Every finding on record at University Nursing Center

Based on observation, interview, and record review, the facility failed to ensure a nurse obtained a physician's order prior to inserting and anchoring a urinary catheter for 1 of 3 residents reviewed for hospitalizations. (Resident B)Findings include:During an interview on 3/23/26 at 3:20 p.m., Resident B indicated he was in the hospital a couple weeks ago, he did not remember what his symptoms were at the time, but the symptoms came on suddenly. He felt that the facility acted promptly and he had no concerns. During an interview on 3/24/26 at 8:50 a.m. RN 19 indicated he arrived at work on 3/1/26 at 6:00 p.m. but did not take over the hall until 10:00 p.m. During report, he was told that Resident B's had blood in his urine that started earlier and LPN 13 had catheterized him. RN 19 checked on Resident B and noted the resident had an anchored urinary catheter and was not actively bleeding and there was no blood in the urinary drainage bag. Lab staff arrived at approximately 4:00 a.m. RN 19 obtained the urine sample and deflated the balloon, and removed the catheter because it was not needed. Resident B began bleeding from his penis. Attempts were made to stop the bleeding, but it was profuse. RN 19 called the on-call NP and sent Resident B to the hospital. During an interview on 3/24/26 at 9:07 a.m. the Director of Nursing (DON) indicated, with the Administrator present, that she started an IV on Resident B on 3/1/26. His blood pressure was low, and he was not acting like himself. He was awake and talking to her. Stat (immediate) labs and a urinalysis were ordered. Bleeding was noted after the in and out catheterization. He had a history of hematuria (blood in the urine). They would not normally anchor a Foley catheter to get a urinalysis.During an interview on 3/24/26 at 12:00 p.m., RN 21 indicated that if she received an order for a urinalysis, she would collect a clean-catch specimen (in a cup) if the resident was able. If the order specified, she would do a straight catheterization (in and out). She would not anchor a Foley catheter for an urinalysis and an order was needed to insert a Foley catheter. A Foley catheter was not temporary, and a diagnosis was needed to anchor one.During an interview on 3/24/26 at 12:10 p.m. LPN 3 indicated that she worked with a QMA on 3/1/26. The QMA reported that Resident B did not take his medication, he tried to eat breakfast with his remote, he had blood in his brief and his scrotum was red. The QMA obtained vital signs, his blood pressure was low, and he had a low-grade temperature. LPN 3 check on Resident B, she had no correlation with him or had ever met him before. He did not smile, he had opened eyes and looked totally drained. The DON was in the facility and started the IV. She did not attempt to obtain the urinalysis as she knew the lab staff did not come until the next day and she was told to wait for second shift to obtain the urine specimen to make sure it was viable. The NP did not send Resident B out and gave orders to treat him in the facility. She would not anchor a Foley to obtain urine specimen and a order was needed prior to inserting a Foley catheter. During an interview with the Administrator and the DON, on 3/24/26 at 3:52 p.m., the Administrator indicated that an incontinent resident would normally be straight catheterized for a urine specimen. The DON indicated that the nurses needed a physician's order to anchor a Foley catheter.During an interview with LPN 13, on 3/24/26 at 4:00 p.m., she indicated, on the day in question, Resident B had not been voiding. He was normally incontinent but the aides reported that he had been dry. She believed he was probably dehydrated. She inserted the smallest catheter available and did not get any urine return. She decided to inflate the 10 cc balloon in the catheter rather than attempting to catheterize him again. He was in pain, as he did not normally have a catheter. She further indicated there was not a physician's order for the Foley catheter and she should have obtained an order prior to inserting a Foley.During an interview on 3/24/26 at 2:37 p.m. the Senior Regional Director of Clinical Services indicated they did not have a policy related to physicians' orders.Resident B's clinical record was reviewed on 3/23/26 at 9:35 a.m. Diagnoses included essential (primary) hypertension, iron deficiency anemia, unspecified sequelae of cerebral infarction, chronic pain syndrome, hypokalemia, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, urinary tract infection, and bandemia.A 1/21/26 quarterly Minimum Data Set (MDS) indicated he had moderate cognitive impairment. He was always incontinent of bowel and bladder.On 3/1/26 at 10:47 a.m., the triage note from the messaging system indicated an on-call Nurse Practitioner (NP) was notified that Resident B had a possible urinary tract infection (UTI). He had blood in his urine, burning with urination, and altered mental status. Orders received included urinalysis with culture and sensitivity.A late-entry nurse's note, dated 3/1/26 at 3:30 p.m., indicated Resident B had a change in condition, including blood in his urine and blood pressure lower than his baseline. The on-call provider was notified. New orders were received for intravenous (IV) fluids and labs. A peripheral IV was inserted into the right forearm.On 3/1/26 at 7:56 p.m., the triage note from the messaging system indicated the on-call NP was notified through the messaging system. The facility nurse indicated that Resident B had a change in condition that morning and had blood in his urine. An order was received for urinalysis. Resident B indicated that he wanted to go to the hospital. The facility nurse indicated that Resident B had a UTI or was possibly septic (blood infection), as he had been in past. The nurse planned to do a urinalysis with culture and sensitivity in the morning and requested antibiotic therapy for a UTI. The facility nurse reported that the urine sample had not yet been collected and was in progress. The on-call NP gave orders for antibiotics but requested the urine sample be collected prior to administration.A nurse's note dated 3/1/26 at 11:17 p.m. indicated the resident was alert and provided eye contact. He refused to eat and had small amount of emesis (vomiting) and phlegm. He grabbed at staff during assessment. A urine sample was attempted but unable to be obtained. He urinated once and passed a blood clot.On 3/2/26 at 4:23 a.m., the triage note from the messaging system indicated the on-call NP was notified that the resident was bleeding profusely from his urethra when his in and out catheter was removed and requested that he be sent to the emergency roomA nurse's note dated 3/2/26 at 9:04 a.m. indicated a nurse at the local hospital reported Resident B was being admitted to the critical care unit for diagnoses of septic shock, UTI, and urosepsis (urinary infection spread to bloodstream). A 16 French catheter had been inserted at the hospital. He had a fever of 103.1 degrees Fahrenheit (F) which was being managed with medications and the fever had decreased to 101.3 F.This citation relates to Intake 2796209.410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(1)

Based on interview and record review, the facility failed to reassess and monitor a resident after a change in condition due to possible aspiration (liquid entering airway) for 1 of 3 residents reviewed for aspiration. (Resident B) This deficient practice resulted in the resident being admitted to the hospital with pneumonia following a subsequent aspiration event.Findings include:An anonymous report submitted to Indiana Department of Health, on 2/16/26 at 12:00 p.m., indicated Resident B choked on his food and clearly aspirated but wasn't sent out to be evaluated. He aspirated again and had to be sent out to the emergency room (ER) for evaluation and was diagnosed with aspiration pneumonia.Resident B's clinical record was reviewed on 2/18/26 at 10:20 a.m. Diagnosis included pneumonia, other disorders of lung and dysphasia (trouble swallowing).Current orders included a one-time chest x-ray (start date 2/12/26), diet orders: no added salt, soft bite- sized. Special instructions: ground meat per request. May have soft cookies and cake (10/24/22). Ipratropium-albuterol solution (breathing treatment) via nebulizer 0.5 milligram (mg)- 3 milligram per 3 milliliters, one nebulizer inhalation every four hours (2/12/26 at 4:00 p.m.) and doxycycline (antibiotic) 100 mg twice a day.A 1/7/26, significant change in status, Minimum Data Set (MDS) assessment indicated Resident B was cognitively impaired, received a mechanically altered diet and required setup or cleanup assistance with eating.A current care plan, initiated on 6/1/22, indicated Resident B had some of his natural teeth. Resident B had a mechanical soft diet related to chewing difficulties. Interventions included monitor for chewing/eating difficulties at meals.A current care plan, dated 9/16/22 and revised on 1/15/26, indicated Resident B was at risk for impaired gas exchange related to pulmonary nodule, history of sinusitis, COVID-19 recovered, history of COVID-19 pneumonia, and newly diagnosed airspace disease. Interventions included assessing vital signs and lung sounds as needed and monitoring oxygen saturation rates as needed/ ordered.A speech Therapy Evaluation and treatment plan, dated 9/16/22, indicated Resident B required a modified diet of thin liquid, soft bite sized foods with mechanical soft/ ground textures.A secure message application, dated 2/12/26 at 1:09 p.m., indicated staff members informed the Nurse Practitioner (NP) that Resident B aspirated on his lunch, he kept coughing up phlegm and had audible congestion at bedside. Current vital signs included oxygen saturation in the 80's while on two liters of oxygen, blood pressure was 96/58 millimeters of mercury (mmHg) (a normal blood pressure reading is 120/80) and temperature was 98.2 degrees Fahrenheit. The NP ordered breathing every four hours for two days and a stat (immediate) chest x-ray.A progress note, dated 2/12/26 at 2:10 p.m., indicated a new order for a stat chest x-ray was received related to possible aspiration.A progress note, dated 2/12/26 at 2:39 p.m., indicated a mobile chest x-ray was completed at that time.A chest x-ray imagine report, dated 2/12/26 at 2:48 p.m., indicated Resident B's lungs showed patchy modest bilateral airspace disease. Pneumonia should be considered in the appropriate clinical setting. Recommend a follow-up examination to confirm resolution of findings.A progress note, dated 2/12/26 at 4:20 p.m., recorded as a late entry on 2/16/26 at 9:21 a.m., indicated Resident B's chest x-ray results indicated patchy modest bilateral airspace disease. The NP was notified.The clinical record lacked documentation that Resident B was reassessed, and vital signs were completed between 2/12/26 at 1:09 p.m. and the NP's note on 2/13/26 at 12:24 p.m.A Physician Progress note, dated 2/13/26 at 12:24 p.m., recorded as a late entry on 2/16/26 at 12:24 p.m., indicated Resident B experienced an episode of hypoxemia (low blood oxygen) following a choking incident during a meal. Currently, patient was in no obvious respiratory distress, and lung examination revealed clear breath sounds. Plan: Administer breathing treatment every four hours for the next 24 hours to assist with bronchodilation (opening airways) and improve oxygenation. Monitor oxygen saturation levels closely. Reassess respiratory status periodically to ensure no further episodes of hypoxemia occur. Chest x-ray findings were suggestive of pneumonia, likely secondary to aspiration during the choking episode. Plan: Initiate doxycycline 100 mg orally twice a day for seven days to treat suspected bacterial infection. Monitor for signs of improvement or worsening, such as fever, increased cough, or dyspnea. Follow up chest x-ray may be considered if symptoms persist or worsen.A February 2026 Medication Administration Record (MAR) indicated doxycycline was not administered on 2/13/26 at 8:00 p.m. or 2/14/26 at 8:00 a.m. On 2/13/26 at 9:13 p.m., staff documentation indicated doxycycline was not available as it had not arrived. On 2/14/26 the MAR did not indicate that Resident B's doxycycline was administered.The clinical record lacked documentation that the doxycycline was administered when delivered to the facility.The clinical record lacked documentation that Resident B was assessed, and vital signs were completed between the NP's documentation on 2/13/26 at 12:24 p.m. and Resident B's decline in condition on 2/14/26 at 1:50 p.m. A Situation, Background, Assessment and Recommendation (SBAR) event report, dated 2/14/26 at 1:50 p.m., indicated Resident B had decreased oxygen saturation, increased congestion, and resident representative requested for him to go to the emergency room (ER) for evaluation and treatment. Resident B's vital signs included a temperature of 98.1 degrees Fahrenheit, heart rate was 113, blood pressure was 105/51 mmHg, and respirations were 12. He was currently on two liters of oxygen via nasal cannula with an oxygen saturation of 80%. Assessment included he had increased congestion and decreased oxygen saturation and was on antibiotics for pneumonia. Orders included sending Resident B to the Hospital for evaluation and treatment.A progress note, dated 2/14/26 at 6:25 p.m., indicated Resident B would be transferred to another hospital with a diagnosis of aspiration pneumonia.A hospital progress note, dated 2/15/26, indicated Resident B was seen for worsening difficulty breathing and lethargy. Resident B was reported to have received treatment for aspiration pneumonia, after an aspiration event two days prior. He was found on CPAP (non-surgical treatment delivering oxygen through a mask to keep a person's airways open), tachypneic (rapid, shallow breathing) with coarse breath sounds in the bases bilaterally on his lung examination on arrival to the Emergency Department. Resident B received some doxycycline shortly prior to arrival and Emergency Medical Staff (EMS) were called due to worsening difficulty breathing. Prior to his arrival, Resident B was hypoxic (body tissues don't receive adequate oxygenated blood causing damage to organs) and tachypneic (high heart rate). He had a headache and a nonproductive cough. His white blood cell count was mildly elevated at 11.2 (indicating infection response). Hospitalist Impression: Resident B who had a prior history of aspiration with residual debility presented with a history of aspiration. Chest x-ray was notable for new patchy interstitial and alveolar opacity particularly in the left chest suggestive of pneumonitis (lung tissue inflammation). Acute hypoxic respiratory failure requiring two liters of oxygen via nasal cannula. Resident B was not on oxygen at his baseline. A hospital progress note, dated 2/17/26 at 2:06 a.m., indicated Resident B continued to have very coarse lung sound bilaterally.During an interview, on 2/19/26 at 10:43 a.m., LPN 4 indicated Resident B sounded like he had a lot of mucous and congested when staff members brought Resident B back to his room. She assessed Resident B and noted that his oxygen saturation was low. She placed oxygen on Resident B at two liters per minute. She used a secure messaging application to notify the NP of Resident B's condition. She received the orders for a stat chest x-ray and breathing treatments.On 2/19/26 at 10:50 a.m., CNA 5 indicated during the lunch meal Resident B sounded like he was gurgling. Resident B tried to drink but couldn't keep anything down. Staff propelled resident back to his room so the nurse could assess him.On 2/19/26 at 10:55 a.m., the Culinary Manager indicated Resident B had coughed after drinking. A nurse was present in the dining room who went over and checked on him. Resident B had a wet-like cough.On 2/19/26 at 11:20 a.m., the Administrator indicated Resident B started coughing during his lunch meal. He wasn't choking, just coughing.On 2/19/26 at 2:15 p.m., the NP indicated she was notified through the secure messaging application around 1:00 p.m. on 2/12/26 regarding Resident B's condition. It appeared Resident B had aspirated during lunch. His oxygen saturation had dropped, and staff placed him on oxygen at two liters per minute. She ordered breathing treatments every four hours and a stat chest x-ray. She did not see his chest x-ray results until she came into the facility on 2/13/26, the following day. She spoke with staff when she arrived to the facility and Resident B was doing better. She assessed Resident B and listened to his lung sounds. She did not check any of his vital signs. He was still wearing oxygen but was not in any distress. After looking at Resident B's chest x-ray results, she wasn't super convinced he had pneumonia, but placed him on doxycycline just in case. She did not speak with the nurse about watching Resident B's oxygen saturation or re-assessing him as he had a change in condition as she had left the facility without speaking with staff members. She assumed it was part of the facility's protocol. There was no further communication from staff after the initial message was received. The next communication notified her of Resident B needing to be sent to the hospital following a change in his condition after a second episode of possible aspiration on 2/14/26. Her reading the triage note, Resident B was very congested and his oxygen saturation was in the 80's while on two liters of oxygen. He had difficulty eating lunch and seemed to aspirate again. He was not in any distress the day prior when she saw him.On 2/19/26 at 4:40 p.m., LPN 9 indicated she noticed Resident B was drooling, having trouble chewing, swallowing, and started coughing during the lunch meal on 2/14/26. She knew Resident B was already on antibiotics as he had already aspirated previously. Her and LPN 4 decided to take Resident B back to his room to be assessed. His oxygen saturation was in the 80's. They called Resident B's representative, who wanted him sent out to the ER for evaluation. LPN 9 validated that Resident B did not have any vitals documented under the vitals tab between 2/9/26 and 2/18/26. There were no notes to indicate Resident B was assessed between the two separate alleged aspirations, on 2/12/26 and 2/14/26, besides the NP's progress note on 2/13/26.On 2/19/26 at 4:55 p.m., LPN 4 indicated Resident B was sent out to the ER on [DATE]. There was no progress note documented in the Electronic Medical Record (EMR). If staff charted on the incident, it would have been listed under the progress notes tab in the EMR. If an issue arose with any resident it would be documented under their progress notes. After a breathing treatment, an assessment was performed and their vitals were to be documented in the MAR along with the breathing treatment orders.On 2/19/26 at 5:08 p.m., LPN 10 indicated she worked 2/13/26. Resident B was fine during her shift. Resident B had breathing treatments and a chest x-ray the day prior. Resident B did not receive any doxycycline during her shift, as the medication hadn't arrived from the pharmacy. She did not do a full assessment of the resident; she only listened to his lungs. No other vitals were taken. The situation didn't warrant her to do a full set of vitals, as Resident B was not showing any signs of distress. She was more worried about Resident B's oxygen levels and breath sounds, but did not take vitals or his oxygen saturation. She would normally place a note under the resident's progress note in the resident's record of her assessment and vitals would be documented under the vitals tab. If a resident was having any respiratory issues, she would do a full set of vitals, but his condition seemed stable and did not warrant a need for her to take his vital signs.On 2/20/26 at 10:15 a.m., CNA 6 indicated she was in the dining room on 2/14/26. Resident B was coughing, and spit out some mucus and food. CNA 6 propelled him down to his nurse so LPN 4 could assess Resident B. LPN 4 and CNA 6 were able to place Resident B in his recliner so LPN 4 could assess him.On 2/20/26 at 10:32 a.m., LPN 11 indicated, on 2/12/26, as she entered the dining room, staff directed her over to Resident B. He was coughing up clear thick liquid. Resident B was still able to talk. LPN 11 asked for thickened liquid which seemed to help. LPN 11 propelled him down the hallway to LPN 4 who could assess Resident B. LPN 11 felt she assessed Resident B later in the day and he did go down to dinner that evening. She did not chart his vital signs anywhere and she did not believe she entered a progress note after she assessed Resident B. There should have been a progress note placed in the EMR due to Resident B's possible aspiration.On 2/20/26 at 10:50 a.m., LPN 12 indicated she was in the dining room with LPN 11 when Resident B started coughing. LPN 12 listened to Resident B's lungs and could hear a gurgling sound. Resident B was spitting out pureed food. LPN 11 asked staff members to get him thickened liquids. He drank the thickened liquids and spit it up as well. LPN 12 felt Resident B had food in his throat. He was still coughing but was able to breathe. He communicated by shaking his head yes and no. Every time Resident B tried to talk, there was food in his mouth that would come out. LPN 11 propelled him out of the dining room to be assessed by LPN 4. The Heimlich maneuver was not used on Resident B.On 2/20/26 at 11:58 a.m., the DON indicated there should have been a progress note in the EMR regarding Resident B's possible aspiration. If not a progress note, at least an SBAR or a documented event. The next shift's nurse should have taken Resident B's vital signs and placed a progress note in the EMR regarding the resident's assessment.On 2/20/26 at 12:00 p.m., the Corporate Consultant indicated staff should have started a hot charting event or an infection control event. The nurse would make a progress note under the open event. She felt LPN 4 did more than what was documented. After the hot charting was opened, on 2/13/26 at 2:41 p.m., regarding Resident B having started on an antibiotic, the following shifts should have documented Resident B's assessments in their progress notes. A current facility policy, dated 8/1988 and revised on 11/2018, titled Resident Change of Condition Policy, provided by the Administrator, on 2/20/26 at 3:30 p.m., indicated the following: .Life Threatening Change: D. All nursing action, physician contacts, and resident assessment information will be documented in the medical record. Acute Medical Change: D. All nursing actions/ interventions will be documented in the medical record as soon as possible after resident needs have been met A current RN and LPN job description, revised 9/2025, titled Charge Nurse Job Specific Orientation Plan, provided by the Administrator, on 2/20/26 at 3:30 p.m., indicated the following: . Daily documentation. 1. Hot charting. 3. Daily event follow up This citation relates to Intake 2744188. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interviews and record reviews, the facility failed to protect the resident's (Resident B) right to be free from verbal abuse by CNA 6 for 1 of 3 residents reviewed for abuse. Findings include:During a random observation in the dementia unit dining room on 2/2/26 at 12:10 p.m., CNA 6 was heard yelling If you give me four seconds I will come and get you! at Resident G. During an observation in the dementia unit dining room, with LPN 16 and the assistant to the facility's nurse practitioner present, on 2/2/26 at 12:14 p.m., Resident F repeatedly said I want to lay down. Will you help me? CNA 6 was heard yelling at Resident F, stating If you are going to lay down, then stay down. I can't help you every four seconds. I am not going to give you ice cream, and I am not going to give you cookies. You are going to eat your food!During an interview on 2/2/26 12:17 p.m., CNA 6 indicated she was not yelling at Resident F, she had to talk over her because she did not hear her. She didn't consider her behavior to be abusive. Resident F would eat 40 cookies a day, she just ate cookies and only wanted ice cream. She was not yelling at her; she was yelling across the dining room to get her to eat. She kind of had to get loud, and ignoring Resident F would be considered as abusing her. During an interview on 2/2/26 at 12:32 p.m., LPN 16 indicated he didn't know if he felt what CNA 6 said to Resident F was abuse and didn't hear exactly what she said. It worked better not to yell at the residents and that's what he taught the staff who worked in the dementia unit. He further indicated it was about vocal approach with residents with dementia, he apologized for using the analogy of a stray dog, but he wouldn't approach a stray dog in that manner. It was all about posture and approach, more resistance was usually met when yelling at a resident. If someone talked to him that way, he doubted that he would do what they were asking of him. CNA 6 was normally pretty bubbly and did a good job.Resident F's clinical record was reviewed on 2/3/26 at 9:09 a.m. Diagnoses included vascular dementia, severe, with mood disturbance, psychotic disorder with delusions due to known physiological condition, depression, anxiety, delusional disorders and hallucinations. A 12/2/26 quarterly Minimum Data Set (MDS) assessment indicated she had severe cognitive impairment. She had a current care plan, dated 11/6/25, that indicated she had increased repetitive behaviors. She came in and out of her room requesting cookies. As she ate, she continued to request food and water. Additionally, she stated that she wanted to go back to bed. She wanted something to eat when food was already provided and she was actively eating. She continued to state, Will you get me something to eat? She came out of her room repeatedly requesting food and verbally expressing, I don't feel good, I need something to eat. I want to lay down, I want to go to bed. She exited and re-entered her room [ROOM NUMBER] times. She came out for breakfast and repeatedly stated I want a drink of water, approximately 30 times in one minute. While being assisted with eating, she said I want something to eat, I want to go to bed, I want to lay down on the floor, so I can sleep. She continued to repeat the statements. Interventions included reminiscing with her while sitting at the table (1/21/26), providing one-on-one interactions (11/24/25), offering her a movie and television to help calm her (11/7/25) and offering her calming music in her room to help her self-soothe (11/6/25). During an interview on 2/3/26 at 2:10 p.m., CNA 5 indicated Resident F didn't take a moment to listen and that staff needed to use positive words of reinforcement. If Resident F asked for a cookie, staff would sit her down in the dining room to give it to her because CNA 5 was concerned that she may choke in her room. Resident F didn't want to do anything that she did not want to do, including eating, drinking and showering, she reminded Resident F that these activities were in her best interest. She further indicated she witnessed CNA 6 using raised tones with the residents, telling the resident That's enough. CNA 5 felt that staff were to physically care for the residents, not to limit what they could say or do. She had not reported CNA 6 speaking to residents in that manner as there were also other staff who handled Resident F the same way. During an interview on 2/3/26 at 2:26 p.m., RN 17 indicated Resident F could sometimes be difficult. She would come out of her room requesting a cookie or saying that she was hungry. During the evening shift, staff assisted Resident F with eating. If she was seated at the table and staff provided her with something to eat, a drink of water, and a tissue, she would not keep asking for things. RN 17 further indicated that if Resident F had a cookie in her mouth, she would still say that she was hungry. RN 17 described abuse as the intent to harm, scare or not provide a need. She described verbal abuse as talking rude to a resident, being impatient, being loud, or having a change in tone. Staff had to provide kindness to the residents and sometimes that was difficult. Review of CNA 6's employee record information, provided by the Administrator on 2/3/26 at 11:46 a.m., indicated she received education on abuse and neglect on 2/27/25, dementia care on 7/9/25 and 3/4/25, and Resident Rights on 3/3/25. A current facility policy, titled Abuse Prohibition, Reporting, and Investigation, and provided by the Administrator on 2/2/26 at 11:09 a.m., indicated the following: American Senior Communities has established policies and procedures which will provide facility personnel with the knowledge and training to further ensure each resident is treated with individual respect and dignity .Verbal Abuse - The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability 3.1-27(a)(b)

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 residents reviewed for abuse. (Residents B and C) Staff did not develop and implement immediate interventions to mitigate risk for recurrence when a cognitively impaired male resident was observed touching a cognitively impaired female resident's buttock. This failure resulted in the residents being observed within two hours following the event on the male resident's bed, with the male resident's hand in the female resident's genital area while she was unclothed from the waist down. Using the reasonable person concept, due to the female resident's impaired cognition and based on interview with the female resident's representative, the female resident would have been distressed and experienced severe psychosocial harm, dehumanization, and humiliation as a result of the sexual abuse by the male resident. The immediate jeopardy began on 10/3/25 when the facility failed to protect the resident's right to be free from sexual abuse by another resident. The Regional [NAME] President of Operations, Corporate Nurse Consultant, DON, Senior Regional Director of Clinical Services, and Regional Social Wellness were notified of the immediate jeopardy on 10/10/25 at 10:15 a.m. The immediate jeopardy was removed on 10/10/25 at 4:55 p.m., and the deficient practice was corrected on 10/7/25, prior to the start of the survey, and was therefore past noncompliance. Findings include:During an observation on 10/8/25 at 10:30 a.m., Resident B was in the memory care dining room ambulating independently while she held a doll. At 10:44 a.m., Resident B approached a male resident in the common area by the dining room and attempted to hand the baby doll to the male resident. Resident B's clinical record was reviewed on 10/8/25 at 1:28 p.m. Diagnoses included Alzheimer's disease with late onset, restlessness and agitation, depression, insomnia, and unspecified dementia in other diseases classified elsewhere with other behavioral disturbances. The resident resided on the secured dementia care unit. A 7/30/25, admission, Minimum Data Set (MDS) assessment indicated Resident B was severely cognitively impaired. Behaviors included disorganized thinking. Resident B required supervision from staff for eating, maximal assistance from staff for upper and lower body dressing, and was dependent on staff assistance for personal hygiene, toileting, and bathing. She walked independently. A current, 8/20/25, care plan indicated the resident had behavioral symptoms of attempting to enter other residents' rooms and became aggressive with staff during redirection and wandered up and down the hall. Interventions included the following: redirect Resident B when wandering into others' rooms (8/20/25), re-approach with preferred staff member (9/15/25), and provide Resident B with a baby doll to hold (9/15/25). Review of progress notes indicated the following: On 8/18/25 at 10:43 a.m., Resident B entered other residents' rooms often and got agitated when the other residents told her to get out. On 8/26/25 at 11:14 a.m., Resident B intrusively wandered into another resident's room. On 8/30/25 at 9:49 a.m., Resident B remained out of other residents' rooms when she was redirected. A 9/2/25 provider note indicated staff reported episodes of Resident B's intrusive wandering. On 9/15/25 at 9:26 a.m., Resident B wandered into other residents' rooms. Interventions were somewhat effective for very short periods of time. On 10/3/25 at 10:38 p.m., Resident B wandered into another resident's room two times. Resident B was found together with another resident, separated, and redirected to the television area. Staff would observe and keep separated by redirection and frequent observation. A late entry event note for 10/3/25, dated 10/6/25 at 8:50 p.m., indicated there was inappropriate contact between two residents. At 6:15 p.m., the CNA reported Resident B was lying in a male resident's bed and the male resident was rubbing Resident B's buttocks. The CNA separated and redirected both residents. At 8:03 p.m., the CNA reported she found Resident B in the same male resident's bed. Resident B's pajama bottoms were down, and the male resident had his fingers in her genitalia. The CNA separated and redirected the residents. The physician and family were not notified of the behavior. Resident B was moved to another room, further away from the male resident's room, and was placed on 15-minute checks. The event was marked invalid on 10/6/25 at 10:34 p.m. An interdisciplinary team (IDT) note, dated 10/7/25 at 2:44 p.m., indicated during the first occurrence on 10/3/25, Resident B had intrusively wandered into Resident C's room. A CNA noted Resident B in Resident C's room and brought Resident B out to the television room for activities. At 8:03 p.m., Resident B intrusively wandered into Resident C's room and was assisted out of Resident C's room by the CNA, taken to the nurse's station, and then assisted to bed. Resident B's room was directly across from Resident C's room. The preventive intervention included a stop sign placed to Resident C's room and a picture of a baby doll placed to Resident B's door to encourage room placement. An IDT note, dated 10/9/25 at 8:21 a.m., indicated on 10/8/25 at 9:00 p.m., Resident B was noted to have intrusively wandered into another resident's room and was found asleep in the other resident's bed. Resident C's clinical record was reviewed on 10/8/25 at 11:42 a.m. Current diagnoses included unspecified other sexual disorder, dementia, and insomnia. The resident resided on the secured dementia care unit. A quarterly MDS assessment, dated 9/3/25, indicated Resident C had moderately impaired cognition and no behaviors were exhibited. He had full range of motion to his upper and lower extremities. Resident C needed partial/moderate assistance from staff for toileting, bathing, dressing, donning and doffing footwear, personal hygiene, and for sit to stand mobility. He needed supervision or touching staff assistance with left and right rolling and walking 50 feet with two turns. Resident C ambulated with a walker. A current care plan, dated 3/4/25, indicated Resident C experienced sexual behaviors towards female staff members. He expressed sexual desires or touched staff members inappropriately. Interventions included the following: If Resident C expressed sexual desires, remind him he had a wife and that it was inappropriate. Guide the conversation to focus on something else such as fishing, rabbit hunting, or the weather (3/4/25) if Resident C tried to touch staff inappropriately, redirect and try talking about something of interest to him (3/4/25), and allow Resident C time to cool off and provide a calm, unhurried, and supportive approach (3/4/25). A current care plan, dated 4/28/25, reviewed/revised on 9/30/25, indicated Resident C touched female staff members between the legs, on their breasts, smacked their buttocks, and gestured for staff to pull their shirts up while providing him care. Resident C requested staff to take a shower with him and had a diagnosis of sexual disorder. Interventions included the following: educate Resident C on appropriate actions to take (9/30/25), provide verbal redirection (9/15/25), provide Resident C with a male caregiver when available (6/10/25), give Resident C personal space and re-approach Resident C at a later time. (5/5/25), reapproach with different staff member, make conversation about interest such as fishing, mushroom hunting, or sports (4/28/25). Prior notes indicating Resident C had demonstrated inappropriate sexual behavior included the following: A behavior note, dated 4/27/25 at 4:45 p.m., indicated on 4/27/25 at 4:30 p.m., Resident C touched a staff member's breast, smacked their buttocks, and gestured for staff members to lift up their shirts. An IDT note, dated 5/5/25 at 4:23 p.m., indicated on 5/4/25 at 4:14 p.m., Resident C slapped a female staff members buttocks and attempted to grab her private area. A behavior note, dated 5/10/25 at 3:19 p.m., recorded as a late entry on 5/11/25 at 6:24 p.m., indicated Resident C made sexual comments to the staff and asked staff to grab their breasts and buttocks. Several staff reported they were uncomfortable providing care to Resident C. A provider progress note, dated 5/12/25 at 6:30 a.m., recorded as a late entry on 5/15/25 at 6:30 a.m., indicated Resident C had recently had an increase in behaviors, and demonstrated inappropriate sexual gestures towards staff. An IDT note, dated 5/12/25 at 10:10 a.m., indicated on 5/11/25 at 1:30 p.m., Resident C made sexual comments towards staff and asked staff to have sex with him and to take a shower with him. Resident C grabbed his penis and asked staff if they liked it. A progress note, dated 6/9/25 at 10: 45 a.m., indicated Resident C touched/grabbed staff inappropriately. Staff instructed Resident C to keep his hands to himself. Resident C continued to touch staff inappropriately. An IDT note, dated 6/10/25 at 2:36 p.m., indicated on 6/9/25 at 10:45 a.m., Resident C grabbed staff inappropriately during care and had demonstrated sexual behaviors towards staff on and off since his admission. A behavior note, dated 9/14/25 at 12:30 p.m., indicated on 9/14/25 at 7:26 a.m., Resident C grabbed a staff member's breast. A provider progress note, dated 9/16/25 at 6:16 a.m. and recorded as a late entry on 9/19/25 at 6: 16 a.m., indicated Resident C was seen related to dementia with behavioral disturbances, inappropriate sexual behaviors, and insomnia. An IDT note, dated 9/30/25 at 7:50 a.m., indicated on 9/29/25 at 9:57 a.m., Resident C touched a female staff member between her legs. A progress note, dated 10/3/25 at 10:44 p.m., indicated that another resident wandered into Resident C's room two times during the evening. The two residents were found together, separated, and redirected. A behavior note, dated 10/4/25 at 8:54 p.m., indicated on 10/4/25 at 8:45 p.m., Resident C entered the lounge area wearing only a shirt. He was not wearing pants or an incontinence brief. He was being continually monitored. A progress note, dated 10/4/25 at 8:56 p.m., indicated Resident C had a head-to-toe assessment completed, one-on-one observations were being completed, and a doorway stop sign was in place. A progress note, dated 10/5/25 at 10:28 a.m., indicated Resident C was transferred to an inpatient geriatric psychiatric care facility. A new/worsening/high risk behavior communication event, dated 10/6/25 at 10:31 p.m., indicated on 10/3/25 at 8:03 p.m., a staff member found another resident on Resident 's bed. Resident C was found with his hand on the other resident's private area. An Interdisciplinary Team (IDT) note, dated 10/7/25 at 4:15 p.m., indicated on 10/3/25 at 8:03 p.m., another resident entered Resident C's room and Resident C was found to have had his hand near the other resident's private area. Root cause of the behavioral expression was Resident C's dementia process had progressed, and his sexual inappropriateness had increased. During a review of the facility video surveillance on 10/8/25 at 4:46 p.m., the Regional [NAME] President of Operations indicated the time stamp on the camera was approximately 30 minutes off from the actual time. Both the Regional [NAME] President of Operations and the Corporate Nurse Consultant confirmed the residents' identities and the staff members throughout the video surveillance observation. On 10/3/25 at 6:38 p.m. Resident B, fully clothed, exited her room, walked across the hallway, and entered Resident C's room. No staff were observed in the area. Resident B remained in Resident C's room until 6:46 p.m. CNA 3 came down the hallway. CNA 3 entered the room and redirected Resident B down the hallway to the other end of the unit. Resident C was not observed on the video. On 10/3/25 at 8:22 p.m., Resident B, who was fully clothed, entered Resident C's room. Resident B remained in Resident C's room until 8:36 p.m. Resident C's door remained open. At 8:36 p.m., CNA 3 walked down the unit hallway towards Resident B's room and looked towards Resident C's room. CNA 3 rushed into Resident C's room. CNA 3 accompanied Resident B out of Resident C's room. Resident B's pants were observed to be twisted as they walked toward the nurse's station. Resident C was not observed on the video. CNA 3 spoke with the nurse and then assisted Resident B towards her room. Resident B and CNA 3 entered Resident B's room at 8:37 p.m. CNA 3 closed the door behind her. CNA 3 remained in Resident B's room until 8:46 p.m. CNA 3 exited Resident B's room with a clear trash bag of items in her hand. CNA 3 looked in Resident C's room then went on down the hallway to dispose of the trash bag. Resident B and Resident C's rooms were both located at the end of the unit hallway, farthest from the nurse's station. Confidential interviews were completed during the survey. During a confidential interview, it was indicated that on 10/3/25 at approximately 6:30 p.m., Resident B, wandered into Resident C's, room. Resident C was observed rubbing Resident B's buttocks over her clothing. Both residents were fully dressed. Resident B and Resident C were separated. Resident B was taken to the lounge area and Resident C remained in room. The CNA reported the incident to the nurse. No other notifications were made. On 10/3/25 at approximately 8:15 p.m., Resident B was again in Resident C's room. Resident B was in supine position on Resident C's bed with her legs bent at the knee and her feet flat on the floor. Resident B's pants and brief were pulled down to her mid-thigh. Resident C had his fingers inside Resident B's vaginal area. Resident C did not have a shirt on, and his lower half was covered with a blanket. It was uncertain if Resident C was wearing clothing under the blanket. Resident B was escorted out of Resident C's room and taken to the nurse's station. Resident C was left in his room. Resident B was then taken to her room, assisted with toileting, and assisted to bed. The brief was thrown away. Resident B was known to intrusively wander and had an intervention in place to use stop sign banners on doors that Resident B frequently wandered into. Resident B did not like to have her clothing removed, even for bathing, and was not known to take off her own clothing. Resident C had been known to be sexually inappropriate with staff prior to the incident on various occasions by asking staff to remove their clothing and he also grabbed at female staff members private areas. As a result, they had a male staff member providing Resident C's showers. During a telephone interview, on 10/8/25 at 7:37 p.m., RN 4 indicated she was on duty on the memory care unit on 10/3/25 and had two separate incidents of inappropriate touching between Resident B and Resident C reported to her by CNA 3 at the time of their occurrences. On 10/3/25, at approximately 6:15 p.m., CNA reported Resident B was found in Resident C's room on his bed. Both residents were dressed, and Resident C was stroking Resident B's buttocks. CNA 3 removed Resident B from Resident C's room and took Resident B to the common area. Resident B intrusively wandered into other residents' rooms and stop signs were used on some of the rooms. The stop signs were effective to redirect Resident B most of the time. RN 4 did not report the inappropriate sexual touching to anyone but rather made herself a note to chart the behavior and pass the information on in shift report. No additional interventions were implemented to prevent Resident B from re-entering Resident C's room. Resident B was again removed from Resident C's room on 10/3/25 around 8:03 p.m. At the time of the second incident, one aide in the Memory Care Unit was at break. RN 4 heard CNA 3 yell out Resident C's name, as she started to run around the nurse's station, RN 4 observed CNA 3 coming out of Resident C's room along with Resident B. CNA 3 was escorting Resident B towards her. RN 4 was unaware if Resident C had any clothing on. It was reported to her by CNA 3 that Resident B had been lying on Resident C's bed with Resident C. Resident B's pants and brief were down and Resident C's hand was in Resident B's genitalia. CNA 3 explained to RN 4 that she had to remove Resident C's hand from Resident B's genitalia. After reporting the information to RN 4, CNA 3 took Resident B to her room and helped her get ready for bed. RN 4 was unsure of what the protocol was but immediately called the Administrator to ask what the next steps were. The Administrator told her to call the DON for instructions. Two unsuccessful attempts were made to contact the DON. RN 4 notified the Administrator she was unable to reach the DON. The Administrator told RN 4 she would have the DON call her back. She did not hear back from the DON but received a call from the Social Services Director (SSD) a few minutes later. RN 4 was instructed by the SSD to implement 15-minute checks on Resident B and Resident C. The checks were started at 10:30 p.m. on 10/3/25. Resident B was moved to another room at the opposite end of the hallway at approximately 10:30 p.m. on 10/3/25. No new interventions were implemented prior to 10:30 p.m. on 10/3/25. No one had instructed her to complete head-to-toe assessments of the residents. RN 4 did not complete assessments of Resident B nor Resident C. No other notifications were made. On 10/6/25, a note was left for RN 4 to ensure event notes were created for Resident B and Resident C for the incidents on 10/3/25. She entered a note, and then struck it out, as she thought it was a duplicate entry. Review of the facility abuse investigation included the following: A typed statement indicated, on 10/3/25, the Administrator was notified by RN 4 that Resident B wandered into the room of Resident C. RN 4 stated that the CNA (could not recall the name of the CNA) reported she found Resident B in Resident C's room with her pants down. Due to the Administrator being out of town, it was requested that RN 4 contact the DON. The Administrator let the DON know that RN 4 would be contacting her about the incident. The DON alerted the SSD who contacted RN 4. RN 4 was instructed by the SSD to start 15-minute checks for Resident B and Resident C and continue to keep the two residents separated. Due to the residents' rooms being directly across from each other, the SSD suggested they move Resident B away from Resident C's room. The nurse temporarily moved Resident B further away from Resident C. On 10/4/25, during the investigation, it was noted that CNA 3 was the CNA that reported the incident to RN 4. CNA 3 stated, earlier in the evening, she noticed Resident B in Resident C's room. CNA 3 redirected the resident out of the room without incident. Later, around 8:15 p.m., CNA 3 noticed Resident B again in Resident C's room, lying on her side across the bed. CNA 3 stated that Resident C's hand was near Resident B's private area. CNA 3 stated that she immediately separated the residents. CNA 3 stated that the female resident's pants were down around her knees and Resident C's hand was placed near the resident's private area. CNA 3 then stated she removed the residents' hand, assisted Resident B to stand, pulled up Resident B's pants, and escorted Resident B out of the room. The CNA alerted RN 4 at that time. The typed statement was signed by the Administrator on 10/4/25, CNA 3 on 10/6/25, and RN 4 on 10/6/25. A facility document indicated 15-minute checks were implemented on 10/3/25 at 10:30 p.m. for both Resident B and Resident C. A facility document indicated one-on-one monitoring for Resident C began on 10/4/25 at 9:00 am. and remained in place until Resident C was sent out for psychiatric services on 10/5/25. A late entry progress note, dated 10/3/25 and created on 10/6/25, indicated Resident B's representative and MD were notified. During an interview, on 10/9/25 at 8:05 a.m., Resident B's representative indicated they were not notified about any abuse concerns involving Resident B and they had no concerns with Resident B's care. No one had reported Resident B was touched inappropriately. On 10/9/25 at 2:13 p.m. Resident B's representative indicated the facility did call her on 10/4/25 at 8:26 p.m. and informed her that Resident B had wandered into a male resident's room and was found lying on the male resident's bed with the male resident above her. The male resident appeared to have had his hand above Resident B's private area. The staff member explained that an investigation was underway. There was no mention of the status of Resident B's clothing. Prior to Resident B becoming cognitively impaired, she was a devoted married woman for many years and would not have responded well to a strange man touching her inappropriately. On 10/9/25 at 10:32 a.m., the SSD indicated she made the progress note regarding notification of Resident B and Resident C's representative and provider notification. The SSD notified the nurse practitioner on 10/6/25, but did not indicate the Resident B's had clothing had been removed during the notifications. The SSD assisted with the investigation by doing resident interviews only. The Administrator did the staff interviews and completed the investigation. The SSD did not request written statements from staff. A facility reportable for incident for 10/3/25 at 8:15 p.m., submitted on 10/4/25 at 9:45 p.m., indicated a female resident on the secured unit wandered into a male resident's room. The male resident was fully clothed, and there was potential for inappropriate touch. The residents were immediately separated. Full body assessments were completed for both residents with no concerns noted. Preventative measures included 1 on 1 supervision with the male resident. Social services would follow both residents for psychosocial distress. Care plans reviewed and updated as needed. During interview, on 10/9/25 at 10:20 a.m., the Medical Director indicated he had not been notified by the facility of either incident that involved Resident B and Resident C on 10/3/25, prior to 10/9/25. The Nurse Consultant notified him when he entered the facility on 10/9/25. He did not examine either resident. With sexual abuse, it may be necessary to send the resident out for further examination or keep items that may have bodily fluids for further evaluation during the investigation. Typically, a nursing staff member would have evaluated the resident(s) to see if further evaluation was necessary. During an interview, on 10/9/25 at 11:33 a.m., the Dementia Director indicated she was not aware of the incident regarding inappropriate touching on 10/3/25 until she came to work on 10/6/25. She assisted with and collected statements from some of the CNAs, including CNA 3. She did not read the statement from CNA 3, but had provided all the collected statements to the SSD. She did not return or dispose of any statements she collected. On 10/9/25 at 12:44 p.m., the Nurse Practitioner indicated she was notified of a potential sexual encounter between Resident B and Resident C when she was at the facility on 10/6/25. She was not notified prior to 10/6/25. The facility staff informed her that Resident C's hand had touched Resident B's thigh, and it was under investigation. She did not complete a physical exam on either resident. With any potential abuse, she would expect the provider to be notified immediately. During an interview on 10/9/25 at 4:04 p.m., the Corporate Nurse Consultant indicated she was notified on 10/4/25 at 3:48 p.m. of the encounter on 10/3/25 between Resident B and Resident C. She called the facility right away to see what had been done so far. She indicated the 15-minute checks for Resident C had been changed to one-on-one checks earlier that morning on 10/4/25 and the SSD was working to get psychiatric placement for Resident C. Resident C had known previous sexual inappropriate behaviors exhibited towards female staff members. Resident B was known to wander about the unit. The facility investigation found that inappropriate contact was made. The Administrator was not available for interview during the survey. A current facility policy, revised June 2023, titled Abuse Prohibition, Reporting, and Investigation, provided by the DON on 10/8/25 at 11:00 a.m., indicated the following: .Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion.American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents.Abuse - .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish.Sexual Abuse - nonconsensual sexual contact of any type with a resident. Examples may include but not be limited to fondling, touching, rubbing, exposing, licking, kissing, gestures, sharing pornography, assault, rape, harassment, seduction, coercion, photographing a resident's rectal, genital, or breast areas and/or exhibitionism.Identification: Abuse Includes: 2. Resident to resident abuse of any type.Types of Abuse:.3. Sexual abuse.Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed, In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services. Resident to Resident Abuse: 1. Any individual who witnesses resident-to-resident abuse will immediately separate and protect the residents involved. 2. Staff member(s) will maintain the resident initiating the abuse under direct supervision until the initial investigation is complete and resident safety is maintained. 3. The Individula who witnessed the abuse will report the situation immediately to his/her supervisor and Executive Director. 4. The staff member in charge will initiate the investigation immediately.6. The DNS/Designee will assess both residents involved to determine if physical injuries have occurred.b. Statements will be taken from individuals witnessing the incident.7. The attending physician will be notified, and any orders will be noted and initiated.8. The family of the resident(s) and/or resident representative will be notified. 9. It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH(Indiana Department of Health) gateway system.19. If staff suspect a crime has occurred, refer to reporting suspicion of a crime policy.Protection: 1. All residents will be protected from physical and psychological harm during and after the allegation and investigation. This will include: a. Responding immediately to protect the alleged victim and protect the integrity of the investigation. b. Assess the resident alleged to be harmed for any sign of injury, including a physical exam, or psychosocial assessment when indicated. c. Provide increased supervision of the alleged victim and other residents. d. Implement room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately.2. The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours to the Long-Term Care Division of the Indiana Stated Department of Health via the Gateway Portal.9.Copies of the completed investigation will also be sent to Adult Protective Services.10. It is the responsibility of every employee of American Senior Communities to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director.12. Each covered individual shall report to the State Department of Health Long Term Care Division via Gateway Portal, and to one or more law enforcement entities any reasonable suspicion of a crime against any resident in the facility.ASC QAPI.Physical or Sexual abuse by staff or other residents will be tracked by the Quality Assessment and Assurance Committee (QAA). The immediate jeopardy that began on 10/3/25 was removed on 10/10/25 when the facility completed abuse training for all staff, increased monitoring and surveillance for Resident B and Resident C, updated care plans, and Resident C was sent to be evaluated at a psychiatric facility. The deficient practice was corrected by 10/7/25, after the facility implemented a systemic plan that included the following actions: education of all staff regarding resident abuse, completed physical assessments of residents on the secured dementia care unit, and developed quality assurance actions for ongoing monitoring. This citation relates to Intake 2636500.3.1-27(a)(1)

Based on record review and interview, the facility failed to conduct a timely and thorough investigation of resident-to-resident sexual abuse and failed to implement immediate interventions to prevent further potential abuse while the investigation was in progress for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes:A facility reported incident, dated 10/4/25 at 9:45 p.m., submitted to the Indiana State Department of Health indicated an incident occurred on 10/3/25 at 8:15 p.m. The reported incident indicated the following: A female resident, who resided in the memory care unit, wandered into a male resident room. The male resident was fully clothed. There was potential for inappropriate touch. The residents were immediately separated. Full body assessments were completed for both residents with no concerns noted. Fifteen-minute checks implemented. The residents' physicians and families were notified. The reported incident contained a follow-up, dated 10/9/25, and indicated the following: The investigation was completed, which included resident and staff interviews, with no additional findings. Head to toe assessments completed, with no findings. Neither resident experienced any psychosocial distress related to the incident. Stop signs were put on resident room doors as appropriate. One-on-one supervision was initiated with male resident until he was sent to the hospital on [DATE] for further evaluation. Both residents' care plans were updated. The plan of care will be updated again for the male resident upon his return from the hospital. The local Police Department was contacted with no concerns noted. Review of the facility investigation included the following: Resident B's Full Body Skin Assessment Shower report dated 10/4/25 was not completed when the abuse occurred on 10/3/25. Resident B's 15-minute Safety Check List did not begin until 10/3/25 at 10:30 p.m. Resident C's Full Body Skin Assessment Shower report dated 10/4/25 was not completed when the abuse occurred on 10/3/25. Resident C's 15-minute Safety Check List did not begin until 10/3/25 at 10:30 p.m. Resident C's One-on-One Observation from 10/4/25 at 9:00 a.m. through 10/5/25 at 10:00 a.m. Eighteen Staff Questionnaires collected from 10/4/25 - 10/7/25 regarding inappropriate contact was collected and did not include any from CNA 3 or RN 4. Additional statements and interviews were not included in the investigation to collect additional information in a sexual abuse investigation. The late note event for Resident C, containing details of the event and charted on 10/6/25 as a late entry for 10/3/25, was not included in the facility investigation. On 10/9/25 at 10:32 p.m., the SSD indicated she had received a secure message from the DON on 10/3/25 at 10:11 p.m. that she needed to touch base with RN 4 at the facility. The SSD spoke with RN 4 via telephone. RN 4 told the SSD there was an incident with Resident B in Resident C's room. Resident B was sitting on Resident C's bed with Resident C's hand near her private area. There was no mention if the residents were wearing clothing. The SSD asked if the residents had been separated and advised RN 4 to contact the Administrator for further directions. The SSD did not give RN 4 any further instructions nor come to the building that night to assist RN 4. The SSD did not recommend or ask for anyone to write up statements to provide any additional information to get additional details. On 10/4/25 at 9:00 a.m. she came to the facility as the weekend manager and assisted with one-on-one monitoring with Resident C and reviewed care plans. She notified the NP on 10/6/25 of the incident that occurred on 10/3/25. On 10/9/25 at 4:04 p.m., the Corporate Nurse Consultant indicated on 10/6/25, when CNA 3 explained to the Corporate Nurse Consultant what happened on 10/3/25 around 8:05 p.m., CNA 3 explained to the Nurse Consultant that she felt Resident C had penetrated Resident B's genitals with his hands. On 10/6/25 the Corporate Nurse Consultant asked CNA 3 and RN 4 to read the typed statement and to sign if they agreed with it. CNA 3 made it clear that she felt the Corporate Nurse Consultant was trying to get her to change her statement. This additional information was not in the facility investigation provided and was not provided to IDOH when the facility was made aware of the additional information to ensure the IDOH acted timely on the resident's behalf. A current facility policy, revised June 2023, titled Abuse Prohibition, Reporting, and Investigation, provided by the DON on 10/8/25 at 11:00 a.m., indicated the following: .Policy: .Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services.2. Staff member(s) will maintain the resident initiating the abuse under direct supervision until the initial investigation is complete and resident safety is maintained. 3. The individual who witnessed the abuse will report the situation immediately to his/her supervisor and Executive Director. 4. The staff member in charge will initiate the investigation immediately.9. It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system.19. If staff suspect a crime has occurred, refer to reporting suspicion of a crime policy .Cross reference F600.This citation relates to Intake 2636500.3.1-28(d)

Based on record review and interview, the facility failed to timely report alleged sexual abuse between cognitively impaired residents (Resident B and Resident C) to the administrator, Indiana Department of Health (IDOH), and the appropriate agencies for 1 of 3 residents reviewed for resident abuse. (Resident B)Findings include: A facility reported incident, submitted to the Indiana State Department of Health and dated 10/4/25 at 9:45 p.m., indicated an incident occurred on 10/3/25 at 8:15 p.m. The reported incident indicated the following: A female resident, who resided in the memory care unit, wandered into a male resident room. The male resident was fully clothed. There was potential for inappropriate touch. The residents were immediately separated. Full body assessments were completed for both residents with no concerns noted. Fifteen-minute checks implemented. The residents' physician and families were notified. The reported incident contained a follow-up, dated 10/9/25, and indicated the local Police Department was contacted with no concerns noted. A police report, provided by the local Police Department on 10/8/25 at 4:15 p.m., dated 10/4/25 at 7:43 p.m., indicated the following: A request was made to make a police report for an incident that occurred the previous night for possible inappropriate conduct with two residents. Upon the Police Officer's arrival, he spoke with the Administrator, who indicated a female dementia resident was found in a male dementia resident's room. The female resident's pants were partially pulled down. Staff examined the female resident afterwards and did not find any signs of sexual assault. The Administrator requested the Police Officer to document the case for their report to the State. On 10/8/25 at 11:32 a.m., the Social Services Director (SSD) indicated the incident between Resident B and Resident C was reported to the Administrator on 10/3/25, the family and medical director were notified on 10/3/25, and the police were notified, but she was not certain of the date. On 10/9/25 at 10:32 p.m., the SSD indicated she had received a secure message from the DON on 10/3/25 at 10:11 p.m. that she needed to touch base with RN 4 at the facility. The SSD spoke with RN 4 via telephone. RN 4 told the SSD there was an incident with Resident B in Resident C's room. Resident B was sitting on Resident C's bed with Resident C's hand near her private area. There was no mention if the residents were wearing clothing. The SSD asked if the residents had been separated and advised RN 4 to contact the Administrator for further directions. The SSD did not give RN 4 any further instructions nor come to the building that night to assist RN 4. The SSD then called the Administrator and told her the information that RN 4 reported to the SSD. She left it in the Administrator's hands at that point. On 10/4/25 at 9:00 a.m. she came to the facility as the weekend manager and assisted with one-on-one monitoring with Resident C and reviewed care plans. She notified the Nurse Practitioner on 10/6/25 of the incident that occurred on 10/3/25. The SSD notified Resident C's representative on 10/4/25 at 3:22 p.m. and Resident B's representative was notified on 10/4/25 at 8:26 p.m. The SSD explained to both representatives that Resident B was in Resident C's room on his bed with Resident C's hand near Resident B's private area. Typically, the Administrator and DON handled abuse investigations. On 10/9/25 at 11:53 a.m., the DON indicated on 10/3/25 at 10:04 p.m. The DON received a call from the Administrator who told her RN 4 had attempted to reach her. The DON was in a bad service area, out of town. The Administrator explained to the DON that Resident B was found in Resident C's room and there was inappropriate touching. The information she received from the Administrator was very vague. There was no mention whether the residents were clothed. In conversation with the Administrator, considering the DON had not experienced a situation like this before, the Administrator told the DON they probably needed to get the SSD involved due to her experience. The DON then messaged the SSD and asked the SSD to contact RN 4. The DON did not contact RN 4. The Administrator and the SSD handled the statements and the investigation. The DON came to the building on 10/4/25 for night shift to assist with one-on-one with Resident C. The DON was off on 10/5/25 and 10/6/25 and was not updated on the investigation while she was off duty. On 10/9/25 at 4:04 p.m., the Corporate Nurse Consultant indicated she was notified of the incident between Resident B and Resident C via telephone on 10/4/25 at 3:48 p.m. A conference call, which included the Administrator, was made and the Corporate Nurse Consultant was told the family, physician, and authorities had been notified at that time. On 10/6/25, RN 4 explained to the Nurse Consultant she had not reported to anyone when Resident B was in Resident C's room on 10/3/25 around 6:30 p.m. with Resident C rubbing Resident B, on what the Corporate Nurse Consultant described as the lower back, while Resident B was seated on the bed. RN 4 did not think there was anything that management needed notified about. When CNA 3 explained to the Corporate Nurse Consultant what happened on 10/3/25 around 8:05 p.m., CNA 3 explained to the Nurse Consultant that she felt Resident C had penetrated Resident B's genitals with his hands. The facility reported the incident to the Indiana Department of Health (IDOH) on 10/4/25. The facility policy indicated alleged abuse should have been reported to the IDOH within two hours of when it occurred on 10/3/25.A current facility policy, revised June 2023, titled Abuse Prohibition, Reporting, and Investigation, provided by the DON on 10/8/25 at 11:00 a.m., indicated the following: .Policy: . Education/Training: 1. Employees, whether direct care, contract staff, ancillary departments, volunteers, or consultants, receive instruction/training on abuse during orientation and periodically during ongoing in-service education. The education/training will include: a. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation. b. Identifying what constitutes abuse, neglect. c. Recognizing signs of abuse, neglect.d. Reporting abuse, neglect. e. Who and when staff and others must report their knowledge related to any alleged violation.g. Understand behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include but are not limited to: 2. Wandering. Investigation:. 3. The individual who witnessed the abuse will report the situation immediately to his/her supervisor and Executive Director. 9. It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system.19. If staff suspect a crime has occurred, refer to reporting suspicion of a crime policy. Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately.2. The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours to the Long-Term Care Division of the Indiana Stated Department of Health via the Gateway Portal.9.Copies of the completed investigation will also be sent to Adult Protective Services.10. It is the responsibility of every employee of American Senior Communities to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director.12. Each covered individual shall report to the State Department of Health Long Term Care Division via Gateway Portal, and to one or more law enforcement entities any reasonable suspicion of a crime against any resident in the facility.A current facility policy, reviewed 10/23, titled Requirements for Reporting Reasonable Suspicion of a Crime, provided by the Regional Nurse Consultant on 10/9/25 at 1:21 p.m., indicated the following: 1) POLICY: a) It is the policy of American Senior Communities to notify owner, operators, employees, managers, agents, and contractors (collectively referred to as covered individuals and individually as a covered individual) of their duty to report reasonable suspicions of crimes to the Indiana State Department of Health and local law enforcement. 2).requires individuals in applicable long term care facilities to report any reasonable suspicion of crimes committed against a resident of the facility.3) Purpose: a) The purpose is to ensure that American Senior Communities comply with the requirements to notify covered individuals of their duty to report crimes to the Indiana State Department of Health and local law enforcement. 4) a) Facility Responsibilities.ii) The facility will post a notice in a conspicuous location that informs all covered individual of his/her reporting obligation under the Elder Justice Act to report a suspicion of a crime to the Indiana Department of Health and local law enforcement.iv) the facility will annually provide all covered individuals a document describing his/her obligations to comply with the reporting law and the facility reporting of crimes policy and procedures.5) Covered individual Responsibilities ( staff herein refers to covered individuals) a) When staff suspect a crime has occurred against a resident at the facility, he/she must report the incident to the Executive Director who will report to the Indiana Department of Health and at least one local law enforcement entity. b) The ED will coordinate timely reporting to the Indiana Department of Health and to law enforcement.f) Staff must report the suspicion of a crime to the Executive Director or designee immediately. g) Examples of crimes that would be reported, but are not limited to: iii) Rape; iv) Assault and battery; v) Sexual abuse.Cross reference F600.This citation relates to Intake 2636500.3.1-28(c)

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for a resident with physical limitations by ensuring the resident's call light was within reach for 1 of 1 residents reviewed for resident rights. (Resident 2)Findings include:Resident 2's clinical record was reviewed on 9/5/35 at 10:22 a.m. Diagnoses included hypertensive heart disease with heart failure, anemia, asthma, age-related osteoporosis, macular degeneration, overactive ladder, cognitive communication deficit, and unsteadiness on feet.Current physician's orders included activity level - up with mechanical lift and two person assist, wheelchair for mobility on unit, bunny boots to be worn in bed at all times and heels to be floated every shift, document in milliliters (mL) all fluids taken with medications every shift, offer additional 240 mL fluids every shift, and head of bed elevated while in bed to alleviate shortness of breath while lying flat related to diagnosis of asthma.A significant change Minimum Data Set (MDS) assessment, dated 8/8/25, indicated Resident 2 was severely cognitively impaired, dependent for all transfers, and was incontinent of both bowel and bladder. During an observation on 9/3/25 at 11:29 a.m., Resident 2 was seated in her room in a wheelchair with a blanket over her legs. The resident's call light was on the floor behind the right head of the bed. On 9/4/25 at 8:58 a.m., Resident 2 was seated in a wheelchair, asleep, next to her bed. The resident's call light was lying on the floor behind her bed. On 9/4/25 at 9:59 a.m., the resident was asleep in bed. A bedside table, approximately three to four feet from her bed, contained an empty cup of water and a fork. The resident's call light was on the floor behind her bed and a clear plastic cup was lying on the left side of her bed, upside down on the floor.On 9/8/25 at 3:34 p.m., Resident 2 was asleep in bed. The call light was lying on the floor behind the resident's right head of the bed. On 9/9/25 at 8:48 a.m., Resident 2 was asleep in bed. The resident's breakfast tray was on the bedside table next to her bed. The silverware was still wrapped in a napkin and breakfast had not been eaten. There was a cup of juice on the breakfast tray, untouched. The resident's call light was on the floor at the right head of the bed.During an interview with CNA 17 on 9/9/25 at 8:57 a.m., he indicated he did not know if the resident required assistance to eat and/or drink. CNA 17 entered Resident 2's room and picked up the call light from the floor at the head of the bed and attached it to the resident's blanket. He indicated the call light should be within reach for Resident 2.During an interview with LPN 7 on 9/9/25 at 10:23 a.m., she indicated she did not know if the resident was able to use the call light. A current care plan, revised on 8/4/25, indicated the resident was at risk for falls and required assistance or supervision for mobility, transfer, and ambulation. Interventions included keeping personal items in reach, call light in reach, and non-skid footwear.During an interview, on 9/9/25 at 8:57 a.m., the DON indicated she would locate a policy for call light access. No further information was provided prior to survey exit. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure residents prescribed antipsychotic medications received appropriate Gradual Dose Reductions (GDR) or had individualized indication for continued use of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 10)Findings include:Resident 10's clinical record was reviewed on [DATE] at 2:48 p.m. Diagnoses included Alzheimer's disease, neurocognitive disorder with Lewy body dementia (a progressive degenerative brain disorder), chronic diastolic heart failure, anxiety disorder, major depressive disorder, and senile degeneration of the brain. Current physician's orders included venlafaxine extended release 150 milligrams (mg) once a day for depression, hydrocodone-acetaminophen 5-325 every eight hours for pain, quetiapine (antipsychotic) 75 mg three times a day, trazodone 25 mg at bedtime for insomnia, and alprazolam 0.5 mg three times a day for anxiety.A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 10 did not exhibit delusions, hallucinations, or behaviors.A quarterly MDS assessment, dated [DATE], indicated Resident 10 did not exhibit delusions, hallucinations, or behaviors.A quarterly MDS assessment, dated [DATE], indicated Resident 10 did not exhibit delusions, hallucinations, or behaviors. A quarterly MDS assessment, dated [DATE], indicated Resident 10 did not exhibit delusions, hallucinations, or behaviors. A significant change MDS assessment, dated [DATE], indicated Resident 10 was moderately cognitively impaired, exhibited no hallucinations, delusions, or behaviors, required supervision for eating and oral hygiene, substantial assistance for toileting, was dependent for showering/bathing, and needed substantial assistance for toileting hygiene.A current care plan, initiated [DATE], indicated the resident was noted to have visual hallucinations as evidenced by seeing things that were not present, seeing people in his room that were not there, and thoughts that others were trying to harm him. He had a diagnosis of Lewy body dementia and received an antipsychotic. Interventions included approaching the resident with preferred staff members ([DATE]) and providing the resident with reassurance ([DATE]).A current care plan, initiated [DATE], indicated Resident 10 exhibited signs and symptoms of yelling he had fallen out of bed. The resident yelled for help but when staff went to assist, he was unable to say what he needed. When staff left the room, the resident would start yelling for help again. He had a diagnosis of dementia. Interventions included making sure the resident had no unmet needs, allowing him to verbalize his feelings and provide validation when able, offer repositioning for comfort, and help him get his feet back into the bed when needed. A current care plan, initiated [DATE], indicated Resident 10 was at the front door, stating he wanted to leave the facility. The environment was quiet, and he grabbed a binder from a table near the door and attempted to hit the front door with the binder. He had a diagnosis of dementia. Interventions included allowing the resident personal space and time to calm down as needed and treat the resident for infection as indicated. A current care plan, initiated [DATE], indicated Resident 10 was visiting with family, got upset with his daughter, and attempted to hit his daughter. He told family to shut up and his daughter needed to listen to him. The daughter was unable to redirect her father. Interventions included reapproaching the resident with a preferred staff member, giving the resident time to calm down, and redirecting the resident away from family members if he was upset. A current care plan, initiated [DATE], indicated Resident 10 was yelling and cursing at staff while they attempted to provide care and medications. He stated he wanted to leave the room and see his wife. The resident had diagnoses of Lewy body dementia and anxiety. Interventions included allowing the resident to calm down before providing care and offering to have him visit his wife after supper when possible. A current care plan, initiated on [DATE], indicated Resident 10 had a history of displaying signs and symptoms of mood distress as evidenced by finding little interest or pleasure in doing things. Interventions included identifying relationships the resident could benefit from, acknowledging to the resident his current situation was difficult, encouraging the resident to verbalize his feelings, concerns, fears, help clarify misconceptions, and establishing a trusting relationship with the resident. A current care plan, initiated [DATE], indicated Resident 10 was noted with restlessness, shortness of breath, anxiousness, irritability, tearfulness, and repetitive statements. He would talk nonsensically, make repetitive statements, and would become nauseated as anxiety increased. He had a diagnosis of anxiety disorder and received medication for anxiety. Interventions included assisting the resident to bed if he desired, offering anti-nausea medication as ordered when needed, offering magazines about birds or wildlife to read, encourage the resident to talk about his wife and daughters, encourage the resident to rest, reapproach the resident later, give him personal space as needed, and provide a calm environment as needed.A current care plan, initiated [DATE], indicated Resident 10 was noted to have tearfulness, restlessness, irritability, a somber mood, sad facial expressions and feelings of sadness. He had a diagnosis of major depressive disorder and received an antidepressant. Interventions included helping him to lay down and rest if desired, taking the resident outside in good weather, providing reassurance, and encouraging the resident to verbalize his concerns and worries. A behavior communication note, dated [DATE] at 1:56 p.m., indicated Resident 10 was very anxious and made multiple statements of confusion and anxiety, to the point he vomited. His daughter was visiting and took him for a walk because he was upset because he could not leave the facility. He continued to be anxious and became nauseated. Anti-nausea medication was administered, and Resident 10 was assisted into bed to rest. He eventually calmed but continued to be tearful. A behavior communication note, dated [DATE] at 5:30 p.m., indicated Resident 10 was in a somber, sad mood and refused to eat dinner or drink fluids. Staff attempted to feed him, but he still refused. Staff offered anti-nausea medication, which he refused. There were no signs of nausea or anxiousness noted. The resident was assisted to bed and by bedtime, he was in a better mood.A behavior communication note, dated [DATE] at 11:30 a.m., indicated Resident 10 refused to eat lunch, complained of nausea, headache, and dizziness, and did not feel well. He was very anxious and stated more than once he needed medication(s). Resident 10 was removed from the dining room to a quieter environment. Anti-nausea medication was administered and after an hour or so, he was able to calm himself. Interventions were effective.A behavior communication note dated [DATE] at 7:00 a.m., indicated Resident 10 was yelling out, stating repeatedly he had fallen out of bed. He did not fall out of bed, but his feet were hanging out of bed. Staff would reposition and reassure the resident as needed. Interventions were somewhat effective.A progress note, dated [DATE] at 10:15 a.m., indicated Resident 10 had an infection which could be contributing to his increased confusion. A behavior communication note, dated [DATE] at 8:00 a.m., indicated the resident was yelling for help but could not identify what he needed. Staff spoke calmly to the resident and reassured him all was well. He was assisted into his wheelchair as a distraction. Interventions were somewhat effective. Resident 10 continued to have moments of confusion with anxiety throughout the rest of the shift.A progress note, dated [DATE] at 1:06 p.m., indicated Resident 10 was upset and repetitively asking for help. He did not know what he needed, was made comfortable, refused breakfast, was given anti-nausea medication, and reapproached later with morning medications.A psychiatric nurse practitioner's note, dated [DATE] at 7:32 p.m., indicated Resident 10's current cognitive status was consistent with dementia. The resident reported confusion and disorientation, such as believing he had been married to his wife for 82 years, which was indicative of the behavioral disturbances associated with dementia. The plan was to monitor Resident 10's cognitive status and behavioral disturbances. Resident 10 reported feeling not like himself and experienced strange sensations behind his eyes, which could also be symptoms related to dementia.A behavior communication note, dated [DATE] at 9:00 a.m., indicated Resident 10 called for the nurse multiple times but was unable to state what he needed. He became increasingly anxious to the point of nausea and vomiting. Anti-nausea medication was administered and effective for a short while. Resident 10 was turned and repositioned, incontinent care was provided, and staff reassured the resident multiple times. Interventions were not effective. A behavior communication note, dated [DATE] at 9:00 a.m., indicated the resident was restless and anxious with behaviors of calling out for the nurse continuously, unable to state his needs. He became quite loud and adamant. He was reassured by staff that all cares would be provided, but he would have to be patient until staff were available to assist him with getting out of bed. Resident 10's blinds were opened, and he was encouraged to watch the birds at the feeder outside his room. Staff returned shortly to assist Resident 10 out of bed. He was placed in his wheelchair and sat in the hallway for closer monitoring and frequent reassurance. Interventions were somewhat effective, and behavior improved but Resident 10 continued to be confused and was quick to become agitated. A behavior communications note, dated [DATE] at 8:30 a.m., indicated Resident 10 was yelling out for (name), stating he needed to see his wife. He became very agitated and hot which caused nausea and vomiting. The room temperature was lowered, and he was given a cool washcloth. Anti-nausea medication was administered. Interventions were effective.A progress note, dated [DATE] at 7:46 a.m., indicated Resident 10 refused to take his opioid pain medication. He insisted that the medication made him sick to his stomach. He was told the medication was for pain but when the nurse tried to put the medication in his mouth, he would push out the pill with his tongue. The conversation was repeated more than once, with the resident refusing the medication and pushing the pill out of his mouth with his tongue. His wishes were eventually honored after more than one attempt to get him to take the medication. A psychiatric nurse practitioner's note, dated [DATE] at 6:16 a.m., indicated Resident 10 was being seen for psychotherapy services for the treatment, monitoring, medication monitoring, and support of symptoms related to dementia, anxiety, major depressive disorder, and insomnia. The resident presented with worry and the therapist and resident discussed his current emotions. He denied any acute distress. The resident noted that he was worried about his roommate. During the session, the therapist and Resident 10 discussed his family and their travels. Resident 10 was pleasant and cooperative, reported feeling fine and denied issues with sleep, depression, anxiety, and auditory or visual hallucinations. A progress note, dated [DATE] at 2:00 p.m., indicated Resident 10 was at the front door of the facility. The environment was busy. The resident was noted to have increased confusion and agitation. He was yelling at his daughters and said he needed to get out of the facility and go home. He was aggressive with staff who attempted to assist/calm him. Resident 10 was given time to calm down before reapproaching him, he was offered the chance to go to the courtyard and offered something to eat or drink. Interventions were ineffective but Resident 10's daughters were able to calm and redirect him. A social services note, dated [DATE] at 10:07 a.m., indicated Resident 10 was experiencing increased urinary urgency and burning while urinating. Urine was to be tested to rule out infection. Resident 10 had diagnoses of anxiety and dementia which could cause increased behaviors when infection was present. A behavior communication note, dated [DATE] at 4:49 a.m., indicated the resident was defiant and became aggressive during incontinent care. He swore at staff, grabbed and pinched them, and was swinging at them. He refused his medications. Two hours later, he readily took his medications. A psychiatric nurse practitioner's note, dated [DATE] at 8:14 a.m., indicated Resident 10 was seen for dementia, anxiety, major depressive disorder, and insomnia. The resident's psychiatric diagnoses were chronic and fluctuated in severity. Resident 10's speech was mumbled and difficult to understand at times. He was unable to answer most questions appropriately. He experienced intermittent non-distressing delusions, though none had been noted recently. No suicidal or homicidal ideations were noted. No depression or anxiety was observed during the session. Resident 10 denied auditory or visual hallucinations. He was diagnosed with severe cognitive impairment and mild depression. Staff did not report recent aggression, agitation, or combativeness with care (though he had episodes of combativeness in the past.) No new or worsening behaviors were reported. The resident was compliant with medications. Resident 10's current medication regimen included venlafaxine 150 mg daily, quetiapine 75 mg three times a day, and alprazolam 0.5 mg three times a day. No anxiety was noted during the evaluation. Medication regimen was to continue, and a follow-up appointment was scheduled. Medications were reviewed for possible gradual dose reduction (GDR) of psychotropics. Any reduction in regimen was likely to risk decompensation and was not recommended. The benefits outweighed the risks and there was no clinical indication for GDR of psychiatric medications.A [DATE] pharmacy recommendation indicated a review was due for quetiapine 75 mg three times a day for neurocognitive disorder with Lewy bodies/delusional disorder. Targeted behaviors included hallucinations and seeing things that were not present. On [DATE], Resident 10 presented with anxiety. On [DATE] the resident was sad and refused meal and fluids. On [DATE], the resident refused meal and had anxiety. Date of the last attempted GDR was [DATE] which was contraindicated by the provider. On [DATE], the provider determined a reduction in the medication could increase psychiatric instability. A [DATE] pharmacy recommendation indicated a review was due for quetiapine 75 mg three times a day for Lewy body dementia/delusions. Targeted behavior was delusional thinking. The resident had recent behaviors (unspecified dates and examples). Last attempted GDR was [DATE] and was declined by the provider. On [DATE], the provider determined a reduction in the medication would be a detriment to the resident's mental health. A 4/14 25 pharmacy recommendation indicated a review was due for quetiapine 75 mg three times a day for delusional disorder. Targeted behavior was delusional thinking. There were no noted recent behaviors. Last attempted GDR was [DATE] and was declined by the provider. On [DATE], the provider determined a reduction in the medication was contraindicated because the resident was seeing his (deceased ) wife.The clinical record lacked documentation of Resident 10 seeing his (deceased ) wife.A [DATE] pharmacy recommendation indicated a review was due for quetiapine 75 mg three times a day for delusional disorder. Targeted behaviors were delusional thinking and hallucinations. There were no noted recent behaviors. Last attempted GDR was [DATE] and was declined by the provider. On [DATE], the provider determined a reduction in the medication was contraindicated because the family declined (all) GDRs and the resident exhibited some behaviors (unspecified dates and examples). The clinical record lacked documentation of Resident 10 exhibiting signs or symptoms of delusions and/or hallucinations.A [DATE] pharmacy recommendation indicated a review was due for quetiapine 75 mg three times a day for delusional disorder. Targeted behaviors were delusional thinking and restlessness. There were no noted recent behaviors. Last attempted GDR was [DATE] and was declined by the provider. On [DATE], the provider determined a reduction in the medication was contraindicated because Resident 10's family refused GDRs, and the resident was stable on current medication regimen.During an observation on [DATE] at 2:23 p.m., Resident 10 was sitting upright in his bed eating a snack. The television was playing but he was not watching. Resident 10's interest remained on the snack.During an interview with LPN 12 on [DATE] at 2:27 p.m., she indicated Resident 10 exhibited behaviors like looking for his car, car keys, or his truck. He was never aggressive. It was his anxiety which caused his distress. She thought his expressions of anxiety had improved. He was taking the quetiapine for his anxiety and behaviors. Resident 10's daughter wanted to be consulted before any GDRs.During an observation on [DATE] at 9:17 a.m., Resident 10 was cooperative with staff during a dressing change. He was able to answer questions appropriately. During an observation on [DATE] at 3:30 p.m., Resident 10 was sleeping in his bed. During an interview with psychiatric Nurse Practitioner (NP) 13 on [DATE] at 4:28 p.m., she indicated Resident 10's family had been consulted on numerous occasions and were not agreeable to GDRs. NP 13 had provided black box warning information to the family. NP 13 did not have access to pertinent information at the time of the interview, but did know Resident 10 exhibited anxiety and restlessness. She did not know much about Resident 10's mental health history and had picked him up as a patient when she hired on with the facility at the beginning of 2025. She had seen Resident 10 during periods of depression and anxiety. Resident 10 had expressed anxiety about his family and how they were doing or that he had not seen them in a while. A current facility policy, titled Medication Stop Orders, provided by the Administrator on [DATE] at 8:49 a.m., indicated the following: .3. (The) facility should ensure that all medications which have run the normal course of therapy or are no longer necessary to treat the resident's condition are discontinued. A current facility policy, titled Medication Regimen Reviews and Pharmacy Recommendations, provided by the Administrator on [DATE] at 8:49 a.m., indicated the following: .It is the policy of (name of facility) that the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed pharmacist, attending physician, medical director, and director of nursing.9.2.1 If the attending physician/prescriber has decided to make no changes in the medication, the attending physician should document the rationale in the resident's' health record. 3.1-48(a)(4)3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure a dependent resident had access to drinking water or other fluids for 1 of 1 residents reviewed for hydration. (Resident 2)Findings include:During an observation on 9/3/25 at 11:29 a.m., Resident 2 was seated in her wheelchair with a blanket over her legs. Across the room, near the other bed, there were two bedside tables. One had a bottle of syrup and a cup of water lying on it. During an observation on 9/4/25 at 9:59 a.m., the resident was asleep in bed. A bedside table, approximately three to four feet from her bed, contained an empty cup of water and a fork. The resident's call light was on the floor behind her bed and a clear plastic cup was lying on the left side of her bed, upside down on the floor.Resident 2's clinical record was reviewed on 9/5/35 at 10:22 a.m. Diagnoses included hypertensive heart disease with heart failure, anemia, asthma, age-related osteoporosis, macular degeneration, overactive ladder, cognitive communication deficit, and unsteadiness on feet.Current physician's orders included activity level - up with mechanical lift and two person assist, wheelchair for mobility on unit, bunny boots to be worn in bed at all times and heels to be floated every shift, document in milliliters (mL) all fluids taken with medications every shift, offer additional 240 mL fluids every shift, and head of bed elevated while in bed to alleviate shortness of breath while lying flat related to diagnosis of asthma.An 8/8/25 significant change Minimum Data Set (MDS) assessment indicated Resident 2 was severely cognitively impaired, did not exhibit delusions, hallucinations, or behaviors, was dependent for all transfers, and was incontinent of both bowel and bladder. The significant change MDS assessment was triggered because the resident had a significant weight loss. A current care plan, revised on 7/22/25, indicated Resident 2 was at risk for fluid imbalance due to a diagnosis of overactive bladder and medications used for overactive bladder. Interventions included provide an extra 240 mL of fluids every shift, encourage fluids, document and notify the medical director of signs and symptoms of fluid volume deficit (dry mucous membranes, thirst, weight loss, decreased blood pressure, weak/rapid pulse, change in mental status, decreased urine output, abnormal labs, poor skin turgor), and record intake of fluids. A current care plan, revised on 7/22/25, indicated Resident 2 required assistance and/or monitoring of am/pm care, nutrition, hydration, and elimination. Interventions included record intake of night shift fluids, record lunch intake percentage and fluid consumption, record dinner intake percentage and fluid consumption, and record breakfast intake percentage and fluid consumption.A current care plan, revised on 8/4/25, indicated the resident was at risk for falls and required assistance or supervision for mobility, transfer, and ambulation. Interventions included keeping personal items in reach, call light in reach, and non-skid footwear.During an observation on 9/8/25 at 3:34 p.m., Resident 2 was asleep in bed. There were no drinks on the bedside table. During an interview with CNA 17 on 9/9/25 at 8:57 a.m., he indicated he did not know if the resident required assistance to eat and/or drink. During an interview with RN 18 on 9/9/25 at 9:04 a.m., she indicated Resident 2 might require some coaxing at first, but could feed herself and drink liquids without assistance.During an interview with LPN 7 on 9/9/25 at 10:23 a.m., she indicated Resident 2 was able to drink fluids without assistance. The CNAs passed water to the residents every shift. A current facility policy, titled Hydration Management, provided by the Administrator on 9/8/25 at 2:47 p.m., indicated the following: .It is the policy of (company) to ensure that each resident is offered sufficient fluid intake to maintain proper hydration.1. Resident hydration status will be assessed upon admission or readmission, with significant change and quarterly utilizing the IDT (interdisciplinary team) hydration review. 2. Any resident with identified risk factors will be assessed by the IDT and documentation will be placed in the electronic medical record (EMR) using the IDT hydration review observation to include but not limited to: a. Resident's risk factors for dehydration. b. Resident's self-performance with fluids. c. Physical assessment including mucous membranes, skin turgor. d. Current labs/electrolytes. e. Hydration interventions. 3. If IDT hydration review deems that a hydration plan is necessary, the plan should be individualized to the resident such as additional 240 mL of fluids each shift, additional 120 mL fluids at med pass, extra fluids identified on tray ticket, specifics based on resident preferences, labs, or therapy screen.7. Fluid intake will be planned to include at least 480 mL per meal for each resident.9. Fresh water or other preferred beverages will be passed to all residents, unless medically contraindicated, on each shift.10. A variety of additional fluids will be offered at various times throughout each shift (medication pass, activities, and per resident request). 11. Nursing staff is responsible for documenting fluid intake at mealtimes in the EMR. 12. Nursing staff is responsible for documenting all other fluid intake in EMR for his/her assigned residents on each shift.3.1-46(2)(b)

A. Based on observation, interview, and record review, the facility failed to follow physician orders to change, label and date oxygen supplies for 1 of 2 residents reviewed for respiratory services. (Resident 17)B. Based on observation, interview, and record review, the facility failed to implement physician orders for oxygen administration for 1 of 2 residents reviewed for respiratory services. (Resident 47)Findings include:A1. During an observation, on 9/4/25 at 10:21 a.m., Resident 17's portable oxygen tank and oxygen tubing bag hung on the back of a wheelchair in the memory care commons area. The oxygen tubing bag was labeled with Resident 17's name, room number, had instructions that indicated portable, and was dated 8/18/25. The portable oxygen tubing was not dated. An oxygen concentrator sat behind a recliner where Resident 17 was sitting in, in the memory care commons area. The oxygen tubing bag hung on the back of the concentrator. The oxygen tubing bag was labeled with Resident 17's name, room number, and instructions that indicated oxygen, and was dated 8/18/25. The concentrator oxygen tubing was not dated. No humidifier bottle was present on the concentrator.During an observation, on 9/5/25 at 11:16 a.m., Resident 17's portable and concentrator oxygen bags remained dated 8/18/25. Both sets of oxygen tubing remained undated and unlabeled.Resident 17's clinical record was reviewed on 9/5/25 at 11:00 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure, and dementia.Current orders included Resident 17 utilized supplemental oxygen at 2 liters per minute via nasal cannula and the oxygen tubing and humidity was to be changed weekly on Sundays on night shift.An 8/12/25, quarterly, Minimum Data Set (MDS) indicated Resident 17 received oxygen therapy.During an interview, 9/05/25 at 12:02 p.m., LPN 16 indicated that Resident 17's portable and concentrator bags were dated 8/18/25, neither oxygen tubing was labeled or dated, and a humidity bottle was not on the concentrator. Tubing and bags were to be changed every Sunday, and it was not good that the dates on the bags reflected 8/18/25.During an interview on 9/5/25 at 12:13 p.m., the DON indicated oxygen tubing and bags were changed weekly on Sundays on the night shift. Nursing staff initialed Resident 17's treatment administration history on 8/24/25 and 8/31/25 and indicated that Resident 17's oxygen tubing and humidity were changed on those dates, but with the bags dated 8/18/25, the electronic record was not correct.During an interview, on 9/5/25 at 4:13 p.m., the Regional Director of Nursing Services indicated the facility did not have a respiratory or oxygen tubing policy regarding oxygen bag changes and concerns identified would be considered infection control.B 1. During an interview, on 9/3/25 at 11:43 a.m., an oxygen concentrator sat between the head of Resident 47's bed and her recliner. Resident 47 indicated she wore oxygen at night because she had sleep apnea and her oxygen levels dropped at night. She wore oxygen during the day as needed if she was short of breath. An oxygen tubing bag hung on the concentrator. The bag contained undated and unlabeled oxygen tubing and was labeled with Resident 47's name, room number, had instructions that indicated oxygen at night, and was dated 8/18/25.During an observation, on 9/5/25 at 10:05 a.m., Resident 47's oxygen bag remained dated 8/18/25. The oxygen tubing remained undated and unlabeled. No humidifier bottle was present on the concentrator.Resident 47's clinical record was reviewed on 9/5/25 at 1:50 a.m. Diagnoses included acute respiratory failure, acute pulmonary edema, obstructive sleep apnea, and hypertensive heart disease with heart failure. The electronic record lacked an order for oxygen use. An 8/5/25, quarterly, Minimum Data Set (MDS) indicated Resident 47 had moderate cognitive impairment. A care plan, dated 3/21/25, indicated that Resident 47 had potential for impaired gas exchange related to acute respiratory failure, obstructive sleep apnea, history of pneumonia, and resident becomes short of breath when lying flat. Interventions included administering oxygen as ordered (3/21/25).During an interview, on 9/5/25 at 11:54 a.m., LPN 16 indicated Resident 47 had worn oxygen at night previously but was unable to locate a current or past order for oxygen administration, and she was unsure if Resident 47 continued to wear oxygen at night. LPN 16 thought Resident 47's oxygen was implemented as a nursing measure on 6/23/25 when the resident exhibited a drop in her oxygen saturation level and went to the emergency room. At 12:04 p.m., LPN 16 confirmed an oxygen concentrator was present in Resident 47's room and the oxygen bag was dated 8/18/25. LPN 16 questioned Resident 47 if she wore oxygen and Resident 47 indicated she wore oxygen every night and sometimes during the day if she needed it. She had worn oxygen at night for years due to having sleep apnea.During an interview, on 9/5/25 at 12:13 p.m., the DON indicated oxygen administration required an order and a care plan in place. Oxygen was able to be applied as a nursing intervention if a resident demonstrated a change of condition and required supplemental oxygen. Immediate notification to the provider was expected if the nurse implemented oxygen so further instructions and orders could be received. The DNS did not believe Resident 47 utilized oxygen at night and felt the concentrator was not removed when she went to the hospital in June.During an interview, on 9/5/25 at 4:27 p.m., RN 19 indicated Resident 47 intermittently wore oxygen at night. As a nurse, he had checked her oxygen saturation levels but he did not place the oxygen on her, as Resident 47 was capable and applied and removed the oxygen herself.During an interview, on 9/5/25 at 4:41 p.m., CNA 20 indicated Resident 47 wore oxygen most nights. The resident removed oxygen tubing to go to the bathroom and would put it back on after she returned to bed. CNA 20 would remind Resident 47 to reapply oxygen if the resident forgot to put it back on.During an interview on 9/8/25 at 11:39 a.m., Resident 47 indicated that the oxygen concentrator was removed from her room two days ago. She voiced her displeasure due to having been on oxygen since 2011 for sleep apnea and heart issues. She had slept in her recliner since the oxygen was removed because she was short of breath when she laid flat. She had oxygen for years and an oxygen company came to her home and checked the machine out and the people here took machine away without an explanation other than she changed rooms and was not able to have O2 anymore.A current policy, last revised April 2023, titled Oxygen Therapy, provided by the Administrator on 9/9/25 at 4:05 p.m., indicated the following: .Procedure: 3. The nurse will coordinate the oxygen therapy services as ordered by the residents physician.A current policy, last revised on September 2025, titled MatrixCare Physician Orders Policy, provided by the Administrator on 9/9/25 at 4:05 p.m., indicated the following: MatrixCare Physician Orders: All new orders will be entered into MatrixCare Physician Orders and verified by a licensed nurse.Monthly Order Re-Caps.b. Nursing managers and/or designated nurse will review the physician order report (re-caps) for accuracy, order omission, and obtain any necessary order clarifications.d. Nursing managers and/or designated nurses will ensure that all telephone orders from the month prior on the physical chart are entered into and correctly match the MatrixCare Physician Orders Report.3.1-47(6)

Based on observation and interview, the facility failed to dispose of unlabeled and unused medications for 2 of 2 medication carts reviewed for medication storage and labeling. (100 Hall Medication Cart and Memory Care Unit Medication Cart) Findings include:1. During a medication storage observation of the Memory Care Unit Medication Cart, accompanied by LPN 16, on [DATE] at 9:50 a.m., a loose pill was found on the bottom of the second drawer. The pill was blue with marking of G on the pill.A small white oblong pill with the markings of K 31 was found on the bottom of the third drawer.During the observation, LPN 16 indicated the loose pills needed to be destroyed in the drug destruction solution.2. During a medication storage observation of the 100 Hall Medication Cart, accompanied by the Assistant Director of Nursing (ADON) on [DATE] at 11:20 a.m., an insulin pen for Resident 42 was undated with an open date. Four loose pills were found on the bottom of the second drawer, toward the back of the cart. The first pill was light pink with markings of 894 and 5 on the pill. The second pill was quartered with no visible markings. The third pill was white with markings of TCL/340. The fourth pill was orange with markings of PLIVA 467.The third drawer contained three loose pills. The first pill was white with markings of LS/85. The second and third were yellow quartered pills with no visible markings.The fourth drawer was pulled completely out, and 10 loose pills were found. The first pill was white and oval with markings of APO/A10. The second pill was round and pink with markings of PAL 6. The third pill was round and light pink with markings of 30. The fourth pill was white with markings of C/12. The fifth, sixth, and seventh pills were capsules with markings of IP 101. The eighth was a round orange pill with markings of 39/H. The ninth pill was small and white with markings of TV/51. The tenth pill was a pink half tablet with markings of GM.During the observation, the ADON indicated the pills needed to be destroyed in the drug destruction solution. Insulin pens needed to have an open date written on the pen. The insulin pen would be destroyed. Five residents received insulin from the 100 Hall Medication Cart.During an interview, on [DATE] at 12:35 p.m., the DON indicated insulin pens needed to be dated as soon as the pen was opened. Any loose medications need to be destroyed in the drug destruction solution. Medication carts were cleaned weekly, with the pharmacy coming monthly to check medication carts.A current policy, titled Storage and Expiration Dating of Medication and Biologicals, provided by the Administrator, on [DATE] at 8:49 p.m., indicated the following: .11. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law 3.1-25(j)

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed during dining services for 4 of 5 residents observed in the memory care dining room. (Residents 1, 21, 22, and 32) Finding includes: During a continuous dining observation, on 9/3/25 from 11:57 a.m. to 12:45 p.m., the following food handling and infection prevention and control concerns were observed:CNA 10 served Resident 32 her meal tray. CNA 10 used her left barehanded fingertips to apply pressure to the top sandwich bun of Resident 32's chicken patty sandwich. CNA 10 held the bun in place with her fingertips and used a knife in her right hand to cut Resident 32's sandwich in half. CNA 10 served Resident 1 her meal tray. CNA 10 removed the top sandwich bun of Resident 1's chicken patty sandwich with her right bare hand and sat the bun upright on the edge of Resident 1's plate. Using both hands, CNA 10 opened a ketchup packet. CNA 10 picked up the top bun and placed it in the palm of her left bare hand. CNA 10 squirted the ketchup from the packet onto the top bun. CNA 10 picked up a knife with her right hand, spread the ketchup on the bun, and placed the top bun on top of the chicken patty. CNA 10 applied pressure to the top sandwich bun with the fingertips of her left bare hand to secure the bun in place and used a knife in her right hand to cut the sandwich in half. CNA 10 served Resident 21 her meal tray. CNA 10 picked up the top sandwich bun with her left bare hand. The top bun was placed upright on the meal tray. Using both hands, CNA 10 opened a mayonnaise packet. CNA 10 picked up the top bun and placed it in the palm of her left bare hand. She squirted the mayonnaise from the packet onto the top bun. She placed the top bun back on the sandwich, applied pressure to the top bun with the fingertips of her left hand to secure the bun in place, and used a knife in her right hand to cut the sandwich in half. Indentions were left in the bun from the pressure applied by CNA 10's fingertips. CNA 10 served Resident 22 her meal tray. CNA 10 picked up the top sandwich bun with her left bare hand. Using both hands, CNA 10 opened a ketchup packet and squirted the ketchup on the top bun. She placed the top bun back on the sandwich, applied pressure to the top bun with the fingertips of her left hand to secure the bun in place, and used a knife in her right hand to cut the sandwich in half. During the observation, CNA 10 indicated to the Regional Consultant that she wasn't sure of the proper technique to assist residents with their sandwiches. During an interview, on 9/3/25 at 12:56 p.m., CNA 10 indicated she was not to touch the bread when she served the residents their sandwiches. She performed hand hygiene between residents and thought it was okay to touch food items. During an interview, on 9/5/25 at 4:19 p.m., the DON indicated staff were not to handle food items with their bare hands. Staff were expected to use a barrier between their hands and food items, or use eating utensils, such as a fork or knife, when food items were handled. A current facility policy, revised in May 2025, provided by the Administrator on 9/8/25 at 10:15 a.m., titled General Food Preparation and Handling, indicated the following: .PROCEDURE: 7. Bare hands should never touch raw or ready to eat food directly. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid bare hand contact of foods. 3.1-18(a)

Based on record review and interview, the facility failed to implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies identified during a post survey revisit survey. Finding includes:Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey, completed on 9/9/25, indicated the facility had deficiencies cited that included oxygen therapy and medication storage.During an interview, on 11/25/25 at 2:20 p.m., the Administrator indicated the Quality Assessment and Assurance (QAA) committee met on October 23, 2025 and reviewed the annual survey results and the plan of corrections (POC) that was put into place. Regular meetings were held and felt the facilities QAPI processes of tracking and trending were effective.During an interview, on 11/25/25 at 2:50 p.m., the Administrator indicated the POC binder included everything that pertained to the annual survey deficiencies. The audits were performed as scheduled. She felt the weekly audits were fine, but moving forward to the monthly audits, problems had occurred. Due to the recurrent identified problems, the audit sheets were going to be revamped to add a certain number of residents or medication carts to be audited. Audits needed to be more detailed, rather than just a spot check.Repeat concerns regarding oxygen therapy and labeling of drugs and biologicals reviewed during medication storage were cited during 9/9/25 survey as follows:The facility failed to dispose of unlabeled and unused medications for 2 of 3 medication carts reviewed for medication storage and labeling. (100 Hall Medication Cart and 300 Hall Medication Cart)The facility failed to follow physician orders to change, label and date oxygen supplies for 6 of 7 residents reviewed for respiratory services. (Residents 9, 22, 24, 46, 55, 63)An undated facility policy titled, Policy, provided by the Administrator on 11/25/25 at 3:19 p.m., indicated the following: It is the policy of American Senior Communities that each facility actively participates in a formalized and documented Quality Assurance and Performance Improvement Process (QAPI).The QAPI Process includes auditing, trending, monitoring, action planning, evaluating, and follow up .QAPI will involve systemic change related to that particular system rather than focusing on a particular part.Goals.To demonstrate systemic identification, reporting, investigating, analysis, and prevention of adverse events, which includes ongoing abuse prevention measures.Cross reference F695.Cross reference F761.3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to ensure staff treated a physically dependent resident with respect and dignity when the resident requested assistance for 1 of 1 residents reviewed for dignity. (Resident 40)Findings include:On 9/3/25 at 11:43 a.m., Resident 40 was resting in bed with her eyes closed. The room lights were off. On 9/9/25 at 1:40 p.m., the resident was seated in a wheelchair, wearing a knitted cap on her head. Resident 40's clinical record was reviewed on 9/9/25 at 12:49 p.m. Diagnoses included epilepsy, muscle weakness, visual loss in both eyes and need for assistance with personal care.A 7/16/25, annual, Minimum Data Set (MDS) assessment indicated Resident 40 was mildly cognitively impaired. Resident 40's vision was highly impaired where she could follow objects but object identification was in question.During an interview, on 9/9/25 at 9:20 a.m., LPN 7 indicated, on 9/8/25, Resident 40 was upset that her headband was not covering the bald spot on her scalp and wanted a hat. CNA 8 stated to Resident 40 that she was already wearing a headband that covered the bald spot and if Resident 40 didn't wear headbands and hats, she wouldn't have the bald spot on her scalp. CNA 8 aggressively took the headband off Resident 40's scalp and went to retrieve a hat from the resident's room. LPN 7 reported the incident to the nurse manager.On 9/9/25 at 9:30 a.m., CNA 8 indicated Resident 40 had been mean to staff lately and the CNA felt there was something going on with Resident 40. The CNA had educated Resident 40 about not putting herself in bed alone due to a risk for falls. CNA 8 felt that was the reason why Resident 40 was upset with her. The facility had been short staffed lately. She was already running behind when the incident occurred at the nurses' station on 9/8/25. CNA 8 was propelling Resident 40 down the hallway toward the dining room when the resident asked where her hat was. CNA 8 told the resident she was wearing a headband and didn't need to wear a hat. Resident 40 insisted on wearing a hat, as her bald spot was not covered. CNA 8 told Resident 40 that they needed to get down to the dining room for lunch. Resident 40 asked CNA 8 to grab her hat from her room. CNA 8 took the headband off Resident 40's head and grabbed a hat from the resident's room. CNA 8 came back and placed the hat on resident 40's head before propelling her down to the dining room. CNA 8 indicated they were already 30 minutes behind, and other residents needed assistance. She was in a hurry when the incident took place; it was a very crazy and hectic day.During a video observation, on 9/9/25 at 9:54 a.m., with the Administrator, Corporate Nurse Consultant, and the DON present, the following was observed:12:36:05 p.m. - CNA 8 exited the shower room door adjacent to the nurses station while Resident 40 sat in her wheelchair at the nurse's station. CNA 8 approached Resident 40. 12:36:19 p.m. - CNA 8 reached up with her left hand and grasped Resident 40's headband from the top of Resident 40's head. CNA 8 looked towards her right, where LPN 7 was at in the nurses' station. Without looking back at Resident 40, CNA 8 abruptly pulled the headband backwards off of Resident 40's head. At the same time, Resident 40 was attempting to fix her hair. As CNA 8 removed Resident 40's headband backwards off Resident 40's head, Resident 40's arm was jerked away. CNA 8's hand gestured up to her face as she walked to edge of the nurses' station. CNA 8 looked directly in Resident 40's direction as she walked past her in the direction of the resident's room. CNA 8 returned and reapproached Resident 40.12:37:18 p.m. - CNA 8 abruptly placed the hat on Resident 40's head and propelled Resident 40 in her wheelchair down the hallway. During an interview, on 9/9/25 at 10:09 a.m., Resident 40 indicated she felt CNA 8 removed the headband aggressively from her head. CNA 8 did not verbalize she was removing the headband before she took it off of her head. She was visually impaired and could only make out shadows.On 9/9/25 at 10:43 a.m., the Administrator indicated CNA 8 could have taken more time switching out the headband for a hat. She felt CNA 8 was rushed and seemed a little bit irritated during the incident. CNA 8 did not take the best approach with a visually impaired resident. The Administrator felt CNA 8 took the headband off abruptly. Resident 40 is known for wearing hats, while the headbands were newer. Resident 40 didn't complain often and had no other issues with CNA 8. Resident 40 was visually impaired and only saw shadows.On 9/9/25 at 10:50 a.m., the DON indicated CNA 8 abruptly removed the headband from Resident 40's head. CNA 8 was frustrated and was in a hurry. She didn't feel it was related to staffing ratios.On 9/9/25 at 10:55 a.m., the Corporate Nurse Consultant indicated the facility was being proactive in providing abuse in-servicing. Abuse education was offered both verbally and individually. On 9/9/25 at 1:27 p.m., CNA 11 indicated CNA 8 has had attitudes with Resident 40 in the past. CNA 11 had notified the DNS last week about CNA 8's attitude toward Resident 40.On 9/9/25 at 1:51 p.m., the DON indicated CNA 8 had no prior disciplinary actions and was never notified by staff members of any concerns with CNA 8.A current policy, titled Abuse Prohibition, Reporting and Investigation, provided by the Administrator, on 9/9/25 at 12:24 p.m., indicated the following: .Neglect. Failure to provide goods and services to a resident(s) necessary to avoid physical harm, pain, mental anguish, or emotional distress.This citation relates to Intake 2611663.

Based on record review and interview the facility failed to provide physician ordered wound treatment for 1 of 3 residents reviewed for physician order compliance. (Resident B) Findings include:Resident B's closed clinical record was reviewed on 7/21/25 at 10:10 a.m. Diagnoses included chronic congestive heart failure, osteoarthritis, atrial fibrillation, peripheral vascular disease, stage 3 chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, malignant melanoma of skin, hypertensive heart and chronic kidney disease with heart failure, severe morbid obesity, obstructive sleep apnea, chronic respiratory failure with hypoxia, and gout. The resident was admitted to the facility on [DATE] and discharged on 7/9/25.A care plan, dated 7/3/25, indicated the resident had impaired skin integrity as evidenced by venous ulcer to the mid lower left leg, medial mid leg and right foot. Diabetic ulcer to the right plantar foot and left second toe. Interventions included: Assess for pain and treat as ordered. Review of physician orders and the Medication/Treatment Administration Record for 6/9/25 through 7/9/25 indicated the following:a. Antifungal powder to bottom of right foot. Place in non-skid sock. Twice daily. Start date: 6/2/25. End date: 7/2/25. No documentation or rationale for missed treatments on evening shift 6/25/25 and evening shift 6/30/25. b. Change socks-due to socks becoming wet causing maceration of feet. Every shift. Start date: 6/5/25. End date: 7/2/25. No documentation or rationale for missed treatments on evening shift 6/25/2025 and evening shift 6/30/25. c. Cleanse left 2nd toe wound and peri wound with wound cleanser. Apply xeroform to wound, cover with 4 x 4 gauze and secure with tape. Change daily. Start date: 7/3/25. End date: 7/8/25. No documentation or rationale for missed treatments on 7/6/2025. d. Cleanse wound and peri wound on left medial mid lower leg with wound cleanser, apply Aquacel Ag Advantage (antimicrobial dressing) to wound bed, cover with ABD pad, then secure with 2 layers of tubigrip size F (base of toes to knee). Change daily. Start date: 7/3/25. End date: 7/8/25. No documentation or rationale for missed treatments on 7/6/25. e. Cleanse wounds and peri wounds to right foot with wound cleanser. Apply mix of calmoseptine (skin barrier) and miconazole powder (antifungal powder) to wound beds. Apply Aquacel Ag Advantage to base of foot and weave between toes. Cover with ABD pads, wrap with kerlix, and secure with paper tape. Apply two layers of tubigrip size F for compression wrap from base of toes to knee. Once daily. Start date: 7/3/25 End date: 7/8/25. No documentation or rationale for missed treatments on 7/6/25.Review of facility the Wound Management Detail Report, dated 7/10/25, indicated on 6/18/25 a venous ulcer to the left shin was identified. Measurements were documented as 0.8 cm x 1.8 cm x 0.1 cm. The wound was described as full thickness with amber colored serous exudate. Comments indicated the area had been healed and had reopened. On 6/26/25, the wound measured 2 cm x 1.5 cm x 0.1 cm. The wound was described as full thickness with serosanguineous exudate. The wound status as documented as improving. On 7/1/25, the wound measured 4 cm x 1.5 cm x 0.1 cm. The wound was described as full thickness with serosanguineous exudate. Comments indicated the resident had been seen at the wound clinic and measurements were post debridement.Review of the visit notes and treatment orders from the wound clinic, dated 7/1/25 through 7/8/25 indicated the following:a. 7/1/25 visit note indicated the resident presented with a venous leg ulcer located on the left medial mid lower leg, venous ulcer to the right foot, a diabetic ulcer on the right plantar foot, and a diabetic ulcer on the left second toe. The diabetic ulcer to the right plantar foot was identified as limb threatening. Procedure: excisional debridement of the subcutaneous tissue. The venous ulcer on the left medial mid lower leg measured 4 cm x 1.5 cm x 0.1 cm with a moderate amount of serous and serosanguineous exudate. The diabetic ulcer located on the left second toe measured 0.4 cm x 0.4 cm x 0.1 cm with a large amount of serous and serosanguineous exudate. Post procedure: the venous ulcer on the left medial mid lower leg measured 4 cm x 1.5 cm x 0.1 cm after 90 % of the wound underwent debridement. The diabetic ulcer on the left second toe measured 0.5 cm x 0.5 cm x 0.1 cm after 100% of the wound underwent debridement. b. Post visit treatment orders: left medial mid lower leg: Aquacel Ag Advantage. ABD pad daily for 1 week. Compression wrap - 2 layers of tubigrip size F. Venous ulcer to the right foot: Calmoseptine to peri wound. Aquacel Ag Advantage with ABD pad, kerlix and paper tape. This treatment was to be done daily for 1 week. Compression wrap with 2 layers of tubigrip. Use tubigrip size F - mix calmoseptine and miconazole powder, Aquacel Ag Advantage and weave between toes and to base of foot. Change twice daily if dressing is soaked through. Check every shift x 2. Elevate legs x 2 hours twice daily.c. Diabetic ulcer right plantar foot: Cleanse the peri-wound and wound area with Wound Cleanser. Treat peri wound are with calmoseptine. Use tubigrip size F - mix calmoseptine and miconazole powder, Aquacel Ag Advantage and weave between toes and to base of foot. Change twice daily if dressing is soaked through. Check every shift x 2. Elevate legs x 2 hours twice daily.d. Diabetic ulcer to left second toe: Cleanse the peri-wound and wound area with Wound Cleanser. Primary dressing: Xeroform with 4 x 4 gauze. Secure with mepitac tape. This treatment will be done every other day for 1 week.e. Edema to right leg treatment: 2 layers of tubigirp size F. This treatment will be done daily for 1 week. Prescriptions: Dankin's Solution: Apply a small amount once daily for 30 days. This order was not transcribed.f. Plan: Cleanse all areas with 1/4 strength Dankins [sic](rx [prescription] sent), Aquacel Ag between toes, antifungal powder mixed with Calmoseptine to R [right] plantar foot, ABD pad, kerlix. Tubigrip for this week until cleared by cards/vasc [sic].g. Visit dated 7/8/25: Venous ulcer located on the left medial lower leg had worsened since the initial visit. Measurements were 9 cm x 4 cm x 0.1 cm. The venous ulcer located on the right foot had worsened since the initial visit and remained limb threatening. Measurements were 14 cm x 14 cm x 0.1 cm. The diabetic ulcer located on the right plantar foot had shown improvement. Measurements were 7 cm x 5 cm x 0.1 cm. The diabetic ulcer on the left second toe was documented as having shown improvement. Measurements were 0.3 cm x 0.2 cm x 0.1 cm. The edema in the right leg status had not changed. Case Management Comments indicated the facility had not followed treatment orders. The resident arrived to clinic with xeroform to all wounds and felt roll to legs and feet. Left 2nd toe had xeroform and gentec (adhesive dressing), again not what was ordered by provider[sic]. Note that if the SNF [skilled nursing facility] does not have aquacel AG [sci] available, they should be using calcium alginate as an alternative for absorption.During an interview on 7/22/25 at 9:46 a.m., the DON and Corporate Clinical Consultant indicated the facility did not have an order for Dakin's Solution during the resident's stay. During an interview on 7/22/25 at 12:19 p.m., LPN 1 indicated medications and treatments were to be documented in the clinical record. If something was missed, it should have a note.During an interview on 7/22/25 at 1:21 p.m., the Corporate Clinical Consultant indicated medications and treatments should be documented in the MAR/TAR. Refusals should be documented. If a treatment or medication was missed or not given/provided per the physician order, there should be a documented rationale. The Corporate Clinical Consultant was unable to provide a policy for documenting refusals or missed medications or treatments. A skills competency, dated 4/2025, titled Medication Administration (Medication Pass Procedure) was provided by the Corporate Clinical Consultant on 7/22/2025 at 1:21 p.m. The competency indicated medications administered would be recorded on the electronic medication administration record after administered. The Corporate Clinical Consultant indicated it was the expectation of the facility that this standard also applied to treatments. This citation relates to complaint 1428035.3.1-37(a)

Based on interview and record review, the facility failed to implement skin assessments to identify pressure injury, failed to obtain orders for a medical device that increased the risk of skin impairment, and failed to develop and implement interventions to prevent pressure injury for 1 of 3 residents reviewed for pressure injury. (Resident B) This deficient practice resulted in Resident B developing an unstageable pressure injury to the right knee requiring hospitalization and eventual amputation of the lower leg. The deficient practice was corrected on February 10, 2025, prior to the start of the survey, and was therefore past noncompliance. Findings include: Resident B's closed clinical record was reviewed on 2/25/25 at 1:26 p.m. Diagnoses included fracture of neck of right femur, subsequent encounter for closed fracture with routine healing, acute posthemorrhagic anemia, and dementia with other behavioral disturbance. The resident admitted to the facility on [DATE] following surgical repair of the right femur fracture and obstructive and reflux uropathy (urinary obstruction). A care plan, dated 12/31/24, indicated Resident B was at risk for skin breakdown due to weakness, incontinence and right leg immobilizer. Interventions included assess and document skin condition weekly and as needed. A care plan, dated 12/31/24, indicated the resident was at risk for falls due to weakness, history of falls, advanced age, medications, tethering equipment, incontinence, impaired cognition, and right leg immobilizer. Review of the 12/30/24 admission assessment indicated Resident B presented with a dressing to the right thigh and a right leg immobilizer. An assessment of the skin under the immobilizer was not completed. Review of a progress note, dated 12/31/24 at 2:12 a.m., indicated Resident B had a brace to the right leg in place. The resident's skin was not assessed. Review of a Skin and Wound note by the Wound Nurse Practitioner, dated 1/3/25 at 11:38 a.m., indicated the resident admitted with a right heel deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) and skin tears to the right elbow and left upper forearm. A dressing to the right hip/thigh surgical area was in place and was to be left in place until resident was seen by the surgeon. The care plan lacked interventions to support healing of the right heel deep tissue injury. The care plan lacked interventions specific to the management of the leg immobilizer, including prevention of pressure injury. Review of a progress note, dated 1/3/25 at 2:30 p.m., indicated the resident required assistance of two people for all activities of daily living and tolerated the use of assistive devices. The most recent admission Minimum Data Set (MDS) assessment, dated 1/6/25, indicated Resident B was at risk for pressure injuries and had impairment to one side on the lower extremity. The resident required partial/moderate assistance for eating, oral hygiene, upper body dressing, roll left to right. Substantial/max assistance for personal hygiene, sit to stand, lying to sitting, picking up an object. He was dependent for toilet/shower transfer, sit- to-stand, footwear application and removal, dressing lower body, showers, and toilet hygiene. He was incontinent of bowel and admitted with an indwelling catheter. An orthopedic surgeon progress note, dated 1/14/25, indicated a necrotic (dead tissue) wound was identified on the resident's right knee, which may have had full-thickness involvement. A petrolatum (for wound care) dressing was applied to the knee wound and its use was added to the plan of care. The wound required monitoring by a wound care provider. An absorbent dressing to the right knee was to be managed by the wound care provider. There was concern about the pressure injury to the right knee and treatment was aimed at healing. An order written by the orthopedic surgeon, dated 1/14/25 during a follow up appointment indicated wound care to the open area on the right knee was to start on 1/17/25. An event progress note, dated 1/17/25, indicated an open area (wound) measuring 4.0 centimeters (cm) long by 3.0 cm wide on the right knee was identified on 1/14/25. Resident B's physician orders, Medication Administration Records (MAR), and Treatment Administration Records (TAR) for 1/14/25 through 1/17/25 lacked orders for right knee wound care until 1/17/25. Resident B transferred to another long-term care facility on 2/17/25 per their choice. A wound management note from the receiving long term care facility indicated Resident B presented with an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure injury to the right knee, measuring 2.0 cm long with a depth of 0.5 cm. The width could not be accurately measured. The wound was covered with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). An orthopedic hospital consultation note, dated 1/29/25, indicated Resident B presented on 1/28/25 with a necrotic wound on the right knee. The wound was identified during an orthopedic follow-up appointment on 1/14/2025 and had developed purulent drainage and then visible bone and hardware (from previous knee replacement). The resident underwent right leg above-the-knee amputation on 1/29/25. During a phone interview on 2/24/25 at 10:25 a.m., the orthopedic surgeon's nurse indicated the surgeon's office note from the hospital to another hospital following surgery (no date provided) did not include the use of an immobilizer brace to Resident B's right leg. During an interview on 2/24/25 at 11:13 a.m., LPN 1 indicated Resident B admitted to the facility with a right leg immobilizer brace in place. No orders for an immobilizer were in place at admission to the facility. LPN 1 did not call to get clarification for the missing order for the immobilizer in place to Resident B's right leg. Residents were to have weekly skin assessments completed and documented in the clinical record. LPN 1 was unable to locate skin assessments completed for Resident B in the clinical record since his admission to the facility on [DATE]. During an interview on 2/24/25 at 11:30 a.m., Physical Therapist (PT) 2 indicated Resident B was on therapy caseload. The resident admitted to the facility with a right leg immobilizer. The immobilizer needed to be adjusted on occasion due to it slipping out of place. PT 2 was not sure but believed the admission orders included non-weight bearing status and a right leg immobilizer. During an interview on 2/24/25 at 12:01 p.m., the DON indicated Resident B's clinical record lacked an order for the use of a right leg immobilizer. The DON thought she had called for clarification but had no documentation of the call. She may have confused two similar residents who admitted around the same time. LPN 1 should have caught the lack of orders for the leg immobilizer and clarification should have been completed and documented. During an interview with CNA 3 and 1 on 2/24/25 at 1:00 p.m., CNA 3 indicated Resident B had a brace on his right leg from his thigh to his ankle during his stay. It had been removed during sleep and for showers. CNA 1 indicated they had given the resident a shower once during their stay and did not notice any new skin impairments. A shower sheet, dated 1/12/25, indicated CNA 3 did not find any new skin impairments. During an interview on 2/24/25 at 1:52 p.m., the Wound Nurse Practitioner (NP) indicated surgeons usually did not want anyone to remove a surgical dressing until the first follow-up visit. She did not have the authority to write orders in the facility. The facility should have gotten a clarification from the surgeon. A current policy, dated 7/24, titled Admission/Return Admission Policy Procedure was provided by the DON on 2/25/25 at 1:57 p.m. The policy indicated the following: Policy: It is the policy of American Senior Communities to provide baseline and accurate documentation of the mental, physical condition of each resident admitted or readmitted to the facility and to assist the resident and family with adjusting to the facility. Admission procedures will be followed for all new admissions including respite care. Initial nursing assessment: Admission Observation 5. A thorough head to toe assessment (including skin) must be done at admission. Any altercations in skin integrity must be identified on nursing assessment. The physician must be notified for specific treatment orders. Physician orders: Verification of orders: 1. The admitting nurse must call the attending physician to verify all orders upon admission. A current policy, dated 7/24, titled Documentation Guidelines for Nursing: was provided by the DON on 2/25/25 at 1:57 p.m. The policy indicated the following: Resident Assessments Completed Weekly skin and vital signs assessment observation (All new skin areas must be reported to the wound nurse with new skin event completed) Review of Resident B's progress notes and assessments in the clinical record lacked weekly skin assessments. During an interview on 2/24/25 at 2:07 p.m., the DON and the Corporate Consultant indicated the facility should have noted the lack of orders related to the surgical wound and the leg immobilizer. This deficient practice was corrected by February 10, 2025 after the facility implemented a systemic plan that included the following actions: assessment of all residents for pressure injuries, in-servicing education to staff related to completion of skin assessments and clarification of or obtaining treatment orders, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI) activities. This citation relates to Complaint IN00452401. 3.1-40 (a)(1)

Based on record review and interview, the facility failed to identify and implement interventions for care of a surgical wound for 1 of 3 resident reviewed for wound care. (Resident B) The deficient practice was corrected on February 10, 2025, prior to the start of the survey, and was therefore past noncompliance. Findings include: Resident B's closed clinical record was reviewed on 2/25/25 at 1:26 p.m. Diagnoses included fracture of neck of right femur, subsequent encounter for closed fracture with routine healing, acute posthemorrhagic anemia, and dementia with other behavioral disturbance. The resident admitted to the facility on [DATE] following surgical repair of the right femur fracture (on 12/24/24) and obstructive and reflux uropathy (urinary obstruction). A care plan, dated 12/31/24, indicated Resident B was a new admission to the facility and required implementation of services to promote physical, emotional, and psychosocial well-being including assistance with activities of daily living related to chronic obstructive pulmonary disease, weakness, right femur fracture with immobilizer. Interventions included an intervention to provide special treatments or devices. A care plan, dated 12/31/24, indicated Resident B was at risk for skin breakdown due to weakness, incontinence and right leg immobilizer. Interventions included assess and document skin condition weekly and as needed. A care plan, dated 12/31/24, indicated the resident was at risk for falls due to weakness, history of falls, advanced age, medications, tethering equipment, incontinence, impaired cognition, and right leg immobilizer. A care plan, dated 1/8/25, indicated the resident had impaired skin (surgical). Interventions included assessing wounds weekly and documenting measurements and description. Notify MD of change in wound such as worsening or signs of infection. Wound location: right hip. Observe for sings of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound. Review of the 12/30/24 admission assessment indicated Resident B presented with a dressing to the right thigh and a right leg immobilizer. An assessment of the skin under the immobilizer was not completed. Review of a progress note, dated 12/31/24 at 2:12 a.m., indicated Resident B had a brace to the right leg in place. The resident's skin was not assessed. Review of the progress notes from 12/20/24 through 1/3/2025 indicated the surgical wound was assessed, but the dressing to the surgical wound was not removed. Review of a Skin and Wound note by the Wound Nurse Practitioner (NP), dated 1/3/25 at 11:38 a.m., indicated a dressing to the right hip/thigh surgical area was in place and was to be left in place until the resident was seen by the surgeon. The dressing was not removed. Review of a progress note, dated 1/3/25 at 2:30 p.m., indicated the resident required assistance of two people for all activities of daily living and tolerated the use of assistive devices. The most recent admission Minimum Data Set (MDS) assessment, dated 1/6/25, indicated Resident B was at risk for pressure injuries and had impairment to one side on the lower extremity. The resident required partial/moderate assistance for eating, oral hygiene, upper body dressing, roll left to right. Substantial/max assistance for personal hygiene, sit to stand, lying to sitting, picking up an object. He was dependent for toilet/shower transfer, sit- to-stand, footwear application and removal, dressing lower body, showers, and toilet hygiene. He was incontinent of bowel and admitted with an indwelling catheter. An orthopedic surgeon progress note, dated 1/14/25, indicated Resident B's right leg surgical site had the staples removed and steri-strips were placed. Resident B's physician orders, Medication Administration Records (MAR), and Treatment Administration Records (TAR) for 12/30/24 through 1/17/25 lacked orders for care of the resident's surgical site. Resident B transferred to another long-term care facility on 2/17/25 per their choice. During a phone interview on 2/24/25 at 10:25 a.m., the orthopedic surgeon's nurse indicated the surgeon's office note from the hospital indicated the dressing to Resident B's right leg surgical site should have been changed five days following the surgery. During an interview on 2/24/25 at 11:13 a.m., LPN 1 indicated Resident B admitted to the facility with a right leg immobilizer brace in place and a surgical wound to the right thigh. No orders for an immobilizer nor for surgical wound care were in place at admission to the facility. LPN 1 did not call to get clarification for the missing orders. Residents were to have weekly skin assessments completed and documented in the clinical record. LPN 1 was unable to locate skin assessments completed for Resident B in the clinical record since his admission to the facility on [DATE]. During an interview on 2/24/25 at 12:01 p.m., the DON indicated, during the NP's surgical wound assessment of Resident B, the dressing was not removed. The NP recommended the dressing to stay in place until the resident was seen by the surgeon. The DON indicated she thought she had called the surgeon's office for order clarification, but she may have confused the resident with another who had similar care needs. The DON could not indicate why weekly skin assessments were not completed for Resident B. During an interview on 2/24/25 at 1:52 p.m., the Wound Nurse Practitioner (NP) indicated surgeons usually did not want anyone to remove a surgical dressing until the first follow-up visit. She did not have the authority to write orders in the facility. The facility should have gotten a clarification from the surgeon. A current facility policy, dated 7/24, titled Admission/Return Admission Policy Procedure was provided by the DON on 2/25/25 at 1:57 p.m. The policy indicated the following: Policy: It is the policy of American Senior Communities to provide baseline and accurate documentation of the mental, physical condition of each resident admitted or readmitted to the facility and to assist the resident and family with adjusting to the facility. Admission procedures will be followed for all new admissions including respite care. Initial nursing assessment: Admission Observation 5. A thorough head to toe assessment (including skin) must be done at admission. Any altercations in skin integrity must be identified on nursing assessment. The physician must be notified for specific treatment orders. Physician orders: Verification of orders: 1. The admitting nurse must call the attending physician to verify all orders upon admission. A current facility policy, dated 7/24, titled Documentation Guidelines for Nursing: was provided by the DON on 2/25/25 at 1:57 p.m. The policy indicated the following: Resident Assessments Completed Weekly Weekly skin and vital signs assessment observation (All new skin areas must be reported to the wound nurse with new skin event completed) Review of Resident B's progress notes and assessments in the clinical record lacked weekly skin assessments. During an interview on 2/24/25 at 2:07 p.m., the DON and the Corporate Consultant indicated the facility should have noted the lack of orders related to the surgical wound and the leg immobilizer. This deficient practice was corrected by February 10, 2025 after the facility implemented a systemic plan that included the following actions: assessment of all residents for wounds, in-servicing education to staff related to completion of skin assessments and clarification of or obtaining treatment orders, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI) activities. This citation relates to Complaint IN00452401. 3.1-(37)(a)

Based on interview and record review, the facility staff failed to report an allegation of abuse to the Administrator per facility policy for 1 of 4 residents reviewed for abuse. (Resident C) The deficient practice was corrected on 12/2/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: During an interview on 1/29/25 at 9:55 a.m., Resident C indicated Resident D had entered her room several times. Resident D continued to open and shut her door several times and then enter the room again. Resident C asked her to leave her alone and Resident D began to argue and yell, then kicked Resident C in the left shin. Staff came in and escorted Resident D out of her room. Her leg was sore, but had no open wound. She was unsure what specific day the incident occurred, but indicated it was in the evening before she went to bed. During an interview on 1/29/25 at 11:13 a.m., with the DON and Administrator, the DON indicated she had not been informed of any incident between Resident C and Resident D in November 2024. The Administrator also indicated she had not been informed of any incident between Resident C and Resident D. During an interview on 1/29/25 at 12:25 p.m., the DON indicated she had reviewed the resident's electronic health record and found no information regarding an incident in November 2024. She had been unable to determine, based on staff interviews, what date the incident had occurred, but had determined it was on the evening shift. During an interview on 1/29/25 at 2:18 p.m., RN 6 indicated Resident C told her that Resident D had entered her room several times and kicked her in the left shin the night before. RN 6 was unable to clarify if this report was on the morning of 11/13/24 or 11/24/24. RN 6 asked the resident if she had reported this to anyone and resident replied no. Upon finishing her morning medication administration that day, she reported Resident C's statement to the Administrator and DON. She had not documented the allegation in the residents clinical record. During a telephone interview on 1/29/25 at 3:18 p.m., LPN 4 indicated she had not witnessed an altercation between Resident C or Resident D. She worked the evening shift on 11/13/25. Resident C had told her about Resident D coming in her room, but no specifics. LPN 4 had not asked any questions of Resident C regarding her statement. During a telephone interview on 1/29/25 at 3:58 p.m., CNA 3 indicated she had not witnessed any altercation between Resident C or Resident D. She had not seen Resident D in Resident C's room. She had worked on the evening shift on 11/12/24 and 11/13/24 on the 300 hall. Another staff member, whom she could not identify, told her that the residents had words and Resident D kicked Resident C in the leg. She was not aware if any staff had reported the altercation to the Administrator. She could not recall if the other staff member had indicated the night the incident occurred. Resident C's clinical record was reviewed on 1/29/25 at 10:58 a.m. Resident C was cognitively intact. Diagnoses included lymphedema, venous insufficiency, peripheral vascular disease, major depressive disorder, and cellulitis. Resident C's progress notes and event charting lacked an entry of an incident with Resident D or assessment following the incident. Resident D's clinical record was reviewed on 1/30/25 at 11:35 a.m. Resident D had moderate cognitive impairment. Diagnoses included vascular dementia with mood disturbance and major depressive disorder. Resident D's progress notes and event charting lacked an entry of an incident with Resident C or assessment following the incident. A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Corporate Nurse Consultant on 1/28/25 at 2:50 p.m., included the following: .Reporting/Response: 1. All abuse allegations must be report to the Executive Director immediately The deficient practice was corrected by 12/2/24 after the facility implemented a systemic plan that included a facility inservice regarding abuse, report of abuse, and investigation. This citation relates to complaint IN00447542. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure reconciliation of controlled medications was completed for 2 of 3 medication carts reviewed. (200 Unit and 300 Unit medication carts). Findings include: Review of the 200 Unit Shift Change Verification of Controlled Substances (12 hour) log from 10/1/24 to 10/4/24 lacked the following information: a. 10/1/24 Night shift- on-coming and ff-going shift signature and count completion b. 10/1/24 Day shift - reconciliation of controlled medication count c. 10/2/24 Night shift- reconciliation of controlled medication count d. 10/2/24 Day shift - reconciliation of controlled medication count During an observation at the time of interview, on 10/4/24 at 6:38 a.m., LPN 3 indicated the night shift nurse on 10/1/24 had not signed the Shift Change Verification of Controlled Substances log on the 200 unit. She recalled who had been on duty when she took over on day shift and placed the night shift nurse's initials on the sheet for both blank spots. Four different shifts on the log for 10/1/24 and 10/2/24 lacked the count completion. Both the on-coming and off-going signatures as well as the count completion should have been on the log for each shift. During an interview on 10/4/24 at 8:48 a.m., the DON indicated the shift to shift log was not signed for night shift on 10/1/24 because she believed they had signed on the wrong log. The Shift Change Verification of Controlled Substances log lacked documentation of count completion for each shift during shift change in October 2024. Both staff members that exchanged keys for a medication cart were required to complete the counts and the logs. Review of the 300 Unit Shift Change Verification of Controlled Substances (8 hour) log from 10/1/24 to 10/7/24 lacked the following information: a. 10/1/24 Night shift- on-coming and off-going shift signatures b. 10/2/24 Night shift- on-coming and off-going shift signatures and reconciliation of controlled medication count c. 10/4/24 Evening shift- reconciliation of controlled medication count d. 10/5/24 Day shift- reconciliation of controlled medication count e. 10/5/24 Evening shift - reconciliation of controlled medication count f. 10/5/24 Night shift- reconciliation of controlled medication count A current facility policy, dated 2/1/18, titled Inventory of Controlled Substances, provided by the DON on 10/7/24 at 3:33 p.m., indicated the following: .Policy: It is the policy . to ensure that the incoming and outgoing nurses count all controlled substances at the change of each shift and document on the Shift Change Verification of Controlled Substances form 3.1-25(e)(2)

A. Based on interview and record review, the facility failed to administer medications according to physician order for 2 of 9 residents reviewed for medication administration. (Residents 19 and 51) B. Based on interview and record review, the facility failed to obtain daily weights according to physician order for 1 of 3 residents reviewed for nutrition. (Resident 65) Findings include: A1. Resident 19's clinical record was reviewed on 10/4/24 at 7:20 a.m. Diagnoses included flaccid hemiplegia (decreased muscle tone) affecting left nondominant side, spastic hemiplegia (muscle tightness) affecting right dominant side, dysphagia (difficulty speaking) following cerebral infarction, aphasia (loss of ability to communicate) following cerebral infarction, and contracture of left hand. Current medications included, depakote sprinkles (anticonvulsant) 125 milligram (mg) twice daily via gastric tube, Eliquis (anticoagulant) 2.5 mg twice daily via gastric tube, gabapentin (anticonvulsant and nerve pain) 100 mg twice daily, and hydrocodone- acetaminophen (pain) 7.5-325 mg every four hours via gastric tube. A September 2024 Medication Administration Report (MAR) indicated she did not receive her dose of hydrocodone- acetaminophen 7.5-325 mg on 9/18/24 at 12:00 a.m., and 9/24/24 at 12:00 a.m. A September 2024 narcotic count sheet indicated the medication was not removed for her 12:00 a.m. dose on 9/18/24. A2. Resident 51's clinical record was reviewed on 10/7/24 at 9:45 a.m. Diagnoses included Parkinson's disease, dementia, type 2 diabetes, chronic pain syndrome, and long-term use of anticoagulants. Current medications included, but were not limited to, furosemide (antidiuretic) 40 mg once daily, hydrocodone-acetaminophen (pain) 7.5-325 mg every 6 hours, warfarin (anticoagulant) 3 mg on Monday, Wednesday, Friday, and Saturday, and warfarin 6 mg on Sunday, Tuesday and Thursday. A September 2024 MAR indicated on 9/18/24 and 9/24/24 he did not receive his 12:00 a.m. doses of hydrocodone- acetaminophen 7.5-325 mg. On 9/24/24 and 9/26/24 he did not receive his 8:00 p.m. doses of Warfarin 6 mg. A September 2024 narcotic count sheet indicated the medication was not signed out on 9/18/24 at 12:00 a.m. On 9/24/24 at 12:00 a.m., it showed the medication was signed out, but the electronic medical record did not show the medication was administered. During an interview, on 10/7/25 at 10:35 a.m., RN 4 indicated the narcotic was to be removed from the mediation card. Staff then sign, along with the date and time the medication was removed on the narcotic count sheet. After administration of the medication, staff was to document in the electronic medical record (eMAR). In the eMAR, staff was to click that the medication was prepped, given, and completed before the medication would show it was administered. Since the medication had been signed out on the narcotic count, he assumed the medication had been administered to the resident. But, he indicated it could have been a drug diversion. During an interview, on 10/7/24 at 10:38 a.m., LPN 7 indicated there were three steps staff must complete before the medication shows it was administered. To document that a medication was given in the eMAR, staff clicked on the prep box, given box, and then the complete box. Once all three steps have been completed, the medication would show it had been administered. If the narcotic count matches the count sheet, it has theoretically been given. It could indicate a possible drug diversion since the eMAR doesn't show the medication was administered. During an interview, on 10/7/24 at 11:35 a.m., the DON indicated scheduled medications that were not marked completed would disappear from the medications to be done list after an hour had elapsed. Staff could have amended the eMAR to show the medication had been administered. She was unable to go back to see if the medication had been marked as prepped but not signed off as administered. If the medication hadn't been signed out of the narcotic book, it indicated it hadn't been administered. Medical Records usually completed the monitoring process for narcotics, but the current staff member was new to the position. A current facility policy was requested for administering mediations per physician orders but was not received prior to facility exit on 10/8/24. 42685 B1. Resident 65's clinical record was reviewed on 10/3/24 at 4:06 p.m. Diagnoses included acute respiratory failure with hypoxia, acute on chronic diastolic congestive heart failure, and pulmonary embolism (blood clot in the lungs). A current physician order, dated 9/5/24, indicated to obtain daily weights for congestive heart failure and notify the physician of a weight gain of three pounds in a day or five pounds in a week. The clinical record lacked daily weights, refusals, or clinical notes indicating why the weights were not obtained on the following dates: 9/7/24, 9/8/24, 9/13/24, 9/14/24, 9/15/24, and 9/16/24. An admission Minimum Data Set (MDS) assessment, dated 9/11/24, indicated the resident had mild cognitive impairment. The resident required partial to substantial assistance with activities of daily living and mobility. A care plan, dated 9/5/24, indicated the resident was at risk for ineffective tissue perfusion related to congestive heart failure and pulmonary embolism. Interventions included, nursing staff were required to monitor vital signs (9/5/24) and obtain daily weights (9/9/24). The care plan lacked indication of resident non-compliance with daily weights. During an interview on 10/4/24 at 6:00 a.m., the DON indicated she would review the resident's daily weights. Evidence of missing daily weights was not provided. During an interview on 10/4/24 at 1:10 p.m., RN 6 indicated she was familiar with Resident 65 and he was not known to refuse any daily weights. Daily weights were obtained first thing in the morning by the CNAs and reported to the nurse on the unit so they could be recorded and reviewed by the nurse. Weights were documented in the Medication Administration Record (MAR) /Treatment Administration Record (TAR). She was not aware of any other area in which daily weights were recorded. At times, CNAs did not obtain daily weights. The weights should have been obtained by the nurse if they were not obtained by the CNA, prior to the end of the shift when the daily weight task was due. During an interview on 10/7/24 at 10:56 a.m., RN 4 indicated daily weights triggered as a task to be completed by the nurse and were documented in the MAR/TAR. He was unaware of any other place in which daily weights were charted. At times, the CNAs did not obtain the daily weights. When daily weights were not completed on his shift, the information was passed on in report to the next shift to obtain the daily weights. During review of the resident's MAR/TAR for September 2024, he indicated several days lacked daily weights. The daily weights should have been completed according to the physician order. During an interview on 10/7/24 at 3:37 p.m., the DON indicated daily weights should have been obtained according to the Physician's order unless the resident refused. Daily weights were typically monitored by the Medical Records staff member, but this position was vacant until recently. The Unit Managers were also responsible for monitoring that daily weights were obtained. The facility's process for monitoring the completion of daily weights was ineffective. A current facility policy, last revised 9/2024, titled Resident Weight Monitoring, provided by the DON on 10/7/24 at 3:33 p.m., indicated the following: POLICY . It is the policy of this facility to weigh residents no less than monthly or per physician orders 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was free from involuntary transfers without identified necessity for 1 of 1 resident reviewed for involuntary transfers (Resident C). This deficient practice resulted in emotional distress to the resident requiring an extra dose of psychoactive medication, the resident experiencing a stressful life change, the resident being moved to a facility not of the family's choosing, and the resident now residing in a facility a greater distance for the family to drive to for visit. Findings include: The current CMS 672 Census and Condition Detail report, provided by the RN Consultant on [DATE] at 2:00 p.m., indicated the following regarding mental status for the current resident population: 34 of the current 67 residents had depression, 25 of the current 67 residents had a psychiatric diagnoses, 42 of the current 67 residents had a diagnoses of dementia or a related disorder. During an interview on [DATE] at 12:27 p.m., Resident C's family indicated the following: The facility discharged the resident and it was not the family's request. The facility did not provide the paper work or opportunity for a 30-day notice of involuntary transfer. They were not told they could appeal or object to the transfer. On or around [DATE], the facility called and said they were going to have to transfer their loved one, as they could not met his needs. The family and facility had 30 days to work all this out. On [DATE], the facility called and said they were transferring Resident C tomorrow. The family was not given a choice, it felt like it was a done deal. The family member told the facility she wanted to inform the resident about the transfer. The Administrator told the resident before the family arrived at the facility and led the resident to believe the move was the family's idea, which upset him even more. After the facility informed the resident , he was very upset and couldn't be calmed. The resident indicated he couldn't calm down and needed medication. An as needed psychoactive medication had to be ordered and given to try to calm him down. He did not deal well with change, and it could make his condition worse. The family had chosen University Nursing Center because it had a good reputation, good star scores, the family had a history with the facility, it was close enough for regular visits. The family did not choose the facility Resident C was transferred to, it was only a three (3) star facility. The new facility was in a different town and further away, making it difficult to visit. Since the transfer, the resident was doing okay and was in the process of adjusting. He was not a danger to himself or others at the new facility. Review of a map search, retrieved from www.maps.google.com, indicated the new facility was 22 miles and approximately 34 minutes' drive from University Nursing Center. During an interview on [DATE] at 2:21 p.m., the psychiatric Nurse Practitioner (NP), who offered in house counseling and psychiatric services to Resident C, indicated the following: She believed the regional or corporate office of the nursing home had been concerned about the resident's mental health needs and had requested more frequent rounding visits. The NP and psychiatric Doctor had both visited regularly. The resident had not been deemed a danger to himself or others at any time following his [DATE] discharge from a mental health facility. He had been doing well during her last visit, and was out of his room and playing Yahtzee with two ladies. He indicated he knew he needed to get out of his room and socialize more for his mental health and well-being and had a positive outlook. According to the doctor's notes, the resident was calm and in a good disposition. She had been told the family was requesting the transfer. The resident had experienced atrial fibrillation (A-Fib) recently and was showing manic symptoms during the event. Research has shown A-Fib can impact bipolar and manic episodes, and she was concerned if that could be the case and sent the resident to the emergency room (ER). As often happened, the resident was out of A-Fib when he arrived to the ER. She would have liked to explore that issue further. The transfer out had been very quick, and she had not been aware it was happening. The resident was regimented and negatively impacted by change, which could potentially cause an increase in manic episodes. Resident C's clinical record was reviewed on [DATE] at 11:10 a.m. The resident was admitted to the facility on [DATE] and discharged from the facility on [DATE]. The resident's admission and discharge diagnoses included dementia, paranoid schizophrenia, major depressive disorder, bipolar disorder, and anxiety disorder. No additional mental health-related diagnoses were received or added during the residents stay in the facility. An [DATE], Preadmission Screening and Resident Review-Level 1 form, completed as part of the admission process, indicated he had a history of suicide attempts or gestures greater than five years prior to the assessment and a history of hallucinations or delusions currently or within the past 30 days. Diagnoses included dementia, schizophrenia, depression, anxiety, and diabetes. He was no longer appropriate to stay in a group home setting and was admitted to the skilled nursing facility for long term placement. The resident's admission orders, dated [DATE], indicated diagnoses of paranoid schizophrenia, bipolar disorder, dementia, and anxiety. The resident received six (6) psychoactive medications for the treatment of paranoid schizophrenia as follows: benztropine( improve the movement side effects caused by antipsychotic drugs), buspirone (an anti-anxiety medication), clonazepam (medication used for panic disorders and anxiety), Risperdal Consta (an injected antipsychotic medication), risperidone (an antipsychotic medication), and sertraline (an antidepressant medication). A [DATE], quarterly, Minimum Data Set (MDS) assessment indicated the resident understood others and was understood by others, was cognitively intact, and displayed no hallucination, delusions or maladaptive behaviors during the assessment period. An [DATE], discharge with return anticipated, MDS assessment did not contain a cognitive assessment and indicated the resident was delusional. He was not rejecting care nor displaying maladaptive behaviors towards himself or others. The resident had the following current care plan problems/needs at the time of his discharge: Mood State: Risk for alteration in mood status: depression/depressive symptoms due to placement in nursing facility, loss of independence. This problem originated at the time of his admission on [DATE], and continued throughout the resident's stay at the facility. Mood State: Resident at risk for signs and symptoms of anxiety as evidenced by worried facial expression, repetitive movements, SOB (shortness of breath), nausea, sweating, tremors, irritability, insomnia, reports of anxiety, etc. Resident had a diagnosis of anxiety. This problem originated at the time of his admission on [DATE] and continued throughout the resident's stay at the facility. Mood State: Resident at risk for signs and symptoms of depression as evidenced by sad facial expression, withdrawal, decreased appetite, tearfulness, insomnia, verbalization of depression, etc. Resident had a diagnosis of major depressive disorder and received antidepressant medication. This problem originated at the time of his admission on [DATE], and continued throughout the resident's stay at the facility. Behavioral Symptoms: Resident exhibited hallucinations and delusions as evidenced by .law enforcement wants to kill him, cop was coming after him, he was locked in a truck and beat him, someone was going to kill him with a gun. Resident had diagnosis of paranoid schizophrenia and received antipsychotic medication. This problem originated on [DATE], and continued throughout the resident's stay at the facility. Resident had a suicide attempt on [DATE], when he was noted to place a trash bag over his head. He was sent for a behavioral health stay, with a return to the building on [DATE]. The physician at the health facility stated the resident was not a threat of self-harm or suicide attempts. This problem originated [DATE] and continued throughout the resident's stay at the facility. Resident had increased manic behaviors. He was sent for a behavioral health stay, with a return to the facility of [DATE]. The psychiatric Nurse Practitioner who rounded at the facility stated the resident was not a threat of self harm or suicide attempts. This problem originated [DATE], following a mental health stay to treat manic behaviors associated with bipolar disorder and continued throughout his stay at the facility. Approaches to this problem included the following: Invite resident to be social with others, involve in activities, and recommend resident to participate in group activities. Review of Progress Notes from [DATE] to [DATE], lacked any documentation that the resident was a danger to himself of others. A [DATE] at 10:09 a.m., Progress Note by the Social Services Director indicated they spoke with the resident's family and discussed the need for resident to transfer to another facility that was able to better meet the resident's needs. A [DATE] at 4:18 p.m., Progress Note by the Social Services Director indicated they referred the resident to a facility that could better meet the resident's needs. A [DATE] at 8:00 a.m., Progress Note made by the doctor from the psychiatric service provider indicated the resident had lost his roommate (who had died ). He seemed more relaxed. When asked, he reported that he was taking his medication and getting himself out of his room to get more involved in activities. His mood was stable and his speech continued to be pressured, but he was more able to change topics today. A [DATE] at 4:18 p.m., Progress Note indicated the resident was informed by staff that he would be transferred to a facility in a neighboring city, and then called his daughter and the resident stated he was told that there was another facility to better care for him due to resident diagnoses. The resident was on the phone with his daughter and staff heard the resident crying and he was highly upset with the information. He stated he wasn't going to lose his life and he was not moving. Staff encouraged the resident to calm down and that everything would be alright, to no avail. The resident remained upset and stated [Administrator's name] is going to pay . A [DATE] at 7:32 p.m., Progress Note indicated the resident's family member approached the nurse and stated that the resident was very anxious and agitated over being told that he would be transferring facilities on [DATE]. They asked if the resident could be given a medication to calm his anxiety and agitation, as he had experienced episodes of crying and verbalizing anger this afternoon. The family member had spent a few hours visiting to help calm the resident, but he was still agitated. The nurse received an order to administer his next dose of Seroquel [an antipsychotic medication] at this time and continue to monitor. A [DATE] at 8:30 p.m., Progress Note indicated the resident continued to have anxiety and to be agitated. He stated that he was going to see [Administrators name] in court and sue him! because the resident was being transferred to another facility tomorrow. No interventions were effective. A new order was received to give Seroquel 50 mg orally right now for increased anxiety and agitation. During an interview on [DATE] at 12:55 p.m., with the Administrator and DON, the facility indicated the resident was not a danger to himself or others at the time of his transfer from the facility. He had not been a danger to himself or others at any time since his readmission to the facility on [DATE], following an inpatient mental health stay. The resident had displayed an increase in manic behaviors such as talking quickly and standing too close. The facility was unable to identify how they could not meet the resident's needs, and felt the other facility could better meet the resident's needs due to their experience with mental illness and mental health needs. During an interview on [DATE] at 1:31 p.m., with the Social Services Director and DON, the facility indicated the facility believed the residents needs would be better met at the other facility that had more skills for dealing with major mental illnesses. The resident had the same mental health diagnoses he had upon admission, when they had indicated they could met the resident's needs. He had three recent inpatient psychiatric stays, and the facility believed moving the resident to a facility with more mental health experience would reduce the chances of additional inpatient mental health stays. The facility could not identify any needs the resident had that the facility was unable to meet. Review of a current, ,d+[DATE], facility policy titled Facility Initiated Discharge, provided by the RN Consultant on [DATE] at 2:09 p.m., indicated the following: .It is the policy of this facility that residents be permitted to continue to reside in the facility and will only be involuntarily transferred/discharged from the facility in the following circumstances: a. The transfer or discharge is necessary for the welfare of the resident's welfare and the resident's needs cannot be met in the facility .1. Documentation .b In cases when the resident's needs cannot be met (reason above), documentation must be made by the resident's attending Physician and include specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and services available at the receiving facility to meet the need(s) This Federal tag relates to complaint IN00418458. 3XXX,d+[DATE](a)(4)(A)