Every finding on record at Warsaw Meadows

Based on interview and record review, the facility failed to ensure a resident with orders for G-tube feedings (a method of delivering nutrition directly into the stomach using a Gastrostomy tube), post feed flushes, G-tube bag and tubing changes, and G-tube placement checks, were completed and documented by licensed nursing staff. Some QMAs (Qualified Nursing Aide) documented that they had administered G-tube feeding, post feed flushes, G-tube bag and tubing changes, and G-tube placement checks, which was outside of the QMAs' Scope of Practice, for 1 of 1 residents reviewed for G-tube feeding, (Resident B).Finding includes:Resident B's clinical record was reviewed on 7/21/26 at 1:07 P.M. The residents' diagnoses included but were not limited to dysphagia (difficulty or discomfort in swallowing food and liquids), gastrostomy, convulsions, and history of traumatic brain injury.The residents' Physician Orders included but were not limited to: NPO (Nothing by mouth), enteral feed (G-tube),Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 calories at 110ml per hour by G-tube for 12 hours a day. Turn the pump on at 5:00 P.M., and turn the pump off when the total of 1320 ml has infused. The start was 10/9/25 and the order was discontinued on 6/30/26.Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 calories at 83ml per hour by G-tube for 16 hours a day. Turn the pump on at 5:00 P.M., and turn the pump off when the total of 1328 ml has infused. The start date was 6/30/26 and the order was discontinued on 7/9/26.Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 calories at 83ml per hour by G-tube for 16 hours a day. Turn the pump on at 5:00 P.M. and turn the pump off when the total of 1328 ml has infused. The start date was 7/9/26 and was discontinued on 7/15/26.Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 cal at 83mLper hour by G-tube for 16 hours a day. Turn the pump on at 5:00 P.M. and turn the pump off when the total of 1328 ml has infused. The start date was 7/16/26 and was discontinued on 7/21/26.Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 cal at 83mL per hour by G-tube for 16 hours a day. Turn the pump on at 5:00 P.M. and turn the pump off when the total of 1328 ml has infused. To be completed by LPN or RN only. The start date was 7/21/26 and ongoing. After stopping the G-tube feed, flush with 60 ml of warm water to prevent clogging. Tube should be clear after flush and formula flushed out of tube one time a day for flush feeding tube after stopping feed. With a start date of 6/7/25 and ongoing.Check the G-tube placement by auscultating air passage and aspirating contents four times a day Document amount of residual, with a start date of 9/3/25 and discontinued on 7/21/26.Check tube placement by auscultating air passage and aspirating contents four times a day for G-tube, LPN or RN must complete this only, document amount of residual. Hold if residual is greater than 150cc. Notify provider. The start date was 7/21/26 and ongoing.Change G-tube bag and tubing every night. Date and initial directly on the tubing. The start date was 3/8/25 and ongoing.Resident B's EMAR (Electronic Medication Administration Record), indicated from 4/1/26 to 7/22/26 three QMAs documented that they had administered the following:Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 calories at 110ml per hour by G-tube for 12 hours a day. Turn the pump on at 5:00 P.M., and turn the pump off when the total of 1320 ml has infused. And Enteral Feed two times a day for nutritional support and NPO status related to dysphagia. Give Jevity 1.5 cal at 83mLper hour by G-tube for 16 hours a day. Turn the pump on at 5:00 P.M. and turn the pump off when the total of 1328 ml has infused.Documented as started by QMA 3 at 5:00 P.M., on 4/11/26, 4/12/26, 4/15/26, 4/25/26, 4/26/26 4/29/26, 5/19/26.Documented as started by QMA 4 at 5:00 P.M., on 6/10/26, 6/25/26.Documented as started by QMA 5 at 5:00 P.M., on 5/21/26, 5/23/26, 5/24/26, 5/28/26, 6/1/26, 6/8/26, 6/11/26, 6/15/26, 6/24/26.Documented as stopped by QMA 3 at 5:00 A.M., on 5/9/26, 5/21/26, 5/24/26, 5/25/26, 5/27/26, 6/2/26, 6/3/26, 6/4/26, 6/10/26, 6/14/26, 6/16/26,6/18/26, 6/23/26.Documented as stopped by QMA 4 at 9:00 A.M. on 7/9/26.Documented as stopped by QMA 5 at 9:00 A.M. on 7/4/26.After stopping the G-tube feed, flush with 60 ml of warm water to prevent clogging. Tube should be clear after flush and formula flushed out of tube one time a day for flush feeding tube after stopping feed.Documented as done by QMA 2 at 5:00 A.M., on 5/90/26, 5/21/26, 5/24/26, 5/25/26, 5/27/26, 6/2/26/6/3/26, 6/4/26, 6/10/26, 6/14/26, 6/16/26, 6/18/26, 6/23/26, 7/2/26.Documented as done by QMA 4 at 9:00 A.M. on 7/9/26.Documented as done by QMA 5 at 9:00 A.M. on 7/6/26, 7/7/26, 7/8/26.Check the G-tube placement by auscultating air passage and aspirating contents four times a day Document amount of residual.Documented as done by QMA 3 at 5:00 A.M., on 5/9/26,5/21/26, 5/2/26, 5/25/26, 5/27/26, 6/2/26,6/3/26, 6/4/26, 6/10/26, 6/14/26, 6/16/26, 6/18/26, 6/23/26.Documented as done by QMA 3 at 8:00 A.M., on 4/11/26, 4/12/26, 4/15/26, 4/25/26, 4/26/26, 4/29/26, 5/19/26.Documented as done by QMA 3 at 5:00 P.M., on 4/11/26, 4/12/26, 4/15/26, 4/25/26, 4/26/26, 4/29/26, 5/19/26.Documented as done by QMA 3 at 8:00 P.M., on 5/8/26, 5/20/26, 5/23/26, 5/24/26, 6/1/26, 6/2/26, 6/3/26, 6/13/26, 6/15/26, 6/17/26.Documented as done by QMA 4 at 8:00 A.M., on 5/28/26, 6/10/26, 6/12/26, 6/25/26.Documented as done by QMA 4 at 5:00 P.M., on 6/10/26, 6/23/26, 6/25/26.Documented as done by QMA 4 at 8:00 P.M., on 6/23/26, 6/29/26.Documented as done by QMA 5 at 8:00 A.M., on 5/21/26, 5/23/26, 5/24/26, 5/27/26, 5/29/26, 5/29/24, 6/11/26, 6/15/26, 6/24/26.Documented as done by QMA 5 at 5:00 P.M., on 5/21/26, 5/23/26, 5/24/26, 5/28/26, 6/1/26, 6/8/26, 6/11/26, 6/15/26, 6/24/26.Documented as done by QMA 5 at 8:00 P.M., on 5/21/26, 6/12/26.Change G-tube bag and tubing every night. Date and initial directly on the tubing.Documented as done by QMA 3 at 5:00 P.M., on 4/11/26, 4/12/26,4/15/26, 4/25/26, 4/26/26, 4/29/26, 5/19/26.Documented as done by QMA 4 at 5:00 P.M., on 6/10/26, 6/23/26, 6/25/26, 7/9/26.Documented as done by QMA 5 at 5:00 P.M., on 5/21/26, 5/23/26, 5/24/26, 5/28/26, 6/1/26, 6/8/26, 6/11/26, 6/15/26, 7/4/26.During an interview on 7/21/26 at 1:48 P.M., the Administrator indicated all nursing staff had been educated on 6/26/26, that starting and stopping G-tube feedings, flushing post feeding, checking for G-tube placement, and changing bag and tubing was out of the QMAs' scope of practice and they were not allowed to do or sign-off on those orders related to the G-tube feedings in residents' medication administration records (MAR). The Administrator indicated she was newer to the facility and had been at the facility approximately three months when she became aware of QMAs working outside of their scope of practice and had implemented an immediate change related to making sure staff discontinuing the activity (QMAs performing G tube related feedings, boluses and assessments) and educating nursing staff that QMAs were not allowed to administer G tube feedings. The Administrator indicated she and the Director of Nursing had only been in their positions at the facility for about three months and when they became aware that QMAs were working outside of their scope of practice, she and the Director of Nursing had immediately educated the staff.During an interview with QMA 4, on 7/21/26 at 2:30 P.M., she indicated she had been instructed by the facility nursing staff that QMAs were allowed to completed the following: administer the G-tube feedings, check for proper G-tube placement, stop completed G tube feeds, and flush the tubing after feeding administration. QMA 4 indicated she had gone to a nursing staff, with her concern that those responsibilities were beyond her scope of practice and she had been told that QMAs were to do G-tube feedings at this facility. QMA 4 indicated the new Administrator and DON had finally realized that QMAs were being instructed to work out of their scope of practice and, at that time, the leadership had changed the orders indicating only licensed nursing staff could administer tube feedings, flushes, placement checks, and tubing changes. QMA 4 indicated every time she initialed the EMAR regarding G-tube feeding and all associated tasks, she had, in fact, provided those services and those signatures were not documentation errors but signatures denoting when QMA 4 had actually administered and/or performed duties outside of her scope of practice. QMA 4 indicated QMA 3 and QMA 5 had also administered G-tube feedings for Resident B, as well as flushes and tubing changes.During an interview, on 7/22/26 at 2:14, with QMA 5, she indicated she had hung Gtube feedings up and initiated their administration at the facility until a couple of months ago. She indicated the nurse on duty had instructed her to complete the task and would not come down and administer the feedings or flushes for her. The nurse had informed QMA 6 that at this facility, QMAs were supposed to start and stop gtube feedings and flush the tubing after the feedings and to check for placement. During an interview on 7/22/26 at 2:23 P.M., with RN 9, she indicated she had been working at the facility for over a year with the current leadership and under the previous leadership. While under the previous leadership, the QMAs had been instructed to hang G-tube feedings. RN 9 indicated she was not aware of all of the rules and regulations so she had followed the instruction of the leadership at the time. RN 9 indicated when the current administrator and DON came to the facility, they had notified nursing staff on 6/29/26 that QMAs were not allowed to check G-tube placement, start feeds, or change tubing. RN 9 indicated she had always signed when she administered any medications or treatments and if the G-tube feedings and treatments were documented by QMAs, then they were to ones who had completed the task.During an interview with RN 6, on 7/22/26 at 2:33 P.M., she indicated that prior to 6/29/26, QMAs regularly started G-tube feedings at the facility. She indicated until the new administrator became aware of QMAs working beyond their scope of practice and then nursing staff had received a message, through their nursing message system on 6/29/26, that QMAs were not allowed to do G-tube feedings, listen for G-tube placement, stop G-tube feeds, or flush after the feeding was completed. RN 6 indicated the previous DON had told nursing staff that G-tube feeding was in the QMAs' scope of practice.Review of Indiana Administrative Code, Title 412 - INDIANA HEALTH FACILITIES COUNCIL, Article 2 - QUALIFIED MEDICATION AIDES,Rule 1 - General Provisions Section 1-9 - Scope of practice Universal Citation: 412 IN Admin Code 1-9, Authority: IC 16-28-1-7; IC 16-28-1-11, dated 6/25/25, and found on line at https://regulations.justia.com/states/indiana/title-412/article-2/rule-1/section-9/, indicated G-tube feedings, flushes, placement checks, and tube and bag changes were not included in the QMAs' scope of practice.A policy titled Enteral Tube Feeding via Syringe (Bolus), dated 2001, was provided by the Administrator on 7/21/26 at 3:13 P.M., indicating it was the current facility policy. The policy indicated, .Documentation The person performing [G-tube] procedure should record the following information in the resident's medical record:.The name and title of the indiviulal9s0 who performed the procedure.On 7/21/26 at 3:13 P.M., a policy regarding who was allowed to administer G-tube feeding and care was requested, but none was provided prior to the survey exit.This citation relates to Intake 3023414.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a).

Based on interviews and record review, the facility failed to implement their policy to report an allegation of verbal abuse in a timely manner for 1 of 3 residents reviewed for abuse, (Resident B). Finding includes:On 12/30/25 at 11:43 A.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, anxiety, depression, benign brain tumor, age-related debility, low back pain, cognitive communication deficit, orthostatic hypotension, insomnia, muscle weakness. Review of a facility reported incident, Incident Number 652, indicated on 12/10/25 at 2:01 P.M., staff reported that Certified Nursing Assistant (CNA) 4, was overheard using profanity to tell Resident B to shut up while in the hallway of the Memory Care Unit. On 12/10/25 an investigation was initiated, and CNA 4 was removed from the schedule pending an investigation. A follow-up dated 12/15/25 indicated Resident B did not recall the event and the staff member involved was interviewed and denied the allegation. The report indicated CNA 4 indicated she said the statement to CNA 3, not to the resident. During an interview on 12/30/25 at 12:50 P.M., CNA 3 indicated just before the lunch meal, on 12/6/25, she and CNA 4 took Resident B to use the restroom. CNA 3 indicated Resident B was talking a lot and actively standing and sitting, not understating she was supposed to use the toilet. CNA 3 indicated that CNA 4 became frustrated with the resident and told the resident to shut the f--- up. CNA 3 indicated she then sent CNA 4 out of the room to gather supplies and she did not return to assist the resident after that. CNA 3 indicated she reported the incident, on 12/6/25 to Employee 5, who was the Weekend Manager. CNA 3 indicated she was aware that she was supposed to report allegations of abuse to the Administrator, but she neglected to do so. CNA 3 indicated she had not reported the allegation of verbal abuse to her Unit Manager. CNA 3 indicated on 12/10/25, she reported the allegation of verbal abuse to Employee 2 and to the Director of Nursing.During an interview on 12/30/25 at 1:13 P.M., Employee 2 indicated on 12/10/25, CNA 3 told her of an incident of verbal abuse that had allegedly occurred on 12/6/25 between Resident B and CNA 4. Employee 2 indicated she immediately notified the Administrator of the allegation of abuse as reported to her from CNA 3. On 12/31/25 at 10:07 A.M., during an interview, CNA 4 indicated she had helped CNA 3 toilet Resident B on 12/6/25, but did not curse at the resident at any time, but on 12/10/25 was sent home pending an investigation. During an interview on 12/31/25 at 10:16 A.M., Employee 5, indicated she was Manager on Duty on 12/6/25 and was never notified of an allegation of abuse at that time. Employee 5 indicated on 12/10/25, during a conversation, CNA 3 indicated she thought maybe CNA 4 might have cussed in front of or at a resident over the weekend. Employee 5 indicated she asked CNA 3 if she had reported the allegation to the Director of Nursing or the Administrator and CNA 3 indicated she had not. On 12/31/25 at 11:33 A.M., an interview with the Administrator indicated an alleged incident of verbal abuse had occurred on 12/6/25 when CNA 4 allegedly cursed at Resident B. The Administrator indicated the allegation was not reported to him until 12/10/25 by Employee 2. The Administrator indicated he immediately suspended CNA 3 pending an investigation, reported the allegation to the State Survey Agency, and initiated an investigation. The Administrator indicated he repeatedly reminds staff of the importance of reporting allegations of abuse to him immediately, but CNA 3 never reported an allegation of abuse to him at any time. On 12/30/25 at 11:50 A.M., the Administrator provided the policy, ABUSE POLICY, dated 9/22, indicating it was the facility's current abuse policy. The policy indicated, .The resident has the right to be free from abuse,.The facility must not use verbal.Abuse.includes verbal abuse, an allegation of abuse.will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse.; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in bodily injury. This citation is related to Complaint 2691463.3.1-28(c)

Based on observation, record review and interview, the facility failed to prevent physical and emotional abuse for 2 of 3 residents reviewed for abuse prevention. (Residents C & D) This deficient practice resulted in 1 of 3 residents sustaining extensive bruising (Resident C) and 2 of 3 residents experiencing mental anguish and fear. (Residents C & D)Findings include:1.A record review for Resident B was completed on 9/29/2025 at 10: 46 A.M. Diagnoses included, but were not limited to: schizophrenia, alcohol abuse, epilepsy, drug induced dyskinesia, major depressive disorder and mood disorder.A Quarterly MDS assessment, dated 9/29/2025, indicted Resident B was cognitively intact, transferred independently, received antipsychotic, antidepressant and anticonvulsant medication, had exhibited behaviors of physical behavioral symptoms for 1-3 days during the assessment period and verbal behavioral symptoms for 1-3 days of the assessment look back period. The current care plans for Resident B, revised on 5/30/2025, included the following plan: Resident is at risk for exhibiting behaviors related to Schizophrenia with history of behaviors. Behaviors exhibited are anger/yelling/cursing. The interventions included, but were not limited to: offer one on one attention with staff (added 9/23/2025 after the altercation), re-direct resident with a snack or an activity and the interdisciplinary team was to review the behavior management program every quarter and as needed. The current care plans for Resident B included the following: had a history of striking out at staff andpeers, initiate on 3/23/2023. The interventions included: At first sighs of agitation please remove from situation and provide a safe place for me to express what's bothering me and to make my feelings known, please offer me a snack such as popcorn, chips, and some tea.Review of a Trauma Evaluation Note, completed on 9/20/2025 at 8:38 P.M., and documented as late entry on 9/23/2025 at 4:10 A.M., indicated the residents were lined up by the courtyard door for their next cigarette break and Resident C was upset because she had not received her medications. Resident B had approached Resident C, who had been standing against the wall. Resident B had placed his wheelchair in front of Recent C and stated, I'm sick of listening to your f---ing mouth. Resident B then began hitting Resident C's upper body and head with his closed fists.A Nursing Progress Note, on 9/20/2025 at 8:45 P.M. and documented as a late entry on 9/23/2025 at 4:01 A.M., indicated the nurse had been notified by staff who had witnessed Resident B approach Resident C, stop his wheelchair in front of her and state, I'm sick of listening to your f---ing mouth and then had hit Resident C with clenched fists in her upper body, face and head. Resident B was taken to his room for a full body assessment and the notes indicated he had sustained a scratch down his face. A Nursing Progress Note, completed on 9/21/2025 at 7:40 P.M., indicated two police officers had interviewed Resident B about yesterday's incident. The note indicated Resident B had not been truthful with the police officers, per staff witnesses. Immediately after the police officers left the facility, Resident B went by Resident D, who had been trying to get to her room. Resident B had screamed at Resident D and stated, You need to mind your own f---ing business. The interaction had been observed by staff, who intervened immediately and redirected Resident B to his room and Resident D to her room.A Trauma Evaluation Note, completed on 9/22/2025 at 9:50 A.M., indicated Resident B had told the writer that he and Resident C were with other residents waiting in the hall to go out to smoke. Resident B indicated that Resident C had been talking very loudly about all kinds of negative stuff. Resident B indicated he made a comment to Resident C and Resident C had commented back to him and then had hit him on his head.A Social Service Note, completed on 9/22/2025 at 9:50 A.M., indicated Resident B had come to the office The Social Service Director (SSD) indicated she had asked the resident what had happened to his head. Resident B indicated he had gotten into a fight with Resident C. Resident B insisted Resident C had initiated physical contact and he had defended himself. A Social Service Note, on 9/22/205 at 11:13 A.M., indicated the SSD had called Resident B's mother and had gotten permission to send Resident B to a psychiatric hospital and a referral had been sent to the acute care facility. A Nursing Progress Note, on 9/22/2025 at 9:30 P.M., indicated the psychiatric hospital ambulance had arrived and had transported Resident B to the psychiatric hospital.During an interview, on 9/29/2025 at 8:47 P.M., Confidential Employee 2 indicated Resident B sometimes had physical altercations if he did not get his way. Confidential Employee 2 indicated the approach made a difference in his behaviors and the more praises he received, the better his attitude. Confidential Employee 2 indicated they were not at the facility on the evening of Resident B and Resident C's altercation. They indicated Resident B sometimes had a good night and sometimes had a bad night. Employee 2 indicated Resident C sometimes could flip the switch quickly and just be hateful.During an interview, on 9/29/2025 at 9:06 P.M., Confidential Employee 3 indicated on the night of the altercation between Resident B and Resident C, Resident C had been talking to herself about not receiving her medications timely. Resident B had told Resident C to shut up as Confidential Employee 3 had been returning a resident to the locked memory care unit. Confidential Employee 3 indicated Resident B had had an incident the prior week with another resident and the employee had been concerned since Resident B had a history of getting angry so quickly. Confidential Employee 3 indicated she had closed the door to the locked memory care unit and had witnessed Resident B lunge at Resident C. Employee 3 indicated she had viewed the altercation through the glass windows of the memory care unit. She indicated she had witnessed Resident B banging on Resident C violently. Resident C was smacking at Resident B's hands , trying to get Resident B off of her. Confidential Employee 3 indicated Resident B was windmill punching (a punch delivered with a wild, circular swing of the arm, often lacking control and accuracy) Resident C. Confidential Employee 3 indicated staff had called the executive director immediately after the altercation and had been instructed to take resident B to his room and not to take him out to smoke until a later time. During an interview, on 9/29/2025 at 10:26 P.M., Confidential Employee 4 indicated monitoring was increased on 9/20/2025 for Resident B, but one to one supervision had not been implemented. Employee 4 indicated one-to-one supervision was implemented after Resident B had yelled at and lunged at Resident D, on 9/21/2025.During an interview, on 9/30/2025 at 11:21 A.M., the Director of Nursing indicated she was not aware of the altercation between Resident B and C until 9/22/2025 when she arrived at the facility. She indicated she was not aware of any interventions implemented for Resident B after the altercation on 9/20/2025. She indicated she was not aware of any documentation completed for one-on-one supervision and that heightened supervision had happened after the altercation with Resident B and C. She indicated one on one supervision had been put into place after Resident B's altercation with resident D.During an interview, on 9/30/2025 at 11:35 A.M., the Executive Director indicated he was informed of the altercation between Resident B and C shortly after the altercation happened. He indicated he had spoken with Resident B on the phone and had tried to calm him down. He indicated Resident B indicated Resident C would not stop talking and so he had hit Resident C. The Executive Director indicated the facility had forms to document one on one supervision, however, the completed one to one supervision documentation forms for Resident B could not be produced. 2. A record review for Resident C was completed on 9/29/2025 at 12:54 P.M. Diagnoses included, but were not limited to: PTSD (post traumatic stress disorder), vascular dementia, schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder and pseudobulbar affect.A Quarterly MDS assessment, dated 6/26/2025, indicated Resident C was cognitively intact, had no impairment with range of motion, walked independently, received medications of an antipsychotic, antianxiety, antidepressant, opioid and anticonvulsant and had delusions and no mood issues. A Nursing Progress Note, on 9/20/2025 at 7:45 P.M., indicated Resident C reported that Resident B had wheeled up to her as she was standing by the courtyard door and started hitting her. Resident C had multiple bruises documented which included the following:-Right forearm 11cm x 6.5cm-Inner right elbow 2.5cm x 2cm,-Under left breast 3cm x 2.5cm, 1.5cm x 1.5cm and 2cm x 1.5-Left palm 7cm x 6.5cm-Left wrist 1.5cm x 1cm-Left fourth digit finger 5cm x 1.5cm-Palmar side of left second digit finger 1cm x 1cm-Back of third digit left finger 5cm x 1.5cm-Left upper shoulder 6.5cm x 6.5cm-Outer left shoulder 8cm x 8cm. The facility executive director was notified of the incident.A Trauma Evaluation form, dated 9/20/2025 at 8:40 P.M. and documented as late entry on 9/23/2025, indicated, Resident C had been standing in line for her smoke break by the courtyard door and had verbalized that she was upset because she had not received her medications. Resident B had approached Resident C, stopped his wheelchair in front of Resident C and stated, I'm sick of listening to your f---ing mouth. Resident B then began hitting Resident C with clenched fists to her upper body, face and head.A Nursing Progress Note, on 9/20/2025 at 8:45 P.M. and documented as a late entry on 9/23/2025, indicated the nurse had been notified by the staff member who had witnessed Resident C in line by the courtyard door. Resident C had been verbalizing she had been upset because she had not received her medications. Resident B had approached Resident C with his wheelchair , stopped in front of her and stated, I'm sick of listening to your f---ing mouth and had begun hitting her with clenched fists in her upper body, face and head. Resident C had been taken to her room. A full body assessment had been completed that showed Resident C had bright purple bruises on the left side of her head, the bottom of her left jawline, her right forearm, her inner right elbow, under her left breast, on her left palm, on her left wrist, on her left 2nd, 3rd and 4th fingers, on her upper left shoulder and on her outer left shoulder. The nurse had remained with Resident C until she was calm. Resident C indicated, He kept hitting me, I don't know why. I swear, I never hit him or scratched him on purpose, I was trying to get him away from me. The note indicated Resident B and C were kept away from each other with increased staff supervision and support.A Trauma Evaluation form, completed on 9/22/2025 at 3:05 P.M., indicated Resident B and Resident C had been in an alleged verbal altercation that turned into a physical altercation. Resident C had received a few bruises and scratched Resident B's face, neck and head. A Social Service Note, on 9/23/2025 at 3:35 P.M. and documented as a late entry, indicated the following: Writer asked resident how she was doing she said that she's a little sore, but she'd be all rightA Social Service Note, on 9/23/2025 at 3:36 P.M. and documented as a late entry, indicated, Resident C was still very upset by the incident. She was overheard talking to a staff member about the incident and blaming the other resident for things that he did not do, or was not responsible for. The note did not elaborate about what things Resident B was accusing Resident B of doing.A Social Service Note, on 9/24/2025 at 2:38 P.M., and documented as a late entry, indicated when Resident C was asked how she was doing, she promptly showed the writer her bruises. Resident C indicated that it looked worse then [than] it felt.A Care Plan, initiated on 12/16/2019 and revised on 4/3/2025, indicated Resident C was at risk for emotional/physical distress related to a history of physical/mental abuse. Interventions included, but were not limited to: allow to express concerns, fears, feelings and expectations, ensure safety, establish trust and to collaborate care with medical providers and psychological services.Care Plan, initiated on 8/7/2025, indicated Resident C was at risk for being injured by her peers and would remain free from injury. Interventions included, but were not limited to: will approach staff for assistance, will continue to receive psychiatric services to help with mental/emotional issues and will learn to identify potentially dangerous situations and leave them before they escalate.During an interview and observation, on 9/29/2025 at 1:21 P.M., Resident C indicated resident B had tried to choke me out. Resident C indicated she had had this type of abuse before from her ex-husband and the incident with Resident B had scared her to death. She indicated her fingers had been swollen and bruised from the incident. Resident C's right forearm, left shoulder and left outer shoulder had deep red, blue and purple colored bruises. Resident C was observed to have darkened areas on her left cheekbone and neck that were covered with make-up. She indicated she was tired of the other residents asking her what had happened, so she had covered up the areas (with makeup).During an interview, on 9/29/2025 at 9:06 P.M., Confidential Employee 3 indicated Resident C had PTSD (post-traumatic stress disorder) due to have been in an abusive situation where this same type of abuse had occurred. The staff member indicated Resident C had cried for most of the night (on 9/20/2025) and this attack had triggered her PTSD issues. Confidential Employee 3 indicated Resident C had been shaking, jumped every time her room door opened and even yelped when staff had knocked on the door. Employee 3 indicated Resident C was scared.During an interview, on 9/29/2025 at 10:26 P.M., Confidential Employee 4 indicated she had not witnessed the attack between Resident B and C. Employee 4 indicated the residents had already been separated when she had arrived. She indicated Resident C stated that Resident B had came up to her and stated, I'm so sick of listening to your f--king mouth, put his head down and started wailing on her. Confidential Employee 4 had completed the nursing assessment for Resident C's bruising. The employee indicated Resident C was crying, shaking and had clearly been traumatized.3. During an observation, on 9/29/2025 at 9:51 P.M., Resident D was observed at the end of the back hallway seated in her wheelchair, looking out the glass door. A record review for Resident D was completed on 9/29/2025 at 10:22 A.M. Diagnoses included, but were not limited to: hemiplegia nondominant side, dysphagia and a history of transient ischemic attack.A Quarterly MDS assessment, dated 9/29/2025, indicated Resident D was cognitively intact and had no behaviors. A Progress Note, on 9/21/2025 at 9:36 P.M., indicated while administering medications Resident began crying and indicated, I don't trust anyone anymore, I'm never coming back to a nursing home. I have my grabber under my pillow, if he comes near me. I'm going to hit him in the head to get him away from me. Resident D was given a hug and assured staff would be outside her door all night.During an interview, on 9/29/2025 at 9:06 P.M., Confidential Employee 3 indicated when the police officers were at the facility for the incident between Residents B and C, Resident D had come down the hallway and asked what was going on. Resident B told Resident D to stay out of his business and the police officers had informed Resident B to keep his anger in check and not to hit anyone else. Resident D indicated to Confidential Employee 3, on 9/21/2025, that Resident B had been following her and at that time Resident B came around the corner of the hallway and stated to Resident D to mind your own business, you bitch and had lunged at Resident D. Confidential Employee 3 indicated Resident D had slept with her grabber stick under her pillow to protect herself if Resident B came into her room.During an interview, on 9/29/2025 at 10:26 P.M., Confidential Employee 4 indicated after the police left on 9/21/2025, Resident D had been attempting to get to her room and Resident B had lunged at her. in a threatening manner Confidential Employee 4 indicated she had not witnessed this action, but Resident D was scared when she went to give Resident D her medication. Confidential Employee 4 indicated Resident D had her grabber stick under pillow and indicated the grabber being under the pillow gave her security.During an interview, on 9/30/2025 at 11:21 A.M., the Director of Nursing indicated she was only informed of a verbal altercation between Resident B and D. She was not informed of Resident B lunging at Resident D and staff intervention to prevent contact. She indicated one on one supervision was put into place for Resident B after the altercation with Resident D.During an interview, on 9/30/2025 at 11:35 A.M., the Executive Director indicated there was only a verbal interaction from Resident B to Resident D. He indicated nothing else had happened. Although Resident B had a known history of angry outburst and physical and verbal altercations and had care plan to address behaviors with interventions to relocate the resident to a quiet, safe place and offer him a snack at the first signs of agitation, staff did not follow the planned interventions which resulted in Resident B physically assaulting Resident C, causing her physical bruising and emotional trauma. In addition, staff did not implement preventative one to one supervision for Resident B to prevent further abuse which resulted in verbal abuse and threatening physical behaviors toward Resident D which resulted in emotional distress and fear.A policy was provided by the Executive Director, on 9/29/205 at 10:20 A.M. The policy titled, Abuse Policy, indicated, .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.Abuse is defined as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Prevention-Provide staff, residents, and family members information on how to and whom to report concerns, incidents, and grievances without fear of retribution, and provide feedback regarding the concerns; identify, intervene, and correct situations of alleged, suspected, or substantial abuse; supervision of staff, monitoring of resident's with needs and behaviors, communication deficits, and/or those totally dependent on staff.This deficient practice relates to Intake 2625615.3.1-27(a)3.1-27(b)

Based on observation, interview and record review, the facility failed to store and serve food in a sanitary manner, related to undated foods, expired foods and thumbing of the plates for 1 of 1 kitchen and 2 of 2 nutritional pantries. This deficient practice had the potential to affect 63 of 63 residents who receive meals from the kitchen. Findings include: 1. During the initial tour of the kitchen, on 9/2/2025 at 9:48 A.M., with the Dietary Manager the following was observed: - in the stand up freezer 2 bags of frozen pancakes with no use by date During an interview, on 9/2/2025 at 9:53 A.M., the Dietary Manager Indicated there should have been a use by date on the pancakes. 2. During a follow up tour of the kitchen, on 9/03/2025 at 10:27 A.M., [NAME] 13 placed an opened container of pureed chicon on the counter top and placed a bucket of sanitizing liquid right next to the open container of chicken. During an interview, on 9/4/2025 at 11:20 A.M., the Dietary Manager indicated food items should not be near the sanitizing water bucket. 3. During an observation, on 9/04/2025 at 11:32 A.M., [NAME] 14 was observed placing her thumb on the eating surface of the plates as she plated food. During an interview, on 9/4/2025 at 11:34 A.M., [NAME] 14 indicted she should not have placed her thumb on the food surfaces of the plates.4. During observations, on 9/8/2025 at 11:16 A.M, of the heritage and freedom hall pantries with QMA 16 the following was observed:expired cranberry juice with a use by date of 9/7/2025, 5 peanut butter bars that had expired on 9/5/2025. -a container of med pass that had expired on 9/7/2025.During an interview, on 9/8/2025 at 11:18 A.M., QMA 16 indicated the expired items should have been removed from the pantries. On 9/8/2025 at 2:14 P.M., the Administrator provided the policy titled, Food Storage, dated 3/26/2020, and indicated the policy was the one currently used by the facility. The policy indicated . Food storage areas shall be maintained in a clean, safe and sanitary manner 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to follow a physician's order for a hypotensive medication, failed to administer bowel protocols for constipation, failed to follow physician's orders for insulin administration and failed to assess and document a skin issue for 4 of 18 residents reviewed for care needs. (Residents 5, 3, 7 & 18)Findings include:1.A record review for Resident 5 was completed, on 9/3/2025 at 2:01 P.M. Diagnoses included, but were not limited to: atrial fibrillation, hypotension and coronary artery disease. An Annual Minimum Data Set (MDS) assessment, dated 7/2/2025, indicated Resident 5 was cognitively intact. A Physician's Order, dated 4/3/2025, indicated the resident was to receive Midodrine 10 milligrams by mouth three times a day for hypotension. In addition there was an order to hold the Midodrine for a systolic blood pressure greater than 110 mmHg (millimeters of mercury). The August 2025 Medication Administration Record indicated the following blood pressure readings with the administration of Midodrine: -8/1/2025 8:00 P.M. 127/63 mmHg -8/3/2025 8:00 P.M. 119/64 mmHg -8/4/2025 8:00 P.M. 123/68 mmHg -8/5/2025 8:00 P.M. 118/68 mmHg -8/6/2025 8:00 P.M. 124/64 mmHg -8/8/2025 8:00 A.M. 126/76 mmHg -8/9/2025 8:00 P.M. 122/71 mmHg -8/10/2025 8:00 A.M. 131/65 mmHg -8/12/2025 8:00 P.M. 119/59 mmHg -8/16/2025 8:00 P.M. 119/60 mmHg -8/18/2025 8:00 P.M. 123/73 mmHg -8/19/2025 8:00 P.M. 123/68 mmHg -8/20/2025 4:00 P.M. 122/78 mmHg -8/22/2025 8:00 P.M. 123/78 mmHg -8/25/2025 8:00 P.M. 130/76 mmHg -8/29/2025 8:00 P.M. 122/69 mmHg The July 2025 Medication Administration Record indicated the following blood pressure readings with administration of Midodrine: -7/3/2025 8:00 P.M. 130/70 mmHg -7/5/2025 8:00 P.M. 126/56 mmHg -7/6/2025 8:00 P.M. 120/68 mmHg -7/10/2025 8:00 P.M. 118/65 mmHg -7/19/2025 8:00 P.M. 123/68 mmHg -7/20/2025 8:00 P.M. 122/73 mmHg -7/21/2025 8:00 P.M. 122/68 mmHg -7/25/2025 8:00 P.M. 128/76 mmHg The July 2025 Medication Administration Record indicated the following blood pressure readings with administration of Midodrine: -6/1/2025 8:00 P.M. 116/73 mmHg -6/2/2025 8:00 P.M. 123/67 mmHg -6/7/2025 8:00 P.M. 117/68 mmHg -6/8/2025 8:00 P.M. 135/78 mmHg -6/9/2025 8:00 P.M. 115/60 mmHg -6/11/2025 1:00 P.M. 122/70 mmHg -6/11/2025 8:00 P.M. 131/74 mmHg -6/14/2025 8:00 P.M. 117/65 mmHg -6/15/2025 8:00 P.M. 123/69 mmHg -6/17/2025 8:00 P.M. 122/70 mmHg -6/19/2025 8:00 P.M. 122/63 mmHg -6/25/2025 8:00 P.M. 123/73 mmHg A Care Plan, initiated on 2/21/2025, indicated Resident 5 had altered cardiovascular status related to congestive heart failure, hypotension, coronary artery disease, atrial fibrillation and hyperlipidemia. Interventions included, but were not limited to: administer medications as prescribed for hypotension and notify the physician of any abnormal readings. During an interview, on 9/8/2025 at 10:04 A.M., RN 6 indicated Resident 5 should not have received the Midodrine medication if his systolic blood pressure was greater than 110 mmHg. 2. A record review for Resident 3 was completed, on 9/4/2025 at 9:14 A.M. Diagnoses included, but were not limited to: neuroleptic induced Parkinsonism, schizoaffective disorder, bipolar disorder and impulse control. A Significant Change MDS assessment, dated 8/8/2025, indicated Resident 3 was cognitively intact and was always continent of their bowel movements. A Point of Care Legend Report, dated July 16-25, 2025, of Resident 3's bowel movements indicated the resident had a medium bowel movement on 8/16/2025 at 5:49 A.M. There were no further bowel movements recorded, except for a small bowel movement, on 7/22/2025 at 1:48 A.M. and 7/24/2025 at 3:26 A.M., which were recorded as hard/constipated. A Nursing Progress Note, on 7/21/2025 at 1:45 A.M., indicated Resident 3 had had a change in condition with decreased alertness and occasional coffee ground enemies. An order was obtained for a KUB (kidney, ureter, bladder) x-ray, laboratory tests of a complete blood count and a basic metabolic panel, urinalysis and intravenous fluids. A KUB x-ray, completed on 7/21/2025 at 2:59 A.M., indicated there was abundant fecal material seen within the large bowel loops and a DDX (differential diagnosis) included constipation in the appropriate clinical setting. A Nursing Progress Note, on 7/21/2025 at 8:13 P.M., indicated Resident 3 had complained of abdominal pain. The abdomen was soft and non-distended, but Resident 3 complained of pain when pressure was applied to the abdomen. A new order was obtained from the nurse practitioner for suppositories related to constipation. The July 2025 Medication Administration Record indicated the following medications had been administered from 7/16-7/25/2025: -Routine medications of Polyethylene Glycol Powder 17 grams daily for constipation and Senna Plus 8.6-50 milligrams one tablet daily for constipation. -Dulcolax rectal suppository one suppository daily as needed for constipation on 7/21/2025 at 8:24 P.M. and 7/23/2025 at 11:49 P.M. -Milk of Magnesia suspension 30 milliliters, on 7/22/2025 at 2:06 P.M. -Fleets Enema one applicatorful on 7/22/2025 at 4:12 P.M.A Nursing Progress Note, on 7/22/2025 at 9:08 A.M., indicated Resident 3 had refused the new order for an enema. A Nursing Progress Note, on 7/22/2025 at 1:59 P.M., indicated Resident 3 had been trying to have a bowel movement and appeared to experience a vasovagal episode (a fainting episode caused by a sudden decrease in blood pressure and pulse) and was lowered to the floor. Resident 3 was assisted back to the toilet and was asked by the nurse to all them to administer an enema to help pass the stool. However, Resident 3 had refused. A new order for Milk of Magnesium was obtained. A Nursing Progress Note, on 7/22/205 at 2:05 P.M., indicated Resident 3 continued to refuse an enema after he was educated and he also refused to go to the hospital for an evaluation. A Care Plan, initiated on 7/22/2025, indicated Resident 3 had constipation related to decreased mobility. The goal was for Resident 3 to have a normal bowel movement every three days. Interventions included, but were not limited to: record bowel movement pattern each day, describe amount, color and consistency and to encourage Resident 3 to sit on the toilet to evacuate bowels if possible. During an interview, on 9/8/2025 at 11:28 A.M., RN 6 indicated the facility had a bowel movement protocol. She indicated if a resident did not have a bowel movement in three days an intervention of MiraLAX, prune juice, senna or docusate sodium would be administered. She indicated the nursing staff were provided with a no bowel movement list when a resident had not had a bowel movement documented for three days in a row. She indicated small bowel movements did not count for a documented bowel movement. 3. A record review was completed for Resident 7 on 9/3/2025 at 2:55 P.M. Diagnoses included, but were not limited to: type 2 diabetes mellitus. A Physician's Order, dated 6/17/2025 indicated Resident 7 was to receive Lantus Subcutaneous Solution 100 UNIT/ML (milliliter) 38 units subcutaneously two times a day. Additional instructions indicated to hold the insulin if residents blood glucoses levels were less than 100 mg/dL and to call the Nurse Practitioner (NP) if the resident's blood glucose levels were above 450 mg/dL. A review of Resident 7's blood glucose levels indicated the resident had received Lantus 38 units subcutaneously when blood glucose levels were outside parameters on the following dates: -On 6/22/2025, Resident 7's blood glucose level was 97 mg/dL. -On 6/26/2025, Resident 7's blood glucose level was 97 mg/dL. -On 6/27/2025, Resident 7's blood glucose level was 91 mg/dL. -On 6/28/2025, Resident 7's blood glucose level was 99 mg/dL. -On 7/4/2025, Resident 7's blood glucose level was 97 mg/dL. -On 7/20/2025, Resident 7's blood glucose level was 90 mg/dL. -On 7/30/2025, Resident 7's blood glucose level was 87 mg/dL.During an interview, on 9/8/2025 at 10:13 A.M., the DON indicated the resident's insulin should have been held on the days her blood glucose level was less than 100 mg/dL 4. During an interview, on 9/4/2025 at 1:55 P.M., CNA 8 indicated about two months ago, when she had arrived to work, CNA 17, the night shift aide had reported that Resident 18 had been up between 2 - 3:00 A.M. and she had had to redirect him back to his room. She indicated the night shift nurse had then shown CNA 8 a picture of Resident 18 with scratches all over his face. The night nurse indicated she had seen the resident and the night aide fighting with each other. During an interview with the Director of Nursing, on 9/5/2025 at 1:39 P.M. and the Administrator, on 9/5/2025 AT 11:14 A.M, they both indicated there had been no further investigation into the incident and no documentation regarding the injuries in the clinical record. During an interview, on 9/5/2025 at 10:59 A.M., the NP indicated she had been informed of the incident on 6/16/2025. She indicated she only knew there had been an altercation between the resident and another staff member. She indicated she had asked for documentation regarding the incident but was informed there was no documentation. She indicated although she had viewed the photograph and saw the scratches, she had not assessed the resident nor had she documented the injuries because the resident was not her resident. The record for Resident 18 was reviewed on 9/08/2025 at 11:02 A.M. Diagnoses included: hypertension, diabetes, hip fracture, Alzheimer's disease, non- Alzheimer's dementia, and depression. A Quarterly MDS (Minimum Data Set) assessment, dated 8/22/2025, indicated Resident 18 was able to make his needs known and had no behaviors, used a wheelchair for mobility, was independent sitting up on the side of the bed, wheeling in his wheelchair and required set up assistance for chair to bed and bed to chair transfers. Physician's Orders, dated 4/7/2025, indicated the facility was to complete a weekly skin review every Monday for Resident 18. A Weekly Skin Assessment, dated 6/16/2025, indicated Resident 18's skin was intact with no skin issues. The clinical record lacked documentation to show the attending physician had been notified of the skin issues; lacked the documentation to show a treatment had been obtained for the scratched areas on the resident's face and lacked documentation to show the skin issue had been monitored until it had healed. During an interview, on 9/8/2025 at 10:19 A.M., the Director of Nursing indicated the physician should have been notified and the area should have been monitored. A current policy was provided, on 9/8/2025 at 1:01 P.M., by the Director of Nursing (DON). The policy titled, Medication and Treatment Orders, indicated, .Orders for medications and treatments will be consistent with principles of safe and effective order writing. A current policy was provided, on 9/8/2025 at 1:01 P.M., by the Director of Nursing (DON). The policy titled, Bowel Protocol, indicated, .To provide effective interventions for signs and symptoms of constipation.Protocol.1. Nursing staff document the resident's bowel movements every shift. 2. The evening shift nurse assesses the bowel movement data daily and responds according to the protocol and/or physician orders. 3. If no bowel movement is recorded for three days, do the following on day four: assess for signs and symptoms of constipation, if the resident is alert and oriented, ask about unrecorded bowel movements and assess for constipation, if acute abdominal symptoms are present, contact the physician immediately. 4. If no bowel movement is recorded for four days, so the following on day five: administer routine or prn laxative, if acute abdominal symptoms are present, contact the physician immediately. On 9/8/2025 at 2:13 P.M., the Director of Nursing provided the policy titled, Change in a Resident's Condition or Status, dated 2/2021, and indicated the policy was the one used by the facility. The policy indicated . Our facility promptly notifies the resident, his or her attending physician. of changes in the resident's medical/mental condition and/or status.1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) a. accident or incident involving the resident. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition/status. 3.1-37

Based on interview, record review and interview, the facility failed to ensure residents were invited to care plan meetings and meetings were held timely for 5 of 21 residents reviewed for care plans. (Residents 15, 21, 17, 4 & 30)Findings include: 1.During an interview, on 9/2/2025 at 10:54 A.M., Resident 15 indicated she had never been to one (care plan meeting). The record for Resident 15 was reviewed on 9/4/2025 at 9:48 A.M. Diagnoses included, but were not limited to bipolar, Schizophrenia, anxiety, PTSD, (post traumatic stress disorder), cancer, insomnia and delusions. A Quarterly MDS (Minimum Data Set) assessment, dated 9/4/2025, indicated Resident 15 had clear speech, make herself understood and understood others. A Multidisciplinary Care Conference Note, dated 5/22/2025, indicated a care conference was held on 5/23/2025 at 9:00 A.M. Attendance at the meeting was documented as an LPN, a QMA and the resident's guardian via phone. The form lacked the documentation indicating the resident had been invited or was in attendance for the care meeting. A Multidisciplinary Care Conference Note, dated 6/14/2025, indicated a care conference was held on 6/17//2025 at 2:00 P.M. Attendance at the meeting was documented as a QMA and the dietary manager. The form lacked the documentation of the resident having been invited or having been in attendance for the care meeting. The Nursing Progress Notes dated 5/23/2025 and 6/17/2025 lacked the documentation to show the resident had been invited or had attended the care plan meetings. During an interview, on 9/8/2025 at 10:14 A.M., the MDS (Minimum Data Set) nurse indicated the SSD (Social Service Director) was responsible for completing the care plan documentation and completing the invitations for the locked unit. During an interview, on 9/8/2025 at 10:14 A.M., the Director of Nursing indicated the resident should have been invited to her care plan meetings. 2. During an interview on, 9/2/2025 at 2:59 P.M. Resident 21 indicated she couldn't remember any meetings. The record for Resident 21 was reviewed on 9/5/2025. Diagnoses included, but were not limited to renal disease, Non Alzheimer's dementia, depression and hypertension. A Quarterly MDS(Minimum Data Set) assessment, dated 7/16/2025,indicated Resident 21 had clear speech, make herself understood and understood others. A Multidisciplinary Care Conference Note, dated 9/24/2024, indicated a care conference was held on 9/25/2024 at 12:00 P.M. Attendance at the meeting was documented as only an LPN. The form lacked the documentation indicating the resident had been invited or had attended the care meeting. A Multidisciplinary Care Conference Note, dated 12/2/2024, indicated a care conference had been held on 12/3/2024 at 11:00 A.M. The form indicated the NP and the Social Service staff had attended the meeting. The record lacked documentation to show the resident had attended the care plan meeting. A Multidisciplinary Care Conference Note, dated 3/9/2025, indicated a care conference had been held on 3/24/2025 at 10:15 A.M. The form indicated the NP, the dietary manager, the social service staff and the resident's guardian had attended the care plan meeting. The record lacked the documentation to show the resident had been invited or had attended the care plan meeting. A Multidisciplinary Care Conference Note, dated 6/14/2025, indicated a care conference was held on 17/24/2025 at 12:00 P. M. Attendance at the meeting was documented as the NP, the dietary manager, the social service staff and the resident's guardian. The record lacked the documentation to show the resident had attended the care plan meeting. During an interview, on 9/8/25 at 10:14 A.M., the MDS nurse indicated the SSD was responsible for completing the care plans and completing the invitations for the dementia unit. 3. A record review was completed for Resident 17 on 9/3/2025 at 1:19 P.M. Resident 17's record indicated he had attended a care plan conference on the following dates: -9/9/2024 -3/27/2025 -6/3/2025 Resident 17's record lacked documentation that a care plan conference had been completed in December 2025. 4. A record review was completed for Resident 30, on 9/4/2025 at 2:19 P.M., and indicated her diagnoses included: Post Traumatic Stress Disorder, chronic respiratory failure, Congestive Heart Failure, Type 2 Diabetes, Peripheral Vascular Disease, morbid obesity, Hypertension, poly-neuropathy, major depressive disorder, and Chronic Obstructive Pulmonary Disease, The progress notes indicated a care plan meeting had been held on 4/16/24. The record lacked documentation of family or resident notification and listed only the Social Services Director and the dietary staff had attended and provided input. A care plan meeting had been held on 10/4/24. The resident's daughter, a representative from the nursing department and the Social Services Director were listed as attending the meeting. The record lacked documentation that the resident had been invited or had attended the meeting. A care plan meeting had been documented as held on 4/1/25. The resident's representative, nursing staff and the Social Services Director were listed as having attended the meeting. There was no documentation to show the resident had been invited to the meeting. Finally, documentation indicated a care plan meeting had been held on 7/22/25. The resident was in attendance with social service director. There were no other staff listed as having attended the meeting. 5. A record review was completed on Resident 4 on 9/8/2025 at 10:15 A.M. Diagnoses included but not limited to Bipolar disorder, colon cancer, vascular dementia and post-traumatic stress disorder. A record review for care plan conferences conducted during past year indicated the meetings had not held quarterly. The care conferences were held on 9/24/2024, 3/27/2025, and 6/30/2025. The only individuals present at the conferences were the resident and the Social Services Director. A record review of an Interdisciplinary Team (IDT) meeting, dated 9/25/24, revealed a meeting attended by pharmacy staff, the Geri-psych Nurse Practitioner, the attending Nurse Practitioner, the Social Services Director, the dementia program coordinator and the Director of Nursing had been held. The meeting did not include the resident and/or the resident's representative and there was no documentation the resident and/or the resident's representative had been invited to the IDT meeting. There were no further IDT meetings with multiple disciplines in attendance documented to have occurred over the past year. During an interview, on 9/8/25 at 1:35 P.M. the Social Services Director indicated a care conference should have been held every 3 months and documentation should have included notification of the resident or the resident's representative. She indicated that all care conferences held were documented in the medical record. On 9/5/2025 at 1:35 P.M., the Executive Director provided a policy called Care Planning - Interdisciplinary Team that indicated .an explanation will be included in the resident's medical record if the participation of the resident and his/her representative for developing the resident's care plan is determined to not be practicable. Furthermore, the policy stated .the Interdisciplinary Team must review and update the care plan: .at least quarterly. 3.1-35(c)(1)

Based on record review and interview, the facility failed to develop a person centered care plan for (Post Traumatic Stress Disorder) PTSD and failed to develop a care plan after a hospitalization with a new initiation of an anticoagulant medication and a diagnosis of severe anemia for 2 of 21 residents reviewed for care plans. (Resident 15 and 6)Findings include: 1. The record for Resident 15 was reviewed on 9/4/2025 at 9:53 A.M. Diagnoses included but were not limited to cancer, non-Alzheimer's dementia, anxiety, depression, psychotic disorder, bipolar, schizophrenia and PTSD (post-traumatic stress disorder). An admission MDS (Minimum Data Set) assessment, dated 6/2/2025, indicated the resident had the ability to express ideas and wants, experienced delusions and received antipsychotic, antidepressant, anticonvulsant, and opioid medications. Current Physician ordered medications included the following: Prazosin 2 mg capsule at bedtime for PTSD. A current Care Plan, initiated on 5/28/2025, indicated Resident 15 had a psychosocial well-being problem related to a history of personal trauma or PTSD (post traumatic stress disorder). Interventions included: allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Consult with Pastoral care, Social Services, and Psych services. Encourage participation from resident who depend on others to make own decisions. There were no interventions specific to the resident's triggers and individual needs related to her trauma history. In addition, the care plan did not address the resident's delusional behavioral issues. During an interview, on 9/8/2025 at 10:10 A.M., the Social Service unit Director indicated she was new and could not provide any information regarding the resident. During an interview, on 9/8/2025 at 10:14 A.M., the MDS Coordinator indicated the social service director was responsible for completing the care plans for residents on the secured dementia unit. 2. During an interview, on 9/2/2025 at 2:12 P.M., Resident 6 indicated he had recently been prescribed an anticoagulant. He indicated had been hospitalized , in July 2025, due to a hemoglobin level of 2 g/dL (grams per deciliter, normal level 13.5-17.5 g/dL) and subsequently deep vein thromboses (blood clots) were discovered in his right upper and lower extremities. A record review for Resident 6 was completed, on 9/5/2025 at 8:44 A.M. Diagnoses included, but were not limited to: cerebral palsy, iron deficiency anemia, spastic hemiplegia cerebral palsy and Parkinson's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 8/15/2025, indicated Resident 6 was cognitively intact and received an anticoagulant. A Hospital History and Physical, dated 7/20/2025, indicated Resident 6's evaluation indicated he had presented with a hemoglobin level of 2 g/dL and had received four units of packed red blood cells which had raised his hemoglobin level to 7.1 g/dL Resident 6 was diagnosed with profound anemia and potential hemorrhagic shock. The record indicated Resident 6 had a history, o occasional bilateral lower extremity edema and was noted to have worsening edema to the right lower extremity. A Physician's Order, dated 7/29/2025, indicated the Apixaban 5 milligrams twice daily for a blood clot and ferrous sulfate 325 milligrams daily for anemia. was prescribed. A Nurse Practitioner Note, dated 7/31/2025, indicated Resident 6 had been hospitalized and had been found to have a hemoglobin level of 2 g/dL, was diagnosed with deep vein thrombosis in the right upper and lower extremities and anemia. Resident 6 had an IVC filter placed for the treatment of the deep vein thromboses. There were no current orders for observation of the side effects of the anticoagulant medication, nor a care plan to address the anticoagulant use or anemia diagnosis. During an interview, on 9/8/2025 at 1:01 P.M., the MDS (Minimum Data Set) Coordinator indicated she had not written a care plan for the anticoagulant use or the anemia diagnoses. She indicated the care plan should have included the anticoagulant use and the anemia diagnoses. A current policy was provided on, 9/8/2025 at 1:01 P.M., by the Director of Nursing (DON). The policy titled, Care Plans-Comprehensive, indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS.4. Areas of concern that are triggered during the resident assessment are evaluated before interventions are added to the care plan.6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician [or primary healthcare provider] is integral to this process.9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly.

Based on record review and interview, the facility failed to ensure physician ordered medications were available for administration for 1 of 5 residents reviewed for medications. (Resident 15)Finding includes: The record for Resident 15 was reviewed on 9/4/2025 at 9:48 A.M. Diagnoses included but were not limited to: bipolar, Schizophrenia, anxiety, PTSD (post traumatic stress disorder), insomnia, cancer and delusions. Current Physician Orders included the following medications:-Lamotrigine (anticonvulsant) 50 mg (milligram) 1 tablet two times a day for Bipolar disease.-Trazadone (antidepressant) 50 mg 1 tablet at bedtime for insomnia.-Prazosin (antihypertensive) 2 mg 1 capsule at bedtime for PTSD. The May Medication Administration Record (MAR) indicated, on 5/30 and 5/31/2025, the Prazosin medication had not been administered because it was not available. The June MAR indicated, on 6/5, 6/6, 6/7, 6/8, 6/9. 6/10, 6/11, and 6/19/2025, the Prazosin medication had not been administered because it was not available. The July MAR indicated, on 7/1, 7/11, 7/12, and 7/17/2025, the Prazosin medication had not been administered because it was not available. The Trazadone medication had not been administered on 7/17/2025 because it was not available, and the Lamotrigine had not been administered, on 7/28/2025, because the facility was waiting on pharmacy. During an interview, on 9/4/2025 at 2:09 P.M., QMA 10 indicated if medications were not available and were not in the medication cart, she would have checked to see when it had been ordered or if it had been ordered. If the medication had not been ordered, she would have ordered it, documented it in the nurse's notes that the medication was out and had been reordered. In addition, she would have notified the nurse of the missing medication. During an interview, on 9/5/2025, QMA 16 indicated she if she could not find an ordered medication, she looked in the bottom of the medication cart for the medications, checked the EDK (emergency drug kit), called the pharmacy regarding the medications informed the Director of Nursing. During an interview, on 9/8/2025 at 10:11 A.M., the Director of Nursing indicated the nursing staff should have looked in the EKD for the meds and if they were not located there, they should have called the Pharmacy and the MD. On 9/8/2025 at 1:03 P.M., the Director of Nursing provided the policy titled, Emergency Pharmacy Service ad Emergency Kits, dated 5/20/2020, and indicated the policy was the one currently used by the facility. The policy indicated . Emergency pharmacy service is available on a 24 -hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the pharmacy. An emergency supply of medications, including emergency drugs, antibiotics, controlled substances and products for infusion are supplied by the pharmacy in limited quantities, in portable, sealed containers 3.1-25(a)3.1-25(g)(3)

Based on interview, observation and record review, the facility failed to report an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 18)Finding includes:During an interview, on 9/4/2025 at 1:55 P.M., CNA 8 indicated when she had came into work one morning about 2 months ago, the night aide, CNA 17, had given her report and said that Resident 18 had been up between 2-3:00 A.M., and she had had to redirect him back to his room. CNA 8 indicated then the night nurse had shown her a picture of Resident 18 with scratches all over his face. The night nurse indicated she had seen the resident and the night aide, CNA 17, fighting each other. CNA 8 indicated the previous Social Service/Unit Director (SSD) had came into work and had seen Resident 18 and asked, staff what had happened to him. CNA 8 indicated she told the former SSD that she was going to text the Administrator (regarding the scratches on Resident 18 and the night nurse's report about a fight between CNA 17 and Resident 18) but the SSD indicated she had already texted him. CNA 8 indicated when she came to work the next day, CNA 17 was not working on the dementia unit, but was working on another unit. CNA 8 indicated she had overheard the Social Service Director stating, they were going to do something about it. The record for Resident 18 was reviewed on 9/08/2025 at 11:02 A.M. Diagnoses included: hypertension, diabetes, hip fracture, Alzheimer's disease, non- Alzheimer's dementia, and depression.A Quarterly MDS (Minimum Data Set) assessment, dated 8/22/2025, indicated Resident 18 was able to make his needs known and had no behaviors, utilized a wheelchair for mobility, was independent with sitting on the side of the bed, wheeling his wheelchair and just required set up help for bed to chair and chair to bed transfers.During an interview, on 9/4/2025 at 2:13 P.M., with the previous Social Service/Unit Manager (SSD), she indicated she was not present when the staff to resident altercation happened. She indicated the night staff had reported the altercation between CNA 17 and Resident 18 and indicated it had occurred because the resident had been giving the staff member difficulty when she had attempted to provide incontinence care. The former SSD indicated when she had came into work, she questioned what had happened and CNA 8 indicated she had taken a picture of Resident 18's face and sent it to the Administrator. The Social Service staff indicated the picture looked worse than his face. When she was questioned if she would consider the incident a potential abuse allegation, the SSD replied, Yes. She indicated she had asked the Administrator about the incident investigation and he had informed the former SSD that it was being dealt with. The former SSD indicated the Administrator had informed her that the retribution was that person (CNA 17) would not work on the dementia unit. When asked if she had spoken to the Administrator any more about it, she replied she had spoken to the Nurse Practioner (NP) and had sent the photo of Resident 18 with scratches to his face.During an interview, on 9/5/2025 at 10:59 A.M., the NP indicated she had been informed of the incident on 6/16/2025. She indicated, all I know, it was an altercation between a resident and another staff member. She indicated she had asked if there was any documentation of the incident and the facility indicated there had been no documentation regarding what had happened. (to cause the scratches to Resident 18's face). She indicated from what she knew, it had occurred on the night shift. She indicated she had not documented the report or any assessment of the scratches/injuries in Resident 18's chart because this was not her resident. During an interview, on 9/5/2025 at 11:14 A.M., the Administrator indicated he had been made aware of an altercation with Resident 18 and another staff member. He indicated the staff had been transferring the resident and the resident was about to fall, so the staff member had tried to keep the resident from falling. He indicated the Social Service /unit director had notified him via a phone text. When asked if the incident had been reported, he indicated he had not reported the incident because he had not considered that there had been any potential abuse. When questioned whether there was any type of investigation, i.e., talk to other staff working with this aide that night, he had replied No, there had not been any investigation on his part. The Administrator was questioned regarding the reason for the change in work assignment for CNA 17, who was involved with the incident , and he indicated the facility had no set staffing assignments on each unit and staff worked all over the building. Review of the nursing working schedules for March, April and May indicated CNA 17 had worked on the locked dementia unit frequently but the schedules for June, July and August indicated CNA 17 had not been scheduled to work on the dementia unit except for two 4-hour shifts.During an interview on 9/5/2025 at 11:58 A.M., the nursing scheduler indicated she had been instructed, by the DON and ADON, not to schedule CNA 17 on the secured dementia unit. She indicated the ADON had stated, It's best that we do not have her back there. The scheduler indicated she had been instructed CNA 17 could work on the secured dementia unit if someone else was also on the unit working with her.During an interview, on 9/5/2025 at 1:39 P.M., the Director of Nursing indicated she could not remember the incident very well. She indicated CNA 17 had been transferring Resident 18 but she did not recall the exact details. When asked if she had seen the scratches after it happened, she indicated she indicated she was unsure of when the resident had obtained the scratches, but there had just been scratches. The Director of Nursing indicated she had been made aware of the incident on maybe the next day after it had occurred, but she did not recall who had notified her even though the staff member had verbally told her face to face about the incident. When asked if anyone had investigated the incident/resident injury, she replied I am not sure. She indicated that they had asked CNA17 to give them a written statement about what had happened. The Director of Nursing indicated she did not have the aide's written statement in her papers for review but indicated the aide had written that she had been attempting to assist Resident 18 with a transfer, when he lost his balance and she had caught him. When asked if she had interviewed the other staff member working on the night shift when the incident had occurred, the DON indicated she did not recall. When the Director of Nursing was questioned regarding why CNA 17 was no longer scheduled to work on the locked unit, she had indicated the facility administrative nursing staff had decided that CNA 17 was not a fit for the locked unit. She confirmed the decision had been made after the incident between Resident 18 and CNA 17. She indicated, prior to the incident, CNA 17 had had one incident where she was sleeping during her work hours. The Administrative staff indicated it was decided to move CNA 17 to another unit so she would be busier and not fall asleep.During an interview, on 9/5/2025 at 3:16 P.M., QMA 18 indicated she had been in the break room and had heard a commotion so she had opened the break room door and walked out into the hall. She had heard Resident 18 yelling, get out- get out. The residents' room door was opened, and she walked in, she saw CNA 17 and the resident. She indicated she noticed a scratch on Resident 18's face. She indicated the scratch was bleeding and indicated she had asked CNA 17 what she had done to Resident 18. CNA 17 told her maybe she had scratched him with her nails. QMA18 indicated she had informed CNA 17 that she would have to report this, and the aide then told her that she was sorry. QMA 18 indicated she had reported the incident and scratches on Resident 18's face to the night shift nurse, who was working on another unit, but she was unable to recall the nurse's name. She indicated the nurse had instructed her to tell management and to take a picture of his face for proof. QMA 18 indicated she had called the Social Service Director of the unit ,and she had instructed her to send the picture of the resident's face to her. When questioned if she had talked to any management staff member, besides the unit SSD about the incident, or had been asked to provide a verbal or written statement, she indicated she had not spoken with anyone else nor had she provided a statement.On 9/5/2025 at 3:26 P.M., the Administrator provided a copy of text messages between himself and CNA 17. The first text, from the Administrator to CNA 17 was dated 6/16/2025 at 7:09 A.M. The text message indicated the Administrator was asking CNA 17 about the scratches to Resident 18's face. The messages from CNA 17 indicated around 2:00 A.M.,(on 6/16/2025) the resident was coming in the hallway and she had asked him to please go back to bed because he was going up and down the hall and other residents were sleeping. The text indicated the resident had started to kick CNA 17 and she had tried to stop him with her hands as he started going backwards in his wheelchair. CNA 17 indicated she had grabbed Resident 19 because she was worried he was going to fall backwards in his chair. She indicated after she had spent a few minutes attempting to calm the resident down, the QMA had walked into the room. She indicated she had told the QMA what had happened and the QMA had pointed out the scratch on the resident's face. CNA 17 indicated she did not know how the resident had obtained the scratch because she was not even by his face, but she had reached for his chair to try and turn him to get him to stop kicking her.On 9/5/2025 at 1:37 P.M., the Administrator provided the policy titled, Abuse Policy, undated, and indicated the policy was the one currently used by the facility. The policy indicated . The resident has the right to be free from abuse. The facility must not use verbal, mental sexual or physical abuse. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff.Prevention-.identify, intervene, and correct situations of alleged, suspected, or substantiated abuse; supervision of staff.Investigating an reporting Allegations of Abuse Guidelines: All repots of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) .shall be reported to local and federal agencies and thoroughly investigated by the administrator or designee. 1. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source, misappropriation of resident property) . will be reported immediately, but no later than: Two (2) hours if the alleged violation involves abuse . or Twenty-four (24) hours if the alleged violation does not involve abuse.3.1-28(c)

Based on interview, observation and record review, the facility failed to fully investigate an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 18)Finding includes:During an interview, on 9/4/2025 at 1:55 P.M., CNA 8 indicated when she had came into work one morning about 2 months ago, the night aide, CNA 17, had given her report and said that Resident 18 had been up between 2-3:00 A.M., and she had had to redirect him back to his room. CNA 8 indicated then the night nurse had shown her a picture of Resident 18 with scratches all over his face. The night nurse indicated she had seen the resident and the night aide, CNA 17, fighting each other. CNA 8 indicated the previous Social Service/Unit Director (SSD) had came into work and had seen Resident 18 and asked, staff what had happened to him. CNA 8 indicated she told the former SSD that she was going to text the Administrator (regarding the scratches on Resident 18 and the night nurse's report about a fight between CNA 17 and Resident 18) but the SSD indicated she had already texted him. CNA 8 indicated when she came to work the next day, CNA 17 was not working on the dementia unit, but was working on another unit. CNA 8 indicated she had overheard the Social Service Director stating, they were going to do something about it. The record for Resident 18 was reviewed on 9/08/2025 at 11:02 A.M. Diagnoses included: hypertension, diabetes, hip fracture, Alzheimer's disease, non- Alzheimer's dementia, and depression.A Quarterly MDS (Minimum Data Set) assessment, dated 8/22/2025, indicated Resident 18 was able to make his needs known and had no behaviors, utilized a wheelchair for mobility, was independent with sitting on the side of the bed, wheeling his wheelchair and just required set up help for bed to chair and chair to bed transfers.During an interview, on 9/4/2025 at 2:13 P.M., with the previous Social Service/Unit Manager (SSD), she indicated she was not present when the staff to resident altercation happened. She indicated the night staff had reported the altercation between CNA 17 and Resident 18 and indicated it had occurred because the resident had been giving the staff member difficulty when she had attempted to provide incontinence care. The former SSD indicated when she had came into work, she questioned what had happened and CNA 8 indicated she had taken a picture of Resident 18's face and sent it to the Administrator. The Social Service staff indicated the picture looked worse than his face. When she was questioned if she would consider the incident a potential abuse allegation, the SSD replied, Yes. She indicated she had asked the Administrator about the incident investigation and he had informed the former SSD that it was being dealt with. The former SSD indicated the Administrator had informed her that the retribution was that person (CNA 17) would not work on the dementia unit. When asked if she had spoken to the Administrator any more about it, she replied she had spoken to the Nurse Practioner (NP) and had sent the photo of Resident 18 with scratches to his face.During an interview, on 9/5/2025 at 10:59 A.M., the NP indicated she had been informed of the incident on 6/16/2025. She indicated, all I know, it was an altercation between a resident and another staff member. She indicated she had asked if there was any documentation of the incident and the facility indicated there had been no documentation regarding what had happened. (to cause the scratches to Resident 18's face). She indicated from what she knew, it had occurred on the night shift. She indicated she had not documented the report or any assessment of the scratches/injuries in Resident 18's chart because this was not her resident. During an interview, on 9/5/2025 at 11:14 A.M., the Administrator indicated he had been made aware of an altercation with Resident 18 and another staff member. He indicated the staff had been transferring the resident and the resident was about to fall, so the staff member had tried to keep the resident from falling. He indicated the Social Service /unit director had notified him via a phone text. When asked if the incident had been reported, he indicated he had not reported the incident because he had not considered that there had been any potential abuse. When questioned whether there was any type of investigation, i.e., talk to other staff working with this aide that night, he had replied No, there had not been any investigation on his part. The Administrator was questioned regarding the reason for the change in work assignment for CNA 17, who was involved with the incident , and he indicated the facility had no set staffing assignments on each unit and staff worked all over the building. Review of the nursing working schedules for March, April and May indicated CNA 17 had worked on the locked dementia unit frequently but the schedules for June, July and August indicated CNA 17 had not been scheduled to work on the dementia unit except for two 4-hour shifts.During an interview on 9/5/2025 at 11:58 A.M., the nursing scheduler indicated she had been instructed, by the DON and ADON, not to schedule CNA 17 on the secured dementia unit. She indicated the ADON had stated, It's best that we do not have her back there. The scheduler indicated she had been instructed CNA 17 could work on the secured dementia unit if someone else was also on the unit working with her.During an interview, on 9/5/2025 at 1:39 P.M., the Director of Nursing indicated she could not remember the incident very well. She indicated CNA 17 had been transferring Resident 18 but she did not recall the exact details. When asked if she had seen the scratches after it happened, she indicated she indicated she was unsure of when the resident had obtained the scratches, but there had just been scratches. The Director of Nursing indicated she had been made aware of the incident on maybe the next day after it had occurred, but she did not recall who had notified her even though the staff member had verbally told her face to face about the incident. When asked if anyone had investigated the incident/resident injury, she replied I am not sure. She indicated that they had asked CNA17 to give them a written statement about what had happened. The Director of Nursing indicated she did not have the aide's written statement in her papers for review but indicated the aide had written that she had been attempting to assist Resident 18 with a transfer, when he lost his balance and she had caught him. When asked if she had interviewed the other staff member working on the night shift when the incident had occurred, the DON indicated she did not recall. When the Director of Nursing was questioned regarding why CNA 17 was no longer scheduled to work on the locked unit, she had indicated the facility administrative nursing staff had decided that CNA 17 was not a fit for the locked unit. She confirmed the decision had been made after the incident between Resident 18 and CNA 17. She indicated, prior to the incident, CNA 17 had had one incident where she was sleeping during her work hours. The Administrative staff indicated it was decided to move CNA 17 to another unit so she would be busier and not fall asleep.During an interview, on 9/5/2025 at 3:16 P.M., QMA 18 indicated she had been in the break room and had heard a commotion so she had opened the break room door and walked out into the hall. She had heard Resident 18 yelling, get out- get out. The residents' room door was opened, and she walked in, she saw CNA 17 and the resident. She indicated she noticed a scratch on Resident 18's face. She indicated the scratch was bleeding and indicated she had asked CNA 17 what she had done to Resident 18. CNA 17 told her maybe she had scratched him with her nails. QMA18 indicated she had informed CNA 17 that she would have to report this, and the aide then told her that she was sorry. QMA 18 indicated she had reported the incident and scratches on Resident 18's face to the night shift nurse, who was working on another unit, but she was unable to recall the nurse's name. She indicated the nurse had instructed her to tell management and to take a picture of his face for proof. QMA 18 indicated she had called the Social Service Director of the unit ,and she had instructed her to send the picture of the resident's face to her. When questioned if she had talked to any management staff member, besides the unit SSD about the incident, or had been asked to provide a verbal or written statement, she indicated she had not spoken with anyone else nor had she provided a statement.On 9/5/2025 at 3:26 P.M., the Administrator provided a copy of text messages from CNA 17, dated ____to him. The messages indicated around 2:00 A.M.,(on 6/16/2025) the resident was coming in the hallway and she had asked him to please go back to bed because he was going up and down the hall and other residents were sleeping. The text indicated the resident had started to kick CNA 17 and she had tried to stop him with her hands as he started going backwards in his wheelchair. CNA 17 indicated she had grabbed Resident 19 because she was worried he was going to fall backwards in his chair. She indicated after she had spent a few minutes attempting to calm the resident down, the QMA had walked into the room. She indicated she had told the QMA what had happened and the QMA had pointed out the scratch on the resident's face. CNA 17 indicated she did not know how the resident had obtained the scratch because she was not even by his face, but she had reached for his chair to try and turn him to get him to stop kicking her.On 9/5/2025 at 1:37 P.M., the Administrator provided the policy titled, Abuse Policy, undated, and indicated the policy was the one currently used by the facility. The policy indicated . The resident has the right to be free from abuse. The facility must not use verbal, mental sexual or physical abuse. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff.Prevention-.identify, intervene, and correct situations of alleged, suspected, or substantiated abuse; supervision of staff.Investigating an reporting Allegations of Abuse Guidelines: All repots of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) .shall be reported to local and federal agencies and thoroughly investigated by the administrator or designee. 3.1-28(d)

Based on observation and record review, the facility failed to ensure physician orders for elopement risk were in place for 1 of 2 residents reviewed for elopement. (Resident 65)Finding includes:A record review for Resident 65 was completed, on 9/4/2025 at10:56 A.M. Diagnoses included, but were not limited to: altered mental status, visual hallucinations and disorientation.An admission Minimum Data Set (MDs) assessment, dated 7/3/2025, indicated Resident 65 had severe cognitive impairment.During an observation, on 9/3/2025 at 10:24 A.M., Resident 65 was observed seated in the common area parallel to the front exit door. A Wanderguard (electronic device that magnetically locks doors if a resident wearing the device comes in close proximity of the door) device was not observed on the resident. During an observation, on 9/4/2025 at 10:55 A.M., Resident 65 was observed seated in the common area parallel to the front exit door. A Wanderguard device was not observed on either wrist or ankle.During an observation, on 9/5/2025 at 11:46 A.M., Resident 65 was observed walking on a hallway and indicated, I'm on the wrong hallway.During an observation, on 9/8/2025 at 8:58 A.M., Resident 65 was observed seated in the common area parallel to the front exit. door. A Wanderguard device was not observed when Resident 65 exposed her wrists and ankles upon request. During an observation, on 9/8/2025 at 10:15 A.M., with RN 6 Resident 65's left wrist was viewed and there was no Wanderguard device on her write. Resident 65 indicated she had cut the Wanderguard off because it had been too tight and she had placed it in the drawers of her bedside nightstand. The Wanderguard was located by RN 6 in Resident 65's upper drawer of her bedside nightstand. The band had been cut. An Elopement/Wander Risk Evaluation, dated 6/27/2025 and 7/21/2025, indicated resident 65 was a moderate wander/elopement risk.A current Care Plan, initiated on 6/27/2025, indicated Resident 65 was an elopement risk/wanderer. Interventions included, but were not limited to: Wanderguard in place on the left wrist and staff to check for placement on every day shift. A Physician's Order, dated 8/18/2025, indicated a Wander-guard to the left wrist and every day shift staff were to check for proper functioning of the Wanderguard. During an interview, on 9/8/2025 at 9:59 A.M., RN 6 indicated the facility had an elopement binder with resident pictures for resident found at risk for wandering and elopement. She also indicated most residents wore a Wanderguard. She indicated Resident 65 should have had a Wanderguard on her left wrist. A current policy was provided, on 9/8/2025 at 1:01 P.M., by the Director of Nursing (DON). The policy titled, Elopement, indicated, .It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge of facility staff.1. Upon admission, readmission, quarterly, and with a significant change of condition, residents will be assessed for elopement risk. 2. Residents that are identified at risk for elopement will have an intervention implemented for their safety.5. Electronic monitoring systems may be implemented as possible interventions as appropriate. If an electronic monitoring device is utilized as an intervention they shall be checked according to manufacturer's recommendations for function and placement.3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a consent for psychotropic medication use was obtained timely for 1 of 5 residents reviewed for psychotropic medications. (Resident 15)Finding includes: The record for Resident 15 was reviewed on 9/4/2025 at 9:48 A.M. Diagnoses included but were not limited to: bipolar, Schizophrenia, anxiety, PTSD (post traumatic stress disorder), insomnia, non Alzheimer's dementia and delusions. The current Physician's Orders for medications included the following:-Trazadone 50 mg (milligram) at bed time ordered on 5/21/2025 for insomnia.-Lamotrigine 200 mg twice a day ordered on 5/21/2025 for Bipolar disease.-Lexapro 10 mg every day ordered on 5/22/2025 for depression.-Clonazepam 1 mg three times a day ordered on 6/4/2025 for anxiety.-Risperdal 0.5 mg at bed time ordered on 6/4/2025 for schizophrenia. A Psychoactive Medication therapy informed consent form, dated 6/17/2025, indicated the POA (power of attorney)/guardian had given a verbal consent on 6/17/2025 for the use of the above medications. The consent was obtained after the medication orders had been obtained and after the facility had commenced administering the medications. During an interview, on 9/8/2025 at 10:09 A.M., the Director of Nursing indicated the consent should have been obtained earlier and was not. On 9/8/2025 at 1:23 P.M., the Director of Nursing provided a policy titled, Psychotropic Medication Use, dated 2/2025, and indicated the policy was the one currently used by the facility. The policy indicated . 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal 3.1-3(w)

Based on record review and interview, the facility failed to ensure a resident survivor of PTSD (Post Traumatic Stress Disorder) received culturally competent trauma informed care to reduce triggers for behaviors and reduce emotional distress for 1 of 1 residents reviewed for PTSD (Resident 15) The record for Resident 15 was reviewed on 9/4/2025 at 9:53 A.M. Diagnoses included but were not limited to cancer, non-Alzheimer's dementia, anxiety, depression, psychotic disorder, bipolar, schizophrenia and PTSD (post-traumatic stress disorder).An admission MDS (Minimum Data Set) assessment, dated 6/2/2025, indicated Resident 15 had delusions and received the following medications: antipsychotic, antidepressant, anticonvulsant, and opioids. A Nurse's Progress Note, dated 6/23/2025 at 5:40 P.M., indicated Resident 15 had received a call from her mother earlier in the afternoon and had been moody and tearful ever since she had received the call. Her behaviors were escalating towards dinner time. When her food tray arrived, the resident went into her room, got her walker and proceeded to walk down to the end of the hallway and began beating on the exit doors with closed fists. The resident was verbally directed to stop banging on the doors and replied, You can't make me! and continued to bang on the door. Staff then told her she needed to head to the dining room for dinner. The resident then began to loudly sob, verbalizing that she wanted to see her mom and dad. Staff then told her that beating on the doors was not acceptable behavior. Resident 15 replied she did not care and continued to sob loudly but had turned around with her walker and headed toward the dining room.During an interview on 9/4/2025 at 1:29 P.M., CNA 7 indicated when the resident was having behaviors or was anxious, she talked with her and tried to fix the problem. She indicated she also attempted to redirect the resident to an activity like coloring or writing notes. CNA 7 indicated Resident 15 would write notes about how she could fix whatever problem was upsetting her. When CNA 7 was questioned as to whether those interventions calmed the resident, she indicated sometimes it calmed her. CNA 7 indicated she had been told that Resident 15's dad was not allowed to visit her She indicated there was a written not note hung up at the nurse's desk with instructions not to allow male visitors.During an interview, on 9/4/2025 at 1:34 P.M. CNA 8 indicated when Resident 15 was upset, she went in and talked to her and encouraged her to read her Bible or listen to music. When questioned if these interventions helped calm the resident, CNA. 8 indicated it was usually not effective but the resident did enjoy coloring. CNA 8 indicated the resident's triggers were if staff told the resident they would be right back and did not return or if staff was to bring her something, like a soda, and did not return and bring the anticipated item. She indicated the note about no male visitors had been up at the nurse's station after the resident's father had first visited in June or July. She indicated the resident had behaviors after the visit. CNA 8 indicated she had been present when Resident 15's father had first visited and after greeting each other, Resident 15 and her father continued moving down the hall together talking. After Resident 15's father left, she had spent the rest of the day crying and sobbing, speaking about her Dad. CNA 8 indicated the resident's mother and father were had visited last Sunday. She indicated the resident's parents had brought her 2 shirts and the resident told them to take them back. Her parent were overheard telling her they were going to bring her back some lunch, however, they never returned.During an interview, on 9/4/2025 at 2:04 P.M., QMA 10 indicated Resident 15 got upset when she was in pain. QMA 10 indicated when the resident was upset, she asked her what was bothering her, tried to redirect her and tried to resolve the resident's problem. QMA 10 indicated Resident 15 had candy and sodas at the facility and she often asked for those items. She indicated she had just been informed that Resident 15's father was not allowed to visit the resident.A current Care Plan, initiated on 5/28/2025, indicated Resident 15 had a psychosocial well-being problem related to history of personal trauma or PTSD (post-traumatic stress disorder). Interventions included, but were not limited to: allow the resident time to answer questions and to verbalize feelings, perceptions, and fears, consult with Pastoral care, social services and psychological services and encourage participation from the resident who depend on others to make own decisions. There was no specific information regarding the resident's PTSD triggers, no personalized interventions and no consistent education to ensure staff were aware the resident's father was not allowed to visit.A policy regarding PTSD was requested on 9/8/2025, but one was not provided prior to the end of the survey.

Based on record review, observation and interview, the facility failed to ensure cleaning chemicals were stored securely on the memory care unit. This failure resulted in a resident with Alzheimer's Disease and dementia that accessed an unlocked water conditioner closet, handling and ingesting drain cleaner. The resident suffered pain, nausea, vomiting and required emergency room services, that included undergoing anesthesia for a gastro-intestinal (GI) endoscopy procedure to evaluate for damages. This affected 1 of 3 residents reviewed for accidents, (Resident B). The deficient practice was corrected on 7/11/25, prior to the start of the survey, and was therefore past noncompliance.Finding includes: Review of a facility reported incident, #633, submitted to the Indiana State Department of Health on 7/10/25, indicated on 7/10/25 at 1:30 A.M., Resident B was found vomiting in the Memory Care hallway and the vomit allegedly had a smell of bleach. The resident was then assisted to his room by staff and no distress was noted by the staff. The staff completed a safety sweep of the hallway and could not locate any chemicals. The resident's physician and the Poison Control Center were notified and it was recommended the resident go to the emergency room (ER) for evaluation and treatment.During an interview on 7/22/25 at 3:39 P.M., CNA 1 indicated she had worked on the memory care unit overnight on 7/10/25 and had taken a break off the unit. CNA indicated upon her return from break, she looked down the straight hall in the memory care unit to the water conditioning closet and saw the back part of Resident B's wheelchair sticking out of the water conditioning room. CNA 1 indicated she went to the resident, pulled him back from the closet in his wheelchair and noted he was holding a bottle of Liquid Plumber (drain clearner) in his hand. CNA 1 indicated she asked the resident what he had been doing and he pointed to his mouth. CNA 1 indicated she took the bottle from Resident B and called for assistance from Qualified Medication Aide (QMA) 3, who was coming down the hall at that time. CNA 1 indicated the resident then began gagging and by the time she got him to the doorway of his room, the resident had begun vomiting. CNA 1 indicated QMA 3 called for Registered Nurse (RN) 2, who was on the memory care unit at that time, and RN2 had arrived to Resident B's room and assessed him. CNA 1 indicated the resident continued to vomit and indicated his mouth and his stomach hurt. CNA 1 indicated RN 2 had notified Resident B's physician and the Poison Control Center immediately.During an interview, on 7/23/25 at 10:28 A.M with RN 2, she indicated on 6/10/25 at 1:41 A.M., she was on the memory care unit checking glucose monitors when CNA 1 called her to Resident B's room. She indicated the resident was seated in his wheelchair, in the doorway of his room with a trash can in his lap, actively vomiting. RN2 indicated CNA 1 had reported that she thought the resident had drank something from the water conditioner closet but the CNA indicated she did not know what Resident B had drank. RN 2 indicated she called the Director of Nursing to get the code to the water conditioner closet and there she found a bottle of Draino (drain cleaner). RN 2 indicated she looked at the bottle label , where it instructed not to induce vomiting if ingested, but the resident had already vomited by the time she had read the label . RN 2 indicated when she knew what the resident had ingested, she had called the Nurse Practitioner and instructed QMA 3 to call the Poison Control Center, thus having both parties on the phone at the same time. RN 2 indicated the Poison Control Center had recommended sending the resident to the ER immediately. RN 2 indicated she then called 911 immediately and had sat with the resident until the Emergency Medical Services (EMS) arrived. RN 2 indicated Resident B had complained of stomach pain while they had waited for EMS and when EMS assessed the resident, he had also complained of throat pain.On 7/22/25 at 3:19 P.M., Resident B's clinical record was reviewed. The resident had diagnoses that included, but were not limited to dementia, depression, and Alzheimer's Disease. Review of Resident B's most recent comprehensive Minimum Data Set (MDS), dated [DATE] for an Annual Assessment, indicated the resident was severely cognitively impaired, experienced delusions and misconceptions that were contrary to reality and demonstrated no unwanted behaviors. Resident B had no range of motion impairments to his arms or legs but required a wheelchair for locomotion.An Elopement/Wander Risk Evaluation, dated 5/17/25 for a quarterly review, indicated Resident B was at risk for elopement and wandering due to a forgetful and short attention span, dementia with psychosis, and independence with his wheelchair. Resident B utilized a wander guard (device worn on wrist or ankle to magnetically lock exit doors when resident came within close proximity of the doors). Resident B's Nursing Progress Notes, on 7/10/2025 at 1:45 A.M., completed by Registered Nurse (RN) 2, indicated she had been called to Resident B's room where the resident was seated in his wheelchair, in the doorway of his room and was vomiting into the trash can. RN 2 indicated there was a smell of bleach and the resident was complaining of stomach pain. RN 2 indicated the resident vomited about five times in the next 30 minutes and that it appeared the resident had ingested something that smelled like bleach and the amount ingested was unknown. RN 2 indicated she had notified the Poison Control Center who recommended sending the resident to the ER for an evaluation and treatment.A nursing progress note, dated 7/10/25 at 2:18 A.M., completed by RN 2, indicated Resident B had had a change in condition. The Change in Condition included abdominal pain, nausea, and vomiting. An EMS report, dated 7/10/25, indicated they had received a call from the facility, on 7/10/25 at 2:00 A.M. and had arrived on scene at 2:11 A.M. The report indicated the nurse stated one of the aids had found the resident with a bottle of Liquid Plumber and the resident had admitted to drinking [NAME] of it and was complaining about his mouth hurting and an upset stomach. The facility had indicated the resident had vomited multiple times withing the first 30 minutes after finding him before vomiting had subsided. Prior to leaving, the drain cleaner was noted to be Liquid Plumber brand gel drain cleaner. The report indicated the EMS had been diverted from the local hospital to another regional speciality hospital while enroute. They had arrived at the specialty hospital at 3:15 A.M.An emergency room report from the specialty hospital, dated 7/10/25 at 3:28 A.M., indicated Resident B's chief complaint reported by facility nursing staff indicated the resident had ingested an uncertain amount of Draino and had complained of abdominal pain with nausea and vomiting. The ER report indicated the resident was found by the CNA in a utility room holding a bottle of drain cleaner and then immediately had non-bloody emesis that had smelled of bleach. The nursing facility staff were not certain the resident had consumed the drain cleaner and was unclear how much he had possibly consumed. The report indicated the resident had reported that he thought the bottle was a Coke and he had drank a small amount and it tasted terrible, so he had not consumed any more. The resident indicated it was slightly painful to swallow but otherwise denied other complaints. On 7/10/25 at 2:18 P.M., the hospital notes indicated the resident had undergone anesthesia for an upper GI endoscopy. The test findings indicated localized mildly erythematous mucosa was found in the cardia and in the gastric body (redness and inflammation of the stomach lining in the cardia [the junction between the esophagus and stomach] and the body of the stomach). On 7/22/25 at 11:18 A.M., during an observation of the Memory Care unit, it was noted the water conditioner closet was three doors down from Resident B's room, on the same side of the hall. The water conditioner closet was observed to be locked with a pad lock, as well as a code lock. The Maintenance Director unlocked the water conditioner closet and the closet was noted to be approximately 4 ft wide by 6 ft long with water softening equipment along the wall opposite the entry door. During an interview at that time, the Maintenance Director indicated he had previously stored a container of Liquid Plumber on the ground against the wall between the wall and the water conditioner equipment. The Maintenance Director indicated the door to the closet was supposed to always be locked. However, on 7/9/25, the local water conditioning company had delivered salt for the water conditioners and he felt the door had not been secured properly after they had left the salt in the closet. On 7/21/25 at 12:00 P.M., the Administrator provided the policy titled, On-Site Chemical Storage, dated 7/15, and indicated it was the current policy. The policy indicated, .Safe chemical storage: Chemicals are stored in areas that are not accessible to residents.On 7/21/25 at 12:00 P.M., the Administrator provided the policy titled Chemical Management Program, dated 7/25, and indicated it was the current policy. The policy indicated, [The facility] recognizes the inherent risks associated with the use of chemicals in a nursing home environment. With a diverse population that includes vulnerable resident, careful management of these substances is critical to ensuring a safe and healthy living space.Chemicals are stored in designated locked areas that residents cannot access.The deficient practice was corrected by 7/14/2025 after the facility implemented a systemic plan of correction that included the following actions: facility wide safety sweep to ensure chemicals were stored securely and all door that needed to be locked, were locked, facility wide sweep to check the automatic closing hinges on all door equipped with this mechanism to ensure the door closed, the installation of an additional pad lock with key on the water conditioning closet in the Memory care unit, all staff education regarding the safe storage of chemicals and review of policies regarding accidental ingestion of harmful chemicals, care plan updates to include a potential to injest harmful substances, review and update of MSDS chemical informaiton sheets to include any cleaner utilized in the facility and education with the water softening vendor staff to regarding safety precautions to ensure they relocked doors to the water conditioning closets. In addition, an audit tool was implemented to ensure all doors were shutting and locking appropraitely and all chemicals were stored appropriately. The audit tool was to be completed by the Administrator for 6 months.This citation relates to Complaint IN002563532 3.1-45(a)(1)

Based on observation, record review and interview, the facility failed to provide appropriate interventions to prevent the development of pressures ulcers for 1 of 2 residents reviewed for pressure ulcers (Resident B). Finding includes: A record review for Resident B was completed on 12/20/2024 at 12:45 P.M. Diagnoses included, but were not limited to: peripheral vascular disease, diabetes mellitus type 2, heart failure and lymphedema. A Braden Scale (assessment to determine a resident's risk for developing pressure ulcers) assessment, completed on 8/21/2024, indicated Resident B was at risk for skin breakdown. A Braden Scale assessment, completed on 9/24/2024. indicated Resident B was at a moderate risk for skin breakdown. A Quarterly Minimum Data Set (MDS) assessment, dated 10/2/2024, indicated Resident B was cognitively intact, required substantial/maximum assistance for bed mobility and transfers, was dependent on shower assistance, was at risk for developing pressure ulcers, had a stage 3 pressure ulcer and diabetic foot ulcers. The assessment indicated the resident utilized a pressure-reducing device for his bed and nutrition/hydration interventions were utilized to manage his skin problems. The assessment indicated the resident had not had any behaviors of rejection of care during hte assessment time frames. A care plan, initiated 5/12/2023 and revised on 4/18/2024, indicated Resident B had the potential for pressure ulcer development or skin breakdown related to immobility, incontinence and seborrhea dermatitis. The goal was for the resident to have no skin breakdown. Interventions included, but were not limited to: encourage not to sit up in wheelchair for prolonged periods of time, pressure relief mattress on bed and assist with turning and repositioning as needed. A care plan titled, ADL (activities of daily living) Self Performance, initiated on 5/12/2023 and revised on 8/25/2024 indicated the resident had deficits related to mobility and incontinence. The interventions, included but were not limited to: Hoyer (mechanical) lift and two assist to transfer to bedside commode. A Weekly Skin Review, dated 11/11/2024 at 10:42 A.M., indicated Resident B's skin was intact. The assessment indicated Resident B had chronic leg and foot wounds, redness to the scrotum with an order for in-house Triad Hydrophilic (a zinc oxide-based paste to facilitate autolytic debridement) paste for incontinence. Resident B was marked as having no new skin issues. However, a Physician's Consultation Note from the wound clinic, dated 11/11/2024, indicated Resident B had complained of a buttock pressure wound that had been present for at least one week. There was no current ordered treatment for the pressure ulcer. A left gluteal ulceration was observed that measured 0.6 centimeters by 1.2 centimeters by 0.1 centimeters. The base was covered in yellow slough and the physician deemed the ulcer, a stage 3 pressure ulcer. In addition, a stage 2 pressure ulceration was noted left of the resident's coccyx, measuring 2 centimeters by 1 centimeter by 0.1 centimeters. The wound base of this ulcer was pink and yellow. There was also a superficial, unstageable wound noted to the left ischial area (the lower and back part of the hip bone). The ulceration measured 0.4 centimeters by 0.4 centimeters. New orders were provided for treatment of the new pressure ulcers. A Nursing Progress Note, dated 11/11/2024 at 2:00 P.M., indicated Resident B had returned from the Wound Clinic and had 3 new pressure areas noted to the left gluteal, coccyx and left ischium areas. A Weekly Pressure Injury Evaluation, completed on 11/11/2024 at 3:19, 3:21 and 3:23 P.M. indicated the following: Resident B had an in-house acquired stage 3 left gluteal ulceration, measuring 0.6 centimeters by 1.2 centimeters by 0.1 centimeters with an onset date of 11/11/2024, an in-house acquired stage 2 pressure ulcer of the coccyx. The pressure ulcer measured 2 centimeters by 1 centimeter by 0.1 centimeter and an in-house acquired stage 2 pressure ulcer of the left ischium. The pressure ulcer measured 0.4 centimeters by 0.4 centimeters. The evaluation indicated pressure relieving devices were in place, which included a low air loss mattress. A Care Plans, initiated on 11/12/2024, indicated Resident B had pressure ulcer development related to a history of ulcers and immobility to the left gluteal, coccyx and ischium. The goal was for Resident B to show signs of healing and to remain free from infection. Interventions included, but were not limited to: administer medications as ordered, administer treatments as ordered and monitor for effectiveness and to assess/record/monitor wound healing by measuring length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress and report improvements and declines to the physician A Physician's Order, dated 11/12/2024, indicated Triad Hydrophilic Wound Cream External Paste was to be applied to left gluteal and ischial wounds every shift and as needed. A Nutrition at Risk/Interdisciplinary Note, dated 11/14/2024 at 4:19 P.M., indicated there were no updates on skin integrity as wounds were managed by the wound clinic. There were no new nutritional interventions implemented to address the resident's new pressure ulcer development. The physician's orders related to nutritional needs for Resident B, prior the new pressure area developments were regular diet with double portions at breakfast and double protein portions at lunch and dinner, dated 5/12/2023 and Glucerna 1.2 (nutritional supplement drink) two time a day, ordered on 12/10/2023. There was also a physician's order, dated 5/10/2023 for the registered dietician to evaluate for nutritional interventions if needed. The only interventions implemented after Resident B's pressure ulcer development was the treatment ordered by the wound clinic for Triad cream and a low air loss mattress. However, per observation, on 12/20/2024 at 1:01 P.M., a low air loss mattress was not in place on Resident B's bed and there was no documentation of the resident refusing the intervention. Weekly Pressure Injury Evaluation reports, completed on 11/18/2024, indicated there was a stage 3 left gluteal pressure ulcer which measured 0.5 centimeters by 1.4 centimeters by 0.2 centimeters, a stage 2 pressure ulcer to the left ischium which measured 0.3 centimeters by 0.4 centimeters and a stage 2 pressure ulcer to the coccyx measured 1.7 centimeters by 0.7 centimeters by 0.1 centimeters. The current treatment for the wounds included Triad paste. A Physician Consultation Note from the wound clinic, dated 11/27/2024, indicated Resident B had been seen for chronic diabetic foot ulcers and a left buttock pressure ulceration that had been present since 11/11/2024. Resident B had reported the dressings were not being changed routinely and the nursing home staff were not following the physician orders. Resident B presented to the physician's office with a new coccygeal ulceration. The left gluteal ulceration measured 0.4 centimeters by 1.3 centimeters by 0.1 centimeters. The wound base was yellow and gray. The peri wound skin was dusky. The wound was consistent with a stage 3 pressure ulceration at a minimum due to the presence of the yellow slough. The ulceration to the left of the coccyx measured 1.6 centimeters by 0.5 centimeters by 0.1 centimeters. The base was yellow and gray with the peri wound dusky. A new non-blanchable wound was noted just to the right of the coccyx and measured 0.5 centimeters by 0.2 centimeters. The wound was consistent with a suspected deep tissue injury. The ischium pressure ulcer was epithelized. A Physician Consultation Note from the wound clinic, dated 12/5/2024, indicated Resident B presented with a worsening left gluteal ulceration. Resident B was incontinent of stool upon his arrival to the appointment. Resident B reported to the physician that his incontinence brief only got changed in the evening and the nighttime but not at all during the day. The gluteal ulceration measured 0.7 centimeters by 1.3 centimeters by 0.1 centimeters. The base was black. The left coccyx wound measured 1.4 centimeters by 0.7 centimeters by 0.1 centimeters. The base was yellow and gray. The non-blanchable redness to the right of the coccyx was resolved. The pressure ulcer of the left buttock had worsened from the prior week and was suspected the worsening was due to contamination of the wound with stool most of the time. The Triad cream was discontinued, and gentamicin (an antibiotic) ointment was ordered to be applied to the wound, three times a day. A Physician's Order, dated 12/6/2024, indicated gentamicin sulfate 0.1 percent cream apply to coccyx wound topically three times a day for wound care. A Physician's Consultation Note from the wound clinic, dated 12/12/2024, indicated Resident B presented to the office with a large amount of dry stool in his incontinence brief. Resident B indicated his brief had not been changed from the time he had gotten up in the morning. He indicated it usually did not get changed until he went to bed late at night. Resident B reported the gentamicin ointment was not being applied to his coccygeal and buttock ulcerations three times a day as ordered. The left gluteal ulceration measured 0.6 centimeters by 1.2 centimeters by 0.1 centimeters. The pressure ulceration to the left of the coccyx measured 1.2 centimeters by 0.4 centimeters by 0.1 centimeters. The pressure ulcer to the left buttock had minimal improvement from the last visit and was likely due to the nonadherence with treatment plan and incontinence of feces. The physician recommended that Resident B be checked for incontinence of stool every 2 hours as the ulcers were likely contaminated with stool frequently which would delay wound healing and could likely cause worsening of the ulcerations. There was no documentation the wound clinic recommendation to check the resident frequently, every two hours for stool incontinence was implemented, no new nutritional interventions were implemented and no new pressure relieving interventions were implemented due to the worsening of the resident's pressure ulcers. During an observation, on 12/20/2024 at 1:01 P.M., Resident B was observed to have a traditional foam pressure relieving mattress on his bed and a pressure relieving device (cushion) in his wheelchair. There was no air loss mattress on Resident B's bed. During an interview with Resident B, on 12/20/2024 at 1:41 P.M., he indicated his last incontinence change had been at 4:00 A.M. Resident B declined a request to observe his brief for incontinence. During an interview, on 12/20/2024 at 3:02 P.M., LPN 2 indicated she when she had completed the skin assessment on 11/11/2024, she had not actually visually assessed Resident B's buttock. She indicated when a resident received a shower, the CNA would provide a shower sheet that indicated if a new skin issue had been observed. LPN 2 indicated she would assess a resident's skin condition based upon the shower sheet information. She indicated Resident B sat in his wheelchair all day and did not lay down. She indicated Resident B was incontinent of his bowel and bladder at times. LPN 2 indicated nurses should apply the treatment cream to Resident B's buttock, but she had left the cream at the bedside for the CNAs to apply and she could not confirm if the cream had actually been applied as ordered LPN 2 indicated Resident B could not change positions in the wheelchair independently, but he might be able to scoot himself some in the wheelchair seat. During an interview on 12/20/2024 at 3:10 P.M., QMA 3 indicated a shower sheet was utilized and any skin conditions was to be communicated to the nurse. QMA 3 indicated Resident B utilized a shower chair when showered and an observation of Resident B's buttock and skin condition should have been reported to the nurse on the shower sheet. She indicated incontinent care was provided when Resident B asked for assistance and he was incontinent of his bowel and bladder. She indicated he was not routinely checked for stool incontinence and had no toileting plan. During an interview on 12/20/2024 at 3:08 P.M., the Medical Records Coordinator indicated the only shower sheets that were kept for records were the shower sheets with resident refusals of showers. The shower sheet for 11/11/2024 was not available for Resident B. During an interview, on 12/20/2024 3:22 P.M., CNA 4 indicated she has showered Resident B and he was dependent on showering assistance. She indicated shower sheets were utilized to communicate any skin issues noted on a resident during a shower. A policy was provided by the Executive Director, on 12/20/2024 at 4:20 P.M. The policy, titled, Skin and Wound Management System, indicated, .It is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes .3. Ongoing weekly evaluations of resident's skin will be completed and documented [in the facilities electronic medical record] on the 'Weekly Skin Evaluation' form .4. Preventative intervention will be implemented for residents identified at risk as appropriate .5. Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection This Federal tag relates to complaint IN00444009. 3.1-40(a)(1)

Based on record review and interview, the facility failed to implement effective interventions to prevent physical and verbal Resident to Resident abuse from recurring. This deficient practice resulted in Resident B exhibiting physically abusive behaviors which caused harm to 3 of 3 residents reviewed for abuse. (Residents C, D, & E) Findings included: 1. On 8/13/2024 at 1:37 P.M., a review of a facility reported incident 8/13/2024 at 1:37 P.M., indicated the following: Incident date: 5/29/2024 at 6:30 P.M. Residents involved: Resident C with the diagnoses of dementia with mood disorder, depression and anxiety. Resident B with the diagnoses of Alzheimer's disease, psychotic disorder with delusions, depression and dementia with agitation. Description added: Staff alleged Resident B made contact with Resident C's shoulders and left forearm while ambulating in the Memory Care hallway. Action taken: Residents were immediately separated. Resident B was placed on 1:1 staff supervision. Nurse completed a skin assessment, no findings. Type of injury: Added 5/29/2024- Discolored areas noted to Resident C's left forearm. Type of preventative measures added 5/29/2024 - blank The record for Resident B was completed on 8/13/2024 at 1:07 P.M. Diagnoses included but were not limited to anxiety, depression, psychotic disorder with delusions, dementia with agitation, and Alzheimer's disease. The Nursing Progress notes included and Incident Note, dated 5/29/2024 at 6:15 P.M.,which indicated the staff alleged the resident made physical contact to the shoulders of Resident C. The Residents were immediately separated, and Resident B was placed on one on one supervision Nursing Progress notes included A Nature of Trauma Note, dated 5/30/2024 at 11:15 A.M., which indicated Resident B put this hands on another resident (Resident C) and left bruises on her arms. Identify triggers: No known triggers. Interventions: Removed from triggering event. Notified IDT team. Notified resident representative when appropriate. Response to Interventions: Unable to recall event. Additional interventions: blank. Resident B was discharged to a Psychiatric hospital on 5/30/2024 and returned on 6/11/2024. The record for Resident C was completed on 8/8/82024 at 2:13 P.M. Diagnoses included, but were not limited to dementia, anxiety, depression and psychotic disorder. Resident C utilized a wheel chair and walker for mobility. A Behavior Note for Resident B, dated 6/16/2024 at 3:05 P.M., indicated he had returned from an outing with his family. Resident B's wife reported the resident was belligerent and had threatened to kick peoples a--- at the bowling alley. A Trauma Evaluation Note for Resident B, dated 6/17/2024 at 7:10 A.M., indicated: he had grabbed another resident's walker and then shoved it into her when she would not let go, which caused the other resident to fall to the floor backwards. Identify Triggers: This resident was already agitated, but all the other resident did was walk by him. Interventions: Removed from triggering event. Notified IDT team. Notified physician. Notified resident representative when appropriate. Response to Interventions: Unable to recall event. No change from baseline . An Incident Note, dated 6/16/2024 at 4:10 P.M., indicated he had made physical contact with a peer as Resident B resident was walking past in the hallway on the memory care unit which resulted in the peer falling. An Incident Note, dated 6/16/2024 at 4:10 P.M., indicated Resident B was placed on one on one monitoring. Resident B was discharged to a Psychiatric hospital on 6/18/2024 and returned on 7/1/2024 A Nursing Note for Resident B, dated 6/21/2024 at 4:49 P.M., indicated the family was notified of Resident B's possible return on the 25 th. The family was concerned the facility stated he would be returning Thursday and the psychiatric hospital had done nothing for him because they could only treat the resident for behaviors that were seen while Resident B was at the hospital. A Behavior Note for Resident B, dated 7/1/2024 at 3:01 P.M., indicated staff alleged that he made physical contact with the left cheek of another resident, after the resident made accidental contact with her walker to his foot. A Behavior Note for Resident B, dated 7/3/2024 at 4:38 P.M., indicated he had been verbally aggressive with staff and other residents. A Behavioral Health Progress Note, dated 7/8/2024, indicated Resident B had been referred to behavioral health to establish the necessity for continued psychotherapeutic and neurocognitive assessment services via the Behavioral health provider to address cognitive and neuropsychiatric symptoms.{Resident name} is back from his psych stay, but staff report ongoing behaviors and is easily agitated which he then can become aggressive A Behavior Note for Resident B, dated 7/10/2024 at 6:20 P.M., indicated he had been verbally abusive to staff and other residents most of the shift. Resident B was walking up and down the unit yelling and threatening staff, stating,Keep it up and I am going to put my fist around your face. A Physician's Progress Note, dated 7/18/2024, indicated a routine follow up visit for Resident B had been completed. Staff reported the resident would be transferring to another facility either later today or tomorrow. 2. A Behavior Note for Resident B, dated 7/22/2024 at 6:15 P.M., indicated staff alleged he approached Resident D and made physical contact with her right cheek with a photo album. The occurrence was unprovoked by Resident D. A facility incident report, dated 7/22/2024, indicated: Incident date: 7/22/2024 at 6:15 P.M. Residents involved: Resident D with the diagnoses of vascular dementia, depression, and delusional disorder. Resident B with the diagnoses of Alzheimer's disease, psychotic disorder with delusions, depression and dementia with agitation. Description added: Staff allege Resident B approached Resident D and made contact with Resident D's right cheek with a photo album. The incident was unprovoked by Resident D. Action taken: Residents were immediately separated. Resident B was offered an activity of interest. Type of injury: None. Type of preventative measures added: Investigation initiated. Pertinent information to be included in the 5- day follow-up. Follow up added: Let this serve as follow up to the incident. Staff allege Resident B approached Resident D and made contact with her right cheek with a photo album. The incident was unprovoked by Resident D. Residents separated. Resident B was offered and activity of his interest. It was effective. Neither resident recalled the incident and returned to their baseline. Care plans have been updated A Trauma Evaluation Note for Resident B, dated 7/23/2024 at 9:01 A.M., indicated: Nature of Trauma: Resident B approached Resident D with a photo album in his hand, and proceeded to use it to hit Resident D's face. Identify Triggers: Non known triggers. Interventions: Removed from triggering event. Notify IDT team. Notify resident representative when appropriate. Response to Interventions: Unable to recall event. No change from baseline. Additional interventions: blank 3. A facility incident report, dated 7/28/2024, indicated: Incident Date: 7/28/2024 at 5:10 P.M. Residents involved: Resident E with the diagnoses of depressive disorder, dementia, delusional disorder, traumatic brain injury and insomnia. Resident B with the diagnoses of Alzheimer's disease, psychotic disorder with delusions, depression and dementia with agitation. Description Added: Staff allege Resident B entered Resident E's room without being asked in. Resident E attempted to push Resident B out of the room. Resident B then made contact with Resident E's right cheek and Resident E made contact with Resident B's forehead. Action Taken: Residents were immediately separated. Nurse completed skin assessments of both residents. Resident B was offered and activity of interest and was effective. No findings. Family, physician and police were notified A Behavior Note for Resident B, dated 7/28/2024 at 5:10 P.M., indicated: staff allege that Resident B entered Resident E's room without being asked. Resident E attempted to push Resident B out of the room. Resident B then made contact with Resident E's right cheek and Resident E made contact with Resident B's forehead. A Trauma Evaluation Note for Resident B, dated 7/29/2024 at 12:41 P.M., indicated: Nature of Trauma: Resident B went into Resident E's room uninvited, and when Resident E tried to ask Resident B to leave, Resident B swung at him and Resident E swung back. Identify Triggers: being asked to leave a room he didn't want to leave. Interventions: Removed from triggering event. Notify IDT team. Notify resident representative when appropriate. Respond to Interventions: Unaffected able to recall event A Behavioral Health Progress Note for Resident B, dated 7/29/2024, indicated the Social Service Director (SSD) reported that Resident B would be moving to {Name of other Facility} as he will be one of two residents on their memory care unit and hoped this decrease his aggressive behaviors. A Social Services Note-Late Entry: dated 7/30/2024 at 3:35 P.M., indicated: Resident E had no recollection of the altercation between himself & a peer on 7/28/2024. A canceled Care Plan, dated 4/12/2023, indicated Resident B had exhibited behaviors including: physical aggression towards peers and staff; yelling an cursing; wandering into rooms of peers, restlessness and difficulty sleeping. Interventions included, but were not limited to: Administer medications as ordered; Attempt to ascertain cause for aggression/wandering such as hunger- offer ice cream, need to toilet, pain- headaches and administer prn medication as ordered; Attempt to guide away from source of distress; Attempt to redirect me by talking to me about cars, my family; continue follow up with psych services, transfer to behavioral health initiated on 5/12/2024, place on one on one initiated on 5/29/2024, placed on 1:1 monitoring initiated on 6/16/2024 and Transfer out to behavioral health initiated on 6/17/2024 During an interview, on 8/13/2024 at 2:40 P.M., the Director of Nursing indicated there were no new interventions added for Resident B for the altercation's with the other residents to prevent abuse recurrence and should have been. On 8/7/2024 at 10:05 A.M., the Executive Director provided the policy titled,Abuse Policy, dated 9/2022, and indicated the policy was the one currently used by the facility. The policy indicated .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents .The Facility shall have processes in place to include screening, training, prevention, identification, protection .to all allegations of potential or actual abuse and neglect This Federal tag relates to complaint IN00434526. 3.1-27(a)(1)

Based on observation, record review, and interview, the facility failed to store food under sanitary conditions related to undated and unlabeled foods and drinks in 1 of 1 kitchens (Main kitchen). This issue had the potential to affect 69 of 69 residents who resided in the facility and received food from the kitchen. Findings include: On 8/7/2024, at 9:41 A.M., during an initial tour of the kitchen with the Dietary Manager, the following items were observed: -: in the double-door freezer there were 2 opened bags of frozen meat patties unlabeled and undated - in the double-door cooler there was a tray of beverages already poured, unlabeled and only one cup bearing the date of 8/8/2024 - the dry pantry contained multiple bread products without labels or dates that included the following: 5 hot dog bun bags, 3 hamburger bag buns and 5 English muffin bags - in the walk-in fridge there were two pitchers of juice without dates or labels. During an interview, on 8/7/2024 at 9:41 A.M., the Dietary Manager indicated all food and beverages should have labels with the name of the item and dates. On 8/13/2024, at 9:53 A.M., the Executive Director provided the policy titled, Food Storage, dated 3/26/2020, and indicated the policy was the one currently used by the facility. The policy indicated . All food will be dated at time of receipt and be inventoried using the first in first out method .Un-served leftovers shall be labeled, dated and stored for a period not to exceed three (3) days. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care was created for residents with delusions (Residents 36 & E) a resident with hallucinations (Resident 55), and for a resident receiving hospice care (Resident 16) for 4 of 21 residents reviewed for comprehensive care plans. Findings include: 1. The record for Resident 36 was reviewed on 8/9/2024 at 1:00 P.M. Diagnoses included, but were not limited to: psychotic disorder with delusions, depression, dementia with agitation, and anxiety. A Significant Change Minimum Data Set assessment (MDS), dated [DATE], indicated the resident had received antipsychotic and antidepressant medications. Resident 36's medications included, but were not limited to: Paliperidone ER (an antipsychotic) Extended Release 24 Hour 3 mg (milligram) give 1 tablet by mouth one time a day for delusions related to psychotic disorder with delusions. The clinical record lacked a person centered care plan for delusions. During an interview, on 8/13/2024 at 9:42 A.M., the Director of Nursing indicated there should have been a person centered care plan for delusions. 2. The record for Resident E was completed on 8/8/2024 at 2:13 P.M. Diagnoses included, but were not limited to: dementia, depression and psychotic disorder. An Admission Minimum Data Set (MDS) assessment, dated 7/22/2024, indicated the resident had delusions. Resident 61'2 medications included but were not limited to: Depakote Delayed Release 250 MG (anticonvulsant) give 1 tablet by mouth one time a day for delusions.- The clinical record lacked a person centered care plan for delusions. During an interview, on 8/13/2024 at 9:24 A.M.,the Director of Nursing indicated there should have been a care plan for delusions. 3. A record review for Resident 55 was completed on 8/09/2024 at 9:17 A.M. Diagnoses included, but were not limited to malnutrition, bipolar, visual hallucinations and depression. A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident had visual hallucinations and received antipsychotic medication. Resident 55's medications, included but were not limited to Aripiprazole (an antipsychotic) 10 mg give 1 tablet by mouth one time a day related to alcohol abuse with intoxication and visual hallucinations. The clinical record lacked a person centered care plan for hallucinations. During an interview, on 8/13/202 at 9:27 A.M., the Director of Nursing indicated there should have been a care plan for hallucinations and the care plan should have been person centered. During an interview, on 8/13/2024 at 9:24 A.M.,the Director of Nursing indicated there should have been a care plan for the delusions. On 8/13/2024 at 10:37 A.M., the Director of Nursing provided the policy titled, Care Plans, Comprehensive Person-Centered, dated 9/2022, and indicated the policy was the one currently use by the facility. The policy indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The service provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The comprehensive, person-centered care plan will .d. Incorporate interventions to address cultural needs, psychosocial needs, mitigate/reduce risk for trauma related triggers .h. Incorporate identified problem areas .10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process 49229 4. The record for Resident 16 was reviewed on 8/8/2024 at 3:37 P.M. Diagnoses included, but were not limited to, alcohol dependence with dementia, vascular dementia, delusional disorders, anxiety, pain, and hypertension. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was rarely/never understood and received hospice care. Current physician orders for Resident 16 included, but were not limited to, Hydrocodone-Acetaminophen 5-325 mg (milligram) one tablet by mouth four times a day for pain related to other chronic pain, Ativan 1 mg (milligram) one tablet by mouth one time a day for anxiety and admit resident to Transitions Hospice for end stage/terminal diagnosis of cerebral atherosclerosis effective 9/15/2023. A current Care Plan, intiated on 5/28/2024, for Resident 16 included, but was not limited to, administration of comfort medications as ordered, allow resident to verbalize fears and concerns about the dying process, hospice aide to meet with resident per schedule, hospice chaplain to meet with resident per schedule, hospice nurse to meet with resident per schedule, hospice social worker to meet with resident per schedule, notify hospice of any change in condition and offer private room if available. On 8/9/2024, at 2:58 P.M., during an interview, the DON indicated the hospice care plan was not person-centered. On 8/13/2024 at 10:37 A.M., the Director of Nursing provided the policy titled, Care Plans, Comprehensive Person-Centered, dated 9/2022, and indicated the policy was the one currently used by the facility. The policy indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The service provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The comprehensive, person-centered care plan will .d. Incorporate interventions to address cultural needs, psychosocial needs, mitigate/reduce risk for trauma related triggers .h. Incorporate identified problem areas .10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process 3.1-35(a)

Based on interview and record review, the facility failed to provide a baseline care plan meeting and routine care plan meeting for 1 of 3 residents reviewed for care planning. (Resident 53) Finding includes: During an interview, on 8/7/2024 at 10:08 A.M., Resident 53 indicated the facility would not let him access his test results until he was discharged . On 8/7/2024 at 11:26 A.M., Resident 53 indicated that he had not had a baseline care plan meeting, nor any care plan meeting since admission. A record review for Resident 53 was completed on 8/9/2024 at 9:24 A.M. Diagnoses included, but were not limited to: alcohol abuse, diabetes mellitus type 2, idiopathic acute pancreatitis, cannabis use, iron deficiency anemia, and chronic kidney disease. Resident 52 was admitted to the facility on [DATE]. During a review of the Electronic Medical Record (EMR) from admission to the current date of 8/7/2024 for Resident 53, no documentation could be located regarding a baseline care plan meeting, nor a routine care plan meeting. During an interview, on 8/12/2024 at 2:19 P.M., the Social Service Director (SSD) indicated most likely Resident 53 had not had a baseline care plan meeting, and had not had a meeting set up since his admission. She indicated Resident 53 was in her office daily, but the communication had not been documented. A policy was provided by the Director of Nursing, on 8/13/2024 at 10:27 A.M. The policy titled, Care Plans, Comprehensive Person-Centered, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .4, Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to: a. Participate in the planning process 3.1-35(d) (2)(B)

Based on observation, record review and interview, the facility failed to provide activities of daily living (ADLs) regarding shower/bathing opportunities (Residentt 53 and 9) and nail, hair and shaving assistance (Resident 1) for 3 of 3 residents reviewed for ADL care. Findings include: 1.During an interview, on 8/7/2024 at 11:22 A.M., Resident 53 indicated he had only received 2 showers in the last month and a half. He indicated the certified nursing assistants (CNAs) would offer to provide showers between 11 P.M. and 3 A.M. He indicated his preference was to clean up himself as he did not like being woken up at midnight to take a shower. A record review for Resident 53 was completed, on 8/9/2024 at 9:24 A.M., Diagnoses included, but were not limited to: alcohol abuse, diabetes mellitus type 2, cannabis use, chronic kidney disease, and iron deficiency anemia. A Quarterly Minimum Data Set (MDS) assessment, dated, 8/9/2024, indicated Resident 53 was cognitively intact. An MDS assessment, dated 5/17/2024, indicated it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. He required partial/moderate assistance with bathing. A current Care Plan for Resident 53, dated 5/10/2024, indicated he had an activities of daily living (ADL) self-performance deficiency related to decreased mobility, mild intellectual deficiency, confusion related to alcohol abuse and withdraw, and incontinence. Interventions included, but were not limited to: Resident 63 required assistance as needed with bathing and showering. The Documentation Survey Report, from 5/1/2024-8/11/2024 indicated the following showers had occurred: -5/16/2024 -5/20/2024 -5/22/2024 -5/27/2024 -6/7/2024 -6/14/2024 -6/26/2024 -6/27/2024 -7/7/2024 -7/8/2024 -7/19/2024 -7/31/2024 -8/2/2024 -8/4/2024 -8/9/2024 A review of the ADL charting from 7/12/2024-8/9/2024 indicated, Resident 53 had refused showers on: -7/12/2024 -7/19/2024 -8/9/2024 Refusal shower sheet form,kept by the facility, indicated Resident 53 had documented refusals of showers on 6/27/2024 and 8/1/2024. During an interview, on 8/12/2024 at 1:20 P.M., the Director of Nursing (DON) indicated upon admission the resident was to be interviewed for their preference for shower times. This included asking for day/evening shift preference (before or after lunch) and evening/night preference (before supper or after supper). She indicated there was no documentation of Resident 53's preferences from the interview available. The DON indicated she was not aware of Resident 53 had an issue with his shower being offered on third shift. She indicated the staff would ask up to 3 times for refusals, and then the refusal would be documented on a shower sheet, and the nurse tried to make a progress note. She indicated shower sheets were not kept for accepted showers. 2. During an interview, on 8/7/2024 at 1:54 P.M., Resident 9 indicated she had not received her showers on Saturdays or Tuesdays. A record review for Resident 9 was completed on 8/9/2024 at 11:19 A.M. Diagnoses included, but were not limited to: vascular dementia, cutaneous abscess of the abdominal wall, schizophrenia, and anxiety disorder. A Quarterly Minimum Data Set (MDs) assessment, dated 6/21/2024, indicated Resident 9 was cognitively intact and had surgical wounds. A Discharge with Return Anticipated assessment, dated 6/17/2024, indicated Resident 9 needed bathing supervision or touch assistance. A current Care Plan, dated 8/2/2017, and revised on 3/6/2020, indicated Resident 6 required assistance with activities of daily living (ADLs) due to dementia, bipolar, schizophrenia, cervical stenosis, neuropathy, fibromyalgia, cancer with chemotherapy, knee replacement, seizures and traumatic brain injury. An intervention, dated 2/28/2018, and revised on 6/9/2024, indicated Resident 6 preferred to complete bathing with assistance as needed. The Documentation Survey Report, dated 7/1/2024-8/12/2024 indicated the following showers occurred: -7/2/2024 -7/17/2024 -7/20/2024 -7/26/2024 Refusal shower sheets, kept by the facility, indicated Resident 9 had documented refusals per the shower sheets for: -7/12/2024 -7/16/2024 -7/17/2024 -7/192024 -7/23/2024 -8/2/2024 During an interview, on 8/12/2024 at 1:23 P.M., the Director of Nursing (DON) indicated Resident 9 was prone to refusing showers. She indicated the staff asked up to 3 times for refusals, and then the refusal would be documented on a shower sheet, and the nurse tried to make a progress note. Shower sheets were not kept for accepted showers. The DON indicated Resident 6 had not been care planned for refusals of showers. 38121 3. During an observation, on 8/7/2024 at 10:13 A.M., Resident 1 was observed with long fingernails with a black substance underneath them, long, dirty facial hair noted thanging over his top lip and greasy hair. During an observation, on 8/8/2024 at 10:52 A.M., Resident 1 was observed with long fingernails with a black substance underneath them, long, dirty facial hair noted hanging over his top lip and greasy hair. A record review for Resident 1 was completed on 8/8/2024 at 1:40 P.M. Diagnoses included, but were not limited to: cerebral palsy, epilepsy, gastrostomy status, intellectual disabilities, diabetes mellitus type 2, protein calorie malnutrition, hyperlipidemia and restlessness. An Nursing Admission assessment, dated 6/4/2024, indicated Resident 1 was a total assist for activities of daily living, including personal hygiene, mobility, toilet use, transfers and bathing. A Quarterly Minimum Data Set (MDS) assessment was completed on 6/11/2024 and indicated Resident 1 had severely impaired cognition and was dependent on staff for all (ADL) activities of daily living, personal hygiene, mobility, toilet use, transfers and bathing. A current Care Plan, dated 6/4/2024, indicated Resident 1 had a self-care deficit and was dependent on staff for all personal hygiene needs. During an interview, on 8/8/2024 at 2:01 P.M., RN 14 indicated Resident 1 needed his nails trimmed and cleaned, his hair needed washed and indicated Resident 1 required total staff assistance for care needs. RN 14 indicated she was unsure of his shower days and did not know when he received his last shower. During an interview, on 8/13/2024 at 1:34 P.M., the Director of Nursing indicated Resident 1 should have scheduled showers completed and staff should be trimming his nails and facial hair. On 8/13/2024 at 10:27 A.M., the Director of Nursing provided the policy titled, Activities of Daily Living, dated 2018, and indicated the policy was the one currently used by the facility. The policy indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's) Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene 3.1-38(a)(3)

Based on record review and interviews, the facility failed to establish a discharge plan and to ensure documentation was accurate and allowed at least 30 days prior to the transfer for a facility initiated transfer and failed to allow a resident to remain the building when the resident verbalized opposition to the transfer for 1 of 3 discharged records reviewed. (Resident B) This deficient practice resulted in the resident inflicting self harm due to the impending transfer. Finding includes: The record for Resident B was reviewed on 10/13/2023 at 9:45 A.M. Resident B was admitted to the facility on [DATE] with diagnoses including, but not limited to: type 1 diabetes mellitus with ketoacidosis with coma, open wound of the lower left leg with subsequent encounter, Crohn's disease of the large intestine without complications, hyperlipidemia, calculus of lower urinary tract, muscle weakness, unsteadiness on feet and pain. An admission assessment, completed on 8/10/2023, indicated the resident was admitted for long term care and there were no discharge plans initiated on his admission. The resident was admitted to the facility with two stage 2 pressure wounds to his bilateral lower extremity amputation stumps (knees). The most recent Quarterly MDS (Minimum Data Set) assessment for Resident B, dated 8/28/2023, indicated the resident was alert and oriented, required staff supervision and/or limited assistance for activities of daily living, and utilized a wheelchair for locomotion. The assessment indicated the resident did not have any wounds. The care plans for Resident B, revised on 9/11/2023 and current through 11/28/2023 did not address any discharge plans. A Social Service Progress Note, completed on 9/8/2023 at 9:35 A.M., indicated the Social Service Director had attempted to have the resident come to her office to work on his social security disability but he was too tired and refused. On 9/18/2023 at 12:03 P.M., a Social Service Progress Note from the SSD indicated the staff member had spoken with the resident about his discharge from the facility. The resident informed the social service director he was going to talk with some family members in hopes they would take him in. The SSD and resident called the Social Security office and the resident's things were still in progress. On 9/19/2023 at 2:32 P.M., a Social Service Progress Note entered as a Late entry indicated the SSD again spoke with the resident regarding his discharge plans. The resident again indicated he was hoping to stay with family and refused to have the SSD assist him in talking to his family. When pressed by the SSD for a solid plan and goal he stated, I guess I'll just go to the homeless shelter then. The SSD informed him that was a possibility. The SSD indicated the resident was reluctant to go to a homeless shelter due to potential drug issues there. The note indicated the SSD was able to assure the resident of the homeless shelter's precautions to prevent drug abuse in their buildings. The note ended with the resident stating he did not want to discuss his discharge plans anymore. On 9/23/2023 at 11:22 A.M., a Social Service Progress Note indicated a discussion with the resident had taken place due to some inappropriate language towards staff and behaviors of asking staff for their phone numbers and asking staff out on dates. After the conversation, the note indicated the resident and SSD talked about the discharge process but the resident refused to talk to the SSD and left the office. On 9/24/2023 at 9:55 A.M., a late entry note from the SSD indicated she had spoken with the Family Member 1 and she was unwilling to take him into her home. The note indicated the Family Member 2 was also unable to provide a home for Resident B. On 9/28/2023 at 3:48 P.M., a Social Service Progress Note indicated she had spoken with the Family Member 3 and she was unwilling to take the resident into her home. Family Member 3 informed the facility, Your facility is not allowed to just throw people on the street, and I won't let you do that to him. A Social Service Progress Note, dated 9/28/2023 at 6:20 P.M., indicated another long term care facility was contacted but the SSD was unable to connect with anyone at the facility and would have to call back. A Social Service Progress Note, dated 10/06/2023 at 12:32 P.M., indicated the homeless shelter was contacted to see if the resident could be discharged to their facility. The note indicated the resident need to come for an intake process and then he could stay at the homeless shelter. Transportation was set up for Monday 10/9/2023 to complete the first portion of the intake process. The note indicated the resident no longer met level of care at the facility and all possible family members had been contacted. A Social Service Progress Note, dated 10/9/2023 at 12:16 P.M., indicated the SSD spoke to a family member of Resident B and she indicated He can't go to a shelter, he won't make it. The note again indicated the resident did not meet Level of care in the facility. The note indicated the resident was packing his belongings and stated I have done (sic) to have to leave, I need to be in the nursing home and I need people to care for me. The SSD assured resident he would be okay and that he does not meet the level of care. A Nursing Progress Note, dated 10/10/2023 at 3:30 A.M., indicated while being assisted with a shower, the resident was observed attempting to pull a scab off of his left knee. The resident was educated regarding not removing the scab, however, the resident continued and eventually pulled a scab off of his left knee stump. The area was documented as bleeding and a pressure dressing was applied. A Nursing Progress Note, dated 10/10/2023 at 3:45 A.M., indicated the resident was yelling in the hallway that now that he had a wound, he could not be discharged . The nurse then indicated she informed the resident it was not an open wound and requested he not yell as other resident's were trying to sleep. ANursing Note, dated 10/10/2023 at 4:30 A.M., indicated the homeless shelter staff were notified regarding the resident's narcotic medications and supplies for checking his blood sugar. A Nursing Note, dated 10/10/2023 at 5:00 A.M., indicated the resident's blood sugar was 424 and he stated he had drank a bunch of juice and believed he could not be discharged to the homeless shelter. On 10/10/2023 at 6:45 A.M., Resident B was transferred per facility van to the homeless shelter in a local city and discharged from the facility. There was no notes regarding reviewing care needs and/or medications with Resident B prior to his discharge. During an interview with the Director of Nursing and the Social Service Director, on 10/13/2023 at 10:58 A.M., the SSD indicated the facility had started discharge planning with Resident B a while back when we figured out he was not going to meet the Level of Care requirement. She indicated the (company) staff member had evaluated the resident in September. The SSD indicated the resident was not offered a 30 day notice of discharge as the facility was not discharging him that way. The SSD indicated there was no discharge plan of care but she had contacted several family members and places regarding the resident's discharge. Review of the documentation from the (assessment company) evaluation, completed on September 13, 2023 and the resident was determined to meet the skilled nursing facility level of care short term for 120 days from September 13 through January 11, 2024. The resident was receiving a State/Federal funded payer source for the nursing home stay. The SSD indicated she had contacted family members and a few long term care facilities. She indicated the resident had no money for assisted living and she had not contacted any type of assisted living facility. She indicated the resident had refused to have her contact any group homes. The Director of Nursing (DON) indicated the resident was in the process of filing for Medicaid disability while he was in the facility. The DON indicated the facility felt it was important to start the discharge process immediately as it was potentially going to be very difficult to find placement for the resident due to his age and criminal background. The Director of Nursing confirmed the homeless shelter had notified the facility regarding their concerns with the resident being unable to care for himself, per their requirements and the Director of Nursing indicated she told the homeless shelter to call the emergency room if they were concerned. The facility's current policy and procedure, titled, Transfer and Discharge Requirements provided by the Director of Nursing on 10/13/2023 at 11:28 A.M., included the following: .12. Except in an emergency, a resident may not be transferred or discharge from the facility without prior notification. The resident and the resident's responsible person shall receive written notification in a reasonable advance of the impending discharge. Reasonable advance notice shall be interpreted to mean 30 days unless appropriate plans can be implemented. The actions shall be documented on the resident record. Suitable clinical notes, list of order and medications as directed by the attending physician shall accompany the resident if the resident is sent to another medical facility The facility's current policy and procedure, titled Post -Discharge Plan provided by the Director of Nursing on 10/13/2023 at 11:28 A.M., included the following: .When a resident is discharged , a post-discharge plan shall be provided to the resident, and his/her representative .1. When the facility anticipates a resident's discharge to a private residence or to another nursing care facility .a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment 6. A copy of the post-discharge plan will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records This Federal tag relates to complaint IN00419541. 3.1-12(a)(6) 3.1-12 (a)(6)(B)

Based on observation, interview and record review, the facility failed to provide supervision to a resident with disorientation/dementia due to a brain mass, with known exit seeking behaviors and identified as an elopement risk, resulting in an elopement of 1 of 3 residents reviewed, who were at risk for elopement. The immediate jeopardy began, on 9/18/22 at 8:14 P.M., when the facility failed to ensure a system was in place, to prevent the elopement of a resident, who had a history of exit seeking wandering, prior to admission, and deemed a high risk for elopement upon admission related to aimless wandering, and expression of a desire to go home, as a result the resident was able to exit the facility where he was found a mile from the facility and taken to a local hospital by a local police department. The Administrator was notified on 9/22/22 at 3:00 P.M. The immediate jeopardy was removed and corrected on 9/24/22 when the facility implemented a systemic plan of action which included, but not limited to: identification and implementation of 30 minute checks for those residents at high risk for elopement, implementaion of shift wandering charting, updated elopement books at each nurses station and reception area, consultation for installation of a wanderguard system and staff education on elopement. Finding includes: On 9/21/22 at 2:19 P.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE]. The resident's diagnoses included, but were not limited to: disorientation, malignant neoplasm of frontal lobe of the brain, cerebral [CONDITION(S)] and nicotine dependence. A hospital report dated 8/29/22, indicated the resident was brought to the ER (emergency room ), via an ambulance, after he was found sitting in a truck with confusion and unable to communicate where he was. A CT (type of x-ray) was obtained which identified bilateral brain masses with a midline shift. A craniectomy (a neurosurgical procedure that involves removing a portion of the skull in order to relieve pressure on the underlying brain) was performed on 9/1/22. A Hospital Consultation, dated 9/7/22, indicated there had been a discussion regarding treatments for the resident. It was decided by physician and family the resident wound be transferred to a nursing home with palliative care. The report indicated the resident had attempted to exit the hospital. A Care Plan, dated 9/14/22, indicated Resident has an alteration in neurological status related to necrotic frontal lobe brain mass, cerebral cyst, cerebral [CONDITION(S)], seizures related to vasogenic brain [CONDITION(S)]. The interventions included, but were not limited to: medications as ordered, monitor for side effects of the medications, cueing and reorientation as needed. A Care Plan, dated 9/14/22, indicated the resident had a history of elopement and/or wandering. The interventions included the following: .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers:watching television and listening to music. Resident chooses not to participate in OOR [out of room] activities On 9/19/22 more interventions were added. Those inventions included by were not limited to: provide 1:1 direct supervision, document on behavior log wandering behavior, attempt diversional interventions and pursue transfer to secure unit. An Elopement/Wander Evaluation form, dated 9/13/22, indicated the resident's score was 12. The form indicated a score of 11 or above indicated the resident was a high risk for elopement/wandering. The form indicated the resident was forgetful/short attention span, expressed a desire to go home, wanders aimlessly with assist of 1 person and had a history of wandering. An Elopement Risk Binder, had a forms enclosed titled Resident Elopement Risk Profile. Resident B profile indicated the following: .Recommendations on Approaching/Reassuring: Tell him that his sister [name of sister] is looking for him A Progress Note, dated 9/13/22, indicated the resident arrived to his room, he was alert but confused, was able to answer questions but required frequent redirection. He denied pain and had a surgical incision to the top of his head. A Medication Administration Record (MAR) for September, indicated 4 medications were administered by LPN 3, at 8:00 P.M. on 9/18/22. An Administration History form indicated, on 9/18/22, the resident received his 8:00 P.M., medications at actually 8:20 P.M. A facility, self reported incident, dated indicated on 9/19/22 at 8:30 A.M., .Resident reported as leaving the facility unattended .Resident returned to facility. Nurse assessed resident. Placed on 1:1 [one on one]. Family physician and police notified .no injury noted A Hospital History, dated 9/19/22 at 5:57 A.M., indicated Resident B was brought to the ER by police .as a emergency detention after he was found sitting in someone's backyard. Patient was confused as to why he was there. He thought he was with some buddies who were here getting their ears pierced. He states he thought he was in Southern Indiana but then indicated that he grew up just South of South Bend. Patient was oriented to his name as well as year he knew that Biden was the president. He denied any type of trauma or fall although he did have a healing cut to his scalp The MDM (medical decision making) part of the history indicated .He had evidence that he had recently been hospitalized with blood draw sites and Band-Aids on his forearm. Calls to local hospitals discovered that he is indeed a patient who is on hospice for inoperable brain cancer. We were able to get a hold of the nursing facility [name of the facility] where he is currently resident and they were unaware that he had left the building. We spoke with his sister and she confirmed that his baseline mental status is approximately what we described .We will go ahead and cancel the emergency detention order and the patient will be discarded to [name of facility] for continued care A Nursing Progress Note, dated 9/19/22 at 06:08 A.M., indicated .At this time this writer noticed this resident was not up in chair in TV room area like he had been the last 2 mornings. I went to room and checked he was not in room or his restroom. I checked the dinning room area and was then returning to desk area to call a code purple, the phone was ringing at this time. When answered it was [name of hospital] ER [name of employee of the hospital] notifying me that this resident was in ER. Notified Administrator, DON, and sister . A Nursing Progress Note, dated 9/19/22 at 08:50 A.M., indicated . at 8:30 am [name of hospital] hospital staff x1 transported [name of Resident B] back to the facility. [Name of resident] amb [ambulated] to his room w/o [without] any problems. He had no c/o [complaints of] pain but said he was tired. Physical assessment noted no injuries or new skin issues . The Note indicated his post surgical incision site was clean and dry. The resident was alert but confused and was placed on 15 minutes checks. A Nursing Progress Note, dated 9/19/22 at 11:35 A.M., indicated the Nurse Practitioner was notified about event at 7:17 A.M. The police were also notified and a copy of the police report was requested by the DON. A statement, typed by the Nurse Consultant, dated 9/20/22, indicated the Consultant had spoken with night LPN 3. The LPN indicated Resident B had been up and down all night and LPN 3 had seen him lying in his bed asleep at 4:00 A.M. A statement, typed by the Nurse Consultant, dated 9/20/22, indicated QMA 4 had seen Resident B walking in the hallway around 9:00 P.M., when the resident had taken his medication, sometime between 8:30-9:00 P.M. QMA 4 was not aware the resident had left the building until the nurse told him about the call from the hospital the next day. An area weather history for September, indicated on 9/19/22 at 3:54 A.M., it was 69 degrees and there was a thunderstorm. Google maps indicated from the facility's address, to the street address where the police located the resident, in a backyard was 1 mile. During an interview, on 9/21/22 at 3:44 P.M., LPN 5, indicated she worked, on 9/19/22, and had clocked into work at 6:00 A.M., and began looking for LPN 3, who she had given reported, to her, the previous day. She indicated LPN 3 was not located at the nurse's station, so she walked passed the TV area, at the front of the building and noted Resident B was not in the area. LPN 5 indicated the resident had been watching TV, the past two mornings, when she arrived to work. She went to his room and he was not there. She proceeded to the nursing station, to call a code purple-elopement announcement when the phone rang and it was a nurse from a local hospital, explaining to her Resident B was in their ER. She indicated the facility was always locked and all persons entering or exiting must have a code to get in or out. She indicated there is a clicker and someone tried to say he took the clicker and left the facility but she indicated the clicker was at the nurse's station, by the computer keyboard. She has no idea how he left the facility. She did not contact the police, as the nurse from the hospital indicated the police were the ones who had found the resident. She did contact the Director of Nursing (DON) who indicated she would let the Administrator know of the situation. A statement, dated 9/21/22, indicated a Social Services Assistant had gone to the local police department to obtain a copy of the police report, which the police would not release, without a subpoena, but did provide the following information: Resident B was observed by police at 2:12 A.M., by a CVS. They did not detain him as he wasn't causing any problems. He was observed again, by the police at 4:16 A.M., and at that time he was taken to a local emergency room . During an interview, on 9/21/22 at 7:22 P.M., the resident's sister indicated she was notified, by the local hospital, on 9/19/22 at 6:20 A.M.,, that her brother had been taken to the hospital, as someone had reported him being in their back yard wandering around at approximately 4:30 A.M. The sister indicated the police reported they had seen him near a local CVS store. She indicated the facility's DON did not contact her, on 9/19/22 until 8:20 A.M., to inform her, a family member needed to come to the facility and sit with the resident as soon as possible. It wasn't until she asked why they told her the resident had gotten outside of the facility. She left work and arrived at the facility, around 8:40 A.M., and her brother was in his room, asleep. His wet clothes were on the floor-a long sleeve t-shirt, black shorts and yellow non-skid socks. She lived in the area and there had been storms during the night. The DON came to talk to her and had no explanation as to how the resident left the building but told her he got out around 4:00 A.M., which she knew was not correct, per her conversation she had previously, with the staff, at the hospital. She indicated she stayed with the resident and another staff member came in the room around 10:00 A.M., to watch her brother. The sister indicated she left the facility around 5:30 and another sister came and left that evening. She had no idea if a staff member was with him over the night to watch him. She indicated the next day, when she went to the facility they were trying to get her to agree to have him sent to a psychiatric hospital and she did not agree. During an interview, on 9/22/22 at 9:17 A.M., the Captain from the city's police department indicated the facility had not made contact with the local police department until yesterday. A representative, from the facility, came to the office, to request a copy of the officer's report, which they were denied and told they would have to get a subpoena to obtain it. The case number was 22-09-0186. The Captain indicated Resident B was observed by someone who called the police regarding a male suspect knocking on the window at a CVS, on 9/19/22 around 2:00 A.M. The officers approached Resident B and he indicated he was fine, officers requested that he move from the area and the gentleman said he had somewhere to go and the officers had no reason to detain him. Later, a call came in at approximately 4:15 A.M., asking the police to respond to a stranger in the backyard. The officers indicated it was the same gentleman, however this time he was not able to tell the officers the year, thought it was 1997 and had not given a reasonable response to the officers questions. It was decided by the officers to take him to a local hospital to detain him. He indicated the facility was contacted by the hospital police around 6:30 A.M., to notify them where the resident was and it was his understanding the facility had no idea the resident was not in the nursing home. On 9/22/22 at 4:14 P.M., Resident B was observed in his room, visiting with his sister. The resident kept his head down during the conversation. A closed healed incision was observed on the top of his head. He was alert to self only and had no idea what month or day it was. He indicated he had no pain and nodded yes to indicate he was comfortable. The room had no odor and the resident was wearing a clean long sleeve shirt and pants. The resident indicated he had no recollection of leaving the facility and stated I don't remember. On 9/22/22 at 11:48 A.M., the Consult Nurse provided a policy titled, Elopement, undated and indicated the policy was the one currently used by the facility. The policy indicated .Nursing personnel must report and investigate all reports of missing residents .Should an employee discover that a resident is missing from the facility, he/she should .9. Notify the administrator and the DON 10. Charge Nurse Notify the resident's legal representative 11. Charge Nurse Notify the attending physician 12. Charge Nurse Notify law enforcement officials .Elopement Risk Assessment It is the policy of this facility to assess all residents upon admission to the facility and quarterly for their risk of elopement. Residents who are assessed as being high risk for elopement will have a plan of care that identifies the risk and appropriate interventions. This Federal tag relates to complaint IN 629. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure 1 of 3 newly admitted residents reviewed received nursing care and medications. This deficient practice resulted in the need for the resident to be transferred to a hospital for medical stabilization. (Resident F) Finding includes: The closed clinical record for Resident F was reviewed on 2/8/2022 at 1:50 P.M. Resident F was admitted to the facility on [DATE] at 5:10 P.M., with diagnoses, including but not limited to pneumonia, debility. A nursing assessment was completed by the admitting nurse, LPN 4. The admission vital signs indicated the resident's pulse was 118 and hx of afib ([CONDITION(S)]) was written beside the pulse documentation. There were no nursing assessment, nursing progress notes or medications administered or documented for the rest of the night on 1/21/2022 and for the entire 24 hour period on 1/22/2022. On 1/23/2022 there was a skilled nursing note documented at 10:42 P.M., with vital signs and lung sounds assessed. There was no other assessments documented or any medications administered until 8:00 P.M. on 1/23/2022. Of the resident's 15 scheduled medications, ordered by the physician from the hospital upon his discharge and subsequent admission to the long term care facility, only 1 medication was administered to Resident F at 8:00 P.M. The only other nursing note, on 1/23/2022 documented the date and time of the resident's upcoming follow up appointment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documentation from the pharmacy that supplied medications to the facility, indicated they did not receive any MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the acute care center discharge instructions, dated 1/21/2022, indicated there were multiple medication orders, including orders for an antibiotic, blood pressure medications, blood thinning medication and medication to address the resident's breathing issues. The discharge orders from the acute care center indicated most of the routinely scheduled medications were to be initiated by the facility on 1/22/2022. Nursing progress notes on 1/24/2022 at 11:10 A.M., indicated the resident was examined by the Nurse Practitioner and was noted to be [CONDITION(S)] (elevated heart rate) and heart rate was erratic. His blood oxygen saturation level was 68-83 percent on oxygen via a nasal cannula. The resident was discharged to an acute care facility via an ambulance. Review of the emergency room notes, dated 1/24/2022 at 11:14 A.M., indicated the resident was noted to have a irregular heart rate of 146 bpm (beats per minute) when he arrived in the emergency room department. The note also indicated he had been transferred to a long term care facility 3 days prior for rehab services, was found to be tachcardic this morning and LTC facility realized he had not received his prescribed medications for the past three days. The resident was admitted to the acute care facility for stabilization of [CONDITION(S)] with RVR (rapid ventricular response). During an interview with the Administrator and the Corporate Nursing Consultant, on 2/08/2022 at 4:20 P.M., they indicated Resident F had been admitted to the facility on a Friday evening by an agency nurse, LPN 4. There was also an agency nurse working the next shift, LPN 5. The admitted nurse completed an admission assessment but failed to put the medication orders into the electronic chart and send the orders to the pharmacy. LPN 5 did not recognize the error and did not put in the medication orders or do any charting for Resident F during her shift. The error was not discovered until 1/23/2022 by the previously acting Director of Nursing, when she audited the chart on Sunday 1/23/2022. The Administrator indicated she had attempted to contact both nurses, regarding the issues with their work performance, but had not received any return calls from either nurse. When queried as to their policy for checking new resident orders, the Administrator indicated the admitting nurse was responsible for putting the medication orders into the electronic charting system and ensuring the orders were sent to the pharmacy. The Director of Nursing was supposed to audit the charts but did not always audit them the next day. There was no system to ensure medication orders were double checked for accuracy prior to sending them to the pharmacy to be filled and delivered. The Regional Nurse Consultant indicated now, as a corrective action, after the admitting nurse input the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the Director of Nursing was to audit the admission charts immediately and then send the review to the Regional Nurse for a second audit. Finally, the nursing staff were being inserviced, starting towards the end of last week, regarding the process for completing the charting and MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator indicated it was also discovered the EDK needed updated to include frequently ordered medications and they were in the process of addressing the issue with their pharmacy. This State Finding relates to Complaint IN 506 3.1-37(a)

Based on record review and interview, the facility failed to ensure 1 of 3 newly admitted residents reviewed was free from significant medication errors of omission, which resulted in the need for the resident to be transferred to a hospital for stabilization. (Resident F) Finding includes: The closed clinical record for Resident F was reviewed on 2/8/2022 at 1:50 P.M. Resident F was admitted to the facility on [DATE] at 5:10 P.M., with diagnoses, including, but not limited to pneumonia and debility. A nursing assessment was completed by the admitting nurse, LPN 4. The admission vital signs indicated the resident's pulse was 118 and hx of afib ([CONDITION(S)]) was written beside the pulse documentation. There were no medication administered on 1/21/2022, 1/22/2022 and during the day time hours on 1/23/2022. There were only two medications administered on 1/23/2022 at 8:00 P.M., [MEDICATION(S)] and Omeprazole. Review of the hospital discharge instructions, dated 1/21/2022, included, but were not limited to, the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge orders from the acute care center indicated most of the routinely scheduled medications, including the antibiotic, were to due to be administered by the facility on 01/22/2022, however, the [MEDICATION(S)], Doxazozin and [MEDICATION(S)] were due to be administered at bedtime on 1/21/2022. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documentation from the pharmacy that supplied medications to the facility, indicated they did not receive any MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Progress Notes, dated 1/24/2022 at 11:10 A.M., indicated the resident was examined by the Nurse Practitioner and was noted to be [CONDITION(S)] (elevated heart rate) and heart rate was erratic. His blood oxygen saturation level was 68-83 percent on oxygen via a nasal cannula. The resident was discharged to a hospital via an ambulance. Review of the emergency room notes, dated 1/24/2022 at 11:14 A.M., indicated the resident was noted to have a irregular heart rate of 146 bpm (beats per minute) when he arrived in the emergency room department. The note also indicated he had been transferred to a long term care facility 3 days prior for rehab services, was found to be [CONDITION(S)] this morning (1/24/2022) and the LTC (long term care) facility realized he had not received his prescribed medications for the past three days. The resident was admitted to the hospital for stabilization of [CONDITION(S)] with RVR (rapid ventricular response). During an interview with the Administrator and the Corporate Nursing Consultant, on 2/8/2022 at 4:20 P.M., they indicated Resident F had been admitted to the facility on a Friday evening by an agency nurse, LPN 4. There was also an agency nurse working the next shift, LPN 5. The admitting nurse completed an admission assessment but failed to put the medication orders into the electronic chart and send the orders to the pharmacy. LPN 5 did not recognize the error and did not put in the medication orders or do any charting for Resident F during her shift. The error was not discovered until 1/23/2022 by the previously acting Director of Nursing, when she audited the chart on Sunday 1/23/2022. The Administrator indicated she had attempted to contact both nurses regarding the issues with their work performance, but had not received any return calls from either nurse. When queried as to their policy for checking new resident orders, the Administrator indicated the admitting nurse was responsible for putting the medication orders into the electronic charting system and ensuring the orders were sent to the pharmacy. The Director of Nursing was supposed to audit the charts but did not always audit them the next day. There was no system to ensure medication orders were double checked for accuracy prior to sending them to the pharmacy to be filled and delivered. The Regional Nurse Consultant indicated now, as a corrective action, after the admitting nurse input the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the Director of Nursing was to audit the admission charts immediately and then send the review to the Regional Nurse for a second audit. Finally, the nursing staff were being inserviced, starting towards the end of last week, regarding the process for completing the charting and MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator indicated it was also discovered the EDK needed updated to include frequently ordered medications and they were in the process of addressing the issue with their pharmacy. This State Finding relates to Complaint IN 506 3.1-48(c)(2)

Based on observation, interview and record review the facility failed to prevent the deterioration of 2 Stage II pressure ulcers to 2 Stage III pressure ulcers, provide a pressure relief and skin assessments, as directed by the plan of care, for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: On 2/20/19 at 12:33 P.M., Resident C was observed sitting in a w/c, in the dining room, with no cushion on the wheelchair seat. On 2/20/19 at 4:31 P.M., a review of the clinical record for Resident C was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A care plan, dated 12/26/18, indicated the resident had a stage 2 pressure ulcer on right buttock which was present upon admission. Interventions included but were not limited to: apply treatment as ordered, dietary interventions as needed, pressure reduction mattress, pressure reducing devices to chair and weekly wound measurements. There was no other care plan regarding the left buttock pressure ulcer provided. A care plan, dated 12/12/18 indicated the resident was at risk for skin breakdown due to impaired cognition. The interventions included, but were not limited to: pressure reducing cushion to wheelchair and sitting chair in room and weekly assessments. The Admission Minimal Data Set (MDS) Assessment, dated 12/19/18, indicated the resident had severe cognitive deficits, with a Brief Interview for Mental Status (BIMS) score of 6. The assessment indicated the resident was an extensive assist of 2 persons with transfers, used a wheelchair & walker, had no pressure ulcers at admission, was always incontinent of bowel and frequently incontinent of bladder. A Braden Skin at Risk Assessment was completed on 12/13/18 and indicated the resident was at risk for skin breakdown. The Medication Administration Record [REDACTED]. For the month of (MONTH) documentation indicated, on 2/9/19 was the only skin assessment that was completed. The MAR indicated [REDACTED]. A physician order, dated 2/11/19, indicated .Cushion in chair for pressure relief every shift The Admission Assessment indicated there was a skin issue involving the right buttock, which measured 0.5 x 0.5 cm (centimeters). A Weekly Nurse Skin Assessment, dated 12/22/18, indicated the following .buttock left 1x1 buttock right 3x2 and another 2x1 .applied Duoderm will notify physician A Progress Note, dated 12/28/18, indicated the Wound Nurse Practitioner (NP) had been asked to assess the residents wounds. The wound assessment indicated the resident had a right and left buttock, Stage II, pressure ulcer. The right ulcer measured 2.7 x 1.0 x <0.1 cm. and the left ulcer measured 1.0 x 0.7 x <0.1 cm. The treatment was to apply [MEDICATION NAME], a dry dressing to both buttock wounds daily and decrease pressure to his buttocks with a roho cushion in his chair. The NP seen the wounds and measured them on 1/11/19 and 1/25/19. The wounds were decreasing in size and on 1/25/19 the treatment order changed to applying a dry foam dressing to both wounds daily. A Pressure Ulcer Wound Sheet, dated 2/1/19, and completed by RN 13 indicated the resident had a Stage II pressure ulcer to his right buttock, which measured 2.1 x 1.1 x <0.1. The wound was described to have 25% [MEDICATION NAME] tissue (protective barrier) and 75% granulation tissue (reddish connective tissue which forms on the surface of a wound). The left buttock Stage II pressure ulcer measured 0.5 x 0.5 x <0.1, with 75% [MEDICATION NAME] tissue and 25% granulation tissue. The treatment for [REDACTED]. A Pressure Ulcer Wound Sheet, dated 2/8/19, and completed by the Director of Nursing 14 indicated right and left buttock Stage II ulcers. The measurement was rt= 0.5 x 1.1 x 0.5 cm. The assessment did not have any measurements for the left wound. The tissue description indicated 70% [MEDICATION NAME] and 30% granulation, but did not indicate if it was for the right or left wound. The current treatment was [MEDICATION NAME] with dry sterile dressing. A NP Progress Note, dated 2/8/19, indicated the right buttock had a Stage II pressure ulcer which was round in shape, with epibole forming around the edges of the wound. (Edges that are rolled - a condition called epibole-indicate a chronic wound, in which [MEDICATION NAME] cells are unable to adhere to a moist, healthy wound bed.) The right wound measured 1.5 x 0.8 x <0.1 cm. The left buttock had a Stage II pressure ulcer with an irregular shape with epibole forming around the wound edges. The left wound measure 1.0 x 0.7 x <0.1 cm. The Plan was described as follows: apply moistened puracol to wound beds and a dry secondary dressing due to wound worsening as evidenced by increased size and utilized roho in chair. A Pressure Ulcer Wound sheet, dated 2/20/19, indicated the resident had a Stage II pressure on his right buttock which measured 0.5 x 1.1 x <0.5 cm. The tissue description indicated 50% [MEDICATION NAME] and 25% granulation. The current treatment was [MEDICATION NAME] daily with dry sterile dressing and pressure cushion to chair. This assessment had no signature indicating who completed the assessment. A NP Progress Note, dated 2/22/19, indicated the right buttock, Stage II pressure wound measured 2.5 x 1.2 x 0.1 cm and edges were attached. The left buttock, Stage II pressure wound measured 1.0 x 1.0 x <0.1 cm with edges attached. The treatment was to continue the moistened puracol to wound beds and utilize roho in chair. The Progress Note indicated the epibole that had formed was now flattened out and wound appeared to improve despite the increase in size. On 2/21/19 at 9:36 A.M., Resident C was observed in his room, sitting in recliner, feet down, shoes on and walker in front of him. There was no cushion underneath the resident or on top on the seat of the recliner. At 10:05 A.M. the resident was observed in his room, in same position but his eyes were closed. At 10:43 A.M. the resident was observed in same position, sitting in recliner. At 11:20 A.M. the resident was observed in same position, eyes open. No staff members were observed going into Resident C's room from 9:36 A.M. thru 11:40 A.M. On 2/21/19 at 11:40 A.M., CNA 9 and CNA 15 entered the room and assisted Resident C out of the recliner and positioned him with his walker. The recliner was observed not to have a pressure relieving cushion on it. CNA 9 indicated she wasn't sure where the cushion was, but a cushion was to be placed, in the chair , when resident was sitting in it. The resident was assisted to the his restroom where his soiled brief was removed by CNA 9. The resident's buttocks was observed to have no dressing on the wounds. LPN 16 entered the area to apply a dressing. She indicated the dressings had been soiled so she told the CNA's she would apply them later. Peri care was done by CNA 9 with soap and water. The resident flinched and indicated the cleaning hurt. 2 Stage III pressure ulcers were observed on the left and right buttock across from each other, both were beefy red with uneven curved edges. No measurements taken by LPN 16 as she didn't bring something with her to measure the wounds. LPN 16 was observed to spray each wound with Wound Wash, applied venelex (Caster Oil & Oil of Peru) wound topical ointment, then placed a cut-down puracol plus collagen over each wound and then applied border gauze, which she cut in two and placed one on each buttock. On 2/21/19 at 12:00 P.M., Assistant Director of Nursing indicated all wound observation and skin sheets for (MONTH) had been provided. She indicated the Wound NP was the one at the facility to measure the wounds. On 2/22/19 at 9:23 A.M., Resident C was observed sitting in a wheelchair near the nurses station, The wheelchair did not have the pressure relieving cushion on it On 2/22/19 at 9:30 A.M., CNA 11 was asked to raise the resident from his wheelchair and the seat of the wheelchair had no cushion on it. CNA 11 indicated she didn't know if the resident was to have a cushion or not in his wheelchair. QMA 4 indicated the cushion might be in his room. A cushion was brought to resident and RN 13 indicated the cushion was not a roho cushion but a mosaic cushion and the resident was to have a roho cushion. On 2/22/19 at 11:55 A.M. the wounds were observed with RN 13 to obtain measurements The right buttock wound measured 3.0 x 1.2 x <0.1 cm , was beefy red with rolled uneven edges, Stage III. The left buttock wound measured 2.0 x 1.5 x <0.1 cm. and was beefy red with rolled edges, Stage III. RN 13 did not apply the venelex ointment prior to placing the puracol plus collagen. On 1/21/19 at 3:15 P.M., the Administrator provided a policy titled, Prevention of Pressure Ulcers, dated 10/2010 and indicated the policy was the one currently used by the facility. The policy indicated .General Preventative Measures 3. For a person in a chair: a. Change position at least every hour; b. Use foam, gel or air cushion as indicated to relieve pressure. c. All residents identified to be at risk for pressure ulcer development should have a pressure reduction chair cushion. 9. Routinely assess and document the condition of the resident's skin. Residents identified to be at risk for pressure ulcer development should have skin assessment completed at least weekly .Risk Factor - Moisture d. Place resident on a minimum of a q (every) 2 hour check and change program On 2/25/19 at 10:20 A.M., the Administration provided a release from the National Pressure Ulcer Advisory Panel, dated (MONTH) 13, (YEAR). The release indicated .Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament , cartilage and/or bone are not exposed This Federal tag relates to complaint IN 622. 3.1-40(b)

1. Based on record review, observation and interview, the facility failed to ensure proper fall interventions were implemented for 3 of 8 residents reviewed for accidents, resulting in a fall causing acute rib fractures for 1 resident. (Residents 30, 21, 26 and 11) 2. Based on observation, interview and record review, the facility failed to continuously provide supervision for 5 of 5 residents who were observed smoking. (Residents 4, 27, 28, 34 and 51) Findings include: 1A. A clinical chart review was completed on 3/6/18 at 10:18 A.M., and indicated Resident 30's [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 1/23/18 indicated the Resident 30 had a BIMS ( Brief Interview for Mental Status) score of 3, moderately cognitively impaired. She required extensive assist of two staff for bed mobility, transfers, dressing, toileting, is always incontinent of bladder and not on a toileting program. Nurses note, dated 11/9/17 at 5:22 P.M., indicated nurse and certified nursing assistant heard a noise coming from the residents room. Resident was found on the floor between bed and bedside table. A Rehab screen, dated 11/13/17, recommended frequent checks when resident is in the bedroom in bed and supervision when in wheel chair. A nurses note, dated 11/15/17 at 7:30 P.M., indicated the resident was found on the floor laying on her right side. Rehab screen, dated 11/16/18 recommended, the patient requires frequent checks when in bed. A nurses note, dated 11/22/17 at 11:45 P.M., indicated resident had fallen out of bed. Rehab screen, dated 11/27/17, recommended wearing gripper socks at all times. A nurses note, dated 11/28/17 at 1:20 P.M., indicated resident was found on her knees behind her wheel chair with one shoe on and one shoe off wearing regular socks. Rehab screen, dated 11/29/17, recommended dressing in bilateral shoes with gripper socks. A nurses note, dated 12/19/17 at 1:55 A.M., indicated the resident was found on the bathroom floor, wearing regular socks. Rehab screen, dated 12/20/17, recommended physical therapy if hospice will ok. A nurses note, dated 1/11/18 at 11:52 A.M., indicated the resident stood up while in the dining room and lost balance and fell into the arm rest of a chair that another resident was sitting in hitting the left side of her ribs, then slid down the side of the chair. A nurses note, dated 1/11/18 at 5:39 P.M., indicated an xray was completed on the left rib area. A X-ray report, dated 1/11/18, indicated Resident 30 had acute fractures lateral seventh through ninth ribs. A current, care plan problem dated 12/7/15, indicated the resident is at risk for injury related to falls. Interventions included, but were not limited to: anticipate common personal needs, assess injuries an initiate neuro checks if an unwitnessed fall or seen hitting/signs of hitting head, assist to toilet upon rising, before and after meals and before HS (hour of sleep) and prn, assist with all transfers due to right side weakness, bed in lowest position with lip mattress, busy apron on top of sensory mat, demonstrate use of call light and ensure call light is within reach at all times, hip protectors, non skid footwear on with transferring and walking, none skid strips in front of bed, resident to be supervised when in wheel chair, resident to be in line of sight at all times when out of bed, staff to check resident frequently while in bed. A resident observation record, dated 2/6/18, indicated Resident 30 was to be on 15 minute checks. Documentation was complete from 7:45 P.M. to 10:00 P.M. The record lacked any further documentation of the 15 minute observations being completed after 10:00 P.M. During an observation of Resident's 30 room, on 3/6/18 at 10:21 A.M., there were no non skid strips to the floor in front of the bed. During an observation on 3/6/18, from 10:21 A.M. to 11:22 A.M., there were no staff observed to check on or enter Resident 30's room during that time. During an observation on 3/7/18 at 5:45 A.M., Resident 30 was lying in bed on her left side fully clothed with regular socks on. During an interview, on 3/7/18 at 5:46 A.M., certified nursing assistant 38 indicated she did not know that Resident 30 should be wearing non skid socks at all times. During an observation on 3/8/18 at 8:45 A.M., Resident 30 was in the dining room with regular socks on. During an observation on 3/8/18 at 9:02 A.M., Resident 30 was in bed with regular socks on. During an interview, on 3/7/18 at 3:53 P.M., the Director of Nursing indicated there were no non skid strips on the floor and that the fall interventions had not been followed. 1B. A clinical chart review was completed on 3/7/18 at 3:49 P.M., indicating Resident 21's [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 7/6/17, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 5, severe cognitive impairment. She required extensive assist of two staff for bed mobility, transfers, dressing, toileting, one staff assist for eating and is always incontinent of bladder. Has limitations to lower extremities and does not ambulate. A current care plan, dated 7/11/17, indicated the resident has the potential for falls related to muscle weakness. Interventions included, but were not limited to: bedside commode, is to have foot pedals on when in wheel chair to assist with proper positioning, will be toileted before going to bed and staff will ensure resident has appropriate footwear on when doing bed checks, be sure the resident's call light is in reach and encourage the resident to use it for assistance as needed. A nurses note, dated 12/9/17 at 7:15 P.M., indicated the resident was found on the floor in the lounge area, was trying to get up to sit on the couch. No foot pedals were on wheel chair prior to fall. Educated staff on keeping foot pedals on wheel chair. A nurses note, dated 12/27/17 at 4:02 P.M., indicated the resident was found on the floor by her bed, she was trying to get up to the bathroom. Therapy to evaluate for use of bedside commode. A nurses note, dated 3/3/18 at 6:01 P.M., indicated the resident was found leaning against the bed on the floor, re-educated resident on self transfers. 1C. A clinical chart review was completed on 3/5/18 at 3:27 P.M., indicating Resident 26's [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 1/16/18 indicated Resident 26 had a BIMS (Brief Interview for Mental Status) score of 4, severe cognitive impairment. He required extensive assist of two staff for bed mobility, transfers, dressing, toileting and limited assist of one staff for eating. He is frequently incontinent of bladder, not on a toileting program and had a fall prior to admission. An admission assessment, dated 1/5/18, indicated Resident 26 was at moderate risk for falls. A fall assessment, dated 2/18/18, indicated Resident 26 was at high risk for falls. A nurses note, dated 2/3/18 at 8:10 P.M., indicated CNA 38 (certified nursing assistant) walking by room and noted resident attempting to get put of bed and slid to the floor on knees. A nurses IDT note, dated 2/5/18 11:04 A.M., indicated the resident was attempting to stand up out of bed and was lowered to the floor by a staff member walking by the room. Intervention is for therapy to evaluate for enabler bars to be placed on the bed to assist with transfers/repositioning. A nurses note, dated 2/18/18 at 4:45 P.M., indicated the resident was found at this time in the hallway laying on the floor on his back. Resident was incontinent at that time. A nurses IDT note, dated 2/18/18 at 12:34 P.M.,indicated the resident took himself back to his room and attempted to self transfer to bed and fell to the floor. Intervention was to encourage resident to lay down after meals for a rest period. A rehab screen, dated 2/19/18 indicated the resident fell on [DATE] at 4:45 P.M., and was found on the floor on his back, wearing slippers, recommendation was for resident to have assistance during all functional transfers. A current care plan problem, dated 1/10/18, indicated the resident has potential for falls related to impaired mobility, weakness and Alzheimer's Dementia. Interventions included: Encourage/assist to bed after lunch, physical therapy to screen for transfers handles to assist with bed mobility, anticipate and meet the residents needs, therapy to evaluate and treat as ordered or as needed, quarterly fall assessments, be sure the residents call light is within reach and encourage the resident to use it The current certified nursing assistant assignment sheet indicated Resident 26 is encouraged to lay down after lunch, able to ambulate to the bathroom, can get confused, will wander an ambulate not using his wheel chair. During an interview on 3/07/18 at 3:25 P.M., the Director of nursing indicated she was unsure why the fall information was different and no further information was given on the interventions being appropriate. On 3/8/18 at 11:32 A.M., the Director of Nursing provided the policy titled, Fall Prevention and Assessment, dated 9/2012, and indicated the policy was the one currently used by the facility. The policy indicated . 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls. If underlying causes can not be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling 1D. A clinical record review was conducted on 3/7/2018 at 3:00 P.M., and indicated Resident 11's [DIAGNOSES REDACTED]. A nurses note, dated 10/15/2017 at 8:50 A.M., indicated .Resident attempted to self transfer from bed to wheelchair and forgot to lock her brakes. Resident fell and hit her head on the wall A nurses note, dated 10/16/2017 at 9:30 A.M., indicated .Resident found on floor in room. Attempted to self transfer from her bed to wheelchair and fell and .Anti rollbackbrakes to be applied to w/c A nurses note, dated 10/16/2017, indicated .Writer alerted by (certified nurse assistant)CNAs that the resident on the floor at this time and .Resident states that she was attempted to self transfer from bed to W/c(wheelchair) in order to use the RR and w/c brakes were not locked causing a fall A nurses note, dated 10/16/2017 at 12:31 P.M., indicated .Resident was found in her room lying on her bedroom floor on her left side perpendicular to her bed, residents left side of her face was against the adjacent bathroom wall, resident had no visible s/s of any new skin issues or injuries observed thus far this shift, resident stated that she had some minor discomfort to the left side of her face, which dissipated over the following hour post fall and .residents wheelchair was near her with brakes unlocked A work order, was provided and indicated Resident 11's antiroll brakes were applied to her wheelchair on 10/17/2017. During an interview on 3/8/2018 at 9:15 A.M., DON indicated Resident 11's antiroll brakes to her wheelchair should have been placed immediately. 2A. During an observation on 3/8/18 at 9:15 A.M., CNA (Certified Nursing Aide) 37 was standing in the area between the locked unit door and an outside exit door looking at a cell phone. Residents 4, 27, 28, 34 and 51 were outside, in the courtyard area smoking and none were wearing protective smoking aprons. There was a wall blocking the view of the residents smoking to CNA 37. During an interview, on 3/8/18 at 9:18 A.M., CNA 37 indicated she could not see all the residents outside and was not supervising them and indicated that the residents were not wearing smoking aprons. During an interview, on 3/8/18 at 9:47 A.M., the Director of Nursing indicated that the residents are to be supervised at all times and should be wearing aprons. On 3/8/18 at 9:47 A.M., the Director of Nursing provided the policy titled, Smoking Policy and Procedure, dated 11/28/16 and indicated the policy was the one currently used by the facility. The policy indicated . 6. All residents who some will be supervises to further insure safety. Smoking aprons will be provided if determined to be necessary 3.1-45(a)(2)

Based on record review and interview, the facility failed to assure 1 resident (Resident A) of 3 residents reviewed for code status in a sample of 3, was provided Cardiopulmonary Resuscitation (CPR) when the resident was found without respirations or a pulse, as ordered and according to the resident's wishes. Findings include: 1. The Director of Nursing Services (DNS), was interviewed, at 10:45 a.m., on [DATE], and indicated an incident occurred on [DATE] regarding Resident A. She indicated Resident A had been declining, and RN #1 had called the Nurse Practitioner, who left orders not to send the resident to the hospital, that the resident was in the process of dying and to leave the resident at the nursing home for "Comfort measures. " The DNS indicated the resident was later found cold with mottled skin and RN#1 did not do CPR (Cardiopulmonary resuscitation) because the nurse thought comfort measures only meant no CPR. The DNS indicated the resident was listed as a full code. Review of the closed record for Resident A, beginning at 1:15 p.m., on [DATE], indicated [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 7:30 a.m., indicated, "Res (resident) unresponsive to verbal stimuli T (temperature) 97.2 P (pulse) 125 R(respirations) 24 O2 (oxygen) sats (saturation) 86%, O2 2/L (liters), resident placed back to bed c (with) 2 assist, HOB(head of bed) (arrow pointing up), B/P (blood pressure) 50/palp(palpable). Skin pale, cool/dry. Unable to take any meds(medications.) The next nursing note, dated [DATE] at 9:15 a.m., indicated the Nurse Practitioner "wants resident kept comfortable." The oxygen saturation level was 97%, respirations were 24, and blood pressure ,[DATE]. The resident's color had improved slightly and the resident was "not so ashen et (and) pale." The nurse's note further indicated the resident remained on oxygen at 2 liters and required a total assist with all activities of daily living on [DATE]. The next nurse's note, dated [DATE] at 12:40 p.m., indicated the Nurse Practitioner was updated on the resident's condition, skin cool and clammy, respirations were 28, oxygen saturation level was 90%, pulse was 128 beats per minute. The nurse's note further indicated the resident would lift her head on occasion, was unable to respond, and the Nurse Practitioner "wants resident just kept comfortable", and the Director of Nursing Services (DNS) was notified of the resident's condition. A nurse's note, dated [DATE] at 1:43 p.m., indicated the resident was found "without respirations, pulse or blood pressure, extremities cool et mottled, N.P.( Nurse Practitioner) notified and order rec'd (received) to release body. " Review of the current physician orders [REDACTED]. Review of a "code classification form", dated [DATE], and signed by the resident, indicated the resident desired a full code to include CPR and potential transfer to hospital with physician order [REDACTED]. The form also indicated the resident had no living will, no health care representative, no Power of Attorney appointed, and no guardian appointed. The face sheet also indicated under the Advanced Directive section that the resident was a "Full Code. " A physician order, dated [DATE] at 12:40 p.m., indicated, "Keep resident comfortable. " Interviews were completed with the following staff, beginning at 11:47 a.m., on [DATE], and continuing through out the day on [DATE]: LPN #'s 3,4,5,6,7,and 8, and RN #'s 2 and 4. All of the RNs and LPNs interviewed indicated there were color coded "dots" on the outside of each resident's chart to indicate the code status of the resident. All indicated the "green" dots meant the resident was a "full code" and were to receive cardiopulmonary resuscitation, and the "red" dots indicated the resident was a DNR (do not resuscitate). They also indicated comfort measures only meant to keep the resident comfortable, with various responses including; keep comfortable if the resident does not want to eat, discontinue a lot of the medications given by mouth, keep on a turning schedule, feeding per choice, moisten the resident's mouth, and give pain medications. All of the nurses interviewed indicated even if a resident was comfort measures only, if the resident was designated as a full code, CPR would still be initiated. RN#1 was interviewed, at 10:24 a.m., on [DATE], regarding Resident A. She indicated she had worked at the facility since April, 2011. She indicated Resident A had been declining in the last month and required more and more care. She indicated on the morning of [DATE], she was called to the dining room during breakfast by a family member visiting another resident. She indicated she went to the dining room and Resident A was sitting at the dining room table, with her head on the table, moaning, and did not look good. She indicated one of the aides helped her put the resident to bed, she checked the resident's vital signs, and called the Nurse Practitioner. RN#1 indicated she could not remember if she got ahold of the Nurse Practitioner right away or she called later, but this would be in her nursing notes. At this time, RN#1 read the nursing notes she had documented on [DATE] regarding the incident, and indicated when she found the resident in the dining room, the resident was unresponsive. She indicated she didn't remember if the Nurse Practitioner was contacted prior to 9:15 a.m., on [DATE], as documented in the nursing notes, or if she contacted her earlier. The RN indicated the Nurse Practitioner had told her to keep the resident comfortable, and she thought this meant "let her die with dignity. " She indicated she didn't realize the resident was listed as a "full code" at the time of the incident because she did not look at the resident's code status on her chart. The RN indicated at 1:43 p.m., on [DATE], she was called to the resident's room, and the resident was cold, with mottled skin, and had no respirations, pulse, or blood pressure. She indicated she did not initiate CPR on the resident because she thought the Nurse Practitioner "said keep comfortable. " She indicated she had contacted the DNS, by phone, on [DATE], to inform her of the resident's condition, then indicated she could not remember if she knew the resident's code status was a full code. The Nurse Practitioner was interviewed, on the telephone, at 10:51 a.m., on [DATE]. She indicated she did not keep a record of the time she received phone calls, but indicated RN #1 had called her on [DATE] to let her know the resident was not as alert, but she was able to get her medications in, so the Nurse Practitioner indicated she told RN#1 not to send the resident to the hospital. The Nurse Practitioner indicated she did remind RN#1 the resident was a full code and she needed to follow the guidelines, as the resident's request had to be honored. She also indicated she would expect the RN to do a "full code" on the resident. The DNS was interviewed, at 11:00 a.m.., on [DATE], and indicated she had documented a statement, regarding a phone conversation with the Nurse Practitioner, on [DATE], and indicated the Nurse Practitioner had told the DNS to keep the resident comfortable, and she (the Nurse Practitioner) would not expect CPR to be initiated since the Nurse Practitioner had said to keep the resident comfortable. She indicated the Nurse Practitioner did not specify in the conversation on [DATE] not to do CPR, but told the DNS she would not expect her to do CPR on the resident. The DNS indicated she did talk to RN#1 on the telephone, on [DATE], after the RN had notified her the resident was declining, and the DNS indicated she told RN#1 if the Nurse Practitioner told her to keep the resident comfortable that she should leave the resident in the facility and keep her comfortable, but also told the RN that Resident A was a "full code" and she should send her to the hospital if necessary. The DNS indicated she knew this was confusing based on what the Nurse Practitioner said in her phone conversation. The DNS indicated the facility had no policy in place for Cardiopulmonary Resuscitation and Do Not Resuscitate, prior to this incident, but had written a policy after the incident. Review of the ongoing investigation, provided by the DNS, on [DATE], entitled "Resident Abuse Investigation Report Form", dated [DATE] at 1:43 p.m., indicated the DNS had received a phone call and "discovery that CPR was not administered" on Resident A. Under the area marked as "Type of Abuse" was marked as "Neglect or injury which involved staff not following plan of care; or severe injury of unknown origin. " Investigation Notes documented by the DNS, and dated [DATE], indicated the DNS was contacted at approximately 12:30 p.m., on [DATE], by RN#1, and notified Resident A was in poor health and the Nurse Practitioner was contacted. The DNS indicated in her note that the Nurse Practitioner did not give the order to send the resident to the hospital, but wanted her to be kept comfortable. The note indicated RN#1 stated the resident was a full code status and inquired if that meant the resident should be sent to the hospital. The DNS replied to RN#1 the resident should be kept comfortable per the Nurse Practitioner's order, but a full code status required CPR be performed if needed. The investigative note indicated the DNS received a phone call from RN#1 at approximately 2:00 p.m., regarding Resident's A passing, and the DNS asked RN#1 if CPR had been initiated, and 911 called. RN#1 indicated she did not initiate CPR and 911 was not called. RN#1 informed the DNS that the resident had been found cold with mottled extremities, and no vital signs, so she thought "that we were keeping her comfortable. " The DNS informed RN#1 she should have performed CPR, called 911, and continued until Emergency Medical Services arrived. The DNS also explained the difference between comfort measures and full code status versus DNR status to RN#1. Another investigation note, signed by the DNS, and the Nurse Practitioner, and dated [DATE], indicated the Nurse Practitioner stated she was notified by RN#1 regarding Resident A's decline and the Nurse Practitioner told RN#1 to keep the resident comfortable with no further orders. The Nurse Practitioner stated she did not tell RN#1 not to do CPR, but did not expect it would be done since she wanted the resident kept comfortable. This Federal tag relates to Complaint IN 867. 3XXX,[DATE](a)

Based on record review and interview, the facility failed to assure 1 resident (Resident A) of 3 residents reviewed for code status in a sample of 3, was provided Cardiopulmonary Resuscitation (CPR) according to the resident's advance directive. Findings include: 1. The Director of Nursing Services (DNS), was interviewed, at 10:45 a.m., on [DATE], and indicated an incident occurred on [DATE] regarding Resident A. She indicated Resident A had been declining, and RN #1 had called the Nurse Practitioner, who left orders not to send the resident to the hospital, that the resident was in the process of dying and to leave the resident at the nursing home for "Comfort measures. " The DNS indicated the resident was later found cold with mottled skin and RN#1 did not do CPR (Cardiopulmonary resuscitation) because the nurse thought comfort measures only meant no CPR. The DNS indicated the resident was listed as a full code. Review of the closed record for Resident A, beginning at 1:15 p.m., on [DATE], indicated [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 7:30 a.m., indicated, "Res (resident) unresponsive to verbal stimuli T (temperature) 97.2 P (pulse) 125 R(respirations) 24 O2 (oxygen) sats (saturation) 86%, O2 2/L (liters), resident placed back to bed c (with) 2 assist, HOB(head of bed) (arrow pointing up), B/P (blood pressure) 50/palp(palpable). Skin pale, cool/dry. Unable to take any meds(medications.) The next nursing note, dated [DATE] at 9:15 a.m., indicated the Nurse Practitioner "wants resident kept comfortable." The oxygen saturation level was 97%, respirations were 24, and blood pressure ,[DATE]. The resident's color had improved slightly and the resident was "not so ashen et (and) pale." The nurse's note further indicated the resident remained on oxygen at 2 liters and required a total assist with all activities of daily living on [DATE]. The next nurse's note, dated [DATE] at 12:40 p.m., indicated the Nurse Practitioner was updated on the resident's condition, skin cool and clammy, respirations were 28, oxygen saturation level was 90%, pulse was 128 beats per minute. The nurse's note further indicated the resident would lift her head on occasion, was unable to respond, and the Nurse Practitioner "wants resident just kept comfortable", and the Director of Nursing Services (DNS) was notified of the resident's condition. A nurse's note, dated [DATE] at 1:43 p.m., indicated the resident was found "without respirations, pulse or blood pressure, extremities cool et mottled, N.P.( Nurse Practitioner) notified and order rec'd (received) to release body. " Review of the current physician orders [REDACTED]. Review of a "code classification form", dated [DATE], and signed by the resident, indicated the resident desired a full code to include CPR and potential transfer to hospital with physician order [REDACTED]. The form also indicated the resident had no living will, no health care representative, no Power of Attorney appointed, and no guardian appointed. The face sheet also indicated under the Advanced Directive section that the resident was a "Full Code. " A physician order, dated [DATE] at 12:40 p.m., indicated, "Keep resident comfortable. " Interviews were completed with the following staff, beginning at 11:47 a.m., on [DATE], and continuing through out the day on [DATE]: LPN #'s 3,4,5,6,7,and 8, and RN #'s 2 and 4. All of the RNs and LPNs interviewed indicated there were color coded "dots" on the outside of each resident's chart to indicate the code status of the resident. All indicated the "green" dots meant the resident was a "full code" and were to receive cardiopulmonary resuscitation, and the "red" dots indicated the resident was a DNR (do not resuscitate). They also indicated comfort measures only meant to keep the resident comfortable, with various responses including; keep comfortable if the resident does not want to eat, discontinue a lot of the medications given by mouth, keep on a turning schedule, feeding per choice, moisten the resident's mouth, and give pain medications. All of the nurses interviewed indicated even if a resident was comfort measures only, if the resident was designated as a full code, CPR would still be initiated. RN#1 was interviewed, at 10:24 a.m., on [DATE], regarding Resident A. She indicated she had worked at the facility since April, 2011. She indicated Resident A had been declining in the last month and required more and more care. She indicated on the morning of [DATE], she was called to the dining room during breakfast by a family member visiting another resident. She indicated she went to the dining room and Resident A was sitting at the dining room table, with her head on the table, moaning, and did not look good. She indicated one of the aides helped her put the resident to bed, she checked the resident's vital signs, and called the Nurse Practitioner. RN#1 indicated she could not remember if she got ahold of the Nurse Practitioner right away or she called later, but this would be in her nursing notes. At this time, RN#1 read the nursing notes she had documented on [DATE] regarding the incident, and indicated when she found the resident in the dining room, the resident was unresponsive. She indicated she didn't remember if the Nurse Practitioner was contacted prior to 9:15 a.m., on [DATE], as documented in the nursing notes, or if she contacted her earlier. The RN indicated the Nurse Practitioner had told her to keep the resident comfortable, and she thought this meant "let her die with dignity. " She indicated she didn't realize the resident was listed as a "full code" at the time of the incident because she did not look at the resident's code status on her chart. The RN indicated at 1:43 p.m., on [DATE], she was called to the resident's room, and the resident was cold, with mottled skin, and had no respirations, pulse, or blood pressure. She indicated she did not initiate CPR on the resident because she thought the Nurse Practitioner "said keep comfortable. " She indicated she had contacted the DNS, by phone, on [DATE], to inform her of the resident's condition, then indicated she could not remember if she knew the resident's code status was a full code. The Nurse Practitioner was interviewed, on the telephone, at 10:51 a.m., on [DATE]. She indicated she did not keep a record of the time she received phone calls, but indicated RN #1 had called her on [DATE] to let her know the resident was not as alert, but she was able to get her medications in, so the Nurse Practitioner indicated she told RN#1 not to send the resident to the hospital. The Nurse Practitioner indicated she did remind RN#1 the resident was a full code and she needed to follow the guidelines, as the resident's request had to be honored. She also indicated she would expect the RN to do a "full code" on the resident. The DNS was interviewed, at 11:00 a.m.., on [DATE], and indicated she had documented a statement, regarding a phone conversation with the Nurse Practitioner, on [DATE], and indicated the Nurse Practitioner had told the DNS to keep the resident comfortable, and she (the Nurse Practitioner) would not expect CPR to be initiated since the Nurse Practitioner had said to keep the resident comfortable. She indicated the Nurse Practitioner did not specify in the conversation on [DATE] not to do CPR, but told the DNS she would not expect her to do CPR on the resident. The DNS indicated she did talk to RN#1 on the telephone, on [DATE], after the RN had notified her the resident was declining, and the DNS indicated she told RN#1 if the Nurse Practitioner told her to keep the resident comfortable that she should leave the resident in the facility and keep her comfortable, but also told the RN that Resident A was a "full code" and she should send her to the hospital if necessary. The DNS indicated she knew this was confusing based on what the Nurse Practitioner said in her phone conversation. The DNS indicated the facility had no policy in place for Cardiopulmonary Resuscitation and Do Not Resuscitate, prior to this incident, but had written a policy after the incident. Review of the ongoing investigation, provided by the DNS, on [DATE], entitled "Resident Abuse Investigation Report Form", dated [DATE] at 1:43 p.m., indicated the DNS had received a phone call and "discovery that CPR was not administered" on Resident A. Under the area marked as "Type of Abuse" was marked as "Neglect or injury which involved staff not following plan of care; or severe injury of unknown origin. " Investigation Notes documented by the DNS, and dated [DATE], indicated the DNS was contacted at approximately 12:30 p.m., on [DATE], by RN#1, and notified Resident A was in poor health and the Nurse Practitioner was contacted. The DNS indicated in her note that the Nurse Practitioner did not give the order to send the resident to the hospital, but wanted her to be kept comfortable. The note indicated RN#1 stated the resident was a full code status and inquired if that meant the resident should be sent to the hospital. The DNS replied to RN#1 the resident should be kept comfortable per the Nurse Practitioner's order, but a full code status required CPR be performed if needed. The investigative note indicated the DNS received a phone call from RN#1 at approximately 2:00 p.m., regarding Resident's A passing, and the DNS asked RN#1 if CPR had been initiated, and 911 called. RN#1 indicated she did not initiate CPR and 911 was not called. RN#1 informed the DNS that the resident had been found cold with mottled extremities, and no vital signs, so she thought "that we were keeping her comfortable. " The DNS informed RN#1 she should have performed CPR, called 911, and continued until Emergency Medical Services arrived. The DNS also explained the difference between comfort measures and full code status versus DNR status to RN#1. Another investigation note, signed by the DNS, and the Nurse Practitioner, and dated [DATE], indicated the Nurse Practitioner stated she was notified by RN#1 regarding Resident A's decline and the Nurse Practitioner told RN#1 to keep the resident comfortable with no further orders. The Nurse Practitioner stated she did not tell RN#1 not to do CPR, but did not expect it would be done since she wanted the resident kept comfortable. This Federal tag relates to Complaint IN 867. 3XXX,[DATE](f)(5) 3XXX,[DATE](f)(7)