the initial tour, LPN 1 and the Assistant Director of Nursing (ADON) indicated those residents who had areas of skin impairment. Neither staff member named Resident J. On 10/3/17 at 9:30 A.M., the ADON provided the current CNA assignment sheets. The assignment sheets indicated Resident J had Wounds. On 10/4/17 at 8:50 A.M., CNA 2 indicated Resident J had wounds on her hip or bottom. She indicated she thought the resident required dressings on the areas. On 10/4/17 at 8:55 A.M., QMA 4 was interviewed. QMA 4 was working on Resident J's unit. She indicated she was unsure if Resident J had any wounds. On 10/4/17 at 9:00 A.M., a skin assessment was requested. The Director of Nursing (DON) and Medical Records Staff indicated they were unsure where the resident's wounds were located. The DON indicated she thought the wounds were on the resident's buttocks or coccyx, and did not see any skin impairment. Abrasions were observed on the resident's left hip area, and were brought to the attention of the DON and Medical Records staff. During the turning of the resident, a circular discolored area was observed on the resident's right outer heel. A skin assessment of the heel was requested. The DON looked at the area, and indicated it was not a skin impairment. She indicated, It's just dirt, and proceeded to rub and scratch at the area. Resident J was in obvious distress, and was crying. The DON indicated, She doesn't like to have her feet touched. The DON indicated she was going to have the staff give the resident a shower at that time. The clinical record of Resident J was reviewed on 10/4/17 at 10:45 A.M., and on 10/5/17 at 9:20 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 9/5/17, indicated Resident J scored a 4 out of 15 for cognition, with 15 indicative of no memory problems. Resident J had exhibited no behaviors in the previous 7 days. She was extensively dependent on two+ staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. She had complained of pain in the previous 5 days, but was unable to answer pain assessment questions. A staff assessment of pain indicated she did not have any indicators of pain in the previous 5 days. She had 1 unhealed pressure ulcer. She had no foot problems. A Wound Care Note, dated 9/26/17, indicated, Wound (Left) buttock .Sheet hydrogel/[MEDICATION NAME] (Change) 2/wk (week) (and) PRN (as needed). Documentation regarding an assessment of the feet was not found in the clinical record. A physician progress notes [REDACTED]. Wound assessments did not document any areas of skin impairment to the heels. On 10/4/17 at 1:10 P.M., another skin assessment was requested. Resident J was observed lying in bed. She had multi-podus, or pressure relieving boots on both feet. The area of skin impairment remained on the resident's right outer heel. The area was approximately 2 cm round, and discolored under the surface. Yellowish, dry tissue was observed. The ADON indicated at that time that LPN 1 usually did the wound care, and that she followed up with the documentation. The area was not touched. The resident did not cry during the skin assessment. On 10/5/17 at 9:05 A.M., the DON indicated the resident's physician had looked at the area, and didn't think it was anything. The DON indicated the physician instructed the facility to monitor the area. The DON indicated she thought the resident could use the multi podus boots, because she laid in bed most of the time. The DON did not indicate why the resident did not have any pressure relieving boots prior to 10/4/17. The DON indicated she would have LPN 1 assess the area. On 10/5/17 at 9:30 A.M., a phone call was made to the Wound Physician's office. The office staff indicated the Wound Physician was out of the state, but that there would be no different documentation at the office than what was at the facility. On 10/5/17 at 9:45 A.M., a skin assessment was requested. When the skin impairment was pointed out, LPN 1 indicated she did see the area, but did not think the area was any kind of wound. LPN 1 indicated the resident had a lot of issues with her legs and feet, and she felt like this was just a discoloration. She indicated the Wound Physician had observed the area on his last visit, and didn't think it was anything. She indicated they had observed the area on the Wound Physician's last visit. She indicated she did not know if there was any documentation of the Wound Physician observing the resident's feet. On 10/5/17 at 10:10 A.M., the primary physician of Resident J was interviewed. He indicated he had seen a lot of residents the previous day, and did not recall specifically looking at Resident J's foot. He indicated, But any good nursing home would attempt to relieve pressure for someone in bed. On 10/5/17 at 11:00 A.M., the Nurse Consultant indicated she had assessed the area on the resident's right heel. She indicated she did not think it was a pressure area, due to the appearance of the resident's legs, but that it was more than likely a stasis or venous problem. She indicated that she did inform the DON that the area would have to closely monitored, or else would develop into a worse area. Documentation prior to 10/4/17 regarding the area on the resident's right outer heel was not found in the clinical record. This Federal tag relates to Complaint IN 226. 3.1-37(a)

Based on interview and record review, the facility failed to administer Cardiopulmonary Resuscitation (CPR) to a resident who had a full code status for 1 of 2 residents reviewed with Advanced Directive for a full code status. (Resident 45) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the staff failed to provide CPR for a resident who had a full code status. The Administrator, DON, and Nurse Consultant were notified of the Immediate Jeopardy on [DATE] at 11:21 A.M. The Immediate Jeopardy was removed on [DATE] at 8:45 A.M., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On [DATE] at 8:18 A.M., Resident 45's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], indicated Resident 45 had mild cognitive impairment. The Care Plans included, but were not limited to:CPR, [DATE]. The interventions included, but were not limited to: CPR to be initiate if his heart stops beating and/or respirations cease, [DATE]. SS (Social Services) to be available to talk with (Name of Resident)/family regarding code status at their request, [DATE]. A physician's orders [REDACTED]. An Advanced Directive, dated [DATE], directed the facility to initiate CPR including chest compressions, artificial breathing, and transportation to the hospital for further treatment, signed by an APS (Adult Protective Services) agent on [DATE]. A Progress note, dated [DATE] at 8:33 P.M., indicated Resident asked CNA for a drink & to reposition arms. Drink given & arms repositioned. No C/O (complaints) voiced. Watching program on phone. A Progress Note, dated [DATE] at 11:00 P.M., indicated Entered room to given (sic) meds (medications). Upon turning on light noted resident grey in color, eyes fixed, cold to touch. No B/P (blood pressure), no pulse & no respirations. Staff unable to close eye lids (sic), written by LPN 1 A Progress Note, dated [DATE] at 11:41 P.M., indicated Resident 45's physician was notified on [DATE] at 11:10 P.M., of Resident 45's death. On [DATE] at 9:29 a.m., LPN 1's employee file was reviewed. LPN 1's CPR certification card recommended a renewal on ,[DATE]. On [DATE] at 3:00 P.M., the DON indicated LPN did not have a current valid CPR certification. The Daily Sheets for [DATE] were reviewed, three staff members working that shift were CPR certified. The clinical record did not indicate they were summoned to Resident 45's room. On [DATE] at 9:42 A.M., the DON, Administrator, and Nurse Consultant were interviewed. The DON indicated on the evening of [DATE] CPR was not initiated on Resident 45 when he was found unresponsive. The DON indicated LPN 1 had felt Resident 45 had been deceased too long. The DON indicated she arrived to the facility 15 minutes later. The DON indicated at that time they discussed whether CPR should have been initiated. On [DATE] at 12:46 P.M., the Facility Owner indicated Resident 45's family member had become guardian on [DATE]. The Facility Owner further indicated the residents code status had not been updated since the Advanced Directive, dated [DATE], from APS. On [DATE] at 2:35 P.M., the Facility Owner provided the State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, dated [DATE]. The form indicated Resident 45 wished for Resident 45 to have a do not resuscitate code status. The form was not signed by a physician. The Facility Owner indicated the residents father had sent the form to the facility on this date ([DATE]). The Facility Owner indicated the facility did not have a copy in their records prior to [DATE]. On [DATE] at 10:18 A.M., the DON provided the Advanced Directives policy, revised [DATE]. The policy included, but was not limited to: The facility shall encourage residents/patients to express and document their wishes regarding life-sustaining treatments (including cardiopulmonary resuscitation) and other aspects of care the facility will comply with related laws and regulations .the social worker will review existing documents to identify their content and to identify issues needing additional clarification . 3XXX,[DATE](f)(5)

Based on observation, interview, and record review, the facility failed to ensure a resident admitted without a pressure injury, developed a pressure injury for 1 of 2 residents reviewed for pressure injuries. This deficient practice resulted in Resident 38 developing a unstageable suspected deep tissue injury to the right heel. (Resident 38) Findings include: The clinical record for Resident 38 was reviewed on 4/10/17 at 1:30 P.M. The record indicated the [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 38 was at risk for developing a pressure ulcer, experienced severe cognitive impairment and needed the extensive assistance of 2 staff for bed mobility. The admit/readmit assessment completed on 3/11/17 indicated Resident 38 had no pressure wounds upon readmission. The Braden Scale Admission assessment dated [DATE] indicated Resident 38 was at risk to develop a pressure wound. The care plan identified risk for impaired skin integrity, but did not include interventions to prevent pressure related skin impairment. A care plan initiated on 4/10/17 read as follows: Focus .Potential for Impaired Skin Integrity R/T (related to) SDTI (suspected deep tissue injury) .Interventions/Tasks . float heels when in bed .Date Initiated: 4/10/17 . multi podus boot .Date Initiated: 4/10/17 . A care plan initiated on 5/6/15 read as follows: Focus .The resident has an ADL (activities of daily living) self-care performance deficit r/t Dementia .Date Initiated: 5/6/15 .Interventions . BED MOBILITY: The resident is able to T/R (turn and reposition) extensive assistance of two staff members .Date Initiated: 2/8/17 .Revised on: 3/23/17 . A Nurses' progress note dated 3/10/17 at 11:08 A.M. indicated, .abduction pillow at all times while in bed, turn bed (turn while in bed) . A Pressure Wound Observation Tool, dated 4/3/17 at 10:31 A.M., indicated that on 3/27/17 Resident 38 developed a suspected deep tissue injury on the right heel. The report further indicated the pressure wound on the right heel was 2.0 cm (centimeters) in length, 2.0 cm in width, and was 100% bluish. A Pressure Wound Observation Tool, dated 4/12/17 at 2:39 P.M., indicated a pressure area on the right heel measured 3.9 cm in length by 4.0 cm in width, 0 depth and 100% black/blue. The Pressure Wound Observation Tool read as follows, .5a. Overall Impression: d. Worsening .Necrotic tissue present (brown, black, leather scab-like) . The admit/readmit form provided by the facility on 4/12/17 at 2:02 P.M., described a Suspected Deep Tissue Injury and Unstageable pressure wound as the following: Suspected Deep Tissue Injury: .Purple or maroon localized area of discolored intact skin .due to damage of underlying soft tissue that is painful, firm, mushy . Unstageable: .Full thickness tissue loss in which the base of the ulcer is covered by slough and /or eschar (tan, brown or black) in the wound bed . During an interview on 4/12/17 at 10:45 A.M., PTA 1 indicated Resident 38 was not able to move herself in bed for 2 weeks after returning from the hospital due to the wedge pillow placement. PTA 1 indicated even though resident 38 had a wedge pillow between her legs it would have been appropriate to float Resident 38's feet on a pillow to ensure her heels had no direct contact with the mattress. During an observation and interview on 4/12/17 at 3:26 P.M., Resident 38 was reclining in a chair wearing a black pressure relieving boot on the right foot and a wedge pillow between her legs with Velcro straps securing the pillow in place. The Wound Care Nurse (WCN) indicated Resident 38 developed a pressure wound on her right heel because the heel had been in direct contact with the mattress. During the observation Resident 38 indicated her heel was painful. During an interview on 4/10/17 at 10:45 A.M., LPN 2 indicted the DON and herself were unaware of a pressure injury on Resident 38's right heel and had no care plan for alteration of skin integrity for Resident 38's right heel. The facility's policy and procedure for Prevention of Pressure Ulcers dated 3/4/15 was reviewed on 4/12/17 at 2:02 P.M., and it read as follows: .5. Risk Factor - Immobility .When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from ankle to knee . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and effective interventions were provided to prevent falls for 2 of 3 residents who met the criteria for the review of accidents. One of one residents randomly observed located behind fire doors out of the sight of staff and without supervision. This deficient practice resulted in Resident G experiencing a fall which resulted in a pelvic fracture, a fall which resulted in a fractured wrist, and Resident C received 10 sutures to the forehead. (Resident G, Resident C,Resident R) Findings include: 1. On 3/17/15 at 2:05 P.M., Resident G was observed receiving therapy with Physical Therapy Assistant #3. Resident G was sitting in a wheelchair and wore a cast on the right lower arm. Resident G was in no apparent distress. The clinical record of Resident G was reviewed on 3/17/16 at 3:31 P.M. The record indicated the [DIAGNOSES REDACTED]. The most recent Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident G experienced severe cognitive impairment and needed the assistance of one person for transfers, ambulation, and toileting. The most recent physician's orders [REDACTED].Up ad lib (at liberty) . A Care Plan for Falls included, but was not limited to, The resident is at risk for falls r/t Unaware of safety needs, confusion, Gait/balance problems . Initial interventions dated 2/10/16 included, but were not limited to, .follow facility protocol .Anticipate and meet the resident's needs .call light within reach .encourage the resident to use it .CNA for assistance as needed. The resident needs prompt response to all requests for assistance .Follow facility's fall protocol. Care Plan for Falls updated on 2/16/16 included, but was not limited to, interventions of .refer to orth (orthopedic doctor) and therapy to eval (evaluation) and treat . Care Plan for Falls updated on 3/8/16 included, but was not limited to, interventions of .pressure pad to bed and chair. Move resident closer to nurses' station . A Fall Risk assessment dated [DATE] indicated Resident G experienced the following, .1 - 2 falls in the past months .chair bound - requires assistance with elimination .Requires assistive device cane, walker, w/c (wheelchair) furniture . The Fall Risk Assessment determined Resident G was at a high risk for falls. A Progress Note Late Entry dated 2/7/16 at 5:00 A.M., .Resident found on the floor beside the bathroom door .states I fell and don't know what happened .grasp left hip and c/o pain. She was 1:1 supervision .Addition intervention was to put slipper socks on when resident going to bed to sleep . Documentation was lacking that a fall risk assessment was completed after Resident G's fall on 2/9/16. A Progress Note dated 2/10/16 at 9:38 P.M., .X-ray report stated fracture of pelvis. A Progress Note dated 3/7/16 at 7:00 A.M., .Resident having increased confusion this morning, blowing .nose on .pants leg, and continually getting up from wheelchair . A Progress Note dated 3/7/16 at 8:36 A.M., Urine is no longer red is dark yellow. Confusion continues. A Progress Note dated 3/8/16 at 6:50 A.M., .Resident was sitting in her wheelchair in the TV room. I heard .Help, I fell . Found resident on her back on the floor in the middle of the room. Unsure if resident hit .head. Complains of right wrist pain .EMS here to get resident . A Progress Note dated 3/8/16 at 12:39 P.M., . Returned from hospital admitted to room 1 .f/u appointment .with orthopedics for distal fx (fracture) Rt arm . An Orthopedic doctor's note dated 3/16/16 read as follows, .intraarticular fracture of lower end of right radius .fracture of lower end of right ulna . During an interview on 3/18/16 at 9:10 A.M., PT #6 indicated Resident G was evaluated by Physical Therapy on 1/28/16. At that time, Resident G had an unsteady gait, experienced decreased safety awareness, and should use the call light to obtain assistance from staff for transferring and ambulating. PT #6 indicated Resident G was not assessed to be up ad lib and was at a high risk to experience a fall. PT#6 indicated Resident G returned from the hospital after the fall on 2/9/16 and was non -weight bearing, in a wheelchair and experienced an increase in confusion which was possibly related to dementia. During an interview on 3/18/16 at 9:45 A.M., LPN #12 indicated upon admission Resident G was up ad lib, did not use a walker, ambulated and transferred without assistance from staff until her 1st fall on 2/8/16 which resulted in a pelvic fracture. LPN #12 indicated that after Resident G returned from the hospital she was in a wheelchair, was non-weight bearing and needed the assistance of one staff for transfers. LPN #12 indicated on the morning of 3/8/16 Resident G had been sitting in the wheelchair in the TV lounge when LPN #12 left the area and walked up the hall. LPN #12 indicated half way up the hall she heard Resident G say, Help, I fell . LPN #12 indicated she returned to the TV lounge and Resident G was observed on the floor, lying on her back, in the middle of the room and complained of pain in the right wrist. During an interview on 3/18/16 at 10:20 P.M., the Director of Nursing (DON) indicated Resident G was assessed upon admission to be at a high risk to experience a fall. The DON further indicated Resident G was up ad lib without any assistance from staff for ambulation and transfers until her fall on 2/9/16. The DON indicated the communication between staff needs to improve. 2. On 3/16/16 at 11:50 A.M., Resident C was observed sitting in a wheel chair in the main dining room (MDR). Resident C was observed to have a large circular shaped wound with intact stitches extending from above his/her right eye up into the hairline and ending above his/her left eye. Resident C was observed to be in no apparent distress. The clinical record for Resident C was reviewed on 3/17/16 at 8:10 A.M. The record indicated Resident C was readmitted to the facility on [DATE] and his/her [DIAGNOSES REDACTED]. The Admission care plans included, but were not limited to, a care plan for falls related to confusion, vision/hearing problems, gait/balance problems. The interventions included but were not limited to, Anticipate and meet the resident 's needs (2/10/15), bed and chair alarms (2/10/15), therapy evaluation and treatment for [REDACTED]. A care plan for pain, related to recent fall and fracture of Resident C's spine initiated 12/20/15. Interventions included, but were not limited to, anticipate Resident C's needs for interventions related to pain (12/20/15). A care plan for self-care deficits initiated 2/10/15. The interventions included, but were not limited to anticipate and meet needs (2/10/15), monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed (2/10/15). A care plan for impaired cognition and impaired thought process initiated 12/20/15. The interventions included, but were not limited to, provide comfort (2/10/15). The nursing notes for Resident C were reviewed and included but were not limited to: On 2/16/17 at 12:48 P.M., Res (resident) crying out confused looking for (name of town). Unable to calm res, offered food, fluids, one on one ref to lay down activities unable to redirect. MD (medical doctor) notified and received order for Ativan (an antianxiety medication) .5 mg (milligrams) po (by mouth) 1x for anxiety. given at 1145 (sic). Res currently calm and eating lunch. Cont (continues) on ATB (antibiotic) for UTI (urinary tract infection) . Fall # 1- 2/17/16 at 10:47 A.M., Fall Report: Heard resident fall resident found face down on floor in hallway. Blanket wrapped around wheels of wheelchair. Resident has a raised area on forehead and an abrasion to nose. Alarms were sounding .MD and family aware. New intervention is to get resident a shorter blanket that will not get caught in wheels of wheelchair. On 2/17/16 at 1:21 P.M., Resident continues to yell, moan, attempt to get up, does not follow commands. MD notified. Staff requested MD come to facility to eval (evaluate) patient for continued decline. Awaiting orders. On 2/17/16 at 6:23 P.M., 1700 (5:00 P.M.) (name of physician) here to see res .Received orders to send res to (local hospital) direct admit for observation. Schedule to CT scan at hospital .Res lethargic now. bump on head has not increased. The Fall care plans were updated to include the intervention lap robe in lap instead of blanket (2/18/16) The emergency room (ER) report dated 2/17/16 was reviewed and included, but were not limited to, [AGE] year old .lives at (name of facility) .history of dementia .increased confusion the past few days .was found to have urinary tract infection .has history of falling fell this morning .sustained bruising to forehead and abrasion to nose . The nurse's notes continued and included: Fall #2- 3/11/16 at 9:10 A.M., Resident had witnessed fall at this time in the dining (sic). Resident did hit (his/her) head has a laceration approx. (approximately) 10 cm (centimeters) x (by) 10 cm moon shaped .EMS (Emergency Medical Services) and MD were called. Pressure applied to head laceration . On 3/11/16 at 9:20 A.M., Alarm was sounding at the time of incident, resident leaned forward and fell straight forward and hit forehead, no other injuries noted. On 3/11/16 at 11:30, Resident arrived back to facility via EMS orders to remove sutures in 10 days .EMS and staff assisted resident back to bed, alarm on and functioning . On 3/11/16 at 6:50 P.M., area (sic) on head has 10-12 sutures .very anxious this evening looking for mother. No change in level of confusion prior to fall . The fall care plan was updated to include the intervention therapy to check positioning and tilt set back to help (name) sit up more straight (3/11/16). An ER report dated 3/11/16 included but was not limited Head Injury, Laceration .Stitches can be removed in 10 days in the ED . Keep wound clean and dry, medications as prescribed . During an interview with the Director of Nursing (DON) on 11:10 A.M., she indicated she considered all residents in the facility at risk for falls. She indicated Resident C was readmitted to the facility on [DATE] following a hospitalization from a previous fall. She indicated Resident C had experienced a cervical fracture after falling from his/her wheel chair on 12/21/15. She indicated Resident C had previously had alarms and these were reinitiated and was to be evaluated by therapy as interventions. She further indicated a fall risk assessment for Resident C was completed on 1/19/15 and Resident C received a score of 14 indicating he/she was a high risk to experience falls. The DON indicated fall #1 occurred on 2/17/15 at 10:15 A.M., She indicated it was an unwitnessed fall that occurred when Resident C was propelling his/herself and his/her blanket became caught in the wheels on the wheel chair and pulled resident C from the wheelchair. She indicated Resident C experienced a bump and bruising on his/her forehead and an abrasion to the nose. She indicated Resident C was sent to the hospital and a CAT scan (CT) of the head was negative. She indicated the intervention at this time was to provide Resident C with a lap blanket so the length would not be a problem. The DON indicated no documentation as to the size of the bump or bruising Resident C had experienced could be provided. The DON indicated Fall #2 occurred on 3/11/16 in the facility's Main Dining Room (MDR) at 9:00 A.M. She indicated this fall was witnessed (no staff names were provided). She indicated Resident C went to reach for an item on the floor and fell forward out of the chair striking his/her head and received a laceration to the forehead. She indicated first aid was provided and Resident C was sent to the local hospital where she received 10 to 12 stitches. She indicated the intervention was to have therapy evaluation for wheelchair positioning. At that time the DON indicated documentation Resident C had been evaluation for wheel chair positioning was lacking. During an interview with Occupational Therapist (OT) #3 on 3/17/16 at 11:40 A.M., she indicated another OT had made adjustments to Resident C's wheel chair upon his/her return from the hospital. OT #3 was unable to provide any documentation of the evaluation and adjustments that were made at that time. The Administrator and the Director of nursing were made aware of the issues concerning adequate supervision and the implementation of effective interventions to prevent falls for Resident C on 3/17/16 at 12:20 P.M. During an interview with the DON at that time, the DON indicated she was unaware of how Resident C's falls could have been prevented on 3/11/16. The DON indicated Resident C was in the dining room in a supervised activity on the day Fall #2 occurred, 3/11/16. The DON was unable to recall what activity was going on at that time. During an interview on 3/17/16 at 2:30 P.M. with the Activity Coordinator (AC) she provided the March activity schedule. She indicated on 3/11/16 at 9:00 A.M., she provided 1 on 1 visits to residents. The AC indicated 1 on 1 activities are activities done with residents who are unable or unwilling to come to the group activities. She indicated she conducts these 1 on 1 visits in the residents' rooms and not in the main dining room. The activity attendance schedule for Resident C was provided by the AC on 3/17/16 at 2:29 P.M., at that time during an interview she indicated Resident C attends most group activities so she is not care planned and has not received 1 on 1 visits. She indicated there were no activities provided in the MDR on 3/11/16. 3. A random observation occurred during an interview with the Activities Coordinator (AC) on 3/17/16 at 2:30 P.M. A set of fire doors located on the west long hall were observed to be closed. Located behind the closed fire doors were 4 residents' rooms where residents were asleep. These residents' rooms were not visible to the nurses' station on the west long hall. A second set of fire doors located further down the west long hall were observed to be closed as well. Resident R was observed seated in a wheelchair and knocking on the 2nd set of closed fire doors, requesting to talk with a nurse. The AC indicated she was unaware of the location of the west hall staff at that time. No staff were observed providing supervision for the residents on the west long hall whose rooms were located behind the 2 sets of closed fire doors. The clinical record for Resident R was reviewed on 3/17/16 at 2:40 P.M. [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident R had a BIMS of 3, indicating he/she was severely cognitively impaired. The MDS listed Resident R as requiring extensive assist of 1 person for personal hygiene, locomotion on and off the unit, and ambulation. During an interview with the Administrator on 3/17/16 at 2:35 P.M., the Administrator indicated the facility had contractors on site to inspect and repair any issues with the facility's fire alarm system. He indicated the magnetic door hardware which held the fire doors open were not working at this time. The Administrator further indicated he had instructed the staff to post at least one staff member on each hall during the scheduled repair. The Administrator indicated it was the facility's policy to provide adequate supervision to all residents. The facility policy titled Falls and Fall Risk, Managing dated 3/4/15 was provided on 3/17/16 at 1:15 P.M. by the administrator. .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with input of the Attending Physicians, will identify appropriate interventions to reduce the risk of falls initial approaches might include exercise and balance training .If falling recurs despite initial intervention, staff will implement additional or different interventions .If underlying causes cannot be readily identified, staff will try various interventions, based on .nature or category of falling, until reduced or stopped If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change intervention . This Federal tag relates to Complaint IN 866. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a dependent resident admitted without pressure ulcers and a dependent resident admitted with pressure ulcers was provided effective interventions and care to prevent the development of a Stage 3 pressure ulcers on the coccyx, stage 2 pressure ulcer on the left heel, and an unstageable pressure ulcer on the right foot (Resident #76) and 2 suspected deep tissue injuries on the right foot (Resident #62) for 2 of 3 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident #76 experiencing one stage 3 pressure ulcer, one stage 2 pressure ulcer, and Resident #62 experiencing 2 suspected deep tissue injuries. (Resident #76, Resident #62) Findings include: 1. During an observation on 1/29/16 at 8:30 A.M., Resident #76 was observed in bed wearing socks on both feet. The left foot was in direct contact with the mattress and a Multi Podus Boot was on the right foot. The following observations were made on 1/29/16 at 8:56 A.M., 9:05 A.M., 9:43 A.M., 10:58 A.M.: Resident #76 was observed sitting in a wheelchair with both feet on the floor. Resident #76 was wearing socks, but no Multi Podus Boot was observed on Resident #76's right foot. Resident #76s Multi Podus Boot was observed to be sitting on top of the dresser, in the room, during all the observations on 1/29/16. On 1/29/16 at 11:35 A.M., Resident #76 was observed on the East hall sitting in a wheelchair without the Multi Podus Boot on the right foot. Resident #76 was observed to be attempting to propel the wheelchair with her Left and Right heel. The following observations were made on 2/1/16 at 9:13 A.M., 10:38 A.M., and 11:02 A.M. Resident #76 was observed sitting in her reclining chair with both feet elevated. A Multi Podus Boot was observed on the resident's right foot. There was no pressure relieving cushion on the seat of the recliner. During an observation on 2/1/16 at 11:10 A.M., Resident #76 was lying in a recliner with her eyes closed. Resident #76 yelled out and moaned in pain as CNA #13 and the Wound Care Nurse (WCN) adjusted the recliner to an upright position and assisted the resident with a transfer to the bedside. CNA #13 indicated it took two people to transfer Resident #76. At that time, there was no pressure relieving cushion on the recliner seat. The WCN stepped into the resident's bathroom to wash her hands. CNA #13 grasped under Resident #76's knees with her right arm and behind the resident's back with her left arm and pivoted the resident from a sitting position to a lying position on the mattress. Resident #76 cried out in pain. The WCN removed the dressing from Resident #76's coccyx and observed the wound. The WCN indicated the wound looked different compared to the last time she viewed it. The WCN indicated the depth of the wound had increased. The WCN cleaned the coccyx wound and indicated she would stage the pressure area as a Stage 3, but that the area had been caused by friction. The width of the wound was 2.3 cm length x 2.5 cm x depth 1.0 cm. There was a slight odor present. Tunneling of 1.4 cm at the 1:00 position, 1.2 cm at the 3:00 position, 0.5 at the 6:00 position, 1.0.at the 9:00 position. The wound bed was 80% white and 20% red. During an observation on 2/2/16 at 2:15 P.M., Resident #76's was lying on the bed. Resident #76's left foot was observed lying on the mattress (not floated or elevated) and the Multi Podus Boot was not on the right foot. The Multi Podus Boot was observed lying in the wheelchair. Resident #76 was moaning and saying her left foot hurt. The WCN removed the resident's sock and a new pressure ulcer was discovered on the left heel measuring length 5.3 cm x width 5 cm x depth 0. The blister was intact. The right foot had a new blister on the heel measuring 2.3 cm x 3.5 cm. The blister was fluid filled. At that time the WCN was made aware that on 1/29/16, Resident #76 had been observed in the wheelchair with both feet on the floor without wearing the Multi Podus Boot on the right foot, and the left foot had not been floated for pressure relief while in bed. Additionally, the WCN was informed that there was no pressure relief cushion on the resident's recliner. The Wound Care Nurse indicated more instruction was needed for the CNA's in regard to pressure relief interventions. The clinical record of Resident #76 was reviewed on 2/1/16 at 1:30 P.M. The clinical record indicated Resident #76 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The ADMISSION NURSING ASSESSMENT dated 10/3/15 indicated Resident #76 had no skin conditions upon admission to the facility. The BRADEN PRESSURE ULCER RISK assessments dated 10/3/15 and 12/10/15, documented a total score of 20 which indicated Resident #76 was not at risk to develop a pressure ulcer. During an interview on 1/29/16 at 10:50 A.M., the Director of Nursing (DON) indicated all residents in the facility were considered at risk to develop pressure ulcers. The Admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #76 experienced severe cognitive impairment, was totally dependent for bed mobility, and was not at risk for developing pressure ulcers. The Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #76 was totally dependent for bed mobility, had developed an unstageable pressure ulcer, but was not at risk for developing pressure ulcers. The Current physician's orders [REDACTED]. .Multi Podus Boot only off at hygiene Dated 12/22/15 .NUTRITIONAL SUPPLEMENT 90 ML BY MOUTH THREE TIMES DAILY Dated 10/22/15. TURN AND REPOSITION EVERY 2 HOURS PER BRADEN SCORE Dated 10/3/15 The MEDICATION ADMINISTRATION RECORD dated 2/16, read as follows: [MEDICATION NAME] wound cleanser to coccyx, Apply silver gel to wound bed, pack with gauze, Cover with dry drsg (dressing) change 3 x (times) /week (M W F) and PRN (as needed) soiled Dated 2/1/16. The Laboratory Cumulative Report dated 12/16/15 indicated Resident #76's lab values (blood levels) were as follows: Total protein was low at 5.1 g/dl (grams per deciliter). The normal range for protein is 6.5 - 8.1 g/dl. [MEDICATION NAME] was low at 2.4 g/dl. The normal range for [MEDICATION NAME] is 3.5 - 5.0 g/dl. The DIETARY CONSULTANTS, INC, NUTRITIONAL ASSESSMENT form dated 11/13/15 indicated Resident #76 experienced an unintentional weight loss and a house supplement had recently been added to Resident #76's diet three times a day. The CNA Assignment Sheet was provided by LPN #7 on 1/26/16 at 10:00 A.M. and a copy of the CNA assignment sheet was provided by the DON on 2/2/16 at 3:23 P.M. The CNA assignment sheets lacked documentation of the following documentation: wound locations, intervention with respect to the wounds, and direction for the Multi Podus Boot application and removal. The Progress Notes dated 12/22/15 indicated Resident #76 had a Deep Tissue Injury (DTI) on the right heel. The physician's orders [REDACTED]. Measurements and wound appearance for the DTI were requested but not provided by the (WCN) Wound Care Nurse. The Pressure Ulcer Treatment policy provided by the DON on 1/29/16 at 9:55 A.M., read as follows: .Suspected Deep Tissue Injury (Definition): purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear .The area may be preceded by tissue that is painful . The Progress Notes dated 1/19/16, read as follows: .Dr. (Physician's name) at bedside for eval .The superficial eschar on her right heel was removed [MEDICATION NAME]. Two smaller areas of eschar remain. We will continue to treat with pressure relieving boots .Resident family stated that she was complaining of her bottom. She slides in her wheelchair .Coccyx - 2.5 x (by) 1.7 x 0.2 cm (centimeters) 80%yellow, 20% black. This is friction . The Progress Notes dated 1/28/16, read as follows: .Coccyx - 2.5 x 1.7 x 2 cm 80% grey, 20% black. Moderate amount of [MEDICAL CONDITION] drainage noted. Slight odor. Wound believed to be friction .MD notified .No new orders at this time. The Progress Notes dated 1/29/16, read as follows: .Dressing change to wound on coccyx. Grey, thick drainage noted.5 cm depth noted. Wound has foul odor. Resident c/o (complained of) pain during procedure . The Progress Notes dated 2/1/16, read as follows: .Resident has wound on coccyx. Originally thought to be caused from friction. Wound is now - 2.3 cm x 2.5 cm x 1.0 cm. Wound is irregular in shape. Moderate amount of purulent drainage. Slight odor present. Tunneling of 1.4 cm @ (at) 0100, 1.2 cm @ 0300, 0.5 @ 0600, 0.7 @0900, 1.0 cm between 0900 - 1200. Wound bed is 80 % white and 20% red. Resident c/o pain with touch . The Pressure Ulcer Treatment policy provided by the DON on 1/29/16 at 9:55 A.M., read as follows: .Stage 3 Pressure Ulcer (Definition): Full thickness tissue loss .Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling . Stage 4 Pressure Ulcer (Definition): Full thickness tissue loss with exposed bone. often includes undermining and tunneling. The Progress Notes dated 2/2/16, at 3:20 P.M., documented a new area on the left heel and read as follows: .Left heel has fluid filled blister measures approximately 5.3 cm x 5 cm x 0. Blister is intact. MD notified . Right heel also has small new area appears to be blister. Blister has small amount of fluid present. Blister measures approximately 2.3 cm x 3.5 cm. No drainage noted . The Care Plan dated 12/2/15 was provided by the DON 1/29/16 at 10:15 A.M., and it read as follows: Focus: .Resident has potential impairment to skin integrity .Goal .The resident will maintain or develop clean and intact skin by review date .Educate family/caregivers of causative factors and measure to prevent skin injury .follow facility protocols for treatment of [REDACTED].Use a draw sheet of lifting device to move resident . Documentation was lacking with respect to wearing the Multi Podus Boot at all times except for hygiene, floating feet at all times when in bed, and turning and repositioning resident every 2 hours. During an interview on 2/1/16 at 12:02 P.M., CNA #13 indicated the CNA assignment sheet was used as a guide for the care of each resident. CNA #13 indicated the CNA assignment sheet needed to be accurate, especially if a CNA was not familiar with the resident's needs. During an interview on 2/2/16 2:10 P.M., CNA #13 indicated she had put Resident #76 to bed and had taken the Multi Podus Boot off the right foot to let it rest. CNA #13 indicated she was not sure if the boot should only be worn at night or if it should be worn during the day as well. The Prevention of Pressure Ulcers policy was provided by the DON on 1/29/16 at 9:55 A.M., and read as follows: .3. a. Change position at least every 2 hours: b. Use foam, gel, air cushion as indicated to relieve pressure .4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging . During an interview on 2/2/16 at 3:45 P.M., the DON indicated the CNA assignment sheets needed to be updated more often and that pressure relieving measures needed to be communicated to all staff. 2. During an interview with Unit Manager #5 on 1/27/16 at 8:45 A.M., she indicated Resident #62 had been admitted with stage 3 and 4 pressure ulcers. On 1/28/16 at 9:40 A.M., Resident #62 was observed to be lying in bed, on his back in no apparent distress. Resident #62 was observed to be wearing Multi-Podus Boots to both his feet with a gauze dressing underneath of them. During an observation of care on 1/29/16 at 10:55 A.M., CNA #6 and CNA #3 were observed assisting Resident #62 out of bed. At that time Resident #62 was observed to lying on his back in bed. When Resident #62 was rolled to the side a large amount of brown drainage was observed on the sheet under him. At that time Resident #62 refused to allow the CNA ' s to change pants or do any hygiene. At that time during an interview Resident #62 indicated he did not want to stay in bed any longer since he had been asking to get up since 6 A.M. CNA #6 indicated at that time she did not know what to do when Resident #62 was refusing care and she and CNA #3 were observed to continue getting Resident #62 up in the wheel chair. During an interview with UM #2 on 1/29/16 at 11:10 A.M., was interviewed in regards to the care of Resident #62. UM #2 indicated Resident #62 often refused care. She further indicated Resident #62 had recently stayed up in his wheel chair for 6 days. UM #2 indicated she was aware Resident #62 had a guardian and indicated the guardian had stated to do care necessary to care for the resident however, she indicated they did not want to go against Resident #62's wishes. The clinical record for Resident #62 was reviewed on 1/28/16 at 10:10 A.M., [DIAGNOSES REDACTED]. A complete guardianship order dated 8/20/15 was observed in chart and notarized. The Nurses notes were reviewed and included, but were not limited to, a nurses note dated 1/17/16 at 6 P.M, included, but were not limited to, .Stage 4 ulcer to (sign for right) buttock .Stage 2 ulcers to bilateral (both) heels . The Nursing notes included, but were not limited to: A Social Service note dated 1/19/16 at 9:45 A.M., SSD and Unit Manager called father, who is guardian, to discuss resident's constant refusal of care. Guardian stated that he has tried to let resident make decisions on his own, but if it is going to go against him receiving the appropriate care, then resident will no longer make decisions. Father stated he is guardian for a reason and wants staff to provide care, regardless of resident's refusal. Father stated to call him with any issues and he would be happy to speak with resident and staff. Father stated he wanted his son taken care of, even if resident has given up, that is why he has a guardian .Phone numbers were verified and father was informed that he would be contacted as needed. Father stated whatever we needed, he will try to help in anyway (sic) possible . A nursing note dated 1/20/16 at 2:32 P.M., res (resident) did not go to bed last night. Slept in w/c. Night shift reports several attempts to go to bed and res refused. Res has refused .and all attempts to lay down in bed for wound care also refused x3 hygiene care . A nursing note dated 1/20/16 at 7:06 P.M., Resident refused dinner .Resident refused to lay in bed but opted to stay in W/C (wheel chair). Resident educated on the importance of laying on air mattress .Resident still refused .Will continue to monitor . A nursing note dated 1/22/16 at 7:22 P.M., Resident stayed in w/c all shift. This nurse offered to assist resident into bed to relieve pressure on wounds. Resident refused . A nursing note dated 1/22/16 at 11:28 P.M., .continues to refuse to go to bed has been up in chair approx .32 hours . A nursing note dated 1/23/16 at 1:19 P.M., .Continues to refuse to go to bed has been in chair 5 days. Refuses all adl (activities of daily living) care unable to verbally redirect . A nursing note dated 1/25/16 6:25 A.M.Resid. (sic) Continues to refuse to go to bed has been up in chair 6 days has refused all treatments showers in room now in w/c with clothes he has had on for day that are dirty and sweat and stool but refuses to be changed covered up with heavy blanket it is quite warm in room and resid. (Resident) Is sweating . A nursing note dated 1/25/16 at 7:22 P.M., Res cont (sic) (continues) to refuse care. Refused both meals today. At 1500 Reached (sic) father/guardian. He stated to give res shower and to put res to bed to do necessary tx (treatment) to wounds. Stated staff to give res care necessary for his health and welfare. Res showered and tx completed as ordered . A BRADEN PRESSURE ULCER RISK assessment dated [DATE] indicated Resident #62 was at high risk to develop pressure. The care plans included, but were not limited to, The resident has [MEDICAL CONDITION] r/t (related to) Spinal injury (initiated 7/29/15) .interventions include, but were not limited to Assist with ADl's and locomotion as required, discuss with resident/and family any concerns, fears, issues regarding [DIAGNOSES REDACTED]. A care plan for actual impairment related to [MEDICAL CONDITION] (initiated 7/29/15) included, .alternating flow air mattress, follow facility protocol for treatment of [REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #62 had a BIMS score (Brief Interview for Mental Status score) of 14 indicating Resident #62 was cognitively intact. The MDS further indicated Resident #62 had no behavioral concerns and was totally dependent on 2 or more staff members for bed mobility, transfers, personal hygiene and bathing. The facility provided wound care documentation for the wound on the right foot included, but was not limited to the following: On 7/17/15 Resident #62 was admitted to the facility with a Stage 4 pressure ulcer measuring 9 cm (centimeters) x (by) 6 cm x 0.3 cm, with a red wound bed with slough in the middle to the Right heel. The interventions put into place where to turn and reposition the resident every 2 hours, air mattress, float heels. The treatment was to clean wound with wound cleanser and apply hydrogel silver and cover with an ABD pad, and wrap with kerlix (wound dressing) daily. On 7/23/15 Resident #62's Stage 4 pressure ulcer to right heel, measuring 9 cm x 8 cm x < (less than) 0.1 cm. The wound bed was dry with eschar. Current treatment was to clean the wound with wound cleanser and apply santyl (a debridement medication) to eschar cover with dry dressing every 2 days. On 10/19/15 the pressure ulcer was assessed as a Suspected Deep Tissue Injury (SDT) to the right heel measuring 1.8 cm x 1.8 cm x 1.4 cm, with moderate amount of clear/purulent drainage, pink wound bed, slight odor and no infection present. No changes to the treatments were made. On 11/3/15 the pressure ulcer was assessed as a SDT measuring 6 cm x 6 cm x < 0.1 cm, no drainage, wound bed black, no infection present. The treatment ordered was wound cleanser [MEDICATION NAME] gel, and cover with gauze. On 12/1/16 the pressure ulcer was assessed as a SDT to right heel measuring 4 cm x 2.4 cm x 0.1 cm with a moderate amount of drainage and black wound bed. No change to treatment. On 12/8/15 the pressure ulcer was assessed as 2 separate areas on the right heel. Pressure ulcer # (number) 1 was a SDT measuring 3cm x 1.8 cm x 0.4 cm with a scant amount of bloody drainage and red wound bed. Pressure ulcer #2 was assessed as a SDT to the right heel measuring 1 cm x 0.8 cm with no depth and a small amount of bloody drainage and red wound bed. On 12/14/15 pressure ulcer #1 was assessed to be a SDI to right heel measuring 2.7cm x 1.3 cm x 0.2 cm, with a small amount of bloody drainage and red wound bed. Pressure ulcer #2 was assessed as being a SDT to right heel measuring 1 cm x 0.4 cm x 0 cm with a scant amount of clear drainage and pink wound bed. No change in the treatment was made. On 12/21/15 pressure ulcer #1 was assessed as being closed and pressure ulcer #2 was measured as being assessed as being 2 cm x 1 cm x 2 cm with a scant amount of bloody drainage and beefy red wound bed.(size increase) No documentation of wound measurements was provided from 12/22/15 to 1/10/16. On 1/11/15 pressure ulcer #2 on Resident #62's right heel was assessed as being a SDT measuring 7.2 cm x 6.2 cm x 0.2 cm with moderate amount of bloody/clear drainage and a wound bed containing 50% (percent) black eschar. On 1/25/16 pressure ulcer #2 to was measured at 6.5 cm x 6.8 cm x 0.2 cm. Documentation of the characteristics of the wound bed was lacking. The facility provided wound care documentation for the left heel which included, but was not limited to the following: On 7/17/15 Resident #62 was assessed as having an unstageable pressure ulcer to his left heel measuring 3.5 x 3.5 cm presenting as a fluid filled blister, with a red black wound bed and no drainage. The treatments put into place were to skin prep area every shift. On 7/23/15 the pressure ulcer to Resident #62's left heel was measured as a 4cm x 4cm fluid filled blister with black wound bed. There were no changes to the treatment. On 7/29/15 the pressure ulcer to Resident #62's left heel was measured the same and Multi Podus Boots were added to the preventive measures. On 8/18/15 the pressure ulcer was assessed as being an unstageable area measuring 1.8 cm x 2 cm x < 1 cm with scant amount of drainage and black eschar in the wound bed. The treatment was changed to santyl ointment to black eschar every other day. On 11/3/15 the pressure ulcer to Resident #62's left heel was assessed as being a suspected deep tissue injury measuring 8 cm x 4 cm x 0.4 cm with a black wound bed, the treatment had been changed to clean with wound cleanser and cover with antasept gel, cover with gauze. On 11/9/15 the pressure ulcer to Resident #62's left heel was assessed as being 3 separate areas. Pressure ulcer #1 was assessed as being a SDT measuring 2 cm x 1.8 cm x 0.2 cm with a black/yellow/pink wound bed and scant drainage. The treatment for [REDACTED].#2 was assessed as a SDT measuring 1.4 cm x 1.6 cm x 0.4 cm with a beefy red wound bed a small amount of clear/purulent drainage. The treatment was the same. Pressure ulcer #3 was assessed as Stage 2 pressure area measuring 2.1 cm x 1 cm x 0.2 cm with no drainage and a pink wound bed. The treatment was ordered as clean with wound cleanser, apply antasept gel and cover with dry dressing. On 11/23/15 pressure ulcer#1 was assessed as being a SDT measuring 2 cm x 1.6 cm x 0.2 cm, with a 25% black wound bed and small amount of clear/purulent drainage. No changes were made to the treatment of [REDACTED]. Pressure ulcer #2 was assessed as being a SDT measuring 0.6 cm x 0.6 cm x 0.2 cm with a red wound bed and a small amount of clear/purulent drainage. No changes were made to the treatment of [REDACTED]. Pressure ulcer #3 was assessed as being a stage 2 pressure area measuring 3 cm x 0.8 cm x > (greater than) 0.1 cm with no drainage, and a wound bed that was black. No change was made to the treatment of [REDACTED]. On 12/14/15 pressure ulcer #1 was assessed as being a SDT measuring 0.5 cm x 0.7 cm with no depth and a pink wound bed draining a small amount of bloody drainage. There was no change to the treatment of [REDACTED]. Pressure ulcer #2 was assessed as being a closed. Pressure ulcer #3 was assessed as being a stage 2 pressure ulcer measuring 4 cm by 0.7 cm with no depth, and a black wound bed. No change to the treatment of [REDACTED]. On 12/21/15 area #1 was assessed being a SDT measuring 0.7 cm x 0.5 cm x 0 cm with a pink, yellow wound bed, and a small amount of drainage. No changes to the treatment of [REDACTED]. Pressure ulcer #3 was assessed as being a stage 2 measuring 4 cm x 0.8 cm x >0.1 cm depth. No changes were made to the treatment of [REDACTED]. No documentation of wound measurements was provided from 12/22/15 to 1/10/16. The nurses' notes indicated on 1/11/16 the two wounds had become one and the areas to Resident #62's left heel as assessed as being a SDT measuring 5.8 cm x 4.2 cm x 0.2 cm with a wound bed containing 25% black eschar and a moderate amount of bloody drainage. No treatment changes were done. During an observation of wound care on 1/28/16 at 10:45 A.M., Resident #62 was observed lying supine in bed, with bilateral Multi Podus Boots in place. The boots were removed by the Wound care nurse (WCN) and dressing removed from the right foot. During this observation the WCN indicated Resident #62 had a new area to the lateral planter area of his foot. She indicated the area was a fluid filled blister measuring 2.5 cm x 2.4 cm. The WCN indicated the area was red/purple like and around the wound appeared to be bruised. The wound care nurse further indicated another friction based area to the resident's anterior ankle measuring 1 cm x 3 cm with no depth with a bruising surrounding the wound area. The WCN indicated the areas were caused by friction and not pressure, she further indicated this was from the residents feet sliding around in his Multi Podus Boots. At the same time the left heel was observed with the WCN. She assessed the wound to Resident #62's left heel as having being a suspected deep tissue injury measuring 7.5 cm by 3.5 cm with a wound bed containing 90% black eschar and 10% red tissue. The WCN indicated the suspected deep tissue injury was caused from the boots sliding around too much. During an interview with the Wound Care Nurse on 2/2/16 at 8:45 A.M., she indicated Resident #62 was admitted on [DATE] with a unstageable fluid filled blister to his left heel measuring 3.5 cm x 3.5 cm and a stage 3 pressure ulcer to his right heel measuring 9 cm by 6 cm with a depth of 0.3 cm. She indicated the wounds had progressed and shown signs of healing. The Wound Care Nurse indicated the discrepancy in the measurements were due to, new instructions on how to measure wounds, different people measuring the wounds, and the resident's refusal to allow staff to do care. She indicated she was aware that Resident #62's guardian had stated to do everything necessary to heal the wounds despite the resident's refusal however staff were scared to make him lay down, or do treatments. She further indicated the new areas found on Resident #62's right foot were friction based from the Multi Podus Boots rubbing and not pressure. The wound care nurse indicated the facility was going to order new Multi Podus Boots for Resident #62. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure that a resident admitted without a pressure ulcer, developed a stage 3 pressure ulcer after admission, was provided proper care for 1 of 3 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident #76 experiencing a Stage 3 pressure area. (Resident #76) Findings Include: The clinical record of Resident #76 was reviewed on 1/9/15 at 10:00 A.M. The record indicated Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record further indicated Resident #76 was readmitted to the facility on [DATE] after a hospitalization . The Nursing Admission Assessment record dated 10/16/14 read, "...No areas noted on body..." The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 experienced severe cognitive impairment, required the extensive assistance of two people for bed mobility and transfers and/or was at risk for developing a pressure area. A Weekly Pressure Ulcer Progress Assessment form dated 12/15/14 indicated Resident #76 developed a Stage 2 pressure area on the coccyx on 12/15/14. The measurements for the wound on 1/5/15 were 1.0 cm (centimeter) length by 0.6 cm width and less than .1 cm for the depth. The report further indicated the wound was pink and no exudate was noted. physician's orders [REDACTED]. During an interview on 1/09/15 at 9:54 A.M., the Director of Nursing (DON) indicated Resident #76 was debilitated after returning from the hospital. The DON further indicated Resident #76's medications had been adjusted and as a result Resident #76 spent a lot of time in bed. The DON further indicated the area on Resident #76's coccyx may have occurred due to shearing when repositioning. During an observation of a dressing change for the pressure area located on Resident #76's coccyx on 1/09/15 at 10:15 A.M., Resident #76 was lying on her back. The wound Care Nurse (WCN) was observed to reposition the resident by grasping the draw sheet and pulling the resident across the surface of the bed. The WCN measured the wound as 1.4 cm length by 1.0 cm width, less than 0.1cm in depth with 75% white slough covering the wound bed. At that time the WCN indicated Resident #76 spent a lot of time in bed after returning from the hospital. A Policy for Wound Staging dated 11/1/14 was provided by the Director of Nursing on 1/09/15 at 3:30 P.M., and it read as follows: "...Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle cannot be seen. Slough may be present but does obscure the dept (sic) of tissue loss..." A Policy for Pressure Wounds was provided by the Assistant Director of Nursing on 1/09/15 at 3:48 P.M., and it indicated that " ...It is the facilities practice...that a resident who enters the facility...without pressure sores does not develop pressure sores..." During an interview on 1/09/15 at 4:16 P.M., the Director of Nursing (DON) indicated that the pressure wound for Resident #76 had been staged incorrectly and was a Stage 3 pressure area. The DON said, "We missed it." 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to provide services to prevent elopement, resulting in wrist fracture and hospitalization for 1 of 1 residents who had eloped in a sample of 4 (Resident A). In addition to Resident A in Immediate jeopardy, the facility failed to adequately identify, assess and implement an effective security system for 12 other residents at risk of elopement out of the facility census of 65. (Residents B, C, D, E, F. J, K, L, M, N, O, P) The immediate jeopardy began on 6/26/11 when Resident A eloped from the facility, fell and fractured her wrist. The Administrator and Director of Nursing were notified of the immediate jeopardy at 3:30 p.m. on 8/18/11. The immediate jeopardy was removed on 8/19/11, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record of Resident A was reviewed on 8/18/11 at 9:15 A.M. [DIAGNOSES REDACTED]. The resident had been admitted to Transcendent nursing home on 2/3/11. The Minimum Data Set Assessment of 6/26/11 indicated the resident's cognition to be moderately impaired with a score of 12 (8-12 moderate impairment, 13-15 cognition intact). It indicated the resident was independent in transfers and ambulation and was always easily distracted or out of touch or had difficulty following what was said. The 7/06/2011 Interdisciplinary Diagnostic and Evaluation Center Significant change analysis provided the only available intact account of the resident's elopement in the clinical record that could be located, according to interview with the Director of Nursing on 8/18/11 at 1:30 P.M. Excerpts from that analysis are as follows: "...admitted to Transcendent 2/3/11...admitted to (Name) Psychiatric Hospital in March 2011 where she was held for 72 hours due to threats to leave the nursing facility...most recent admission to (psychiatric hospital) was on 6/27/2011 after she snuck out of the nursing facility after 11:00 P.M. on 6/26/11, walked to a convenience store, fell on her walk back, and broke her right arm...(Resident name) had reported she had asked for a cigarette but she was told she did not have any. Reportedly she went back to her room, dressed in street clothes, then snuck out through a dining room door. (Resident name) had the code to exit the door without setting off the alarm system as she was able to go in and out to a side porch for smoking times. (Resident name) then walked to a (Name) store, about a mile from the nursing facility and fell on her return walk back. She related afterwards, she was going to purchase cigarettes. However, her roommate at the nursing facility told staff that (Resident name) was going to meet a man the roommate knew and had arranged to meet (Resident name). The man's name was learned but it is not known if (Resident name) actually met up with him. When the nursing facility did their resident census at midnight they found she was missing from her bed. After a search of the facility with administrative personnel called in to help search and family notified, the facility received a call from (Name) Hospital emergency room to inform them the resident had been brought there for treatment. In relation to the above noted March 72 hour hospitalization , following threats to leave the nursing home, there was corresponding documentation in the business office of a hospitalization on [DATE], 16, 2011 followed by readmission to the facility. A 3/14/11 social services note included the resident "States she is leaving today. 'I am going back to my husband'...Dr (name) told nurse the cops will be here today to take (resident) to the hospital to get an evaluation and hold her 72 hours." A 3/18/11 social service note after the return of the resident to the facility indicated a continuing resident agenda to leave "tearful and somewhat angry because she wants her money so she can leave with her husband." Documentation was lacking of an elopement risk assessment until 5/2/11. The front page of this assessment was completed; however, the back page categories for summary, conclusions/recommendations and interventions were blank with the signature of the LPN responsible entered at the bottom of the page. The Care Plan from 3/28/11, after the hospitalization for threats to leave, did not address wandering/ elopement risk. The elopement risk was not addressed until 7/10/11, after the elopement and injury with hospitalization and return to the nursing facility's locked secured unit. That care plan had a single intervention "secured unit." Documentation was provided by the facility on 8/18/11 at 11:15 A.M. regarding an investigation of the 6/26/11 elopement, with witness accounts. Excerpts included: From the investigation portion, "At 9:00 P.M. (6/26) the documentation indicated that the resident was still angry and stated that if the guy shows up, she is leaving the facility and no one is going to stop her..." From the night shift CNA witness statement "...around 11:00 P.M. (Resident name) was on the back porch sitting." From the RN witness statement "At 11:15 P.M. asked this nurse for cigarettes and wanted to smoke. Was upset when I told her I did not smoke and felt it was late and dark outside. She was upset and started to talk about events that happened earlier in the day...offered opportunity to verbalize and invited to stay at the nurses station to talk...would not reply and at 11:30 P.M. returned to her room...At 12 midnight census bed check the resident was recognized to be missing...search began and at 12:55 A.M. the hospital called to report the resident admission to the ER." Documentation was lacking to identify facility assessment of elopement risk, preventive monitoring of security breaches i.e. resident knowledge of codes, resident outdoors at night unsupervised, resident expressed elopement ideation or a plan of care to address these problems. Documentation of the event of the 6/26/11 elopement was absent from the medical record as well as all documentation of any staff responses, notifications or communications with either the first hospital ER or the psychiatric hospital to which the resident was sent. During interview with the current DON on 8/18/11 at 1:00 P.M. and on 8/19/11 at 9:30 A.M.,she indicated the documentation was "missing" and she was at a loss to know what happened to it, and believed it could not be located. On 8/18/11 the undated policy and procedure for elopement prevention was reviewed. It directed "Obtain information during pre-admission screens with the resident and family regarding any history of wandering or a potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. Upon assessment, Care Plan will be developed and implemented with specific approaches and goals for the wanderer. Upon assessment if a resident is identified as an elopement risk the resident's name, picture and physical description are placed in the wander book located at the nurses station." On 8/18/11 the facility identified 13 residents at risk of elopement in the facility. They were Residents A, C, D, E, F, J, K, L, M, N, O, and P housed on the locked unit. The remaining elopement risk, Resident B, was housed on the regular open unit where residents were given codes by staff to use for smoking on the porch. Of the 13 residents identified to have a risk of elopement, Resident A was the only resident pictured or described in the wander book. On 8/19/11 at 10:00 A.M. LPN #1 was interviewed regarding security practices on her open unit. She indicate several alert and oriented residents knew codes and had the capability of letting other residents out or sharing the codes although she did not know if that "happened very much." She indicated Residents G, H and I knew the codes for sure and had free access. On 8/18/11 the porch door of the facility was observed to be a double wide glass door with a double key pad system of locking and a resonator which was functioning properly when manual numerical code entry was made. Residents were observed to request assistance of staff to enter codes when they were unable to do so, often related to physical inability. Resident G and I were observed to enter the codes and exit the door independently, mid morning several times between 10:00 A.M. and 11:00 A.M. Resident G was asked how to obtain the code and stated "You get it from any of them (referring to staff). There is only one code; it's always the same." An Immediate Jeopardy that began on 6/26/11 was removed on 8/19/11 when the facility reconfigured security codes and implemented a policy prohibiting the codes being given to residents, reassessed and identified all residents at risk of elopement in the facility, revised and updated the Elopement Identification book with resident photographs, and inserviced staff on the changes, but the noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with the facility continuing to assess implementation and its effectiveness. This federal tag relates to complaint IN 056. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the necessity of 2 attempted discharges of 1 of 3 residents reviewed for discharge rationale from a sample 4. This resulted in treatment being required for a panic attack in a resident awaiting heart surgery. Resident A Findings include: The clinical record of Resident A was reviewed on 8/18/11 at 9:15 A.M. [DIAGNOSES REDACTED]. The resident had been admitted to Transcendent nursing home on 2/3/11 and on 6/26/11 eloped from the facility, fractured her arm during the elopement, was sent to a local ER and transferred to a Psychiatric Hospital. Documentation of nurses' notes, Social service notes, or any verification of the event and related issues of transfer/ discharge by documentation was "missing" according to the Director of Nursing (DON)during interview on 8/19/11 at 9:30 A.M. and the Social Service Designee (SSD)on 8/19/11 at 1:50 P.M.. The business office record of transfer and discharges indicated the resident was hosptalized on [DATE], discharged from the facility on 7/1/11 and readmitted to the facility on [DATE]. During the SSD interview 8/19/11 at 1:50 P.M. she indicated she had worked with the discharge planners at the Psychiatric hospital in relation to taking Resident A back "But when the Ombudsman came was when we decided to take her back." Discharge Planner #1 at the Psychiatric hospital was interviewed on 8/19/11 at 2:10 P.M. The planner indicated good recall of the discharge and concern for "How (resident name ) could have eloped and broke her arm." The planner indicated when the resident was stable and able to be managed in a nursing home the Transcendent home would not allow her back. The planner indicated working on alternative placement until the intervention of the ombudsman on behalf of the family resulted in the resident being returned to Transcendent on 7/8/11. The planner indicated the facility was fearful she would elope again and did not want her back. On 8/17/11 at 3:50 P.M. the area Ombudsman was interviewed. She indicated she was requested to advocate for the resident by the resident's guardian when Transcendent refused readmission to the resident. The Ombudsman recounted going to the facility to work with the facility to gain resident readmission. The facility took the resident back utilizing the option of placement on their locked secure unit with enhanced supervision and security. She indicated the family was concerned to have the resident living as near to them as possible. An undated communication from the Administrator to the staff of the secure locked Seasons unit (where Resident A was admitted on [DATE]) was posted in the elopement information and monitoring book for Resident A. It included the facility intention "Her placement here is only for temporary reasons. We anticipate her to be discharged early in the week of 7/10/11." On 8/18/11 at 8:30 P.M. an interview with the area Ombudsman by phone indicated Transcendent had notified Resident A's guardian/mother that evening at 6:10 P.M., that the resident was being discharged and the guardian was to pick the resident up as they were no longer able to care for her since they had received an Immediate Jeopardy Notice (IJ) from the ISDH related to the resident's July elopement .The ombudsman notified the guardian not to comply with the facility directive and visited the facility. A follow up written report to ISDH of the events included the following : "Guardian was relieved not to have to remove the resident with care needs she can't meet...The resident had been told by staff to pack her things; that she was going home with her mother. Resident was visibly upset and complaining of chest pain at 9:21 PM." Excerpts from the 8/18/11 nurse's notes entered for the above event were as follows: 9:00 P.M.. Resident has been upset on and off this shift related to possible leaving facility. Becomes very tearful. At this time 'my chest hurts' then 'I can't breathe'." The O2 saturation was 98% the vital signs were B/P 158/84 Pulse 84 respirations 22. " While saying she could not breathe the resident was yelling out. Staff and Ombudsman were able to redirect the resident and for seconds will laugh then cry." The resident requested to speak to her physician (a family relative) at home, did so, and the nurse then spoke with the physician at 9:45 PM. The physician gave a new order "[MEDICATION NAME] 25 mg now and let her smoke 2 cigarettes that should help because resident "is having an anxiety/panic attack." At 11:00 P.M. the resident was in bed with eyes closed and offered no further complaints of chest pain, shortness of breath or anxiety." On 8/19/11 at 2:30 P.M. the Seasons Unit Director and the DON were interviewed regarding the status of Resident A on the seasons unit since her readmission on 7/08 until the attempted discharge on the evening of 8/18/11. They indicated the resident was not a danger to herself or to others, had identified no danger of harm to her or others related to her residence there and had not had any problems on the unit. They indicated she was being transferred because they had been informed the July elopement was an Immediate Jeopardy. The DON stated "We did that last night because I understood the Immediate Jeopardy meant she was in danger. I understand better now. I had input on the discharge decision but did not have the final decision which the Administrator and Owner made." This federal tag relates to complaint IN 056. 3.1-12(a)(4)

Based on interview and record review, the facility failed to provide a calm, assistive environment while intending to discharge 1 of 1 resident on the specialty dementia unit whom the facility was in the process of relocating from a sample of 4. This resulted in anxiety with associated panic attack requiring treatment. Resident A Findings include: The clinical record of Resident A was reviewed on 8/18/11 at 9:15 A.M. [DIAGNOSES REDACTED]. The resident had been re admitted to Transcendent nursing home on 7/8/11 2/3/11 from a Psychiatric Hospital. The Minimum Data Set Assessment of 6/26/11 indicated the resident's cognition to be moderately impaired with a score of 12 (8-12 moderate impairment, 13-15 cognition intact). It indicated the resident was independent in transfers and ambulation and was always easily distracted or out of touch or had difficulty following what was said. On 8/18/11 at 8:30 P.M. an interview with the area Ombudsman by phone indicated Transcendent had notified Resident A's guardian/mother at 6:10 P.M. that evening that the resident was being discharged , and the guardian was to pick the resident up from the Seasons unit. They indicated were no longer able to care for her since they had received an Immediate Jeopardy Notice (IJ) from the ISDH related to the resident's July elopement .The ombudsman notified the guardian not to comply with the facility directive and visited the facility at 8:30 P.M. in hopes of preventing a sudden traumatic discharge. A follow up written report to ISDH of the events included the following : "Guardian was relieved not to have to remove the resident with care needs she can't meet...The resident had been told by staff to pack her things; that she was going home with her mother. Resident was visibly upset and complaining of chest pain at 9:21 PM." Excerpts from the 8/18/11 nurse's notes entered for the above event were as follows: 9:00 P.M. Resident has been upset on and off this shift related to possible leaving facility. Becomes very tearful. At this time 'my chest hurts' then 'I can't breathe'." The O2 saturation was 98% the vital signs were B/P 158/84 Pulse 84 respirations 22. " While saying she could not breathe the resident was yelling out. Staff and Ombudsman were able to redirect the resident and for seconds will laugh then cry." The resident requested to speak to her physician (a family relative) at home, did so, and the nurse then spoke with the physician at 9:45 PM. The physician gave a new order "[MEDICATION NAME] 25 mg now and let her smoke 2 cigarettes that should help because resident "is having an anxiety/panic attack." At 11:00 P.M. the resident was in bed with eyes closed and offered no further complaints of chest pain, shortness of breath or anxiety." On 8/19/11 at 2:30 P.M. the Seasons Unit Director and the DON were interviewed regarding the status of Resident A on the seasons unit since her readmission on 7/08 until the attempted discharge on the evening of 8/18/11. They indicated the resident was not a danger to herself or to others, had identified no danger of harm to her or others related to her residence there and had not had any problems on the unit that warranted an immediate evening transfer without preparation for or assistance to the resident or family. This federal tag relates to complaint IN 056. 3.1-32(a)

Based on observation, interview and record review, the facility failed to ensure side rails were consistent with the FDA (Food and Drug Administration) guidelines for safety regarding entrapment prevention for 23 beds of 56 total beds with side rails in the facility. These were beds in rooms: 6 A, 9 A, 11, 13, 14 B, 18 B, 19 B, 20 A, 21 B, 25, 26 B, 26 A, 27 B, 28 B, 29 B, 30 A, 32 A, 32 B, 33, 35 A, 35 B, 36 A and 36 B. Findings include: On 6/21/11 at 10:00 A.M., the facility was toured with maintenance staff #1 who measured the space between the bars of the side rails of the resident beds. The following resident beds were observed to have 1/2 side rails with space between the bars which measured 7 and 3/4 inches and 5 and 3/4 inches. These resident beds were in resident rooms: 6 A, 9 A, 11, 18 B, 19 B, 20 A, 21 B, 25, 26 B, 26 A, 27 B, 28 B, 29 B, 30 A, 32 A, 32 B, 33, 35 A, 35 B, 36 A, and 36 B. On the 6/21/11 10:00 A.M., tour with maintenance staff #,1 the side rails in resident room 13 were measured as space between the bars of 8 and 1/2 inches and 10 inches. The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment-Guidance for Industry and FDA Staff issued March 10, 2006 indicates the FDA (Food and Drug Administration) recommends openings within the rail, between rail supports, under the rail or next to a single rail support and between the rail and mattress should be small enough to prevent the head from entering or being entrapped. The "Hospital Bed Safety WorkGroup (HBSW)" and the "International Electrotechnical Commission (IEC)" along with the FDA recommend the space be less than 4 3/4 inches. The FDA recommends the space under the rail-at the ends of the rail be small enough to prevent neck entrapment. The HBSW and the IEC along with the FDA recommend this space be less than 2 3/8 inches and greater than a 60 degree angle. On 6/21/11 at 10:07 A.M., during tour with the maintenance staff #1, he indicated he was aware of the problem with the side rails in regard to the potential for entrapment. He indicated he had received the covers for the side rails the day before yesterday. He indicated that the covers would be applied to the side rails by the end of the day. 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to provide services to prevent elopement, resulting in wrist fracture and hospitalization for 1 of 1 resident who had eloped in a sample of 9 (Resident A). In addition to Resident A in Immediate jeopardy, the facility failed to adequately identify, assess and implement an effective security system for 12 other residents at risk of elopement out of the facility census of 65. (Residents B, C, D, E, F. J, K, L, M, N, O, P) The immediate jeopardy began on 6/26/11 when Resident A eloped from the facility, fell and fractured her wrist. The Administrator and Director of Nursing were notified of the immediate jeopardy at 3:30 p.m. on 8/18/11. The immediate jeopardy was removed on 8/19/11, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record of Resident A was reviewed on 8/18/11 at 9:15 A.M. [DIAGNOSES REDACTED]. The resident had been admitted to Transcendent nursing home on 2/3/11. The Minimum Data Set Assessment of 6/26/11 indicated the resident's cognition to be moderately impaired with a score of 12 (8-12 moderate impairment, 13-15 cognition intact). It indicated the resident was independent in transfers and ambulation and was always easily distracted or out of touch or had difficulty following what was said. The 7/06/2011 Interdisciplinary Diagnostic and Evaluation Center Significant change analysis provided the only available intact account of the resident's elopement in the clinical record that could be located, according to interview with the Director of Nursing on 8/18/11 at 1:30 P.M. Excerpts from that analysis are as follows: "...admitted to Transcendent 2/3/11...admitted to (Name) Psychiatric Hospital in March 2011 where she was held for 72 hours due to threats to leave the nursing facility...most recent admission to (psychiatric hospital) was on 6/27/2011 after she snuck out of the nursing facility after 11:00 P.M. on 6/26/11, walked to a convenience store, fell on her walk back, and broke her right arm...(Resident name) had reported she had asked for a cigarette but she was told she did not have any. Reportedly she went back to her room, dressed in street clothes, then snuck out through a dining room door. (Resident name) had the code to exit the door without setting off the alarm system as she was able to go in and out to a side porch for smoking times. (Resident name) then walked to a (Name) store, about a mile from the nursing facility and fell on her return walk back. She related afterwards, she was going to purchase cigarettes. However, her roommate at the nursing facility told staff that (Resident name) was going to meet a man the roommate knew and had arranged to meet (Resident name). The man's name was learned but it is not known if (Resident name) actually met up with him. When the nursing facility did their resident census at midnight they found she was missing from her bed. After a search of the facility with administrative personnel called in to help search and family notified, the facility received a call from (Name) Hospital emergency room to inform them the resident had been brought there for treatment. In relation to the above noted March 72 hour hospitalization , following threats to leave the nursing home, there was corresponding documentation in the business office of a hospitalization on [DATE], 16, 2011 followed by readmission to the facility. A 3/14/11 social services note included the resident "States she is leaving today. 'I am going back to my husband'...Dr (name) told nurse the cops will be here today to take (resident) to the hospital to get an evaluation and hold her 72 hours." A 3/18/11 social service note after the return of the resident to the facility indicated a continuing resident agenda to leave "tearful and somewhat angry because she wants her money so she can leave with her husband." Documentation was lacking of an elopement risk assessment until 5/2/11. The front page of this assessment was completed; however, the back page categories for summary, conclusions/recommendations and interventions were blank with the signature of the LPN responsible entered at the bottom of the page. The Care Plan from 3/28/11, after the hospitalization for threats to leave, did not address wandering/ elopement risk. The elopement risk was not addressed until 7/10/11, after the elopement and injury with hospitalization and return to the nursing facility's locked secured unit. That care plan had a single intervention "secured unit." Documentation was provided by the facility on 8/18/11 at 11:15 A.M. regarding an investigation of the 6/26/11 elopement, with witness accounts. Excerpts included: From the investigation portion, "At 9:00 P.M. (6/26) the documentation indicated that the resident was still angry and stated that if the guy shows up, she is leaving the facility and no one is going to stop her..." From the night shift CNA witness statement "...around 11:00 P.M. (Resident name) was on the back porch sitting." From the RN witness statement "At 11:15 P.M. asked this nurse for cigarettes and wanted to smoke. Was upset when I told her I did not smoke and felt it was late and dark outside. She was upset and started to talk about events that happened earlier in the day...offered opportunity to verbalize and invited to stay at the nurses station to talk...would not reply and at 11:30 P.M. returned to her room...At 12 midnight census bed check the resident was recognized to be missing...search began and at 12:55 A.M. the hospital called to report the resident admission to the ER." Documentation was lacking to identify facility assessment of elopement risk, preventive monitoring of security breaches i.e. resident knowledge of codes, resident outdoors at night unsupervised, resident expressed elopement ideation or a plan of care to address these problems. Documentation of the event of the 6/26/11 elopement was absent from the medical record as well as all documentation of any staff responses, notifications or communications with either the first hospital ER or the psychiatric hospital to which the resident was sent. During interview with the current DON on 8/18/11 at 1:00 P.M. and on 8/19/11 at 9:30 A.M.,she indicated the documentation was "missing" and she was at a loss to know what happened to it, and believed it could not be located. On 8/18/11 the undated policy and procedure for elopement prevention was reviewed. It directed "Obtain information during pre-admission screens with the resident and family regarding any history of wandering or a potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. Upon assessment, Care Plan will be developed and implemented with specific approaches and goals for the wanderer. Upon assessment if a resident is identified as an elopement risk the resident's name, picture and physical description are placed in the wander book located at the nurses station." On 8/18/11 the facility identified 13 residents at risk of elopement in the facility. They were Residents A, C, D, E, F, J, K, L, M, N, O, and P housed on the locked unit. The remaining elopement risk, Resident B, was housed on the regular open unit where residents were given codes by staff to use for smoking on the porch. Of the 13 residents identified to have a risk of elopement, Resident A was the only resident pictured or described in the wander book. On 8/19/11 at 10:00 A.M. LPN #1 was interviewed regarding security practices on her open unit. She indicate several alert and oriented residents knew codes and had the capability of letting other residents out or sharing the codes although she did not know if that "happened very much." She indicated Residents G, H and I knew the codes for sure and had free access. On 8/18/11 the porch door of the facility was observed to be a double wide glass door with a double key pad system of locking and a resonator which was functioning properly when manual numerical code entry was made. Residents were observed to request assistance of staff to enter codes when they were unable to do so, often related to physical inability. Resident G and I were observed to enter the codes and exit the door independently, mid morning several times between 10:00 A.M. and 11:00 A.M. Resident G was asked how to obtain the code and stated "You get it from any of them (referring to staff). There is only one code; it's always the same." An Immediate Jeopardy that began on 6/26/11 was removed on 8/19/11 when the facility reconfigured security codes and implemented a policy prohibiting the codes being given to residents, reassessed and identified all residents at risk of elopement in the facility, revised and updated the Elopement Identification book with resident photographs, and inserviced staff on the changes, but the noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with the facility continuing to assess implementation and its effectiveness. This deficiency was cited on 6/27/11. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)