Every finding on record at Waters Edge Village

Based on observation, interview, and record review, the facility failed to ensure daily staffing was posted in a timely manner.Finding includes:During a 3/9/26 observation at 10:50 a.m. , an empty plastic binder labelled Daily Staffing Hours, was observed outside the Business Office. During a 3/11/26 observation at 8:07 a.m. , the daily nursing hours binder contained staffing for 3/9/26 and 3/10/26. The binder lacked staffing for 3/11/26.During a 3/12/26 observation at 8:31 a.m. , the daily nursing hours binder contained staffing for 3/9/26 and 3/10/26. Staffing for 3/11/26 and 3/12/26 was observed in the binder at 10:31 AM.During a 3/13/26 observation at 8:18 a.m. , the daily nursing hours binder contained staffing for 3/11/26 and 3/12/26. During a 3/13/26 interview at 11:13 a.m. , the Administrator indicated he was responsible for posting the daily staffing hours. Staffing for the current day (3/13/26) was located behind the staffing paper observed (3/11/26 and 3/12/26). The paperwork for 3/13/26 and 3/14/26 would not be posted until the actual hours worked for 3/12/26 were reported. Residents and visitors would not be able to see staffing information for the current day without taking the papers out of the plastic binder. A current facility policy titled, Posted Nurse Staffing Data and Retention Requirements revised 12/2025, and provided by the Administrator on 3/13/26 at 11:37 a.m., indicated the following: .Procedure: 1. The facility must post the following information at the beginning of each shift a. The facility name b. The current date c. Resident census d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.12. The Nursing Staffing Data should be updated each shift if there are changes to the daily posting.

Based on interview and record review the facility failed to complete thorough and accurate investigations of resident-to-resident abuse to mitigate risk to other residents for 5 of 5 residents reviewed for abuse. (Resident B, Resident C, Resident D, Resident E, and Resident F.)Findings include:Resident B's clinical record was reviewed on 2/2/26 at 10:37 a.m. Diagnoses included dementia, hypertension, major depressive disorder, and anxiety.A current resident care plan indicated a 12/25/25 problem of Resident B may have threatened to hit or physically attack other residents. Resident B may also shove. Resident B may also have episodes of shoving, hitting, scratching. Review of Resident B's progress notes indicated the following:12/14/25 at 2:00 p.m. The resident pushed another resident out his personal space, causing the other resident to lose balance. Resident B was placed on 1-on-1 monitoring.1/15/26 at 7:45 a.m. Resident B reportedly shoved another resident causing a fall.1/23/26 at 6:34 p.m. Resident B pushed another resident against the wall in the hallway, creating a laceration to the right side of the other resident's head and bruising to her right shoulder. The physician was notified and the resident was transferred to the emergency room (ER).1.Resident E's clinical record was reviewed on 2/3/26 at 9:52 a.m. Diagnoses included dementia, generalized anxiety disorder, and mild neurocognitive disorder due to known physiological condition.A 12/16/25, quarterly, MDS assessment indicated the resident was severely cognitively impaired.Review of the resident's current care plan, last reviewed/revised on 12/22/25, indicated a 4/17/23 problem of the resident is at risk for falls due to impaired mobility, respiratory failure, sepsis, pneumonia, medications, and age. Interventions included (12/15/25) encourage the resident to not be in others' personal space.A 12/14/25 at 2:01 p.m., Fall Event note indicated the following:Description: Resident lost balance, which caused the resident to fall onto the ground on buttocks.Was fall witnessed: noDescribe what the resident was doing prior to the fall: Resident was walking down the hall, while approaching another resident, who then pushed resident out of his personal space which caused resident to lose balance.Position of resident when first observed after fall: Resident sitting on buttocks on floor, legs straight out in front of resident, back up against wallResident/Witness statement of how fall occurred: Resident reports walking down the hallway when fall occurred.Interventions put in place to prevent another fall: Residents to be separated.Notifications: Physician and resident representative were notified 12/18/25 at 9:07 a.m.A 12/15/25 2:01 p.m. IDT Fall Review indicated the following: Date/Time of fall: 12/14/25 at 2:01 p.m. Resident was close to another resident and other resident pushed her, causing her to fall. No injuries sustained, no ER transfer, no change in condition were noted. Determined root cause for the fall was the resident being in another resident's personal space. Interventions included staff encouraging the resident to not be in other's personal spaces.2.Resident F's clinical record was reviewed on 2/3/26 at 11:20 a.m. Diagnoses included vascular dementia with unspecified severity and other behavioral disturbance, psychotic disorder with delusions due to known physiological condition, and anxiety disorder.A 12/30/25, quarterly, MDS assessment, indicated the resident was severely cognitively impaired. No behaviors were present during the assessment period.A progress note, dated 1/16/26 at 12:57 p.m., indicated Resident F had a fall on 1/15/26 at 8:30 a.m. Resident F was pushed by another resident and lost her balance, resulting in a fall without injury. The determined root cause of the fall was loss of balance after being pushed. The interventions put in place to address the root cause of the fall included a stop sign placed on the doorway of the room she preferred to wander into.3.Resident D's clinical record was reviewed on 2/2/26 at 3:16 p.m. Diagnosis included severe dementia without behavioral disturbance, psychotic disturbance, mood disturbance, schizophrenia, and anxiety disorder.A 1/14/26, quarterly, MDS assessment indicated the resident was moderately cognitively impaired. No behaviors were exhibited during the assessment period. The resident required a wheelchair for mobility. Resident D required partial assistance from staff for transfers. He did not have any falls since the prior assessment. Resident D's progress notes indicated the following:A progress note, dated 1/23/26 at 6:18 p.m., indicated a CNA notified the nurse that Resident D was sitting on the floor between the bed and the wheelchair. The resident stated another resident pushed him to the floor from the bed. The resident denied pain. No injuries were noted on assessment.On 1/24/26 at 10:21 p.m., Resident D was assessed related to a resident-to-resident altercation. Resident D reported the crazy man punched him in the head and then pushed him out of the wheelchair. No injuries were found.On 1/26/26 at 1:47 p.m., an IDT note indicated the resident fell on 1/23/26 at 6:25 p.m. The resident stated another resident came into his room and pushed him to the floor. The resident was sitting upright on the floor beside the wheelchair with no injuries. An immediate intervention put into place at the time of the fall included: The resident chose to be assisted to bed. The intervention put into place to address the root cause of the fall included a stop sign to the resident's doorway to help detour other residents from entering the room.Review of the facility's investigation files, provided by the Administrator following entrance conference, lacked investigations for the resident to resident abuse of Resident E, Resident F, and Resident D by Resident B. During an interview on 2/2/26 at 3:54 p.m., the Administrator indicated the entirety of the facility investigations was included in the files and all abuse investigations for the past 60 days had been provided. During an interview, on 2/4/26 at 4:08 p.m., the Administrator indicated a resident-to-resident altercation that occurred on 1/15/26 between Resident B and Resident F was reported to him. He was uncertain who reported it to him and when it was reported. He was told that Resident B pushed Resident F and Resident F fell because she went into Resident B's room. Resident F was not injured or in distress. Pushing residents down could be considered abusive depending on the circumstances. It was considered a behavior that needed reviewed when the same resident kept pushing other residents down. Cross reference F600. This citation relates to Intake 2727442.3.1-28(d)

[NAME] on observation, interview, and record review, the facility failed to protect residents' rights to be free from resident-to-resident physical abuse for 4 of 5 residents reviewed for abuse. (Residents C, D, E and F)Findings include:Resident B's clinical record was reviewed on 2/2/26 at 10:37 a.m. Diagnoses included dementia, hypertension, major depressive disorder, and anxiety. An 11/10/25, admission, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired with fluctuating levels of inattention and disorganized thinking observed during the assessment period. A current resident care plan indicated a 12/25/25 problem of Resident B may have threatened to hit or physically attack other residents. Resident B may also shove. Resident B may also have episodes of shoving, hitting, scratching. Interventions included 1/23/26 encourage fluids and make sure fluids are in reach, 1/16/26 added stop sign to keep others out of room, offer to take a walk, 1/15/26 likes to tinker per family - offer to disabling a remote, offer PVC pipes and fittings, 1/9/26 show pictures of grandchildren, and 12/25/25 listen and respond to or anticipate needs. Review of Resident B's progress notes indicated the following: 12/14/25 at 2:00 p.m. The resident pushed another resident out his personal space, causing the other resident to lose balance. Resident B was placed on 1-on-1 monitoring. 12/25/25 at 11:16 a.m. The resident was speaking to a male peer in the common area when a female resident walked near him. He turned and pushed her, causing her to fall and kicked her in the abdomen. The residents were separated and resident B was placed on 1-on-1 monitoring. 12/25/25 at 2:40 p.m. A referral was made to inpatient psychiatric care. 12/25/25 at 2:49 p.m. The resident was visiting with family, telling them everyone knows what he did, he is a child molester, and I guess I lost my temper. 12/26/26 at 3:25 a.m. The resident removed a plastic frame from the wall in his room. He remained on 1-on-1 supervision. 12/26/26 at 2:40 p.m. The resident was transported to inpatient psychiatric care. The resident returned to the facility on 1/5/26. 1/8/26 at 3:13 p.m. The resident threw his phone into the dining room at the wall and shouted expletives. 1/8/26 at 4:07 p.m. His antipsychotic medication was increased and he was placed on 15-minute checks. 1/13/26 at 1:56 p.m. Resident B paced around another resident's room. 1/15/26 at 7:45 a.m. Resident B reportedly shoved another resident causing a fall. 1/15/26 at 11:50 a.m. Interdisciplinary Team (IDT) met with family to discuss behavioral expression. Family expressed interest in referral to a smaller facility. 1/16/26 at 10:27 a.m. Resident B wandered into other resident rooms. 1/17/26 at 6:26 a.m. Resident B was agitated in his room and said, I am going to break this place and have broken some hangers this time. 1/18/26 at 9:38 a.m. Resident B became agitated attempting to vocalize wants, pulling on other resident's wheelchairs, jerking, and yelling at staff members. 1/18/26 at 9:00 p.m. Resident B was pacing hallways, wandering in and out of other residents' rooms, and punching walls. He became aggressive with staff by drawing back his fist when staff attempted to use non-pharmacological redirection. 1/19/26 at 1:39 p.m. Resident's B's family requested a referral to inpatient psychiatric care. 1/19/26 at 1:40 p.m. Resident B was wandering in other resident rooms and shouted expletives when staff attempted to redirect him. He stood in the hallway picking at things in the air and on the floor that were not there. 1/23/26 at 1:16 a.m. Resident B threw his cup at his roommate, who was resting in bed. He was confused and mumbled incoherently when staff attempted to reorient him. 1/23/26 at 2:23 p.m. Resident B was pushing dining room chairs across the floor. When staff attempted to redirect told staff, I'll rip your f**king head off. 1/23/26 at 2:37 p.m. The IDT was aware of resident behaviors such as wandering, throwing items, pushing and throwing dining room chairs. Staff attempted multiple interventions without success. 1/23/26 at 6:34 p.m. Resident B pushed another resident against the wall in the hallway, creating a laceration to the right side of the other resident's head and bruising to her right shoulder. The physician was notified and the resident was transferred to the emergency room (ER). 1/29/26 at 11:53 a.m. The IDT met to review the resident's chart. Resident B was transferred to inpatient psychiatric services on 1/28/26. Resident B remained out of the facility during the survey dates. Review of a 12/25/25 facility reported incident, submitted to IDOH (Indiana Department of Health) indicated Resident B was having a conversation with a male peer in the common area of the dementia unit when Resident E passed by them. Resident B turned toward Resident E and pushed her, resulting in a fall. No injury was reported. Preventative measures included monitoring residents for psychosocial distress. Resident B was placed on 1:1 care. Residents will remain separated during meals and activities. Root cause was to be determined. Follow up, included on 12/29/25, indicated Resident B was transferred to inpatient psychiatric care for aggressive behavior. He suffered from dementia and believed the female resident was a male and a child molester. Staff and family were unable to redirect this delusion. Care plans were to be updated once updated information from psychiatry was obtained. All medications and non-pharmacological interventions were reviewed. A 1/23/26 at 7:18 p.m. facility reported incident to IDOH indicated, on 1/23/26, Resident B made contact with Resident C, causing her to hit her head on a door jamb. Resident C sustained a shallow laceration (a cut) and hematoma (bruising) to the side of her head. Action taken- Staff intervened promptly and separated the residents. Full body assessments were completed with no other apparent injuries not listed in the injury section. Resident B was placed on 1:1 observation. The residents will be kept separated during meals and activities. Resident B will be seen by facility psychiatric services. Root cause will be investigated and appropriate interventions will be put in place to help prevent further altercations. Follow up, included on 1/27/26, indicated Resident B remained in the hospital. The plan was to transfer from the hospital to an inpatient psychiatric unit when he was deemed stable for transfer. IDT will attempt to determine root cause and implement appropriate interventions. Resident C was recovering and had no lasting psychosocial issues. A document included in the facility investigation for the altercation between Residents B and E, titled 1/26/26 Behavior/High Risk Peer Review, indicated Resident B had previous incidents pushing other residents. 12/25/25 Resident B pushed Resident E causing her to have a fall. Per progress notes review, 1/15/26 resident B shoved another resident causing them to fall. Resident B's clinical record lacked care plan interventions specific to mitigating the risk of Resident B engaging in resident-to-resident altercations. A 12/25/25 statement, signed by Housekeeper 25, indicated she observed Resident B acting aggressive about some pants he was holding. Resident E walked by, into the dining room. The housekeeper heard a loud noise and observed Resident E on the ground. Staff were trying to get Resident B back, but he kicked Resident E, so she ran in between them and stood over Resident E. Resident B tried to kick again, and staff took him down the hall and shut the big door. During an interview on 2/2/26 at 4:05 p.m., RN 4 indicated, on 1/23/26, she observed Resident B push Resident C against a wall. Resident B looked mad and aggressive. Resident B was previously on 15-minute checks and 1-on-1 care due to previous aggressive behaviors toward Residents E and F. During a telephone interview on 2/2/26 at 4:35 p.m., CNA 5 indicated Resident B frequently became overstimulated around other residents on the dementia unit. On 1/23/26, he was teetering with his emotions and staff would leave him alone, in an effort to not trigger him. She and CNA 19 were performing patient care and Resident C approached them and said there was a man in another man's room. The CNAs went down the hallway and Resident B came out of a room with an aggressive look on his face, so CNA 5 and CNA 19 put Resident C in front of them and began walking away from Resident B. Resident B then pushed CNA 5 and pushed Resident C into the wall. CNA 5 covered Resident C with her body, then several staff entered the dementia unit. The residents were separated and a fire door between the main area of the unit and resident rooms were closed to further separate the two residents. CNA 22 was heard shouting that Resident D was on the floor of his room. During the days prior to this incident, Resident B was intermittently on 1-on-1 care. During an interview on 2/4/26 at 4:11 p.m. the Administrator indicated he was notified by phone by RN 8 of an altercation with Residents B and C. Resident C approached CNA 5, stating two residents were going at it. 1.Resident E's clinical record was reviewed on 2/3/26 at 9:52 a.m. Diagnoses included dementia, generalized anxiety disorder, and mild neurocognitive disorder due to known physiological condition. A 12/16/25, quarterly, MDS assessment indicated the resident was severely cognitively impaired. Review of the resident's current care plan, last reviewed/revised on 12/22/25, indicated a 4/17/23 problem of the resident is at risk for falls due to impaired mobility, respiratory failure, sepsis, pneumonia, medications, and age. Interventions included (12/15/25) encourage the resident to not be in others' personal space. A 12/14/25 at 2:01 p.m., Fall Event note indicated the following: Description: Resident lost balance, which caused the resident to fall onto the ground on buttocks. Was fall witnessed: no Describe what the resident was doing prior to the fall: Resident was walking down the hall, while approaching another resident, who then pushed resident out of his personal space which caused resident to lose balance. Position of resident when first observed after fall: Resident sitting on buttocks on floor, legs straight out in front of resident, back up against wall Resident/Witness statement of how fall occurred: Resident reports walking down the hallway when fall occurred. Interventions put in place to prevent another fall: Residents to be separated. Notifications: Physician and resident representative were notified 12/18/25 at 9:07 a.m. A 12/15/25 2:01 p.m. IDT Fall Review indicated the following: Date/Time of fall: 12/14/25 at 2:01 p.m. Resident was close to another resident and other resident pushed her, causing her to fall. No injuries sustained, no ER transfer, no change in condition were noted. Determined root cause for the fall was the resident being in another resident's personal space. Interventions included staff encouraging the resident to not be in other's personal spaces. A 12/25/25 at 11:00 a.m. Fall Event indicated the following: Description: Resident shoved and kicked by another resident Was fall witnessed: yes Is the resident on blood thinning medications: yes Describe what the resident was doing prior to fall: Resident was walking past another resident, when another resident shoved this resident to the floor (resident did not strike head) and kicked them. Position of resident when first observed after fall: Resident on floor having been shoved and kicked by the other resident and was sitting upright. Fall location: Dementia unit dining room Resident/witness statement of how fall occurred: Resident was walking past other resident, when other resident shoved resident to floor (resident did not strike head) and kicked resident. Interventions put in place to prevent another fall: Staff separated other resident from resident to create safe space for resident. Assess resident and noted no signs/symptoms of injury. Nurse Practitioner (NP) and contact notified. A 12/25/25 at 11:00 a.m. progress note indicated Resident E was walking past another resident when the other resident shoved her down and kicked her in the stomach. Resident E exhibited no signs/symptoms of injury. Resident E voiced no complaints, but was intermittently tearful. During a telephone interview on 2/3/26 at 4:47 p.m. CNA 21 indicated she was on duty and witnessed the altercation on 12/25/25 between Residents B and E. Resident B was sitting across from the dining room yelling at another resident on the other side of the dining room. Resident E walked into the dining room and was pushed by Resident B, causing her to fall. Then he kicked her in the stomach and had his fists drawn back and CNA 21 was able to get between them. She took Resident B to his room. She indicated she wrote out a statement for the altercation. During an interview on 2/2/26 at 4:05 p.m., RN 4 indicated Resident B had shown previous aggressive behaviors toward Resident E. 2.Resident F's clinical record was reviewed on 2/3/26 at 11:20 a.m. Diagnoses included vascular dementia with unspecified severity and other behavioral disturbance, psychotic disorder with delusions due to known physiological condition, and anxiety disorder. A 12/30/25, quarterly, MDS assessment, indicated the resident was severely cognitively impaired. No behaviors were present during the assessment period. A progress note, dated 1/16/26 at 12:57 p.m., indicated Resident F had a fall on 1/15/26 at 8:30 a.m. Resident F was pushed by another resident and lost her balance, resulting in a fall without injury. The determined root cause of the fall was loss of balance after being pushed. The interventions put in place to address the root cause of the fall included a stop sign placed on the doorway of the room she preferred to wander into. During an interview on 2/2/26 at 4:05 p.m., RN 4 indicated Resident B had shown previous aggressive behaviors toward Resident F. During an interview on 2/3/26 at 2:46 p.m., QMA 18 indicated Resident F was known to randomly enter other residents' rooms from time to time to offer them snacks that her family brought into the facility. QMA 18 was present on the dementia unit when there was an altercation between Resident B and Resident F on 1/15/26. QMA 18 exited from another room to the hallway when she heard the CNA yelling, Oh my gosh. QMA 18 observed Resident F on the floor in the hallway, on the opposite side of the hallway, directly across from Resident B's room. Resident B was known to have previous physical altercations with Resident E and previous verbal altercations with other residents. Resident B had been agitated. The aide explained to QMA 18 that Resident F walked up to the door of Resident B's room and Resident B pushed Resident F, resulting in a fall. QMA 18 was instructed to keep Resident B and Resident F separated the remainder of the shift on 1/15/26. During an interview on 2/3/26 at 4:08 p.m., RN 20 indicated she was working on a different unit on 1/15/26 when QMA 18 reported a fall to her for Resident F. She completed a fall event note and did not find any injuries for Resident F. During a telephone interview on 2/3/26 at 4:32 p.m., CNA 21 indicated she witnessed what happened on 1/15/26 between Resident B and Resident F. Resident F came out of her room and was walking by Resident B's room on his side of the hallway when Resident B stepped forward from his doorway. Resident B pushed Resident F pretty hard. This propelled Resident F across the hallway, where she hit into the wall and door on the other side, and landed on the floor on her buttocks and left side. CNA 21 immediately intervened by closing Resident B's door. During an interview, on 2/4/26 at 12:30 p.m., LPN 10 indicated, on 1/15/26, an aide came to get her due to an altercation that occurred on the Dementia Unit. LPN 10 observed Resident F on the floor in the hallway, just through the doorway between the Dementia Unit and the dementia unit dining room. Resident B was in his room with an aide. CNA 21 told LPN 10 when Resident F walked past Resident B's room, Resident B stepped out of his room and pushed Resident F which resulted in Resident F's fall. LPN 10 assessed Resident F. She did not assess Resident B. On 2/4/26 at 4:08 p.m., the Administrator indicated he was told that Resident B pushed Resident F and she fell because she went into his room. Resident F was not injured or in distress. Pushing residents down could be considered abusive depending on the circumstances. This instance was considered a behavior that needed reviewed when the same resident kept pushing other residents down. 3.Resident D's clinical record was reviewed on 2/2/26 at 3:16 p.m. Diagnosis included severe dementia without behavioral disturbance, psychotic disturbance, mood disturbance, schizophrenia, and anxiety disorder. A 1/14/26, quarterly, MDS assessment indicated the resident was moderately cognitively impaired. No behaviors were exhibited during the assessment period. The resident required a wheelchair for mobility. Resident D required partial assistance from staff for transfers. He did not have any falls since the prior assessment. Resident D's progress notes indicated the following: A progress note, dated 1/23/26 at 6:18 p.m., indicated a CNA notified the nurse that Resident D was sitting on the floor between the bed and the wheelchair. The resident stated another resident pushed him to the floor from the bed. The resident denied pain. No injuries were noted on assessment. On 1/24/26 at 10:21 p.m., Resident D was assessed related to a resident-to-resident altercation. Resident D reported the crazy man punched him in the head and then pushed him out of the wheelchair. No injuries were found. On 1/26/26 at 1:47 p.m., an IDT note indicated the resident fell on 1/23/26 at 6:25 p.m. The resident stated another resident came into his room and pushed him to the floor. The resident was sitting upright on the floor beside the wheelchair with no injuries. An immediate intervention put into place at the time of the fall included: The resident chose to be assisted to bed. The intervention put into place to address the root cause of the fall included a stop sign to the resident's doorway to help detour other residents from entering the room. During an interview on 2/2/26 at 3:55 p.m., CNA 19 indicated she went into Resident D's room to check on him after Resident B was sent out to the hospital on 1/23/26. Resident D told CNA 19 some [NAME] came into his room, punched him in the back of his head while he was watching television in his wheelchair, then he fell from his chair after the individual hit him. On 2/2/26 at 4:39 p.m., RN 4 indicated she was working on the Dementia Unit on 1/23/26 when there was an altercation between Resident B and Resident C. The CNA explained to RN 4 that Resident B was seen coming from Resident D's room. RN 4 observed Resident D in his room on the floor. Resident D explained that Resident B shoved Resident D into the floor. She placed a note in the clinical record. During a telephone interview on 2/3/26 at 3:39 p.m., CNA 22 indicated he was called over to the Dementia Unit on 1/23/26 in the evening to assist with the aggressor, Resident B, for monitoring. CNA 22 observed Resident D sitting on the floor in Resident D's room. 4. Resident C's clinical record was reviewed on 2/2/26 at 1:39 p.m. Diagnoses included Alzheimer's disease and cognitive communication deficit. A late entry progress note dated 1/23/26 at 7:17 p.m. for 1/23/26 at 6:00 p.m., indicated the resident was involved in a physical altercation in the living area. The resident was pushed into a wall and struck on the right side of the head and has a laceration on the right side of the head and a bruise to her right shoulder. Staff immediately intervened and separated both residents. The resident was sent out to the Emergency Room. The charge nurse and POA were notified. During an interview on 2/2/26 at 3:55 p.m., CNA 19 indicated she was working on 1/23/26 along with CNA 5. At approximately 6:00 p.m. that day, Resident C came to CNA 19 and CNA 5 in the Dementia Unit dining area and reported to them that two men were in a room fighting. Before they got to Resident D's room, Resident B came out of Resident D's room. Resident B's fists were balled up, he was angry, and was headed towards CNA 5, CNA 19, and Resident C. CNA 5 and CNA 19 turned around and instructed Resident C to walk the other way towards the dining room. Resident B picked up the pace and caught up with them when they were near the doorway by the dining room. CNA 5 tried to shield resident C. Resident B grabbed Resident C and pushed her against the door jam. The aides yelled for assistance and the ADON helped separate Resident B from Resident C. Resident C suffered a bruise on her shoulder, a cut on her head, and was sent out. The ADON took Resident B down the Dementia Unit hallway and shut the door between the Dementia Unit and the dining room. CNA 19 and CNA 5 tried to go back down the Dementia Unit to Resident D's room to follow up on Resident C's report of fighting and they were redirected by the ADON to go back to the dining room. CNA 22 was called to the Dementia Unit to assist with monitoring Resident B on the Dementia Unit. When CNA 22 went down the unit hallway and stated Resident D was on the floor. During an interview on 2/4/26 at 1:17 p.m., the ADON indicated she had stopped on the Dementia Unit on 1/23/26 in the evening prior to leaving when she observed the resident-to-resident altercation between Resident B and Resident C. Resident B grabbed the back of Resident C's head and slammed her head against the metal door frame. Resident C had a small laceration on the right side of the head and immediate bruising to her right shoulder. On 2/4/26 at 4:08 p.m., the Administrator indicated the facility followed the Indiana Department of Health and Federal guidelines for abuse. A current facility policy, revised 6/2023, titled Abuse Prohibition, Reporting, and Investigation, provided by the administrator on 2/2/26 10:37 a.m., indicated the following: .It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This is includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion.American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents.Definitions/Examples of Abuse: Willfull, used in the definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury or harm. Abuse-Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish.Physical Abuse- A willful act against a resident by another resident, staff member, or other individual (s). Examples may include but not be limited to hitting, slapping, punching, and choking. Identification: Abuse includes: .2. Resident to resident abuse of any type.Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed.Resident to Resident Abuse:.6. The DNS/Designee will assess both resident involved to determine if physical injuries have occurred. A. Residents will be questioned (if alert and competent) about the nature of the incident. B. Statements will be taken from individuals witnessing the incident.9.It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system. 10. Follow up assessments will be completed/documented every shift until the resident (s) is stable, and resident (s) safety is maintained. 11. The Interdisciplinary Team will assess the situation and make recommendations for further interventions. 16. The Executive Director/Designee will analyze the occurrence to determine root cause, and what changes are needed to prevent further occurrence and report to the QAPI committee. 17. Based on the root cause, ED/Designee will determine how care provision will be changed. The care plan will be updated accordingly. 18. A comprehensive record of the abuse investigation will be kept by the facility Executive Director and/or Director of Nursing Services.Protection: 1. All residents will be protected from physical and psychological harm during and after the allegation and investigation. This will include: Provide increased supervision of the alleged victim and other residents.Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately.2. The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately.8. In cases where an altercation has occurred but does not meet the criteria for reporting, the facility must meet the following requirement: Appropriate assessment, Care planning by the interdisciplinary team, Providing care and services according to acceptable standards of practice to prevent harm as a result of resident-to-resident altercations, and The development and implementation of policies and procedures to prevent abuse of residents. 9. Upon completion of the investigation, which will occur within 5 working days of the reporting of an occurrence, a report of the investigation will be forwarded to the Long-Term Care Division of the Indiana State Department of Health. Copies of the completed investigation will also be sent to Adult Protective Services.10. It is the responsibility of every employee of American Senior Communities to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director.13. The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long-Term Care Incident Reporting Policy This citation relates to intake 2727422. 3.1-27(a)(1)

Based on interview and record review, the facility failed to report allegations involving abuse immediately to the Administrator and to the State Agency (Indiana Department of Health) as required for 2 of 5 residents reviewed for abuse. (Residents D and F)Findings include:Resident B's clinical record was reviewed on 2/2/26 at 10:37 a.m. Diagnoses included dementia, hypertension, major depressive disorder, and anxiety.An 11/10/25, admission, Minimum Data Set (MDS) indicated the resident was severely cognitively impaired with fluctuating levels of inattention and disorganized thinking observed during the assessment period.A current resident care plan indicated a 12/25/25 problem of Resident B may have threatened to hit or physically attack other residents. Resident B may also shove. Resident B may also have episodes of shoving, hitting, scratching. Interventions included 1/23/26 encourage fluids and make sure fluids are in reach, 1/16/26 added stop sign to keep others out of room, offer to take a walk, 1/15/26 likes to tinker per family - offer to disabling a remote, offer PVC pipes and fittings, 1/9/26 show pictures of grandchildren, and 12/25/25 listen and respond to or anticipate needs.Review of progress notes indicated the following:On 1/15/26 at 7:45 a.m., Resident B reportedly shoved another resident causing a fall.On 1/23/26 at 6:34 p.m., Resident B pushed another resident against the wall in the hallway, creating a laceration to the right side of the other resident's head and bruising to her right shoulder. The physician was notified and the resident was transferred to the emergency room (ER).Resident F's clinical record was reviewed on 2/3/26 at 11:20 a.m. Diagnoses included vascular dementia with unspecified severity and other behavioral disturbance, psychotic disorder with delusions due to known physiological condition, and anxiety disorder.A progress note, dated 1/16/26 at 12:57 p.m., indicated Resident F had a fall on 1/15/26 at 8:30 a.m. Resident F was pushed by another resident and lost her balance, resulting in a fall without injury. The determined root cause of the fall was loss of balance after being pushed. The interventions put in place to address the root cause of the fall included a stop sign placed on the doorway of the room she preferred to wander into.During an interview on 2/4/26 at 3:34 p.m., the DON indicated she was made aware of a resident-to-resident altercation between Resident B and Resident F, but she could not recall when it was reported or who reported it to her. She assumed she heard about it when she got to the facility. During an interview on 2/4/26 at 4:08 p.m., the Administrator indicated a resident-to-resident altercation between Resident B and Resident F was reported to him, but he was uncertain who reported it or when it was reported. He was told Resident B pushed Resident C and she fell because Resident C went into Resident B's room. The resident was not in distress and did not have any injuries. The altercation was not reported to IDOH because it did not meet the facility's guidance to do so. Residents pushing other residents down could be considered abuse, depending on the circumstances. When the same resident kept pushing other residents down, it was a behavior that needed to be looked at. He reviewed the statements from staff. The staff typically reported abuse and resident-to-resident altercations to the charge nurse. Then the charge nurse reported to the Administrator. If staff chose to, all of them may report the abuse and resident-to-resident altercations to the Administrator.Resident D's clinical record was reviewed on 2/2/26 at 3:16 p.m. Diagnosis included severe dementia without behavioral disturbance, psychotic disturbance, mood disturbance, schizophrenia, and anxiety disorder.A progress note, dated 1/23/26 at 6:18 p.m., indicated a CNA notified the nurse that Resident D was sitting on the floor between the bed and the wheelchair. The resident stated another resident pushed him to the floor from the bed. The resident denied pain. No injuries were noted on assessment. The ADON was made aware.On 1/24/26 at 10:21 p.m., Resident D was assessed related to a resident-to-resident altercation. Resident D reported the crazy man punched him in the head and then pushed him out of the wheelchair. No injuries were found.On 1/26/26 at 1:47 p.m., an Interdisciplinary Team note indicated the resident fell on 1/23/26 at 6:25 p.m. The resident stated another resident came into his room and pushed him to the floor. The resident was sitting upright on the floor beside the wheelchair with no injuries. An immediate intervention put into place at the time of the fall included: The resident chose to be assisted to bed. The intervention put into place to address the root cause of the fall included a stop sign to the resident's doorway to help detour other residents from entering the room.During an interview on 2/2/26 at 3:55 p.m., CNA 19 indicated, on 1/23/26 at approximately 6:00 p.m., a resident reported to her that two men were fighting down the hallway. The CNA followed the resident toward Resident D's room and she observed Resident B coming out of Resident D's room, with his fists balled up and an angry expression on his face. The CNA was pulled away before she could check on Resident D, because Resident B grabbed the reporting resident and pushed her against the door jamb. Following this altercation, she headed back towards Resident D's room but was instructed by the ADON to go to the dining room to assist. CNA 19 then heard CNA 22 indicate that Resident D was on the floor. Resident D later reported to CNA 19 that some dude came into his room, punched him in the back of the head while he was watching TV while seated in a wheelchair, causing him to fall from the wheelchair. This allegation was not reported to the Administrator or DON.During a telephone interview on 2/3/26 at 3:39 p.m., CNA 22 indicated he was called over to the Dementia Unit on 1/23/26 in the evening to assist with Resident B, who was being aggressive with other residents. When CNA 22 rounded up Resident B, he noticed Resident D was sitting on the floor in Resident D's room. He then alerted RN 4 and the ADON that Resident D was on the floor.During an interview, RN 4 indicated, on 1/23/26, she observed Resident D on the floor in his room, when she went to check on him following a report of Resident B being seen leaving Resident D's room. Resident D indicated to RN 4 that Resident B had shoved him to the floor. RN 4 assessed him for injuries, found none, and entered a progress note into the clinical record. RN 4 did not report the allegation to the Administrator since RN 8 spoke with the Administrator.On 2/4/26 at 4:08 p.m., the Administrator indicated RN 8 had notified him on 1/23/26 at 6:05 p.m. of a resident-to-resident altercation between Resident B and Resident C and Resident D alleged he had been pulled out of bed. The Administrator was aware, in two of the statements provided in the facility investigation, of the altercation between Resident B and Resident C, and that Resident C had reported to the aides that two male residents were going at it down the hallway. Resident D was not included in the report to the Indiana Department of Health (IDOH) because Resident D did not have any injuries and he was not upset. Resident D was also known to embellish things and had inconsistencies in what he reported. It was not a reportable incident and the facility believed the two events were unrelated.A current facility policy, revised 6/2023, titled Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 2/2/26 10:37 a.m., indicated the following: .It is the policy . to provide each resident with an environment that is free from abuse. Identification: Abuse includes: .2. Resident to resident abuse of any type.Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed.Resident to Resident Abuse: .9. It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system Reporting/Response: 1. All abuse allegations must be reported to the Executive Director immediately.2. The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately.10. It is the responsibility of every employee. to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director.13. The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long-Term Care Incident Reporting Policy.Cross reference F600.This citation relates to Intake 2727422.3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure residents were free from staff to resident verbal abuse for 3 of 4 residents reviewed abuse (Resident B, F and G).Findings include:During an interview on 11/24/25 at 9:27 a.m., Resident B indicated he and LPN 1 had previously had a verbal argument. They both got upset and cursed. He was fine. He wasn't scared then, or currently. People swear when they are angry.During an interview on 11/24/25 at 1:46 p.m., LPN 2 indicated on the evening of 9/30/25, she was working with LPN 1 when Resident B came to the medication cart and asked her to contact his hospice company for an increase in his anxiety medication because he felt his current dosage wasn't effective. She looked and saw LPN 1 was at the nurses station. She indicated perhaps LPN 1 could call because he was at the station with the phone. Resident B replied NO, that m----r f----r won't help me. In reply, LPN 1 loudly called Resident B a m----r f----r. She immediately told LPN 1 he could not talk to a resident that way. Resident B and LPN1 continued to curse at each other saying F----r. LPN 2 then said to stop, loudly. Both quieted. She asked Resident B to please go to his room. The resident went to his room. Because the exchange was loud, two other residents who were in the hallway heard the exchange as well, Residents F and G. While Resident B went to his room, she called the DON to report the verbal abuse and cursing. LPN 1 remained seated at the desk and did not interact with residents. He stayed at the desk until a member of management arrived, spoke with him and sent him home. During the same interview, LPN 2 indicated she had filled one other concern related to LPN 1. The concern was months earlier, she believed in the summertime. Resident E was crying out, yelling, and banging on things. She had asked LPN 1 if the resident should have a pain pill now. LPN1 stated that because of his behavior, the resident was going to wait for his pill until there very last minute. She requested him give the pill more than once and was told he would have to wait. She reported her concern to Management Nurse 3 and was asked to give a written statement, which she provided. She was not informed of the outcome, but believed Management Nurse 3 did investigate her concern.During an interview on11/24/25 at 11:00 a.m., QMA 4 indicated she had not worked on 9/30/25 and had not witnessed an exchange between LPN1 and Resident B. However, she had previously filled a concern on behalf of Resident H, who had alleged LPN 1 had come into his room and given him a urine sample collection cup and told the resident he had to catch the bedbug and put it in the cup or no one was coming in his room to provide care. At the time the resident made the statement, she observed an urine sample cup in the room. The resident was upset. He indicated he did not have bedbugs and LPN 1 had made him feel dirty. QMA 4 told the resident staff were not allowed to withhold care. She then provided care and found chocolate cake crumbs that she believed other staff members had thought were bedbugs. After discussing it with the resident, she completed a concern form that alleged LPN1 threatened to withhold care due to bedbugs and made 3 copies placing them under the office doors of the Administrator, DON and ADON. She was never interviewed regarding the concern. She referenced this previous concern on her 10/2/25 written statement regarding the 9/30/25 event. Resident B's clinical record was reviewed on 11/21/25 at 1:07 p.m. Current diagnoses include chronic obstructive pulmonary disease, bipolar disorder, depression and anxiety. An 11/13/25, significant change, MDS (Minimum Data Set) Assessment indicated the resident was cognitively intact and had not displayed maladaptive behaviors during the assessment period. The resident had a 7/25/25, care plan problem/need regarding a past history of trauma and PTSD (post traumatic stress disorder) with a history of self- harming, a history of suicidal and homicidal ideations, a history of fighting and using profanity when angry/frustrated. He was at risk for retriggering trauma. An approach to this problem was to encourage the resident to express anger and frustration in an appropriate manner.A 10/01/2025, 1:40 p.m., Progress Note indicated, Resident did not have much to say about last night's incident with a nurse. Resident states he feels safe in the building, no staff have been mean to him, and he hasn't heard staff be mean to anyone else . A 10/01/2025, 12:00 p.m., Progress Note indicated, Resident reports that 'last night me and a nurse had a few words' and it led to 'arguing between us'. Resident reports that he feels safe in the facility and was not fearful during the verbal exchange. Stated 'ain't nothin that scares me but a little gray mouse', with smile. Resident denies any physical interaction between he and the staff member. A 9/30/25, facility self-reported incident filed with the Indiana Department of Health indicated the facility received and allegation of verbal abuse that LPN 1 had cursed at Resident B during a verbal argument on 9/30/25. LPN1 was suspended pending investigation. Resident B and all other residents who overheard the exchange would be monitored for signs and symptoms of distress.An undated, handwritten statement signed by LPN2, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated Resident B had asked for an increase in his antianxiety medication. She asked could LPN 1 make the call because he was seated at the station. Resident B said f--- him, he ain't gonna do sh--. LPN 1 then screamed F--- you. The two went back and forth screaming F---you several times. LPN1 also called the resident a F---ing idiot. She stepped between them and told LPN1 to knock it off. You can't talk to residents like this. They said a few more words. She said stop loudly and it finally ended. She asked the resident to please go to his room. She then called the DON and reported the event.An undated, handwritten statement signed by Resident B, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated Resident B and LPN 1 had argued and one thing led to another some cuss words were said F word was said a lot between the two of us.A 9/30/25, handwritten statement signed by LPN 1, which was contained in the facility investigation file related to the 9/30/25 reported event, Resident B had yelled at him and he yelled back. The statement did not indicate profanity was used by either party.A 9/30/25, handwritten statement signed by Resident F, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated Resident D was seated in the hallway and overheard an argument between Resident B and LPN 1. The resident had wanted to increase his medication. He didn't feel LPN 1 would help him. The resident called LPN 1 a f---ing a-hole. LPN called Resident B a f---ing idiot. This made me upset. I wish I never saw it. I am ok now.An undated, handwritten document labeled as a verbal statement by Resident G, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated he was seated in the hallway by the nurse's cart. He heard a bunch of cussing by a staff and a resident. He was surprised but not distressed. A 9/30/25, handwritten statement signed by C.N.A. 5, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated they had completed patient care and came out of the room to hear LPN 1 yell F--- you it was the right f---ing dose at Resident B.A 9/30/25, handwritten statement signed by C.N.A. 6, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated he witnessed LPN1 cuss at Resident B after the resident cursed at him. A 10/2/25, handwritten statement signed by QMA 4, which was contained in the facility investigation file related to the 9/30/25 reported event, indicated she had not worked the night of 9/30/25. However, she had made a written statement of concern about LPN 1 on a previous occasion.During an interview with the Administrator and DON on 11/14/25 at 2:30 p.m., they indicated they had no documented record of QMA 4 filling a concern regarding Resident H and withheld care due to bedbugs. They were aware of a bedbug concern, which ended up being cake crumbs. They had no documentation regarding an allegation of a concern regarding a statement to withhold care. The facility had looked into a concern about Resident E not being given pain medication in a timely manner. The record indicated the resident received his medication on time.During the same interview, they indicated LPN 1 was suspended during the investigation of the 9/30/25 allegation of verbal abuse. He resigned as a result. The results of the investigation indicated LPN 1 would have been terminated had he not resigned. An Employee Communication Form, which was provided by the Administrator on 11/24/25 at 2:42 p.m., indicated LPN 1 had been suspended pending investigation of an event which occurred 9/30/25. The violated policy was Rude/unprofessional Behavior, discourteous treatment of a resident. LPN 1 ha resigned in response to the investigation. A current facility policy revised on June 2023, titled Abuse Prohibition, Reporting, and Investigation, which was provided by the Administrator in 11/24/25 at 3:04 p.m., indicated: Verbal Abuse-The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to a resident or their family within their hearing distance. This citation relates to intake 2631871. 3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure nursing staff followed the five rights of medication administration (right resident, right medication, right dose, right time, and right route) to prevent a medication error for 1 of 5 residents reviewed for unnecessary medications. (Resident 8) Finding includes: Resident 8's clinical record was reviewed on 1/28/25 at 2:46 p.m. Diagnoses included peripheral vascular disease and a non-pressure chronic ulcer of an unspecified lower leg. A physician's order, dated 12/9/24, included hydrocodone-acetaminophen (narcotic pain reliever) 10-325 milligrams (mg) - give one tablet by mouth every six hours for pain. This medication was scheduled to be administered at the following times: 5:00 a.m., 11:00 a.m., 5:00 p.m., 11:00 p.m. The order was discontinued on 1/9/25. A current physician order, dated 1/9/25, included hydrocodone-acetaminophen 10-325 mg- give one tablet by mouth every four hours for pain. This medication was scheduled to be administered at the following times: 3:30 a.m., 7:30 a.m., 11;30 a.m., 3:30 p.m., 7:30 p.m., and 11:30 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated the resident was cognitively intact. Opioids were received during the assessment period. A current care plan, dated 5/10/24, indicated the resident was at risk for pain related to peripheral vascular disease. Interventions included, administer medications as ordered. A Nurse's note, dated 1/11/25 at 5:18 a.m., indicated the resident received and additional dose of hydrocodone 10-325 mg in error. Vital signs were within normal limits. The resident was alert and oriented and monitored frequently. A Nurse's note, dated 1/11/25 at 5:46 p.m., indicated the provider ordered to observe the resident for 4 hours and to hold the next dose of hydrocodone. A Nurse's note, dated 1/11/25 at 2:03 p.m., indicated the resident was resting in his bed with even and non-labored respirations and no shortness of breath. The resident took medications per order. Review of the January 2025 MAR indicated Resident 8 received the scheduled dose of hydrocodone-acetaminophen on 1/11/25 at 3:30 a.m. The doses scheduled on 1/11/25 at 7:30 a.m., 11:30 a.m. and 3:30 p.m. were held. The dose scheduled on 1/11/25 at 7:30 p.m. was left blank. Review of the resident's narcotic count sheet indicated a dose of hydrocodone-acetaminophen 10-325 mg was administered in error on 1/11/25 at 5:00 a.m. by LPN 9. The previous dose scheduled on 1/11/25 at 3:30 a.m. was administered at 4:00 a.m. by LPN 9. During an interview on 1/31/25 at 9:20 a.m., the DON indicated LPN 9 had administered a dose of hydrocodone-acetaminophen 10-325 mg in error on 1/11/25. LPN 9 had administered the additional dose of medication based on her memory rather than looking at the new order prior to the medication administration. The previous order of the same medication had been due at 5:00 a.m., but the order had been changed and was not scheduled at that time. The physician and family were notified by LPN 9 of the medication error. Staff were not permitted to pass medications based on memory, nor without verification of the physician's order for the medication. During an interview on 1/31/25 at 9:45 a.m., the DON indicated LPN 9 administered the additional dose of medication on 1/11/25 at 5:00 a.m. If the nursing staff charted by exception, they would not have charted anything in the clinical record unless abnormalities were found, when a resident received a medication in error. During an interview on 1/31/25 at 10:10 a.m., LPN 9 indicated she had administered an additional dose of the resident's hydrocodone-acetaminophen 10-325 mg in error on 1/11/25 by accident. She automatically got out the dose that had previously been ordered to administer at 5:00 a.m. (no longer ordered at that time) and administered it to the resident. The Medication Administration Record (MAR) had not triggered her to administer the dose at 5:00 a.m., as the next dose was not due until 7:30 a.m. She was in a hurry because she had assisted another staff member on another unit with medication administration and had her own medication cart as well. She felt she had adequate time to complete her tasks, but she rushed and it was her fault. The facility required staff to check the five rights prior to administration of medications. She had notified the provider and the on-call nurse manager, assessed the resident, and obtained vitals. The provider gave her orders to monitor the resident for sedation for four hours, and to hold the next dose of hydrocodone-acetaminophen 10-325 mg scheduled for 1/11/25 at 7:30 a.m. The on-call nurse instructed her to continue the resident's assessments. This occurred at the end of her shift and she had reported the medication error all of the above mentioned orders to RN 10 during morning report, at the end of her shift around 6:00 a.m. on 1/11/25. During an interview on 1/31/25 at 10:28 a.m., the DON indicated additional doses were held because the order to hold the hydrocodone-acetaminophen for the next dose had been entered and timed to hold until 11:00 p.m. During an interview on 1/31/25 at 11:03 a.m., RN 10 indicated she provided care for the resident on 1/11/25 after he had the medication error on the previous shift. LPN 9 had given her report at the shift change and made her aware of the resident's medication error and the need for continued observation for sedation. She was uncertain of the specific length of time the resident needed observed on her shift. LPN 9 had explained the hydrocodone was on hold and the orders had been placed in the computer. She was unaware the medication was ordered to be held only for the next dose. She was unaware of any other reason the resident's hydrocodone-acetaminophen 10-325 mg was held for additional doses. A current facility policy, revised 11/2018, titled Medication Errors, provided by the Corporate Nurse Consultant on 1/31/25 at 12:26 p.m., indicated the following: POLICY . It is the policy of this provider to ensure resident residing in the facility are free from medication errors 3.1-14(i)

Based on observation, record review, and interview, the facility failed to post the daily facility census number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily. Finding includes: During an observation and record review, on 1/28/25 at 11:43 a.m., the Nursing Staffing Data was posted from 1/28/25- 2/3/25 on the wall outside the Business Office and indicated the following: On 1/28/25, the total number of licensed and unlicensed staff were 2 Registered Nurses (RN), 2 Licensed Practical Nurses (LPN), 2 Qualified Medication Aides (QMA) and 15 Certified Nursing Assistants (CNA). The form lacked a shift to shift breakdown. The form lacked a census number. On 1/29/25, the total number of licensed and unlicensed staff were 2 RNs, 2 LPNs, 2 QMAs and 15 CNAs. The form lacked a shift to shift breakdown. On 1/30/25, the total number of licensed and unlicensed staff were 2 RNs, 1 LPN, 3 QMAs and 15 CNAs. The form lacked a shift to shift breakdown. On 1/31/25, the total number of licensed and unlicensed staff were 1 RN, 4 LPNs, 1 QMA and 15 CNAs. The form lacked a shift to shift breakdown. During an interview, at the time of the observation, the Administrator indicated he completed staffing weekly, as it was easier to keep track of that way. The previous 4 weeks remained in the plastic holder behind the current posting. During an observation and record review, on 1/31/25 at 11:00 a.m., of the Nursing Staffing Data, the census number column remained blank for 1/29/25, 1/30/25, and 1/31/25. During an interview, on 1/31/25 at 11:25 a.m., the Administrator indicated the Director of Nursing filled out the direct care staffing numbers on the Nursing Staffing Data form. He indicated he did not see a shift to shift breakdown on the form. During an interview, on 1/31/25 at 11:30 a.m., the DON indicated she filled out the forms with the nursing staffing information for a 24-hour time frame and not shift to shift. She indicated some of the previous dates were missing a census number. A facility policy, last revised 7/23, titled, Posted Nurse Staffing Data and Retention Requirements, provided by the Administrator on 1/31/25 at 12:35 p.m., indicated the following: .The facility must post the following information at the beginning of each shift .c. Resident census. d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, licensed practical nurses, certified nursing aides .

Based on observation and interview, the facility failed to ensure food was prepared and served under safe and sanitary conditions for 1 of 3 units observed during dining (Cottage Unit). This had the potential to affect 21 of 21 residents who were served meals on the Cottage Unit. Findings include: During a Cottage Unit dining observation on 1/27/25 from 11:43 a.m. through 12:03 p.m. the following was observed: CNA 13 handled Resident 45's sloppy joe sandwich with her bare hands while she assisted the resident with his meal in the dining room. CNA 13 handled Resident 46's breaded tenderloin sandwich with her bare hands while she set up the residents food for the resident to eat in the dining room. CNA 13 grasped three of Resident 45's cups from the top, touching the rim of each cup, at the dining room table. During an interview on 1/30/25 at 12:08 p.m., the Memory Care Support Specialist indicated that the residents' cups should have been handled at the bottom of the cup. It was not proper technique to touch the rim of the cup. The proper procedure to assist a resident with a sandwich depended on a resident's abilities. Staff should have assisted residents' with their condiments and then placed the top bun on the sandwich using a fork or spoon. Staff should have never used their hands. During an interview on 1/30/25 at 12:10 p.m., CNA 6 indicated cups were required to be handled from the bottom, avoiding the rim. After she applied condiments, she flipped the top bun onto the sandwich. She held up her hands and demonstrated she used her hands to place the top bun on the sandwich. During an interview on 1/30/25 at 12:26 p.m., CNA 13 indicated that cups should not have been touched by staff around the rims. The top bun of a sandwich should have been placed using silverware or gloves. She had touched the above mentioned sandwiches and cups because it was a habit. Perhaps she was rushed and just forgot to do the proper technique. A current facility policy, dated 1/24, titled Hand Hygiene in the Dining Room, provided by the MDS Coordinator on 1/30/25 at 2:22 p.m., indicated the following: Do Not Touch Food With Your Hands (Gloved or Ungloved) . Always use utensils when touching food . Avoid Touching Food Contact Surfaces of Dishware . (cup rims, surfaces of silverware ) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident was provided services to maintain a dignified existence related to available clothing for 1 of 3 residents reviewed for activities of daily living. (Resident 47) Finding includes: During an observation on 1/27/25 at 10:52 a.m., Resident 47 wore a gray long sleeve shirt and lounge pants as he walked out of his room. During an observation on 1/28/25 at 10:09 a.m., the resident wore gray long sleeve shirt and white/black plaid/checkered lounge pants, unchanged from the previous day, as he participated in an activity in the dining area. During an interview on 1/28/25 at 10:51 a.m., the resident tugged on his shirt and indicated that he did not have a change of clothing. The resident opened his drawer, which contained a blue polo Special Olympics shirt with his name on it. The resident opened his closet, which contained a tote with a button-up dress shirt. No other clothing items were observed in the resident's room. Resident 47's clinical record was reviewed on 1/28/25 at 3:03 p.m. Diagnoses included dementia, cerebral infarction, and mild intellectual disabilities. An annual Minimum Data Set (MDS) assessment, dated 12/4/24, indicated the resident had moderate cognitive impairment. The resident required partial assistance from staff for toileting, lower body dressing, and personal hygiene. The resident required supervision from staff for upper body dressing. The resident had frequent urinary and bowel incontinence. A current care plan, dated 11/29/24, indicated the resident required assistance and/or monitoring with morning care, evening care, and elimination. Interventions included, morning cares to include bathing and dressing (11/29/24), and evening cares to include bathing and dressing (11/29/24). A current care plan, dated 12/5/24, indicated the resident was unable to make daily decisions without cues and supervision. Interventions included, encourage resident to self-evaluate decisions made (12/5/24). A current care plan, dated 12/5/24, indicated the resident had absence of personal contact with sisters as they live out of town. Interventions included, Provide opportunity for resident to express feelings (12/5/24) A current care plan, dated 12/6/24, indicated the resident required assistance from staff with activities of daily living (ADL's) related to dementia and intellectual disability. Interventions included, provide assistance with dressing, grooming, and hygiene as needed (12/6/24). A Nurse's note, dated 11/27/24 at 3:40 p.m., indicated Resident 47 arrived at the facility from another nursing facility, and had brought belongings with him. The belongings were placed in his room. Review of Resident 47's inventory log, dated 12/6/24, indicated the following clothing items: 15 blouses/shirts, 1 pair of shorts, 1 slacks/trousers, 1 sweat/lounge top, 1 sweater/blazer, 2 undershirts, 1 pair of jeans, and a jean jacket. During an observation on 1/29/25 at 9:46 a.m., the resident wore a gray long sleeve shirt and white/black plaid/checkered lounge pants, unchanged from the previous observations, as he sat at a table in the dining area. During an interview on 1/29/25 at 3:47 p.m., CNA 4 indicated Resident 47 needed supervision to limited assistance from staff for activities of daily living. The resident was continent most of the time. He dressed himself and she believed that he had adequate clothing available. Staff was required to report to a nurse if a resident was without adequate clothing/personal items. During an interview on 1/29/25 at 3:47 p.m., CNA 5 indicated Resident 47 needed supervision to limited assistance from staff for activities of daily living. The resident was continent most of the time. He dressed himself and she believed that he had adequate clothing available. Staff was required to report to a nurse if a resident was without adequate clothing/personal items. During an observation on 1/30/25 at 9:46 a.m., the resident wore a gray long sleeve shirt and white/black plaid/checkered lounge pants, unchanged from the previous observations, as he participated in an activity in the dining area. During an interview on 1/30/25 at 11:31 a.m., CNA 6 indicated the resident lacked the ability to follow directions and often needed cued or a demonstration of the task to be completed. She gave the resident a shower on 1/27/25. The clothing that the resident had been wearing this week was obtained from the boutique due to the resident not having any clothing available at the time of his 1/27/25 shower. He lacked an adequate amount of clothing in his room and she had discussed this with another aide previously. He had plenty of clothing when he first arrived to the facility. His clothing had been missing prior to the resident's room change. She went to the boutique and to the lost and found in laundry when she needed clothing for the resident. She confirmed the closet was empty. A drawer had two rolled up items and one shoe. A second dresser drawer lacked any clothing. During an interview on 1/30/25 at 1:48 p.m., the SSD indicated the laundry staff labeled clothing when residents admitted to the facility. The standard policy was to send clothing items for labeling on the day of admission. She had a boutique in her office of donated clothing. Items selected from the boutique were required to go straight to laundry to be labeled with the resident's name. Three to five outfits could have been obtained at one time from the boutique. During an interview on 1/30/25 at 1:48 p.m., the Memory Care Support Specialist indicated that she was not aware of the resident's lack of clothing. Staff were required to inform her when residents lacked clothing. Multiple outfits should have been obtained from the boutique during the resident's clothing shortage. She did not think that the resident came with very much clothing when he admitted . She worked on the resident's unit Monday-Friday from 9 a.m.-5 p.m. She observed the resident in the same clothing the week of 1/27/25. She was aware the resident normally wore the same outfit for 2-3 days . During an interview on 1/31/25 at 1:25 p.m., Laundry Aide 11 indicated the resident received facility laundry services. A current facility policy, revised 4/18, titled Resident's Personal Laundry, provided by the SSD on 1/30/25 at 2:13 p.m., indicated the following: Policy .Staff will wash resident's personal laundry on a regular basis . Procedure .Once laundry is gathered . should be taken to the laundry room, sorted, washed, dried, folded or hung, and returned to the apartment timely . The clean, folded, or hung garments shall be returned along with the laundry container/bag to the resident's apartment. If assistance is required, staff shall assist with putting clothing in resident's closet and drawers 3.1-9(a) 3.1-9(b) 3.1-9(f)

Based on record review and interview, the facility failed to protect a resident's dignity and failed to assist him with ADL care, leaving him in a soiled bathroom for another staff member to assist following an incontinence episode for 1 of 2 residents reviewed for quality of care. (Resident C) Using the reasonable person concept, it would be likely that a dependent, vulnerable person unable to care for themselves could experience recurrent fear or anxiety when the facility staff failed to assist them during a vulnerable episode of incontinence where he was found to be unsupervised, and covered in feces, seated on a bathroom floor with staff closing the door. Findings include: A complaint filed with the Indiana Department of Health indicated Resident C had been in a bathroom, alone, with his door shut and was unable to open doors due to his diagnoses. Resident C's clinical record was reviewed on 10/9/24 at 11:15 a.m. Diagnoses included dementia, depression, psychotic disorder with delusions, anxiety disorder, dystonia, and history of alcohol abuse. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/24, indicated the resident had severe cognitive impairment, required substantial/maximal assistance with eating and was dependent on staff for toileting, oral hygiene, bathing, dressing, mobility, and transfers. The resident was able to ambulate with supervision and touching assistance. A current care plan, dated 9/11/23, indicated Resident C required assistance with toileting due to incontinence of bowel and bladder, impaired mobility, and potential to play in his own feces at times. Interventions included, (10/8/24) resident's legal representative wished for his dignity to be maintained as much as possible during times of incontinence and to allow privacy by guiding him to his room as he allows. During an observation on 12/9/24 at 11:45 a.m., Resident C was seated at a table in the dining area being assisted by a staff member to eat lunch. He was bent forward in his seat with his face positioned down. A document provided by the Administrator, dated 11/22/24 and titled, [Resident C] Investigation summary, indicated the following: A surveillance system was reviewed and CNA 8 was observed on the memory care unit to take CNA 2 home due to sickness. CNA 8 and CNA 2 talked for a few seconds, then CNA 8 began to walk down the hallway looking into resident rooms. When she got to Resident C's room, she entered for approximately one minute then reappeared. She then entered another resident room where CNA 4 was providing care to a resident. Then CNA 8 and CNA 2 left the facility. CNA 4 was observed approximately three minutes later exiting the room she had been providing care and entering Resident C's room. After just a few seconds, CNA 4 was observed in the hallway using her cell phone. CNA 5 was observed entering the unit and going into Resident C's room. The two CNAs were seen escorting Resident C down the hallway to the shower room. CNA 4 reported to the Administrator she had found Resident C in the bathroom, soiled with feces on his feet, pants, shirt, and beard. A conclusion statement indicated [Resident C] was found in his toilet area by CNA 8. She closed the door to the toilet to provide dignity. [Resident C] was not in any distress from being in his toilet area alone as none of the 3 CNAs reported that he was displaying any distress and the internal surveillance showed [Resident C] calmly walking with staff to the shower. [Resident C] was cared for within a reasonable period of time, approximately 6-7 minutes. However, CNA 8 should have stayed with the resident until the staff responsible for his care could arrive. The summary lacked specific time stamps from the surveillance video. During a telephone interview on 12/9/24 at 6:22 p.m., CNA 8 indicated she knew she should have changed Resident C before she left the facility. She didn't know why she had not cleaned him up. He was seated on the floor of his bathroom, with his pants down. There was feces on his back, his front, his socks. It was all over him. The CNA indicated there was feces on the walls and floor of the bathroom. She had reported his condition to CNA 4, who was working on that unit, and then she left the facility for her break and to take CNA 2 home. During an interview on 12/9/24 at 2:14 p.m., CNA 4 indicated Resident C was part of her assignment. CNA 4 was providing care to another resident in a room across the hallway from Resident C. CNA 2 was providing care to the resident's roommate and had finished and left the room. CNA 2 and CNA 8 returned to the room she was working in and reported Resident C was covered in feces. CNA 8 indicated she had shut him in the bathroom. When she completed caring for the resident, which she thought was around three minutes, she went across the hall to Resident C's room. The bathroom door was closed and when she opened it, she observed Resident C seated on the floor with feces in his hair, face, entire clothing, and socks. The walls, sink, and floor were also smeared with feces. When Resident C saw her, he began to curse at her. She indicated to Resident C she was going to get help and would return. She indicated she left the bathroom door open about 12 inches or so. She left the room and informed CNA 5 that she needed his assistance with Resident C as soon as possible. She indicated CNA 5 was assisting other residents to smoke, and arrived on the memory care unit about 6-7 minutes after she had spoken with him. CNA 5 was able to get Resident C to the shower room. CNA 4 indicated she remained in the room to clean up the bathroom. She was surprised that CNA 2 and CNA 8 would leave Resident C in that condition and had shut the door to the bathroom leaving him alone. She called the administrator as soon as she could to report the incident, as she felt it was possible abuse leaving him like that and leaving the facility. During an interview on 12/9/24 at 1:58 p.m., CNA 5 indicated he was outside with other residents during smoke time. CNA 4 had indicated Resident C needed assistance and was covered in feces. Resident C could become aggressive and it was usually a two staff job to care for him. CNA 5 indicated it was about 5-7 minutes before he completed the smoke time supervision. When he arrived in Resident C's room, the bathroom door was closed. The resident was seated on the floor of the bathroom. Resident C was more agitated that his usual when getting him to the shower, but calmed when he felt the water. During an interview on 12/9/24 at 12:34 p.m., the Administrator indicated the reason CNA 8 had shut the door to the bathroom was so he would not come out into the hallway. If the resident had wanted to come out, the Administrator felt the resident would have done so because he could open and close doors. He may not do this on command, but he had seen him open doors before. During an interview on 12/10/24 at 10:16 a.m., the Administrator indicated CNA 2 was scheduled on the memory care unit on 11/21/24 from 2:00 p.m. to 10:00 p.m. and became ill. CNA 8 was preparing to go on break and was going to take her home. It was like anyone else at the end of their shift, they reported off to the staff before leaving the facility. It was not CNA 8's end of shift, but she was not assigned to that unit to begin with and her immediate assignment was to take CNA 2 home. A current facility position description, revised 10/2014, titled, Certified Nursing Assistant Position Description, provided by the DON on 12/9/24 at 1:40 p.m., indicated the following: .Essential Position Functions .Provides delivery of care in a compassionate, quality manner with kindness, respect and dignity A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 12/10/24 at 10:16 a.m., included the following: Policy: .American Senior Communities has established policies and procedures which will provide personnel with the knowledge and training to further ensure each resident is treated with individual respect and dignity Neglect Failing to provide personal hygiene resulting in embarrassment, depression, poor self-esteem . This Federal tag relates to complaint IN00447929. 3.1-28(c)

Based on interview and record review, the facility failed to report an allegation of abuse to the Indiana Department of Health for 1 of 2 residents reviewed for quality of care. (Resident C) Finding includes: During an interview on 12/9/24 at 2:14 p.m., CNA 4 indicated she called the Administrator on 11/21/24 following an incident with Resident C, who was part of her assignment. She was providing care to another resident in a room across the hallway from Resident C. CNA 2 was providing care to the resident's roommate and had finished and left the room. CNA 2 and CNA 8 returned to the room she was working in and reported Resident C was covered in feces. CNA 8 indicated she had shut him in the bathroom. When CNA 4 completed caring for the resident, which she thought was around three minutes' time, she went across the hall to Resident C's room. The bathroom door was closed and when she opened it, she observed Resident C seated on the floor with feces in his hair, face, entire clothing, and socks. The walls, sink, and floor were also smeared with feces. When Resident C saw her, he began to curse at her. She was surprised that CNA 2 and CNA 8 would leave Resident C in that condition and had shut the door to the bathroom leaving him alone. She called the administrator as soon as she could to report the incident, as she felt it was possible abuse leaving him like that and leaving the facility. During an interview on 12/9/24 at 12:34 a.m., the Administrator indicated they had looked into the incident regarding Resident C. The corporate nurse consultant had also looked at the incident and they felt it was not abuse or neglect. The Administrator had reviewed the surveillance video from that evening. During an interview on 12/10/24 at 10:16 a.m., the Administrator indicated CNA 4 had called him the evening of 11/21/24 and reported the situation with Resident C and the two CNAs who had left the facility. He asked CNA 4 if the two other CNAs had informed her they were leaving the facility, and she replied yes. He indicated he told her that this was not abuse, but poor care on their part. He indicated to CNA 4 he would take care of it in the morning. The facility did not report the alleged abuse to the Indiana Department of Health. A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 12/10/24 at 10:16 a.m., indicated the following: .Reporting/Response: .The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long-Term Care Incident Reporting Policy Review of the Indiana Department of Health policy titled Long Term Care Abuse and Incident Reporting Policy, effective date 12/8/23 through 12/8/24, and retrieved from https://www.in.gov/health/ltc/files/LTC-Abuse-Reporting.pdf, indicated the following: .B. Types of Incidents Reportable Under Federal and State Rules .3. Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) .11. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Cross reference F550. This Federal tag relates to complaint IN00447929. 3.1-28(c)

Based on interview and record review, the facility failed to conduct a complete and thorough investigation of alleged neglect for 1 of 2 residents reviewed for quality of care. (Resident C) Findings include: A document provided by the Administrator, dated 11/22/24, titled, [Resident C] Investigation summary, indicated the following: A surveillance system was reviewed and CNA 8 was observed on the memory care unit to take CNA 2 home due to sickness. CNA 8 and CNA 2 talked for a few seconds, then CNA 8 began to walk down the hallway looking into resident rooms. When she got to Resident C's room, she entered for approximately one minute then reappeared. She then entered another resident room where CNA 4 was providing care to a resident. Then CNA 8 and CNA 2 left the facility. CNA 4 was observed approximately three minutes later exiting the room she had been providing care and entering Resident C's room. After just a few seconds, CNA 4 can be observed in the hallway and used her cell phone. CNA 5 was observed entering the unit and going into Resident C's room. The two CNA's were seen escorting Resident C down the hallway to the shower room. CNA 4 reported to the Administrator she had found Resident C in the bathroom, soiled with feces on his feet, pants, shirt, and beard. A conclusion statement indicated the following: [Resident C] was found in his toilet area by CNA 8. She closed the door to the toilet to provide dignity. [Resident C] was not in any distress from being in his toilet area alone as none of the 3 CNAs reported that he was displaying any distress and the internal surveillance showed [Resident C] calmly walking with staff to the shower. [Resident C] was cared for within a reasonable period of time, approximately 6-7 minutes. However, CNA 8 should have stayed with the resident until the staff responsible for his care could arrive. The summary lacked specific time stamps from the surveillance video. During an interview on 12/9/24 at 2:14 p.m., CNA 4 indicated she called the Administrator on 11/21/24 following an incident with Resident C, who was part of her assignment. She was providing care to another resident in a room across the hallway from Resident C. CNA 2 was providing care to the resident's roommate and had finished and left the room. CNA 2 and CNA 8 returned to the room she was working in and reported Resident C was covered in feces. CNA 8 indicated she had shut him in the bathroom. When CNA 4 completed caring for the resident, which she thought was around three minutes' time, she went across the hall to Resident C's room. The bathroom door was closed and when she opened it, she observed Resident C seated on the floor with feces in his hair, face, entire clothing, and socks. The walls, sink, and floor were also smeared with feces. When Resident C saw her, he began to curse at her. She was surprised that CNA 2 and CNA 8 would leave Resident C in that condition and had shut the door to the bathroom leaving him alone. She called the administrator as soon as she could to report the incident, as she felt it was possible abuse leaving him like that and leaving the facility. During a telephone interview on 12/9/24 at 6:22 p.m., CNA 8 indicated she knew she should have changed (cleaned) Resident C before she left the facility. She didn't know why she had not cleaned him up. He was seated on the floor of his bathroom, with his pants down. There was feces on his back, his front, his socks. It was all over him. She indicated there was feces on the walls and floor of the bathroom. She had reported his condition to the CNA 4, who was working on that unit, and then she left the facility for her break and to take CNA 2 home. During an interview on 12/9/24 at 12:34 a.m., the Administrator indicated they had looked into the incident regarding Resident C. The corporate nurse consultant had also looked at the incident and they felt it was not abuse or neglect. The Administrator had reviewed the surveillance video from that evening. The surveillance video was no longer available and had been overwritten. During an interview on 12/10/24 at 10:16 a.m., the Administrator indicated CNA 4 had called him the evening of 11/21/24 and reported the situation with Resident C and the two CNAs who had left the facility. He asked CNA 4 if the two CNAs had informed her they were leaving the facility, and she replied yes. He indicated he told her that this was not abuse, but poor care on their part. He indicated to CNA 4 he would take care of it in the morning. He indicated no employee statements or investigation documentation were available. He believed he may have put them in the shredder box because the incident was not considered abuse or neglect. The facility had not reported the alleged abuse to the Indiana Department of Health. A current facility policy, revised June 2023, titled, Abuse Prohibition, Reporting, and Investigation, provided by the Administrator on 12/10/24 at 10:16 a.m., included the following: .Reporting/Response: .The Executive Director will follow the reporting guidance delineated through the Indiana State Department of Health, Division of Long-Term Care Incident Reporting Policy Review of the Indiana Department of Health policy titled Long Term Care Abuse and Incident Reporting Policy, effective date 12/8/23 through 12/8/24, and retrieved from https://www.in.gov/health/ltc/files/LTC-Abuse-Reporting.pdf, indicated the following: .B. Types of Incidents Reportable Under Federal and State Rules .3. Deprivation of goods and services by staff: The deprivation of goods and services by staff is a form of abuse in which residents are deprived by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s) .11. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Cross reference F550 and F609. This Federal tag relates to complaint IN00447929. 3.1-28(d)

Based on record review and interview, the facility failed to ensure narcotic medication administration was documented according to policy for 3 of 3 residents (Resident A, E, and F), and that controlled substance reconciliation was complete and accurate according to facility policy for 3 of 3 medication carts, to assure medications were not diverted by a staff member. Findings include: Review of a Facility Reported Incident dated 9/26/24 at 1:20 p.m., indicated Resident A had reported she had not received her scheduled pain medication on 9/25/24 from the night nurse. Following an investigation, LPN 3 was suspended until the investigation could be completed. a. The clinical record review for Resident A was completed on 10/22/24 at 10:38 a.m. Diagnoses included schizoaffective disorder/depressive type, anxiety disorder, and chronic pain syndrome. She admitted to the facility on [DATE]. A physician's order, dated 9/13/24, indicated to give morphine (pain medication) extended release 15 mg (milligram) every eight hours for pain. The order was discontinued on 9/18/24. A current physician's order, dated 9/18/24, indicated to give morphine extended release 30 mg, every eight hours for pain. A review of the documentation of narcotic administration indicated the following: On 9/13/24 at 5:00 a.m., an EDK (emergency drug kit) Narcotic form was completed for Morphine 15 mg extended release. A note on the form indicated the pharmacy had authorized one tablet to be removed. The form indicated two tablets were removed. The form was signed by LPN 3. On 9/15/24 at 5:00 a.m., an entry on the narcotic medication count sheet for Resident A had an entry signed by LPN 3 that was marked out with a line through it, and the word dropped indicated next to her signature indicating descruction of the dropped medication. The entry lacked any other staff initials, signature, or indication of disposal. An entry below indicated another dose was removed on 9/15/24 at 6:00 am. On 9/24/24 at 5:00 a.m., entry on the narcotic medication count sheet for Resident A had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated and timed 9/24/24 at 5:00 a.m. b. The clinical record review for Resident E was completed on 10/22/24 at 9:20 a.m. Diagnoses included colon cancer, malnutrition, and colostomy. The resident was admitted on [DATE] and was discharged to another facility on 10/7/24. A physician's order, dated 6/18/24, indicated to provide hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg, every four hours as needed for moderate to severe pain. The order was discontinued on 7/25/24. A physician order, dated 7/25/24 indicated to provide hydrocodone-acetaminophen 10-325 mg, every four hours as needed for pain. The order was discontinued on 9/23/24. A physician's order, dated 9/23/24, indicated to provide hydrocodone-acteaminophen 5-325 mg, every four hours as needed for pain. The order was discontinued on 10/7/24. On 7/19/24 at 9:00 p.m., an entry on the narcotic medication count sheet for Resident E had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 7/19/24 at 9:00 p.m. On 7/28/24 at 3:30 a.m., an entry on the narcotic medication count sheet for Resident E had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 7/18/24 at 3:30 a.m. On 8/24/24 at 2:30 a.m., an entry on the narcotic medication count sheet for Resident E had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 8/24/24 at 2:40 a.m. c. The clinical record review for Resident F was completed on 10/22/24 at 10:05 a.m. Diagnoses included chronic kidney disease III, diabetes mellitus type II, acute respiratory failure, and depression. The resident was admitted on [DATE]. A physician order, dated 5/24/24, indicated to provide oxycodone (pain medication) 5 mg, every four hours as needed. The order was discontinued on 7/11/24. A physician's order, dated 7/11/24, indicated to provide hydrocodone-acetaminophen 5-325 mg, every six hours as needed. On 7/19/24 at 7:00 p.m., an entry on the narcotic medication count sheet for Resident F had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 7/19/24 at 7:00 p.m. On 8/24/24 at 4:30 a.m., an entry on the narcotic medication count sheet for Resident F had an entry signed by LPN 3 that was marked out with a line through it, and the word dropped indicated next to her signature. The record lacked a staff co-signature/initials indicating descruction of the dropped medication. An entry below indicated another pill was removed by LPN 3 and was dated on 8/24/24 at 4:30 a.m. On 9/7/24 at 3:30 a.m., an entry on the narcotic medication count sheet for Resident F had an entry signed by LPN 3 that was marked out with a line. The record lacked an explanation of reason for duplicate pills being obtained or staff co-signature/initials. An entry below indicated another pill was removed by LPN 3 and was dated on 9/7/24 at 3:30 a.m. 2. Review of the medication cart narcotic Shift Change Verification of Controlled Substances sheet, included the following: a. The [NAME] 100 hall, [NAME] 200 hall, and Memory Care unit medication carts for August 2024 lacked documentation for item count which includes number of cards, bottles, or boxes containing narcotic medications. The record lacked any additions or removals of narcotic medications. b. The [NAME] 100 hall, [NAME] 200 hall, and Memory Care unit medication carts for September 2024 lacked documentation through night shift on 9/27/24 for item count which includes number of cards, bottles, or boxes containing narcotic medications. The record lacked any additions or removals of narcotic medications through this time. During an interview on 10/22/24 at 11:38 a.m., the DON indicated the staff should have reported any incomplete or incorrect documentation entered by LPN 3 when performed the shift to shift narcotic counts. She indicated the staff were not completing the narcotic count shift to shift record appropriately and thoroughly. She has performed staff education upon completing the investigation of possible diversion of narcotic medications. She had been unable to determine an accurate count of the potential diverted narcotic medications due to poor shift to shift documentation. A current facility policy, dated 11/2015, titled, Controlled Substances, provided by the Administrator on 10/21/24 at 2:44 p.m., included: Policy The staff at the Community must also maintain strict records of the controlled substances stored in the Community as well as the dose given to the resident. It is essential to make certain the resident requiring the controlled substance receives it as ordered by the physician .Procedure .5.all unused medication will be destroyed with two licensed nurses and document on the medication destruction logs. A current facility policy, dated 2/1/2018, titled, Inventory of Controlled Substances, provided by the DON on 10/22/24 at 9:10 a.m., included: Policy: It is the policy of [provider name] to ensure that the incoming and outgoing nurses count all controlled substances at the change of each shift and document on the Shift Change Verification of Controlled Substances form. Procedure: .The on-coming and off-going nurse will also count the narcotic cards, boxes, and bottles to ensure accurate reconciliation. The off-going nurse will document an explanation on the Shift Change Verification of Controlled Substance form if there are any discrepancies or changes with the card, box, or bottle counts. If there are unexpected changes in the shift verification of controlled substances the Director of Nursing Services will be notified immediately. This Federal deficiency is related to Complaint IN00444118. 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to implement care plan approaches to prevent falls for 1 of 3 residents reviewed for accident prevention. (Resident 51) Findings include: Resident 51's clinical record was reviewed on 1/4/24 at 10:52 a.m. Current diagnoses included, dementia, difficulty walking, weakness, and low back pain. The resident had a history of falls, fall events, and injuries of unknown origins as follows: 7/7/23-The resident had a fall in the shower room. 7/31/23- The resident stumble with his walker entering his room and landed on his knees. 8/13/23-The resident was found on the floor by his bed. 10/7/23- The resident had an unwitnessed fall. 11/27/23- The resident had fall in the hallway which resulted in a skin tear. 12/4/23-The resident had an unwitnessed accident which resulted in a laceration on his forehead and abrasion on his nose. A 12/5/23, 7:48 p.m. IDT (Inter Disciplinary Team) progress note indicated the most likely cause for the injury was an unwitnessed fall. The resident had a current care plan problem/need regarding the risk for falls and related injury, initiated 9/16/22. Approaches to this problem included brightly colored signage on walker to encourage use (11/27/23) and non-skid strips on floor next to bed (10/9/23). A 12/5/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired, was rarely or never understood by others, used a walker for mobility, and rejected care 1 to 3 days of the assessment period. During the survey period from 1/4/24 at 11:01 a.m. until 1/8/24 at 10:01 a.m., floor strips were not present on the floor by the resident's bed. There was no visible signs of adhesive residue on the floor where strips had been removed. During an observation on 1/4/24 at 11:16 a.m., the resident was in the dining room with his walker near his dining seat. There was no bright signage on the walker. During an observation on 1/5/24 at 11:44 a.m., the resident was in the dining room with his walker near his dining seat. There was no bright signage on the walker. During an observation and interview on 1/8/23 at 10:01 a.m., RN 5 indicated there were no non-skid strips by Resident 51's bed. The resident was resting in the bed at the time. RN 5 looked at the resident's walker and indicated there was no bright signage or any signage posted. She did not remember the last time she had seen either item in place. During an interview on 1/8/24 at 10:07 a.m., the Dementia Unit Manager indicated she did not know why Resident 51 did not have non-skid strips on his floor nor signage on his walker. The CNA assignment sheet specifically identified needed tools and devices. If a staff member noticed these items were missing, they should notify the charge nurse or unit manager to correct the problem. Review of the CNA assignment sheet provided by the Dementia Unit Manager on 1/8/24 at 10:10 a.m. indicated Resident 51 should have brightly colored signage on walker to encourage use and non-skid strips next to bed. During an interview on 1/8/24 at 10:33 a.m., the DON indicated she did not know why the bright signage or non-skid strips were not in place. She reviewed the resident's record and the resident's bed placement was changed on 12/4/23 as an intervention. Perhaps the placement of the non-skip strips in the new location was accidentally overlooked. A current, 8/2022, policy titled, Fall Management Policy, provided by the DON on 1/8/24 at 10:40 a.m., indicated the following: .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered according to physician order for 1 of 1 resident reviewed for oxygen therapy. (Resident 22) Finding includes: During an observation on 1/3/23 at 3:26 p.m., Resident 22 was in bed in her room. Her oxygen was on via nasal cannula and set at 4 liters per minute. The oxygen concentrator was to the left of the resident's bed. During an interview at the time of observation, the resident indicated she had trouble with staff putting her oxygen on in the mornings because they failed to adjust the oxygen setting once they removed the Trilogy (non-invasive mechanical ventilator) mask. She was unable to ambulate, and the oxygen concentrator was not within reach. She relied on staff to manage her respiratory equipment. During an observation on 1/4/23 at 8:09 a.m., the resident was in bed with her oxygen on via nasal cannula at 4 liters per minute. The resident indicated staff had just removed her Trilogy mask and put the nasal cannula on her. Resident 22's clinical record was reviewed on 1/4/24 at 11:35 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), shortness of breath, multiple sclerosis, and generalized muscle weakness. An order, dated 1/26/22, indicated Trilogy on at bedtime and off upon waking with oxygen at 4 liters per minute. An order, dated 11/22/22, indicated oxygen at 3 liters per minute was to be worn daily via nasal cannula. An annual Minimum Data Set assessment, dated 11/9/23, indicated the resident was cognitively intact. She was dependent for toileting, personal hygiene, and lower body dressing. The resident was dependent on staff to roll left and right and to move from sitting to lying. Chair transfers, toilet transfers, and sit to stand transfers were not attempted due to the resident's medical condition. Special treatments included oxygen therapy and a non-invasive mechanical ventilator. A care plan, revised 12/27/23, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath. Interventions included administer oxygen as ordered (11/16/21), and Trilogy machine for sleep apnea (3/1/23). A Nurse's Note, dated 10/10/23, indicated the resident's oxygen was on at 4 liters per minute via nasal cannula. During an observation on 1/5/24 at 9:18 a.m., the resident was in bed with oxygen on at 4 liters per minute via nasal cannula. The resident indicated staff had removed her Trilogy mask for her that morning and placed the nasal cannula on her. During an interview at the time of observation on 1/5/24 at 2:54 p.m., LPN 2 indicated the resident's oxygen via nasal cannula was on 4 liters per minute. The oxygen should have been set at 3 liters per minute according to the physician order. During an interview on 1/5/24 at 3:05 p.m., the DON indicated oxygen therapy should have been administered according to the physician orders. A current, undated, facility document, titled Oxygen Concentrator, provided by the DON on 1/5/24 at 4:13 p.m., indicated the following: .Purpose .To provide Oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration level of oxygen . Procedure 1) Verify and understand the physician's order. 2) Know the flow rate and duration of use . 9) Adjust the flow meter control knob to the flow setting prescribed by the physician. The graduated line of the meter should be aligned with the center of the floating ball 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies regarding storage and maintenance of respiratory equipment for 1 of 7 residents reviewed for infection control. (Resident 22) Finding includes: During an observation on 1/3/23 at 3:26 p.m., Resident 22 was in bed in her room. Her oxygen was on via nasal cannula. The nasal cannula oxygen tubing was dated 12/24/23. The Trilogy (non-invasive mechanical ventilator) mask was not in use and was directly against the Trilogy machine on the right side of the bed. During an interview at the time of observation, the resident indicated she was unable to ambulate and both the oxygen concentrator and the Trilogy machine were not within reach. She relied on staff to manage her respiratory equipment. The resident had never seen staff use a barrier or bag for the Trilogy mask when they removed it from her face. During an observation on 1/4/23 at 8:09 a.m., the resident was in bed with her oxygen on via nasal cannula. The oxygen tubing date remained unchanged from the previous day. The Trilogy mask rested directly against the Trilogy machine on the side of the mask that fits against the residents face when worn. The resident indicated staff had just removed her Trilogy mask and placed it on the Trilogy machine in the corner . Resident 22's clinical record was reviewed on 1/4/24 at 11:35 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), shortness of breath, multiple sclerosis, and generalized muscle weakness. An order, dated 1/26/22, indicated Trilogy on at bedtime and off upon waking with oxygen at 4 liters per minute. An order, dated 11/22/22, indicated oxygen at 3 liters per minute worn daily via nasal cannula. An order, dated 12/17/21, indicated oxygen tubing and humidity were to be changed once a day on Sundays. An annual Minimum Data Set assessment, dated 11/9/23, indicated the resident was cognitively intact. She was dependent for toileting, personal hygiene, and lower body dressing. Special treatments included oxygen therapy and a non-invasive mechanical ventilator. A current care plan, revised 12/27/23, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath. Interventions included administer oxygen as ordered (11/16/21) and Trilogy machine for sleep apnea (3/1/23). During an observation on 1/5/24 at 9:18 a.m., the resident was in bed with oxygen on at 4 liters per minute via nasal cannula. The nasal cannula oxygen tubing remained dated 12/24/23. The Trilogy mask was not in use and rested directly against the contaminated surface of the Trilogy Machine on the side that rests against the face when worn. A barrier was not in use, and it was not in reach of the resident. The resident indicated staff had removed her mask for her that morning and placed it on the Trilogy machine in the corner. During an interview at the time of observation on 1/5/24 at 2:54 p.m., LPN 2 indicated the resident's nasal cannula oxygen tubing was dated 12/24/23. Oxygen tubing should have been changed according to the order, every Sunday. The resident's Trilogy mask was placed directly on top of the Trilogy machine and should have been stored in a bag when it was not in use. During an interview on 1/5/24 at 3:05 p.m., the DON indicated oxygen tubing should have been changed every Sunday according to the physician orders. Trilogy masks and Continuous Positive Airway Pressure (CPAP) masks should have been stored in a bag when they were not in use. Improper storage and maintenance of respiratory equipment were potential risks for infection. During an interview on 1/5/24 at 4:14 p.m., the DON indicated the facility policy lacked information on how the respiratory equipment should be stored. A current facility policy, dated 3/2022, titled Infection Prevention and Control Program Policy, provided by the facility following entrance conference on 1/2/24 at 1:50 p.m., indicated the following: .POLICY: The facility shall establish and maintain infection prevention and control program [IPCP] designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections . GOALS: The goals of the infection prevention and control program are to: 1. Decrease the risk of infection to residents through investigation and surveillance . 5. Maintain compliance with state and federal regulations related to infection prevention and control 3.1-18(a)

Based on observation, interview and record review, the facility failed to allow residents food choices and preferences for 4 of 6 residents reviewed. (Resident 29, Resident 42, Resident 47 and Resident 215) Findings include: 1. During an interview on 10/28/22 at 1:46 p.m., Resident 29 indicated he had not received a menu of what the facility planned to serve for any meals. The staff had not asked him to select his meals nor given him any choices regarding breakfast, lunch or supper each day. He preferred to stay in his room in the morning. He received a food tray at each meal, but the items he received on his meal trays each day were not chosen by him. Resident 29's clinical record was reviewed on 10/31/22 at 3:33 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current dietary order indicated a regular diet with the following special instructions: may have ground meats at the resident's request. A 7/22/22, Quarterly Minimum Data Set (MDS) assessment indicated the resident's cognitive status was moderately impaired. He required limited assistance of 1 staff member for bed mobility, transfers and toileting. The resident required extensive assistance of 1 staff member for dressing. A wheelchair was utilized for mobility. He lacked any exhibited rejection of care behaviors. A current care plan for cognitive loss, indicated the resident exhibited cognitive impairment. Interventions included, give resident choices throughout the day regarding decisions and provide the resident with prompts and cues as needed. During an interview at the time of observation on 11/1/22 at 12:37 p.m., the resident sat in his wheelchair in his room. His lunch tray was in front of him on his over-the-bed table. His lunch tray lacked any method for the resident to make a meal selection. He indicated staff members had not asked him what he wanted to eat for his meals the next day. During an interview at the time of observation on 11/2/22 at 10:39 a.m., the resident sat in his wheelchair in his room and watched television. He indicated staff members had not given him any choices for his meals for the next day. Every meal each day was a surprise, sometimes for the better and sometimes for the worse. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated the resident had not attended the Coffee and Meal Plans Activity any times from 10-1-22 to 10-31-22. 2. During an observation at the time of interview on 10/28/22 at 11:10 a.m., Resident 42 was in her bed with the television on. She indicated she fractured her back 3 years ago so she required a significant amount of assistance to get out of bed. She preferred to remain in bed rather than to bother the staff members. Though she was on hospice, she still wanted to have some choices when it came to meals. She was not made aware what the facility planned to serve each day. A menu was not provided. She indicated a meal tray was delivered each meal but she just got whatever they brought her. If she sent the tray away they sent the facility chosen alternative. She never had any options to select for each meal. Resident 42's clinical record was reviewed on 10/31/22 at 3:56 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current dietary order for a regular diet was in place. An 8/26/22, Quarterly MDS assessment indicated the resident's cognitive status was intact. She required extensive assistance of 2 staff members to total dependence for bed mobility, transfers, dressing and toileting. She lacked any exhibited rejection of care behaviors. A current care plan for death with dignity and physical comfort indicated the resident's advanced directive wishes were honored. Interventions included to involve the resident in care and decision making to the maximum potential and provide food and fluids for comfort or based on resident preferences. A current care plan for depression indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/1/22 at 11:30 a.m., the resident indicated she preferred meals in her room. She had not been to the dining room. Staff had not asked her to make any choices for her meals so she was unaware what they planned to bring her. She had asked for a menu but it was not provided. During an interview at the time of observation on 11/1/22 at 12:31 p.m., her lunch tray was on her over-the-bed table at bedside. The tray lacked any method for menu selections. She indicated she was unaware why staff members were unable to find a menu for the week to ensure she was informed of the meals in advance. No one had offered her meal choices for the next day. During an interview on 11/2/22 at 10:45 a.m., the resident indicated activities staff members still had not offered her any menu choices for the next day. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated the resident had not attended any Coffee and Meal Plans Activities for the month of October. 3. During an observation at the time of interview on 10/28/22 at 1:14 p.m., Resident 47 was in her bed, wore pajamas and had the television on. She indicated the residents were only permitted to choose their meals for the next day if they went to the dining room for coffee. Since she did not feel well and wanted to stay in bed in her pajamas, she did not have the opportunity to make meal selections for the next day. Resident 47's clinical record was reviewed on 10/31/22 at 1:11 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current dietary order for a regular diet was in place. An Annual MDS assessment, dated 9/16/22, indicated the resident's cognitive status was intact. She required extensive assistance of 2 staff members for bed mobility, transfers, and toileting. A wheelchair was required for mobility. She lacked any exhibited rejection of care behaviors. A current care plan for activities indicated the resident enjoyed independent activity persuits such as word searches, puzzles and other reading materials. A long term goal indicated the resident would participate in independent activities to their level of satisfaction. Interventions included, but were not limited to, offer items for room. During an interview at the time of observation on 11/1/22 at 11:05 a.m., the resident was in her pajamas in bed and watched television. She indicated she had not been to the dining room. Staff had not offered her menu selections for the next day. During an interview at the time of observation on 11/2/22 at 12:53 p.m., the resident indicated she had not gone to the dining room to make menu selections. Staff had not offered her menu selections for the next day. She would like to have made her own choices for each meal especially when she did not feel well. She preferred to have chosen all of her meals each day, but the facility had not offered her any menu options when she had not gone to the dining room. Since she had a stroke, she required assistance to get up and preferred to stay in bed. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated they resident had not attended the Coffee and Meal Plans Activity from 10/1/22 to 10/31/22. 4. During an interview at the time of observation on 10/28/22 at 2:03 p.m., Resident 215 indicated the doctor wanted her up in the wheelchair only once per day to avoid additional risks of a compromised external fixation device on her right lower leg. She was in her bed with her right leg elevated and the external fixation device in place. A mechanical lift was used to get her in the wheelchair. As a result, she chose to get up during the time she went to smoke. She ate in her room. No one offered her the opportunity to select any meals. A meal was just sent to the resident's room. She was not provided a menu. If she did not want the meal they sent to her room, then they brought a peanut butter and jelly sandwich to replace it but she was not offered any options. She made the dietary department aware not to send tomatoes on her tray, but they still sent tomatoes. Resident 215's clinical record was reviewed on 10/31/22 at 3:20 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan for activities indicated the resident enjoyed activities such as word searches, bingo and being outside. A long term goal indicated the resident would participate in independent activities to their level of satisfaction. Interventions included provide independent supplies for room as needed when scheduled programming does not meet the resident's preferences or interests. A Nurse's note, dated 10/29/22 at 1:49 p.m. indicated the resident was alert and oriented to person, place and time. During an observation at 11/1/22 at 12:08 p.m., Certified Nurse's Aide (CNA) 11 delivered a lunch tray to the resident. The meal ticket was observed with no tomatoes listed at the bottom. Tomatoes were sent on her meal tray. During an observation on 11/1/22 at 12:11 p.m., an unidentified staff member came to the resident's room and informed her the dietary department was notified again of her preference for no tomatoes. Review of the Activities Attendance Record for the resident, provided by the Activity Director on 11/2/22 at 11:29 a.m., indicated they resident had not attended the Coffee and Meal Plans Activity any since she admitted during the month of October. During an interview on 11/1/22 at 4:23 p.m., CNA 8 indicated she was unaware how the dietary department received the residents meal choices. Meal choices were not obtained during second shift. During an interview on 11/1/22 at 4:26 p.m., CNA 9 indicated she was unaware know how meal choices were offered and sent to the dietary department. During an interview on 11/1/22 at 4:33 p.m. Registered Nurse (RN) 6 indicated the activities department collected meal choices in the dining room on a tablet. She was not certain when the meal choices were obtained. During an interview on 11/1/22 at 4:40 p.m., the Activity Director indicated the residents who came to the dining room during coffee time, before 11:45 a.m., have their meal choices entered for the next day by an activity staff member. The residents who had the physical ability to go to the Coffee and Chat in the dining room, but chose not to attend, received a system generated standard meal ticket rather than resident chosen meals. Next, an activity staff member offered meal choices to the 3 residents in the facility who were not able to attend the Coffee and Chat in the dining room. Resident 42 was listed as a resident unable to attend the Coffee and Chat. Residents 29, 47 and 215 were not listed as unable to attend. Residents who attended Coffee and Chat in the dining room were offered the opportunity to choose their drinks, made choices between the main meal and expanded alternates and condiment selections. When a resident, who did not attend Coffee and Chat to select their meals, refused the standard meal, the facility chosen alternate meal was provided. They were not given different expanded options for an alternate. He indicated they previously provided weekly paper menus to the residents but they have not done that for quite some time. The electronic menu selection only provided the day by day menu options. During an interview at the time of observation on 11/2/22 at 9:38 a.m., Coffee and Chat was underway in the dining room with 7 residents in attendance. Activity Assistant 7 obtained meal choices for breakfast, lunch and dinner from the residents for the next day. Choices included the drinks, main coarse or expanded alternates and the way they wanted their eggs cooked for breakfast. Residents 29, 42, 47 and 215 were not in attendance. Meal choices were not offered at a later time to the resident's who did not attend Coffee and Chat. Instead, they received the standard meal. During an interview on 11/2/22 at 9:59 a.m., the Dietary Manager indicated the meal tickets were printed from Meal Tracker the evening they were collected by the activity staff member. Every resident had a meal ticket printed even if they did not choose the meals. The alternate meal was Chef's Choice, if the standard meal was refused, because they lacked adequate time to make individualized requests at the last minute. If they attended in the dining room and chose an alternate, the residents had more alternate options. Food allergies and preferences should not have been sent to the residents on their meal tray. Food preferences were collected within 72 hours of the resident's admission. The printed meal tickets did not differentiate if they were system generated due to non-selection or manually generated due to the residents' choices. A request was made for copies of meal tickets from 10/24/22 to 11/2/22. She indicated she did not have a way to print previous meal tickets because they are wiped clean on a daily basis. Further documentation of meal tickets was not provided prior to the survey exit on 11/2/22 at 4:07 p.m. During an interview on 11/2/22 at 11:51 a.m., the Administrator indicated the residents had the right to choose if they wanted to participate in an activity. He indicated the resident who were able to make their meal choices in the dining room, but did not attend during that time, received a system selected standard meal ticket. Residents did not have menus. During an interview on 11/2/22 at 12:10 p.m., the Director of Nursing (DON) indicated the residents who did not come out of their room would not have had access to the menu to see what was served. During an interview on 11/2/22 at 12:12 p.m., the Assistant Director of Nursing (ADON) indicated the residents had to take responsibility and attend in the dining room to make their own meal choices if they were able. It would have been burdensome on staff to go to the residents' rooms when the residents chose not to attend in the dining room to make their meal selections. This change was made to encourage residents to participate more. A current document, titled RESIDENT RIGHTS, provided by the Administrator on 10/27/22 at 3:00 p.m., indicated the following: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident Exercise of Rights .The resident has the right to exercise his or her rights as a citizen or resident of the United States, and to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights Self-Determination .A resident has the right to: Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care Make choices about aspects of his or her life in the facility that are significant such as schedules, including but not limited to sleeping, waking, eating, and bathing 3.1-3(u)(1)

Based on interview and record review, the facility failed to prevent staff to resident verbal and physical abuse for 2 of 3 residents reviewed for abuse ( Resident D and Resident H). The immediate jeopardy began on 8/21/2019 when staff observed CNA 1 pushing his elbow into a resident and became verbally aggressive with a resident. The Administrator was notified of the immediate jeopardy on 11/13/2019 at 4:47 p.m. The immediate jeopardy was removed on 11/14/2019, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an interview on 11/13/2019 at 12:20 p.m., QMA (Qualified Medication Aide) 3 indicated approximately 2 months ago, she witnessed CNA 1 push his elbow into the Resident D's shoulder to force him (Resident D) to sit on the toilet. CNA 1 became verbally aggressive and demanded the resident to sit down using inappropriate language. On a separate occasion she witnessed CNA 1 pull the resident from the bed real hard while the resident was not yet awake. The resident was taken to the bathroom and while she was cleaning his (Resident D) legs, CNA 1 used a thumb hold (putting pressure between the thumb joint) on the resident to get him (Resident D) to sit on the toilet. The resident asked CNA 1 why he was doing this. After the resident was cleaned, CNA 1 threw (forcefully shoving) the resident back into the bed. CNA 1 indicated if he (CNA 1) had known the man (Resident D) would remember, I would whip his _ss. QMA 3 indicated she did not report the incidents. She indicated her intervention was telling CNA 1 she could finish the care of Resident D to attempt to get him to leave the bathroom. During an interview on 11/13/2019 at 12:27 p.m., CNA 2 indicated approximately 2 months ago while providing incontinent care for Resident D, she witnessed CNA 1, take his thumb and grind it into the resident's knuckles to over power him. She indicated CNA 1 became verbally aggressive with the resident when the resident became combative. CNA 2 indicated CNA 1 asked Resident D, Does it make you feel like a man to hit women?. CNA 2 indicated she has witnessed CNA 1 hold Resident D down on the toilet. CNA 2 was unable to give an exact date for any of the witnessed incidents involving CNA 1, but indicated she began working at the facility in (MONTH) 2019 and the incidents began when she started working at the facility. During an interview on 11/13/2019 at 1:17 p.m., CNA 4 indicated approximately two months ago she witnessed CNA 1 grind his knuckles together and stated This is how you get him (Resident D) to do what you want. She indicated she witnessed CNA 1 pull the resident's thumb towards his wrist and force him to sit down on the toilet. She indicated while working with CNA 1 she had witnessed him shoving the resident into his bed. The facility investigation, dated 9/30/19, indicated CNA 1 was accused of verbally and physically abusing two cognitively impaired residents on the memory care unit. Written statement by the Clinical Educator (no longer employed at the facility) dated 10/1/2019, indicated CNA 2 told her CNA 1 was being rough with Resident D during resident care. The statement indicated the Clinical Educator got the impression CNA 2 had already reported the incident. The clinical record for Resident D was reviewed on 11/12/2019 at 11:58 a.m. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 9/30/2019, indicated the resident was moderately cognitively impaired. A current health care plan, dated 3/11/2019, indicated the resident was unable to make daily decisions without cues/supervision related to activities of daily living, dressing, toileting and interactions with others. Interventions included, but were not limited to, allowing time for resident to process request, show him what needs to be completed in short steps, without rushing; provide cues and supervision for dressing, meal times, interactions with others, toileting and all activities of daily living. 2. During an interview on 11/13/2019 at 12:27 p.m., CNA 2 indicated approximately 2 months ago she witnessed CNA 1 take the Resident H by the arms and turn her forcefully towards the wall and indicated that was how he kept the resident from screaming. CNA 2 did not intervene or report the incident. The clinical record for Resident H was reviewed on 11/13/2019 at 11:00 a.m. [DIAGNOSES REDACTED]. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 9/4/2019, indicated the resident was severely cognitively impaired. During in interview on 11/13/2019 at 1:00 p.m., the Administrator and the Director of Nursing indicated they became aware of the allegations of abuse on 9/30/2019. Review of the working schedules on 11/12/2019 at 1:48 p.m., indicated CNA 1 and CNA 2 worked together on (MONTH) 21, 2019. Review of a current facility policy, revised (MONTH) (YEAR), titled Abuse Prohibition, Reporting and Investigation, which was provided by the Administrator on 1/12/19 at 9:09 a.m., indicated the following: .Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion. The immediate jeopardy that began on 8/21/2019 was removed on 11/14/2019, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy when staff interviews confirmed the facility had put into place a monitoring system to observe direct resident care and staff inservicing on the abuse and the reporting process had occurred. This Federal tag relates to Complaint IN 274. 3.1-27(a)(1)

Based on interview and record review, the facility staff failed to ensure staff who witnessed verbal and physical abuse reported the alleged abuse to the facility Administrator per policy for 2 of 3 residents reviewed for abuse. ( Resident D and Resident H). The immediate jeopardy began on 8/21/2019 when staff observed verbal and physical abuse of two cognitively impaired residents by a staff member and failed to provide interventions or report the allegation to the Administrator. The Administrator was notified of the immediate jeopardy on 11/13/2019 at 4:47 p.m. The immediate jeopardy was removed and the deficient practice corrected on 10/1/2019, prior to the start date of the survey and was therefore Past Noncompliance. Findings include: 1. The clinical record for Resident D was reviewed on 11/12/2019 at 11:58 a.m. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 9/30/2019, indicated the resident was moderately cognitively impaired. A current health care plan, dated 3/11/201, indicated the resident was unable to make daily decisions without cues/supervision related to activities of daily living, dressing, toileting ad interactions with others. Interventions included, but were not limited to, allowing time for resident to process request, show him what needs to be completed in short steps, without rushing; provide cues and supervision for dressing, meal times, interactions with others, toileting and all activities of daily living. During an interview on 11/13/2019 at 12:20 p.m., QMA (Qualified Medication Aide) 3 indicated she witnessed CNA 1 push his elbow into the resident's shoulder to force him to sit on the toilet. She indicated CNA became verbally aggressive and demanded the resident to sit down using inappropriate language. On a separate occasion she witnessed CNA 1 pull the resident from the bed real hard while the resident was not yet awake. The resident was taken to the bathroom and while she was cleaning his legs CNA 1 used a thumb hold on the resident to get him to sit on the toilet. The resident asked CNA 1 why he was doing this. After the resident was cleaned, CNA 1 threw the resident back into the bed. CNA 1 indicated CNA 1 indicated if he (CNA 1) had known the man (Resident D) would remember, I would whip his _ss. She indicated she did not report the incidents nor did she attempt to intervene. During an interview on 11/13/2019 at 12:27 p.m., CNA 2 indicated approximately 2 months ago while providing incontinent care, she witnessed CNA 1, taking his thumb and grinding it into the resident's knuckles to over power him. She indicated CNA 1 became verbally aggressive with the resident when the resident became combative. CNA 1 stated, Does it make you feel like a man to hit women?. She indicated she did not report the incident. The CNA was unable to give exact dates as to when theses incidents occurred but indicated she was hired in (MONTH) 2019 and the incidents happened soon after her hire date. During an interview on 11/13/2019 at 1:17 p.m., CNA 4 indicated approximately two months ago she witnessed CNA 1 grind his knuckles together and stated This is how you get him (Resident D) to do what you want. She indicated she witnessed CNA 1 pull the resident's thumb towards his wrist and force him to sit down on the toilet. Approximately two days later she reported the incident to management but failed to report it to the abuse coordinator. She indicated while working with CNA 1 she has witnessed him shoving the resident into his bed. The facility investigation, dated 9/30/2019, indicated CNA (Certified Nursing Aide) 1 was accused of verbally and physically abusing two cognitively impaired residents on the memory care unit. 2. The clinical record for Resident H was reviewed on 11/13/2019 at 11:00 a.m. [DIAGNOSES REDACTED]. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 9/4/2019, indicated the resident was severely cognitively impaired. During an interview on 11/13/2019 at 12:27 p.m., CNA 2 indicated approximately 2 months ago she witnessed CNA 1 take the resident by the arms and turn her forcefully towards the wall and indicated that was how he kept the resident from screaming. She indicated she did not report the incident. During an interview on 11/13/2019 at 1:00 p.m., the Administrator and the Director of Nursing indicated they became aware of the allegations of abuse on 9/30/2019. Review of a General Employee Orientation Checklist, QMA 3 signed she understood the policy on resident abuse and rights on 6/19/2019. Review of a General Employee Orientation Checklist, CNA 2 signed she understood the policy on resident abuse and rights on 8/8/2019. Review of a General Employee Orientation Checklist, CNA 4 signed she understood the policy on resident abuse and rights on 8/30/2019. Review of time record for indicated CNA 1 worked 180.5 hours after the first observation of abuse was alleged. Review of a current facility policy, revised (MONTH) (YEAR), titled Abuse Prohibition, Reporting and Investigation, which was provided by the Administrator on 1/12/19 at 9:09 a.m., indicated the following: .Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion. Resident Abuse-Staff member, volunteer, or visitor: . 2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director. Review of the current Employee Handbook, which was prided by the Director of Nursing on 11/13 at 1:00 p.m., indicated the following: . Reporting Resident Abuse and Neglect . If you are ever witness to a situation where you believe that a resident's physical, mental, or general well-being has been or may be abused or neglected, you must report it immediately to the Executive Director/General Manager of the facility. You will also need to make an immediate written report of the situation to your supervisor. The past noncompliance immediate jeopardy that began on 8/21/2019 was removed and the deficient practice corrected by 10/1/2019 after the facility implemented a systemic plan that included staff inservicing on the abuse reporting process and monitoring to ensure staff knew what to do in the case of abuse. This Federal tag relates to Complaint IN 274. 3.1-28(c)

Based on record review and interview the facility failed to ensure a Minimum Data Set (MDS) assessment was completed within the 120 day time frame for 1 of 1 residents reviewed for resident assessments. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 7/30/2019 at 1:24 PM. [DIAGNOSES REDACTED]. The most current Quarterly MDS assessment, was dated 3/10/2019. The resident was discharged from the facility on 6/6/2019. The clinical record lacked a discharge MDS as of 7/30/2019, which was beyond the allowed 120 day window. During an interview on 7/ 9 at 2:00 PM, the MDS Coordinator indicated the discharge MDS had been missed for Resident 2. She indicated normally upon discharge, a discharge MDS was opened right away. The facility followed the Resident Assessment Instrument (RAI) as the guidelines for MDS completion. 3.1-31(a)

Based on interview and record review, the facility failed to ensure a resident had received the appropriate due process related to a 30 day notice of discharge, resulting in fear of retaliation for 1 of 6 residents reviewed for resident rights (Resident B) and 1 of 3 residents reviewed for discharge. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/6/2016 at 11:00 a.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/19/2016, was reviewed on 7/6/2016 at 11:00 a.m. The MDS indicated Resident B was cognitively intact with a BIMS (Brief Interview for Mental Status Score) of 15 out of 15. Review of the clinical record, on 7/6/2016 at 11:00 a.m., from 8/15/2014 to 6/23/2016, indicated the clinical record lacked any care plan for non compliant behaviors related to smoking or documentation of any prior smoking policy violations. Review of a nursing note, dated 6/12/2016, indicated the following: 6/12/2015 at 8:31 p.m., res (resident) (sic) was observed with smoking materials in the court yard. the (sic) materials were ceased (sic) and secured. Review of an IDT (interdisciplinary team) note, dated 6/13/2016, indicated the following: 6/13/2016 at 11:55 a.m., IDT met to review confirmation of resident having possession of inappropriate smoking materials according to sign facility policy via resident. Resident was caught smoking outside with other residents against facility policy. SSD (Social Service Director) and CNA (name of CNA) searched resident room per policy. SSD, DNS (Director of Nursing Services) and ED (Executive Director) met with resident and made resident aware of safety check. SSD and CNA made resident aware of the finding of cigarettes and lighters. Resident (sic) family made aware via SSD. DNS contacted ombudsman at residents (sic) request. ED issuing (sic) resident 30 day d/c notice facility found. Resident request to d/c to a facility in Muncie, Indianapolis and Bloomington if possible. ED, DNS, UM (Unit Manager), MR (Medical Records), and writer in attendance. Review of a nursing note, dated 6/23/2016, indicated the following: 6/23/2016 at 2:30 p.m., res (sic) left via facility bus to discharge to another facility. res (sic) took all belongings with her. All medications were sent along with progress notes and lab work and cigarettes. Res (sic) signed discharge papers and copy was sent with her. Review of a Notice of Transfer or Discharge form, dated 6/13/2016, indicated a signature by the ED but lacked Resident B's signature. The form indicated Resident B was a danger to the facility. During an interview on 7/6/2016 at 9:33 a.m., the Ombudsman indicated she had been called to the facility at the request of Resident B. The Ombudsman's investigation concluded Resident B had no prior documented events related to smoking policy violations. The Ombudsman indicated Resident B feared retribution in the form of with held medications if an appeal to the Notice of Transfer was initiated. The Ombudsman indicated in her interviews with the SSD (Social Service Director), the SSD indicated to her Resident B was not a danger to the facility. The Ombudsman indicated in her interview with the ED (Executive Director), the ED indicated the facility might be discharging many people who don't fit into (name of parent company) model - dementia diagnosis. During an interview on 7/6/2016 at 1:18 p.m., the SSD denied making a statement to the Ombudsman indicating Resident B was not a danger to the facility. During an interview on 7/7/2016 at 12:12 p.m., the ED indicated he had given Resident B the 30 day Notice of Discharge letter after she had been found in violation of the smoking policy. The ED denied making a statement to the Ombudsman regarding the discharge of residents with a [DIAGNOSES REDACTED]. During an interview on 7/8/2016 at 8:20 a.m., Resident B verbalized a fear of having the anti anxiety medications held if an appeal was initiated. I was wanting to appeal it until they started taking my Klonopin (anti-anxiety medication). I didn't want to leave. That place was my home and I had friends there - like family. I told (name of Ombudsman) they were taking my medicines from me. I can't have that!I need my anxiety medicine! I knew about the appeal because I read it. No one told me about it. Resident B became visibly upset and tearful during this interview. This federal tag relates to Complaints IN 993. 3.1-12(a)(7)

Based on observation, interview, and record review, the facility failed to prevent the thermostat in the room from being turned on high for 1 of 3 residents reviewed for accidents. This failure resulted in burns requiring hospitalization in a burn unit and skin graft surgery (Resident # B). Findings Include: During the initial tour on 1/10/14 at 2:00 p.m., RN # 3 provided general information on all current residents. Rooms 106, 114, 210, 215, 216, 222, 224, 309 and 311 were carefully inspected with all baseboard heater covers intact. Resident (B)'s room was within a normal temperature range. The baseboard heater was cool to touch. No additional rooms appeared overly warm. During an interview on 1/10/14 at 2:53 p.m., LPN #1 indicated she was the nurse on duty who found Resident (B). She indicated during report, she was informed Resident (B) and his roommate both needed a weight to be recorded. She indicated she asked CNA #2 for assistance weighing both residents. She indicated she was pushing her medication cart behind CNA #2 and was at the doorway of Resident (B) when she heard the CNA call his name and he did not respond. She indicated the light was off in his room and the curtain was pulled. LPN #1 then indicated Resident (B) was laying on his right side with his head parallel to the foot of the bed. She placed him on his back to assess him. She indicated his eyes were open but he did not verbally respond. She indicated he was approximately 2" from the heater and she could feel the heat coming from the baseboard heater. She indicated he was incontinent of urine and was partially laying across his bedside table with one foot partially under the bed. She indicated one of his feet had a cord loosely wrapped around it. She indicated the resident did not shake or nod his head while he was on the floor to respond to her questions. She indicated herself and the CNA moved Resident (B) to the bed and removed his clothing for a complete assessment. She indicated Resident (B) has obvious injuries to his face and shoulder. She immediately called 911 and directed others to start the paperwork for transfer to the local hospital. She indicated she took vital signs and a blood glucose level. She indicated his pupillary response was normal. She indicated Resident (B) had a raised hematoma to his right forehead, swelling of right eye, red area to bridge of nose, swollen lip, "small tennis ball" size red open area to the right shoulder, red area approximately 8 cm x 8 cm to the right posterior shoulder, fluid filled blister to his right index finger and a large red area from his elbow to his shoulder that had fluid-filled blisters. She indicated the resident was often up early because he went out to smoke first thing in the morning. She indicated she had not seen the resident since she came to work approximately 6:20 a.m. on 1/9/14. The clinical record of Resident #B was reviewed on 1/13/14 at 9:30 a.m. The record indicated the resident's [DIAGNOSES REDACTED]. The Initial Minimum Data Set (MDS) Assessment, dated 6/12/13, indicated the resident displayed memory loss and no mood assessment was completed. A Quarterly MDS dated , 12/11/13, indicated the resident's BIM score was 10 of 15, which indicated the resident was moderately, cognitively impaired. The care plan, dated 6/14/13 and updated 1/9/14, indicated the resident had a [DIAGNOSES REDACTED]. The Initial MDS further indicated Resident # B transferred, ambulated in the room and used the toilet independently. The resident required supervision for ambulation in the hallway and assistance with hygiene and bathing. A nurse note, dated 1/9/14 at 6:45 a.m., indicated"...CNA (Certified Nursing Assistant) yelled at to me (writer). Turned on light and had staff go to get help. Resident was laying on R (right) side, under bedside table but over the metal bar, and left foot had power cord wrapped up or looped around L (left) foot. Asked resident, 'Are you okay?' No response. Rolled on back. 2 assist lifted up to bed, resident's clothes wet (shirt, jeans, & socks) & had staff safely remove them...". The following nurse notes indicated 911 was called and the resident was transferred to the hospital emergency room . An emergency room nurse, was interviewed on 1/9/14 at 3:45 p.m. The nurse indicated, the resident had been intubated at the emergency room then transferred by helicopter to another hospital's burn unit for treatment. A nurse note, dated 1/9/14 at 9:00 a.m., indicated " Reviewed events... felt heat from heater on where resident was lifted up from off floor...". The facility form entitled, "Admission Skin Assessment", dated 1/9/14, included the following findings by the nurse. "1- 7.5 centimeter (cm) by 4.5 cm of red and dried blood on the resident's forehead 2- Nose swollen with 2 cm by 2 cm red intact area on the bridge of nose 3- Mouth swollen and unmeasurable 4-Right eye, red swollen, unmeasurable 5- Right shoulder red with 7 cm by 3.5 cm open area 6- Left arm was red from shoulder to elbow with 10 cm by 1.5 cm fluid filled blister 7- Back of right shoulder had a 8 cm by 8 cm red area with 'skin rolled back' 8- 8 cm by 3 cm red area to right index finger with 1 cm by 1 cm fluid filled blister" The "Pain Data Collection Assessment" dated 1/9/14, rated the resident's pain at 8 out of 10. This assessment was completed using facial grimacing. Resident # B's room was observed again on 1/10/14 at 3:30 p.m. The resident's bed was approximately three feet from the electric baseboard heater. A night stand with two drawers sat between the head of the bed and wall that the large baseboard heater was attached to under a window. The thermostat to control the heater was on the opposite wall by the bathroom door. The bed side table sat across the resident's bed. The thick black power cord for the bed stretched under the bed from the foot of the bed to where it was plugged in on the wall at the head of the bed. The DoN (Director of Nursing) was interviewed in the resident's room on 1/13/14 at 9:45 a.m. The DoN indicated the resident was found by staff on the floor, partially under the bedside table and partially on top of the baseboard heater. The bedside table had reading materials covering the top. The DoN indicated nothing on top of the table had been moved. The baseboard heater was cool to the touch at the time of interview. The DoN indicated Resident # B was a "fiddler". He fiddled with everything and maybe he was fiddling with the power cord on his socks when he fell . The power cord for the bed was at the time long enough to lay on the floor stretching from one end of the bed to the other. The DoN indicated the maintenance man had affixed the cord to the under frame of the bed so it could not be reached by the resident. The DoN further indicated at the time of the fall, the resident was wearing pants, shirt, and socks. The DoN indicated the resident was seen by staff fully dressed at 5:00 a.m. in the hallway, so he probably went back to bed after that. The DoN was again interviewed on 1/13/14 at 1:40 p.m. The DoN indicated her investigation had found that after Resident # B's fall, a CNA found the baseboard heater in the resident's room to be on "high". The CNA turned the thermostat down. CNA # 2 was interviewed on 1/13/14 at 2:10 p.m. The CNA indicated the resident liked to get up early. The CNA indicated when she went into the resident's room on 1/9/14 at 6:45 a.m., the room was warm. The CNA did not look at the thermostat because the resident was often cold. The CNA indicated she found the resident on the floor. The resident's face and arm were on the baseboard heater, and the power cord for the bed was looped around his foot. The CNA indicated she called for the nurse. When she and the nurse rolled the resident, they saw what she thought were burns on the resident's arms and face. The CNA further indicated she worked the facility on all three shifts. The CNA indicated the resident did often get up early in the morning then go back to bed, or some nights, not go to bed at all. She indicated the resident was "cold a lot". She would bring him a jacket or blanket on different occasions. The CNA indicated the resident "liked to fiddle" with things. The DoN was again interviewed on 1/13/14 at 2:15 p.m. The DoN indicated the thermostats in some of the resident room were locked so that only nurses and management staff could access them. The DoN indicated staff would sometimes tell the maintenance man that a thermostat was turned on high in a resident's room and the maintenance man would put the lock on that particular thermostat. She indicated the facility did not have a policy for covering the thermostats. She indicated the thermostat in Resident B's room was not locked. The DoN indicated, thinking back, the resident was a fiddler and the thermostat probably should have had a lock. 3.1-45(a)(1)

Based on record review and interview, the facility failed to provide interventions to prevent 1 (Resident B) of 3 residents in the sample of 7, reviewed for pressure ulcers, from developing an unstageable, necrotic pressure sore to a heel. This pressure sore was discovered in the local hospital emergency room when Resident (B) was sent for evaluation and treatment of diaphoresis, and decreased mental status. This pressure sore required surgical debridement of dry gangrene which involved a circular dimensional surface of the heel and the surrounding tissue area. Findings include: Social Services (SS) Case Worker #1 at the local hospital was interviewed by telephone at 10:00 AM, 3/7/12, and indicated family members of Resident (B) were unhappy with the care provided at the facility. Hospital SS Case Worker #1 indicated the emergency room (ER) nurse had found open areas on the initial assessment of Resident (B). SS Case worker #1 indicated Resident (B) had been discharged to another facility the evening of 3/6/12, at the request of family. The facility record of Resident (B) was reviewed 3/7/12, at 10:10 A.M., and indicated a 10/15/08, admission with [DIAGNOSES REDACTED]. The current, 12/7/11, minimum data set (MDS) quarterly assessment indicated Resident (B) was cognitively alert, required extensive assistance with activities of daily living, including transfer to a wheel chair, and was at risk for pressure ulcers. Resident (B) was assessed as currently without unhealed pressure ulcers. The assessed skin/ulcer treatments included pressure reduction devices for bed and chair and a turning, re-positioning program. The 2/12/12, Braden risk assessment scale for pressure ulcers indicated a score of 14, moderate risk. The 2/21/12, plan of care indicated frequent urinary incontinence with use of an adult pull-up brief. The 2/12/12, skin integrity assessment: prevention and treatment plan of care indicated a concern of a pressure ulcer risk with goals of remaining free of open areas, and being cooperative with position changes. Interventions included use of a commercial moisture barrier cream and absorbent adult incontinence products that wicked and held moisture; no massage of reddened bony prominences; no do-nut type devices; protection of heels, and avoidance of dry skin. Documentation did not indicate if Resident (B) required assistance with turning and re-positioning, nor a specific intervention of how to protect the heels. The 2/25/12, 9:00 A.M., nursing note, documented by Licensed Practical Nurse (LPN#1) indicated a check of the vital signs, temperature-98 degrees, and oxygen saturation (O 2 sat) level of 90% on 2 liters of oxygen by nasal cannula. A respiratory treatment was given which raised the O 2 sat level to 95%. Resident (B) was incontinent of bowel and bladder. Pedal (foot) pulses were present. Resident (B) verbalized not feeling well and requested a bed bath instead of a shower. A 2/25/12, 10:00 P.M., nursing note indicated assessment of vital signs and lung sounds. Documentation indicated Resident (B) was not feeling well, ate little at dinner, and stayed in bed all evening. The skin was warm. The 2/26/12, 7:15 A.M., nursing note, documented by LPN #1, indicated assessment of vital signs with a decreased level of consciousness, and no response to verbal commands. The skin was wet, hot, and diaphoretic. The oxygen level was increased to 3 liters, a breathing treatment and Tylenol suppository were given (temperature not indicated). A 2/26/12, 7:45 A.M., nursing note indicated Resident (B) had not responded to the Tylenol suppository or respiratory treatment. Documentation indicated writer (LPN #1) believed Resident (B) had not responded well to the current [MEDICATION NAME] (antibiotic) therapy for pneumonia. 911 was called for transfer to the local hospital emergency room (ER) for evaluation and treatment. Attempts were made to contact family member #1 twice, and report was called to the hospital. At 8:20 A.M., 2/26/12, the emergency medical services (EMS) arrived and transferred Resident (B) to the hospital. Documentation in the nursing notes indicated at 9:00 A.M., 2/26/12, the ER physician called to inquire if the facility had contacted the family. Documentation indicated the ER physician talked about end of life care, and indicated Resident (B) was septic and may not survive. The 2/26/12, facility transfer form indicated a full code status, a current history of pneumonia with decreased lung sounds, and a temperature of 102.8. The skin/wound care section of the form, which indicated high risk for pressure ulcer,with a yes or no check, and a space for documentation of a pressure ulcer, was blank On the morning of 3/7/12, the Director of Nursing (DoN) provided the 2/12, skin examination report sheets (shower assessment sheets) for Resident (B). The sheets contained a picture of the human body with word descriptive body parts which were to be checked if any pressure area was observed. The 2/22/12, sheet indicated zero red areas. Two sheets were enclosed for 2/25/12. The first indicated Resident (B) refused a shower. The second sheet, signed by LPN #1 to indicate assessment, had documentation a bed bath had been given. A circle with a diagonal line through it (zero) was drawn to the side of the form next to the picture of the body form. At 11:50 A.M. ,3/7/12, a visit was made to the area hospital, which was also a regional referral site, to review the 2/26 - 3/6/12, record. Documentation indicated the ER arrival time was 8:26 A.M., 2/26/12. At 9:56 A.M., 2/26/12, ER Registered Nurse (RN #1) documented a, "pressure ulcer to the right heel, dry, necrotic tissue, eschar." Measurements were not provided. The ER physician's report documentation included presence of a [MEDICAL CONDITION] with necrotic area to the right heel. Resident (B) was intubated in the ER and sent to the critical care area at 10:59 A.M., on 2/26/12. The initial impression was [MEDICAL CONDITIONS], and dehydration. Hospital Critical Care Manager #1 was present during the record review and indicated protocol required a total skin assessment on admission to the unit, with wound consult if necessary. The 2/26/12, 12:00 P.M., initial critical care skin assessment indicated the presence of a pressure ulcer to the right heel and right ankle with multiple deep tissue areas and scattered unstageable ulcers along the right lateral foot. The pressure ulcer to the right heel was described as black with dry necrosis and erythemia about the surrounding tissue. The pressure ulcer to the right ankle was described as purple, red. Documentation also indicated a deep tissue pressure ulcer to the left heel,and a stage II to the right thumb. A 2/28/12, wound nurse consultation indicated a large, deep, tissue injury to the right heel measuring 7 by 7 centimeters(cm) with unstable eschar. Documentation also indicated 5 other areas along the right lateral foot up to the ankle, 1 by 1 cm. each. The wound nurse questioned if the areas could possibly be due to a device at the nursing facility. A 3/2/12, wound nurse consultation indicated a 7 by 6 cm. black eschar to the right medial heel, with an 8 by 2 cm. section on the right lateral foot of eschar covered wounds, and 2 wounds inside of the ankle, 1 by 1 cm. each. Documentation indicated all were eschar covered. A surgical consultation was sought. The 3/3/12, 3:15 P.M., operative note indicated a [DIAGNOSES REDACTED]. Excisional debridement was made. The surgeon described dry gangrene involving an 8 by 8 cm. circular dimensional surface area of the right heel. Documentation indicated the tissue overlying the calcaneus (heel) was not viable. The surgeon documented to remove the tissue would leave exposed bone. The surgeon documented similar debridement of a 4 by 2 cm area along the right lateral foot. Documentation indicated pure dry gangrene. Documentation indicated the physician would speak with the family as whether further treatment would be desired in the event of a need for above the knee amputation. After return to the facility, a 3/7/12, 2:00 P.M., interview was conducted with RN Unit Manager #1. RN Unit Manager #1 indicated Resident (B) had worn sneakers and did not have a foot or leg device. After review of the record, RN Unit Manager #1 indicated Resident (B) did have a right leg splint ordered. LPN #1 was interviewed by telephone at 2:30 P.M., 3/7/12, and indicated she had not performed a total skin assessment on Resident (B). LPN #1 indicated she had care of Resident (B) on 2/25, and 2/26/12. LPN #1 indicated she recalled on 2/25/12, Resident (B) did not feel up to a shower and was given a bed bath. LPN #1 indicated she had assessed the skin and saw nothing. LPN #1 indicated on 2/26/12, Resident (B) had a temperature elevation, was shaking, and very diaphoretic. LPN #1 indicated 911 was called and Resident (B) was sent to the hospital for evaluation. LPN #1 indicated Resident (B) always wore socks and sneakers. LPN #1 could not recall use of a leg splint. LPN #1 indicated Resident (B) had been able to self propel in the wheel chair until the decline on 2/25/12. LPN #1 recalled Resident (B) had been in bed most of the day on 2/25/12. LPN #1 indicated she had looked the resident up and down on 2/26/12, and saw nothing on the legs or feet. LPN #1 indicated Resident (B) was very ill and she was focused on his condition. LPN #1 indicated she could have over looked something. At 2:35 P.M., 3/7/12, the DoN and Corporate RN #1 were advised of the concern of Resident (B) having an unstageable necrotic right heel pressure ulcer discovered in the ER, following transfer from the facility on 2/26/12. Corporate RN #1 inquired if the hospital had provided documentation on the right patient. Corporate RN #1 indicated on the last Braden (pressure ulcer risk) Resident (B) had been assessed at 14, moderate risk. Corporate RN #1 indicated facility documentation did not indicate the presence of a pressure ulcer and inquired why hospital documentation would be seen as accurate and facility documentation seen as inaccurate. RN Week-End Supervisor #1 was interviewed at 3:10 P.M., 3/7/12, and indicated she recalled being asked to assist with the transfer of Resident (B) on 2/26/12. RN Week-End Supervisor #1 indicated she had not done a skin assessment and was not sure if one was completed prior to the hospital transfer. CNA #1 was interviewed by telephone at 3:40 P.M., 3/7/12, and indicated she had done a bed bath on Resident (B) on 2/25/12. CNA #1 indicated she had lotioned the feet and did not see any areas. CNA #1 indicated she was pretty sure she had seen the heels, however, could not really recall. CNA #2 had been interviewed by telephone at 2:40 P.M., 3/7/12, and indicated she had care of Resident (B) on 2/26/12, noticed a change in condition after the shift report, and got LPN #1 to assess him. CNA #2 indicated Resident (B) usually stayed up most of the day, CNA #2 indicated Resident (B) stayed in bed over the 2/25-2/26/12, week-end. CNA #2 indicated Resident (B) was diaphoretic with sticky skin. CNA #2 indicated she was so concerned about the change in condition she probably did not look at the feet. At 12:15 P.M., 3/8/12, Corporate RN #1 provided copies of written statements from all staff who had cared for Resident (B). Twelve statements were provided. Nine of the statements did not indicate the date of care provided. All nine of the unknown dates of care statements indicated no areas observed. Statement #7, documented by LPN #2 indicated care the evening prior to the hospital transfer without observation of open areas on the coccyx or buttocks. Statement #8, documented by RN #1 indicated the writer was the charge nurse on the night shift prior to the 2/26/12, hospitalization and saw zero open areas. Statement #12, illegible signature (unknown CNA) indicated night shift prior to the 2/26/12, hospitalization with completion of a 5-6 A. M., bed check without visible sores on Resident (B). The facility's 4/09, revised Wound Prevention and Treatment Policy indicated the corporation strived to ensure a resident entering the center without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates unavoidable skin breakdown. The corporation also recognized even the most vigilant nursing care may not prevent the development and/or worsening of pressure ulcers in some residents. In those cases, intensive efforts will be directed at the following: managing risk factors, providing preventive interventions, and providing treatment. This federal tag also relates to Complaint IN 543. 3.1-40(a)(1)