Every finding on record at Waters of Dillsboro-Ross Manor, The

Based on interview and record review, the facility failed to report allegations of abuse to State Department of Health for 1 of 2 abuse allegations reviewed. (Resident G) Findings include:During an interview, on 08/13/2026 at 2:20 P.M., Staff Member 4 indicated there was an incident after Resident G admitted to the facility that Resident H came into her room and had sex with her. The police were called, and the facility never reported it. The clinical record for Resident G was reviewed on 08/13/2026 at 3:50 P.M. An admission Minimum Data Set (MDS) assessment, dated 06/02/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes (a chronic metabolic disease where blood sugar levels stay too high ), and weakness. The clinical record for Resident H was reviewed on 08/13/2026 at 4:00 P.M. A Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anxiety (feelings of fear, dread, and uneasiness), and bipolar (mental health condition that causes extreme shifts in mood, energy, and activity levels between high emotional states and deep lows). A Progress Note, dated 06/07/2026 at 05:41 A.M., indicated a male resident had been in her room, and Resident G stated they had intercourse. The Administrator and Director of Nursing were notified. A Local Police Report, dated 06/07/2026 at 11:33 A.M., indicated they were dispatched to the facility for a sex offense. The investigation concluded that the sexual intercourse was consensual between Resident G and Resident H. During an interview, on 08/13/2026 at 3:06 P.M., the Social Service Director indicated she was notified of the incident with Resident G and H having intercourse and she was unsure if it was reported to the State Department of Health. She indicated the police were called, because initially Resident G said it was not consensual but later said it was consensual to the police. During an interview, on 08/13/2026 at 3:15 P.M., the Administrator indicated she had received a call that a resident reported sexual abuse. When she got to the facility the police were already there, and the investigation had already been started. After being interviewed Resident G informed them the two residents use to have intercourse before being admitted to the facility, and that it was consensual she just did not like the position. She did not report the incident to the State Department of Health but would in the future. The current facility policy, dated 10/22/2022, titled, Abuse Prevention Program, was provided by the Director of Nursing on 06/16/2026 at 3:30 P.M. The policy indicated, . When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately. State Licensing and Certification Agency (i.e. ISDH) . Sexual abuse of a resident by a staff member, another resident, or a visitor . Abuse involving one resident upon another resident will be reported to ISDH . This citation relates to Intake 3155934.

Based on interview, and record review, the facility failed to ensure staff treated a resident with respect and dignity for 1 of 3 residents reviewed. (Resident F) Findings include:The clinical record for Resident F was reviewed on 08/13/2026 at 12:15 P.M. An admission Minimum Data Set (MDS) assessment, dated 07/11/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia (blood lacks enough healthy red blood cells to carry sufficient oxygen to your body's tissues), and weakness. A Facility Reported Incident, dated 08/09/2026, indicated Resident F reported staff members were disrespectful during medication administration. During an interview, on 08/13/2026, Resident F indicated he and Resident E went to the medication cart to receive their evening medications. QMA (Qualified Medical Assistant) 2 handed him his medications in a pill cup. He informed QMA 2 the medications were not right. QMA 2 replied that they were correct it was a melatonin (a sleep aid medication) pill. He replied that he needed his blood pressure pill as well. QMA 2 replied that was all of his medications. He informed her he had been taking a 8:00 p.m. blood pressure medication for years and he needed it. QMA 2 then requested help from LPN 3. LPN 3 was able to locate the blood pressure medication. He responded that it was not rocket science to administer medications right. QMA 2 and LPN 3 responded that the resident was being nasty with them. A few minutes later QMA 2 walked back to take Resident E's coffee cup and leaned down in Resident F's face and asked in a condescending and hateful voice, Is it okay with you if I go get Resident E a cup of coffee now. He told her he didn't care what she did. During an interview, on 08/13/2026, Resident E indicated she was standing next to Resident F when the incident occurred. When Resident F had told the QMA he was missing a pill, QMA 2 was rude and told him no he was not missing a pill, then when she went to refill my coffee, she leaned in real close to him and asked him if it was alright with him if she refilled my coffee in a condescending way. She was very rude and hateful towards him. The clinical record for Resident E was reviewed on 08/13/2026 at 12:05 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 07/02/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension (high blood pressure), and depression (mood disorder characterized by persistent sadness). A Facility Email Document, dated 08/09/2026 at 6:16 P.M., QMA 2 indicated while administering medications a resident told me he took two pills. She told him to give her a minute and she would double check. After checking again she did not see another medication and she informed the resident again. The resident became upset, and she went to find the nurse on duty to look. QMA 2 informed the resident it was out of her control over the computer system, and that management could fix it on Monday. He began yelling and another resident sitting next to him asked for a cup of coffee. QMA 2 asked Resident F if it would be okay if she got the other resident a cup of coffee. When QMA 2 returned the resident asked for her name and yelled at her. QMA 2 told him she was ending the conversation there, and that they will figure everything out when management was back on Monday. During an interview, on 08/13/2026 at 3:15 P.M., the Administrator indicated that staff were never to speak to residents disrespectfully. The current undated facility policy titled, Your Rights and Protections as a Nursing Home Resident, was provided by Director of Nursing on 08/13/2026 at 3:30 P.M. The policy indicated, .You have the right to be treated with dignity and respect . The past noncompliance was corrected, on 08/12/2026, prior to the start of the survey, after the facility interviewed or assessed all residents, provided education to all staff related to respect and dignity, and updated residents service plans. This citation relates to Intake 3155934. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)

Based on observation and interview, the facility failed to store medications appropriately for 3 of 5 medication carts observed. (Upstairs Medication Cart 3-2, Upstairs Medication Cart 3-1, and the Dementia Unit Medication Cart)Findings include:During an initial tour observation, on 03/22/2026 at 9:51 A.M., the Upstairs Medications Cart 3-2 was sitting in the hallway outside the nurse's station, unlocked, and unattended. Three staff members walked by the unlocked medication cart. At 9:52 A.M., a staff member walked by the cart and locked it. Upstairs Medication Cart 3-2 was observed with RN 11 on 03/22/2026 at 9:58 A.M., and contained the following in the bottom of the medication cart drawers:-One loose round tan pill, - One loose oval tan pill,- One small white pill, and - One oval green pill.At the time of the observation RN 11 indicated two of the pills in the bottom of the medication cart were Protonix and Eliquis. Upstairs Medication Cart 3-1 was observed with Qualified Medication Aide (QMA) 12 on 03/22/2026 at 10:00 A.M., and contained the following:- An unopened and undated Novolog insulin pen for Resident 70, was in the top drawer - An opened vial of Novolog for Resident 2 that had approximately 1/4 of the solution removed with an open date of 02/11/2026 and expiration date of 03/11/2026, was in the top drawer, and- Several crumbs and paper debris were scattered throughout the drawers.At the time of the observation QMA 12 indicated insulin was good for 28 days once it was opened. The Dementia Unit Medication Cart was observed with Licensed Practical Nurse (LPN) 13 on 03/22/2026 at 10:15 A.M., and contained the following:- An unopened and undated Lantus insulin pen for Resident 72, in the top drawer- Two loose round white pills, in a drawer- One loose round tan pill, in a drawer, and - One 1/2 white pill, in a drawer. The nurse indicated she was unsure what the pills were or who was responsible for cleaning the medication carts. She did attempt to clean the cart when she had time. During a continuous observation on 03/22/2026 from 10:49 A.M. through 11:11 A.M., the following was observed:-At 10:49 A.M., the medication cart was sitting in the locked unit outside of the nurse's station, in the common area. The medication cart was unlocked. A nurse was sitting in the nurse's station behind a locked door with her back to the cart, there were residents and nursing staff in the common area, - At 10:52 A.M., a staff member walked by the unlocked medication cart, - At 10:54 A.M., the Maintenance Director and a family member walked by the unlocked medication cart, - At 10:56 A.M., the Maintenance Director walk by the unlocked medication cart, there were also four residents sitting in the common area, - At 10:57 A.M., nursing staff staff members walked by the unlocked medication cart, - At 11:02 A.M., a housekeeper went to the unlocked medication cart and removed the trash on the side of the cart, the nurse was still behind the nurse's station with her back to the cart, - At 11:08 A.M., more nursing staff went behind the nurse's station, walking beside the unlocked medication cart, there were also four residents sitting in the common area where the cart was located, - At 11:09 A.M., two nursing staff members came out of the nurse's station, walked past the unlocked medication cart, and left the unit, - At 11:11 A.M., LPN 10 walked out the nurse's station and locked the medication cart. During medication administration pass, QMA 14 prepared medications for Resident 36. She left the medication cart in the hallway, unlocked and went to the resident's room. The medication cart was not visible from the resident's room. There were no residents or staff in the hallway and remained unlocked and unattended for less than two minutes. During an interview, on 03/25/2026 at 10:34 A.M., LPN 10 indicated medication carts should be locked or remain locked anytime the nurse walked away from the cart. During an interview, on 03/25/2026 at 12:42 P.M., the DON indicated medication carts should be locked if the nurse was not present. The current facility policy titled, Medication Storage in the Facility, dated February 2017, was provided by the Director of Nursing on 03/25/2026 at 1:10 P.M. The policy indicated, .Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked or attended by person with authorized access.Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Medications requiring storage 'in a cool place' are refrigerated unless otherwise directed on the label.Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists.Medication storage areas are kept clean, well lit, and free of clutter.the facility is required to keep the carts clean. A Novolog insert was provided by the DON on 03/25/2026 at 2:56 P.M. The insert indicated, .Unpunctured Novolog FlexPen or Novolog FlexTouch and PenFill cartridges can be used until the expiration date printed on the label if they are stored in the refrigerator. A Lantus insert was provided by the DON on 03/25/2026 at 2:56 P.M. The insert indicated, .Storage.single-patient-use SoloStar prefilled pen.Not in-use (unopened) Refrigerated.until expiration date. Not in-use (unopened) Room Temperature.28 days. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(o)

Based on interview and record review, the facility failed to act promptly regarding residents' concerns voiced during the Resident Council meetings for 4 of 12 months of meeting minutes reviewed. (August, September, October, and December 2025) Findings include:During the Resident Council Meeting, on 03/24/2026 at 1:45 P.M., the residents indicated the call lights were not answered in a timely manner and sometimes it took up to an hour to get assistance. The Resident Council Meeting Minutes were reviewed and indicated issues related to call lights were concerns on the following months: -August 2025, Residents indicated nursing staff were sitting in the office discussing personal things instead of coming to help answer call lights when needed. On Station 3 it was taking 45 minutes to an hour to answer call lights, -September 2025, Residents indicated they felt the Certified Nurse Aides (CNAs) sat in the nurse's station, didn't respond to the call lights, were forgetting to come back, and were told the CNAs didn't have time, -October 2025, Residents indicated one resident had to go to the bathroom at 11:30 P.M. At 12:30 P.M., still no one had come to help. Another resident had waited for 25 minutes for help. Another resident had waited for someone to change her, she couldn't stay in a Diaper due to wound care, and -December 2025, Residents indicated staff were not responding to call lights in a timely manner and residents were waiting longer than 15 minutes to get assistance. During an interview, on 03/24/2026 at 2:53 P.M., the Activity Director, who assisted the residents with the Resident Council meetings, indicated she typed up the concerns voiced by the residents at the meetings, then she distributed the concerns to each department. The paper given to each department was called a Resident Council Action Form. Then, she attached the completed action forms to the Resident Council Meeting Minutes the issues were brought up in for each month. During an interview, on 03/26/2026 at 9:44 A.M., the Regional Director of Operations indicated the concern forms were completed following a Resident Council Meeting, distributed to the identified departments, the response was documented on the forms, the forms were then placed with the Resident Council Meeting Minutes record to be reviewed with the residents at the next meeting. There were no Resident Council Action Forms completed for the August, September, October, or December 2025, Resident Council Meetings indicating the residents' concerns were addressed. The current GUIDELINES FOR RESIDENT COUNCIL policy, dated 06/20/2023, was provided by the Administrator on 03/24/2026 at 3:39 P.M. The policy indicated, .Residents have the right to be involved in making decisions that affect their lives .Group Concerns and Follow-Up .The council group members who voice a concern usually expect a timely response about the resolution to their concern. This must happen. The Administrator monitors this process .A concern is any issue identified by the group that requires a response from the facility in the form of a resolution to some degree that satisfies the group with an explanation and comment . 410 IAC (Indiana Administrative Code) 16.2-3.1-3(l)

Based on interview, observation, and record review, the facility failed to follow appropriate infection control guidelines for a resident with indwelling devices and for a resident during medication administration for 2 of 20 residents reviewed for infection control. (Residents 6 and 7)Findings include:1a.During an interview, on 03/22/2026 at 10:35 A.M., Resident 6 gave permission to observe care related to her indwelling urinary catheter. During an observation, on 03/23/2026 at 1:07 P.M., Resident 6 was in her room in bed. Approximately three inches of her indwelling urinary catheter bag was touching the floor. There was no clean barrier between the bag and the floor. During an observation, on 03/23/2026 at 2:26 P.M., Resident 6 was in her room in bed. Approximately three inches of her indwelling urinary catheter bag was touching the floor. There was no clean barrier between the bag and the floor. The clinical record for Resident 6 was reviewed on 03/23/2026 at 1:15 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/11/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, renal insufficiency and neurogenic bladder. The resident had an indwelling urinary catheter and was always incontinent of bowel. The resident had a feeding tube while residing in the facility. Incontinence care for Resident 6 was observed on 03/25/2026 at 9:29 A.M., with Qualified Medication Aide (QMA) 2 and Certified Nurse Aide (CNA) 3. The two staff members entered the resident's room, explained the process to the resident, prepared garbage bags for the soiled items, and donned gloves. The CNA prepared wash clothes and laid them on the over bed table. The two staff members uncovered the resident who was lying in bed. The resident's indwelling urinary catheter tubing was anchored to her right thigh. The staff members rolled the resident and removed the feces soiled brief and placed it in a garbage bag. The CNA cleaned the feces off the resident's backside and placed the soiled washcloths in the garbage bag. The staff members rolled the resident onto her back, and the CNA cleaned feces from the front periarea (private area) turning the washcloth, then, using the same washcloth, cleaned the indwelling catheter tubing. The two staff members changed gloves, the QMA applied ointment to the resident's front private area, then they applied a clean brief. The QMA emptied the urine from the catheter drainage bag and hung the bag on the side of the resident's bed that was against the wall. The staff members assisted the resident with her pants, covered her with a blanket, pushed the bed against the wall, and lowered the bed. The staff members gathered the trash and soiled linens, washed their hands, and exited the room. The staff members did not don gowns prior to providing care and six to eight inches of the urinary catheter bag were left lying against the floor following care. The resident's room door had a sign on the outside indicating the resident was in Enhanced Barrier Precautions (EBP) and the staff were to don a gown and gloves prior to providing care. During an interview, on 03/25/2026 at 9:42 A.M., QMA 2 indicated, with the resident's bed against the wall, she wasn't sure how she would know if the resident's catheter bag was on the floor. The catheter bag should not be touching the floor. During an interview, on 03/25/2026 at 9:43 A.M., with QMA 2 and CNA 3, they indicated, when providing incontinence care, they usually started with the front of the private area, but the resident's bowel movements were usually runny, so they cleaned the back first. When going from the back of the private area to the front, you should change your gloves. During an interview, on 03/25/2026 at 9:59 A.M., CNA 3 indicated, for a resident in EBP, they should have worn a gown and gloves when providing care to the resident. 1b.Gastrostomy tube (G-tube) care for Resident 6 was observed with Licensed Practical Nurse (LPN) 4 on 03/25/2026 at 9:50 A.M. The LPN entered the resident's room, raised the bed, placed gloves, a small bottle of liquid, and gauze packages on the over bed table. The nurse washed her hands, donned gloves, and pulled the resident's blanket down to reveal the G-tube apparatus on the resident's stomach. There was no dressing on the G-tube site. The nurse opened the bottle of liquid, soaked gauze pads with the liquid, and cleaned around the entry site to the abdomen. A moderate amount of dried blood was noted on the gauze pads. The nurse applied a split gauze pad to the G-tube site against the resident's skin, removed her gloves, and applied tape to the gauze dressing. The nurse bagged the trash, ruffled through the drawers in a small cart in the resident's room, then washed her hands. The nurse lowered the bed. During an interview, on 03/25/2026 at 9:58 A.M., LPN 4 indicated she should have worn a gown when providing care since the resident was in EBP. During an observation, with the Infection Preventionist (IP), on 03/25/2026 at 10:05 A.M., Resident 6's bed was pushed up against the wall. Her indwelling urinary catheter bag had several inches of the bag laying on the floor by the wall. The IP donned gloves moved the catheter bag up higher on the side of the resident's bed, then raised the bed up to ensure the bag was no longer touching the floor. The IP indicated the bag should not be touching the floor and staff were educated often regarding indwelling urinary catheter care. The resident had not had an infection involving her G-tube. The Enhanced Barrier Precautions STOP sign, posted on the outside of the resident's room door, indicated staff must, .Wear gloves and a gown for the following High-Contact Resident Care Activities .Providing Hygiene .Device care or use .urinary catheter, feeding tube . 2. During an observation, on 03/23/2026 at 11:08 A.M., LPN 5 was preparing medications for Resident 7. With her bare hands, the nurse unlocked the medication cart, pulled open the narcotic drawer, unlocked the narcotic drawer, popped two pills into her bare hands, and dropped them in a medication cup. She then administered the medications to the resident. During an interview, on 03/25/2026 at 2:41 P.M., the IP indicated staff should not touch resident medications with their bare hands during medication administration. The current facility policy titled, Medication Administration dated February 2017, was provided by the Director of Nursing on 03/25/2026 at 2:29 P.M. The policy indicated, .To administer all medications safely and appropriately. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(2)

Based on observation, record review, and interview, the facility failed to develop a resident's care plan related to the resident's leg prosthesis for 1 of 18 residents reviewed for care plans. (Resident 3)Findings include:Resident 3 was observed in his room on 03/22/2026 at 10:58 A.M. The resident was sitting in his wheelchair. The resident had an above the knee amputation of his left leg, his prosthetic leg was leaning against his bed. During an observation, on 03/23/2026 at 11:18 A.M., the resident was sitting in his wheelchair, he indicated there was something wrong with his prosthetic leg. The prosthesis was leaning against the side of his bed. He indicated he used to wear the prosthetic leg. During an interview, on 03/25/2026 at 11:12 A.M., Licensed Practical Nurse (LPN) 10 indicated Resident 3 did wear his prosthetic leg sometimes. During an interview, on 03/25/2026 at 1:52 P.M., Certified Nurse Aide (CNA) 3 indicated Resident 3 used to wear his prosthetic leg daily and occasionally needed staff assistance with putting it on and taking it off. During an interview, on 03/25/2026 at 2:20 P.M., the Therapy Manager indicated the resident participated in therapy from 12/10/2025 to 02/11/2026. During that time, he wore his prosthetic leg. Interview for Care plan tag at Waters of Dillsboro The clinical record for Resident 3 was reviewed on 03/23/2026 at 1:50 P.M. An admission Minimum Data Set (MDS) assessment, dated 12/15/2025, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, hypertension (high blood pressure), diabetes (metabolic disease characterized by high blood glucose due to the body's inability to produce enough insulin or effectively use the insulin), and acquired absence of the left leg. There was no indication the resident had a limb prosthesis. The resident admitted to the facility on [DATE]. The resident's Care Plans were reviewed on 03/23/2026 at 1:55 P.M. The resident's Care Plan lacked a plan of care related to the resident's care and interventions related to the resident's prosthetic leg. During an interview, on 03/26/2026 at 9:18 A.M., the MDS Coordinator indicated she started baseline and admission care plans. She would update the care plans based on any new orders or assessments of the resident. There should have been a care plan for the resident's prosthetic leg. The current facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 03/23/21, was provided by the Director of Nursing (DON) on 03/25/2026 at 2:40 P.M. The policy indicated, .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident with a visual impairment received optical services in a timely manner for 1 of 1 resident reviewed for vision. (Resident 33) Findings include:Resident 33 was observed on 03/23/2206 at 11:25 A.M., sitting in her wheelchair in her room. An activity calendar was posted on her wall, and a monthly meal menu was sitting on her bedside table. There were no eyeglasses observed in the resident's room. During an interview, on 03/23/2026 at 11:29 A.M., Resident 33 indicated she had cataract removal surgery some time ago, but she still needed eyeglasses to read. She had an appointment with the eye doctor, but he referred her to a specialist. She went to the specialist, and he referred her back to the regular eye doctor. She kind of got the runaround and did not know what was happening with getting eyeglasses. She enjoyed coloring and reading, but she needed readers. The resident's record was reviewed on 03/23/2026 at 2:16 P.M. A document, scanned into the resident's Electronic Health Record (EHR), indicated the resident visited the ophthalmologist's office on 01/16/2026. The document was a prescription for the resident's eyeglasses. During an interview, on 03/24/2026 at 2:37 P.M., the Social Services Director (SSD) indicated a company routinely came to the facility and provided ancillary services that included dental, vision, and podiatry services. Usually, when the eye doctor examined a resident in the facility, they would write a prescription for eyeglasses, if needed. The eyeglasses would be ordered and sent to the facility within a few weeks. She would deliver the eyeglasses to the residents. She reviewed the records and indicated there was a prescription for eyeglasses in the resident's chart dated 01/16/2026. She reviewed the transportation logs and indicated that the resident did go out to an eye doctor appointment on 01/16/2026. She was not sure why the prescription was uploaded to the resident's EHR but was not followed up on. During an interview, on 03/24/2026 at 3:27 P.M., the SSD indicated the resident had been seen in the facility by the eye doctor and they had referred her to an ophthalmologist. She came back from that appointment with a prescription for eyeglasses. It probably should have been followed up on sooner. The current, undated facility policy, titled Vision and hearing services was provided by the Regional Nurse Consultant on 03/26/2026 at 10:41 A.M. The policy indicated, .It is the standard of the organization to ensure that residents receive the proper treatment and assistive devices to maintain hearing and vision abilities . 410 IAC (Indiana Administrative Code) 16.2-3.1-39(a)(1)

Based on record review and interview, the facility failed to have medications available for a resident for 1 of 18 residents reviewed for pharmacy services. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 03/23/2026 at 2:52 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/09/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to Alzheimer's disease (a progressive, incurable neurodegenerative disorder and the most common cause of dementia) and anxiety. The current, open-ended physician's order, with a start date of 02/24/2026, indicated the resident was to be administered Risperdal (an antipsychotic medication) 2 milliliters (ml) intramuscularly, every 14 days for delusions. The February and March 2026 Electronic Medication Administration Record (EMAR) indicated the resident had not received the medication on 02/24/2026 and 03/24/2026. A Progress Note, dated 02/24/2026 at 11:05 A.M., indicated the resident had not received the Risperdal medication due to the medication not being available at the pharmacy. A Progress Note, dated 03/24/2026 at 9:50 A.M., indicated the resident had not received the Risperdal medication due to the medication not being in the facility. The clinical record lacked documentation indicating the physician was notified of the resident not receiving the medications on 02/24/2026 and 03/24/2026. The Emergency Drug Kit (EDK) list was reviewed on 03/25/2026 at 10:37 A.M., the list excluded Risperdal injectable medications. During an interview, on 03/25/2026 at 10:34 A.M., Licensed Practical Nurse (LPN) 10 indicated if a resident didn't have medications available to be given, then she would check their EDK. If the medications were not available there, then she would call the pharmacy to see if it could be sent as soon as possible from a local pharmacy. If they couldn't get it from a local pharmacy, she would have the facility pharmacy get it to the facility as fast as they could. In the EMAR she would mark that the medication was not available and call the physician. She would document it in a progress note. During an interview, on 03/25/2026 at 12:42 P.M., the Director of Nursing (DON) indicated if medications were not available for residents, the staff were the check the EDK. If they were not available in the EDK, then they needed to get it ordered from the pharmacy. If a resident missed a dose of medication, then the provider would be notified. They typically would just verbally let the provider know and didn't document in the clinical record. The current facility policy tilted, Out of Stock Medications, dated July 2024, was provided by the DON on 03/25/2026 at 1:11 A.M. The policy indicated, .will maintain an inventory of medications available to meet resident's needs. In the event the facility orders a medication that the pharmacy does not currently stock:. Alternative suppliers will be contacted to check availability and expected date and time of delivery. The facility should call the patient's physician to let him/her know that the ordered medication is not available. The physician can then decide whether to hold the medication until it is available or change the medication to one that is readily available in the emergency dispensing kit. The original medication that was ordered will be sent as soon as it becomes available. If the resident requires the medication sooner.other area pharmacy sources will be contacted to supply the item. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheters for 2 of 3 residents reviewed for Urinary Tract Infections (UTI). (Residents 4 and 52)Findings include:1.During an observation, on 03/22/2026 at 10:15 A.M., Resident 4 was sitting in a recliner in the common area of the dementia unit. The resident's feet were propped up, and his urinary catheter drainage bag with a dignity flap, was lying on the floor. There was no dignity bag covering the urinary catheter bag. During an observation, on 03/24/2026 at 2:59 P.M., Resident 4 was sitting in a recliner in the common area of the dementia unit. The resident's urinary catheter drainage bag with a dignity flap, was touching the floor. There was no dignity bag covering the urinary catheter bag. During an observation, on 03/24/2026 at 3:15 P.M., Resident 4 was sitting in a recliner in the common area of the dementia unit. Approximately four to five inches of the resident's urinary catheter drainage bag with a dignity flap, was touching the floor. There was no dignity bag covering the urinary catheter bag. During an interview, on 03/24/2026 at 3:19 P.M., Licensed Practical Nurse (LPN) 5 indicated residents' urinary catheter drainage bags should not be touching the floor. The clinical record for Resident 4 was reviewed on 03/23/2026 at 2:52 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/09/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, neurogenic bladder (a dysfunction of the lower urinary tract caused by damage to the nerves and muscles controlling bladder emptying). The resident had an indwelling urinary catheter. The resident used a wheelchair and was dependent on staff for care. A Progress Note, dated 02/13/2026 at 10:39 A.M., indicated the resident had new orders for an antibiotic for a UTI. A Progress Note, dated 03/19/2026 at 12:37 P.M., indicated the resident had a new physician's order to obtain a urine sample related to a foul-smelling odor. A Progress Note, dated 03/20/2026 at 2:09 P.M., indicated the Nurse Practitioner ordered to discontinue the residents Keflex (an antibiotic medication) and start Cefdinir 300 milligrams (mg), twice a day, for a UTI and cellulitis. 2. During an interview and observation, on 03/23/2026 at 10:23 A.M., Resident 52 was sitting in her room in her wheelchair. She indicated she had a urinary tract infection recently. Her urinary catheter drainage bag, with a dignity flap, was hanging under her wheelchair with approximately two inches of the bag touching the floor. There was no dignity bag covering the urinary catheter bag. During an observation, on 03/23/2026 at 10:57 A.M., Resident 52 was sitting in the dining room with approximately one inch of her urinary catheter drainage bag, with a dignity flap, touching the floor. There was no dignity bag covering the urinary catheter bag. During an observation, on 03/23/2026 at 1:05 P.M., Resident 52 was sitting in the dining room. Her urinary catheter drainage bag, with a dignity flap, was touching the floor. There was no dignity bag covering the urinary catheter bag. During an observation, on 03/24/2026 at 9:03 A.M., Resident 52 was sitting in the dining room. Three to four inches of the resident's urinary catheter drainage bag, with a dignity flap, was touching the floor. there was no dignity bag covering the urinary catheter bag. During an interview, on 03/24/2026 at 9:13 A.M., Qualified Medication Aide (QMA) 9 indicated residents' urinary catheter drainage bags should not touch the floor. During an observation and interview, on 03/24/2026 at 9:15 A.M., the Assistant Director of Nursing (ADON) indicated the resident's urinary catheter drainage bag should not touch the floor and that she would fix it at that time. The clinical record for Resident 52 was reviewed on 03/24/2026 at 2:55 P.M. The resident had an impairment to the upper and lower extremities and was dependent on staff for care. A Progress Note, dated 02/27/2026 at 6:52 P.M., indicated a new order was received for IM Ertapenem related to a UTI. The current facility policy titled, GUIDELINS FOR INDWELLING FOLEY CATHETER CARE dated 10/16/2024, was provided by the ADON on 03/24/2026 at 9:37 A.M. The policy indicated, .The main purpose of proper indwelling foley catheter care is to prevent catheter associated urinary tract infections. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on interview and record review, the facility failed to maintain complete and accurate resident records related to medication administration for 1 of 18 residents reviewed for medical records. (Resident 36)Findings include:Resident 36's record was reviewed on 03/23/2026 at 2:11 P.M. An admission Minimum Data Set (MDS) assessment, dated 01/02/2026, indicated the resident's diagnosis included, but was not limited to, diabetes (a chronic metabolic disease characterized by high blood glucose due to the body's inability to produce enough insulin or effectively use the insulin it makes).The resident's physician's orders included, but were not limited to, a current, open-ended order, with a start date of 01/15/2026, for Lantus (a long-acting insulin). The resident was to receive 10 units every morning (between 8:00 A.M. and 10:00 A.M.) and at bedtime (between 8:00 P.M. and 10:00 P.M.) for diabetes. The resident's February and March 2026 Electronic Medication Administration Records (EMARs) were reviewed and there were blank spaces that indicated the resident did not receive the medication on the following dates and times:- On 02/01/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 02/04/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 02/08/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 02/11/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 02/15/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 02/16/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 02/26/2026 the EMAR lacked documentation the resident received the morning dose,- On 03/03/2026 the EMAR lacked documentation the resident received the bedtime dose,- On 03/13/2026 the EMAR lacked documentation the resident received the bedtime dose, and- On 03/22/2026 the EMAR lacked documentation the resident received the bedtime dose. During an interview, on 03/25/2026 at 1:54 P.M., RN 8 indicated there should not be blanks in the EMAR. When the medications were administered they should have been documented as given. If a medication was not administered, the nurse should indicate the medication was not given and document the reason why. The resident's progress notes were reviewed and lacked documentation related to the medication that was not documented as administered. The current facility policy, titled, Medication Administration, dated February 2017, was provided by the Director of Nursing on 03/25/2026 at 2:29 P.M. The policy indicated .Circle initials on MAR if medication is not administered as ordered and record reason in the PRN/Omission Medication section of the MAR . 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a newly admitted resident's weight was obtained as ordered and address a significant weight gain for 1 of 2 residents reviewed for nutrition. (Resident 11)Findings include:Resident 11's clinical record was reviewed on 03/23/2026 at 1:49 P.M. An admission Minimum Data Set (MDS) assessment, dated 03/03/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, and morbid obesity. The nutrition section of the assessment indicated the resident had not experienced a weight loss or weight gain of 5% or more in the last month or a weight loss or weight gain of 10% or more in last 6 months. The resident was 5' 3'' and weighed 365 pounds (lbs.). The resident's current physician's orders included an open-ended order, with a start date of 03/01/2026 to obtain the resident's weight once a week on Sundays. The March Electronic Medication Administration Record (EMAR) indicated the following:- On 03/01/2026, the resident's weight was 365 lbs.,- On 03/08/2026, the resident's weight was not obtained,- On 03/15/2026, the resident's weight was 389 lbs., and- On 03/22/2026, the resident's weight was 393 lbs. During an interview, on 03/24/2026 at 3:38 P.M., the Director of Nursing (DON) indicated all newly admitted residents were reviewed in SWAT (Skin and Weight Assessment Team) meetings each week for the first four weeks the resident was in the facility, and then longer if needed. The meetings were held on Thursdays, and the Registered Dietician participated through video conferencing and completed the assessment. The DON was unaware of the resident's 24 lb. weight gain between 03/01/2026 and 03/15/2026. A SWAT assessment, dated 03/06/2026, indicated the resident was on weekly weights. The comments section of the assessment indicated the resident's weight was up 5 lbs. since admission and to monitor for further changes. Lab tests obtained on 02/25/2026 indicated high cholesterol and triglycerides and low red blood cells and low hemoglobin and hematocrit levels. The resident was not receiving any nutritional supplementation. They would continue the current plan of care and continue to monitor the resident weekly on SWAT. A SWAT assessment, dated 03/14/2026, indicated the resident was on weekly weights. The comments section in the assessment indicated the resident needed an updated weekly weight. The resident's Electronic Health Record (EHR) lacked any further SWAT assessments and lacked documentation that indicated the resident refused to be weighed. During an interview, on 03/24/2026 at 3:42 P.M., the DON indicated the resident's weight should have been obtained weekly as ordered and the significant weight gain should have been addressed. The current facility policy, titled GUIDELINES FOR OBTAINING RESIDENTS' WEIGHTS, and dated 07/24/2023, was provided by the DON on 03/25/2026 at 11:43 A.M. The policy indicated, .Weight is an indicator of nutritional and health status and changes in weight can often indicate other medical changes.Compare the obtained to the previous weight. If there is a significant variance (Ex: 5 lbs. more or less), be sure to reweigh the resident to verify the weight.If a weight is found to be incorrect-note this and initial the error-then notify the nurse for guidance.Weekly weights mean WEEKLY month to month-record and then report to physician per physician order and/or policy. The current, undated facility policy, titled S.W.A.T. PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM, was provided by the DON on 03/25/2026 at 11:43 A.M. The policy indicated, .It is the policy of this facility to assess the nutritional status of each resident. SWAT is designed to aggressively review and address those residents exhibiting significant weight change or skin breakdown. These residents will be monitored through this team effort on a weekly basis, involving all applicable disciplines to best cater to the improvement of the resident's nutritional status.Indicators determining implementation of SWAT monitoring.new admission.SWAT will meet weekly. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to provide behavior health services for a resident who required 15-minute monitoring for 1 of 3 residents reviewed for behaviors. (Resident C) Findings include:The clinical record for Resident C was reviewed on 02/05/2026 at 10:10 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/21/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, bipolar (a chronic mental health condition) and non-Alzheimer's dementia (a progressive, irreversible brain disorder). A Psychiatric Progress Note, dated 01/27/2026 at 11:46 A.M. , indicated Resident C had increased physical and verbal aggression towards peers, and was currently on one-on-one staff monitoring. The staff and provider determined Resident C was currently not a risk of harm to himself or to his peers. The provider ordered 15-minute monitoring for 72 hours unless an inpatient facility accepted the resident prior to initiating the monitoring. Resident Location Monitoring Forms were provided by the Social Services Director on 02/05/2026 at 1:30 P.M. The forms indicated Resident C was started on one-on-one monitoring on 01/26/2026 at 3:15 P.M. and the monitoring was discontinued on 01/29/2026 at 6:00 A.M. There was no indication of when the resident had transitioned to 15-minute monitoring and there was no indication to indicate what staff member was documenting the resident's location. Documentation then continued on a new form, dated 01/29/2026 at 6:00 P.M. During an interview, on 02/05/2026 at 2:00 P.M., the Social Services Director indicated that they used the same form for one-on-one monitoring as they used for 15-minute monitoring. And she was unable to determine when they switched from one-on-one to 15-minute monitoring on Resident C. The form should have had staff initials next to every entry on the form, and that the new form was restarted due to the resident needing monitoring after the resident's behaviors increased again. During an interview, on 02/05/2026 at 2:05 P.M., the Director of Nursing (DON) indicated that Resident C was switched from one-on-one monitoring to 15-minute monitoring on 01/27/2026 at 10:15 A.M. by the Psychiatric Nurse Practitioner , but due to already scheduled staff for the one on one monitoring they kept the resident on the one-on-one monitoring until midnight on 01/27/2026. The resident was then taken off 15-minute monitoring due to decreased behaviors on the morning of 01/29/2026 but was started back on one-on-one monitoring at 6:00 P.M. that evening due to behaviors increasing again. After reviewing documentations, the DON indicated the resident should have stayed on 15-minute monitoring the full 72 hours after being seen by the Psychiatric Nurse Practitioner on 01/27/2026. The current undated facility policy titled, Fifteen Minute Monitoring, was provided by the DON on 02/05/2026 at 2:20 P.M. The policy indicated, .Fifteen Minute Monitoring provides additional supervision and guidance to the resident at times when the resident may have physical or psychosocial needs that require more direct supervision. The current facility policy titled, Guidelines for handling and addressing behavioral emergencies dated 03/18/2023, was provided by the DON on 02/05/2026 at 2:31 P.M. The policy indicated, .Residents displaying a behavior need to have a staff member with them from the time of the onset of the behavior until it is resolved or managed. This supervision may be able to reduce to lesser supervision such as every 15-minute checks . This citation relates to Intake 2728236.

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity related to Activities of Daily Living (ADL) care and monitoring inventory of personal belongings for 4 of 9 residents reviewed for resident rights. (Residents B, C, K, and L) Findings include:1. During an interview and observation, on 07/17/25 at 10:17 A.M., Resident B indicated she was bruised during ADL care a couple of weeks ago. Staff members had come into her room early in the morning, after breakfast, and said she was going to take a shower. The resident held onto the grab bar on the side of the bed and kept saying she refused. The staff peeled her fingers off her side grab bar and proceeded to use the mechanical lift, transferred her to a shower chair, and forced her to take a shower. The resident indicated she was just bruised on her hands. There were no visible bruises observed to the resident's hands. The resident indicated she gave one of the aides a good titty twister when they got one of her hands loose, she should not have touched the aide, she was just angry. She had not been bruised during care in the past. Her shower days were Wednesdays and Saturdays. The staff that were working with her were Certified Nurse Aide (CNA) 2 and CNA 3. The clinical record for Resident B was reviewed on 07/18/25 at 1:08 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, anxiety, chronic pain syndrome, and depression. The resident was dependent on staff members to assist her with bathing and required maximal assistance. An Interdisciplinary Team (IDT) note, dated 06/30/25, indicated the resident had discoloration to her left forearm and right knuckle. The root cause of the discoloration was determined to be due to the resident grabbing on to the breast of a staff member, twisting, and pulling. Staff had to remove the resident's hand off the staff member's breast, on 06/25/25. Additional factors included the enabler bars the resident used to promote mobility and the use of Xarelto (a blood thinning medication) increasing risks of bruising During an interview, on 07/18/25 at 1:35 P.M., the DON indicated the resident had bruising on her arm. Multiple times, the resident thought it was from her bed, then she thought it happened during a shower. The facility did resident and staff interviews and had nothing substantiated. The resident indicated she did not want CNA 3 to give her a shower, which was typical of Resident B, she would choose who she didn't want to help her. For that instance, CNA 2 put the resident in the shower and gave her a shower. The resident was in the shower chair, holding on to the bed rail, and they were afraid she would fall out of the chair. During an interview, on 07/17/25 at 10:38 A.M., CNA 2 indicated if a resident was resistive to care or refusing care, staff were not to force them. Residents were to be encouraged to allow staff to provide care. If a resident was resistive or combative with care, staff were to stop and then come back a little later to try again. They might have a different staff member attempt to provide care. If the resident still refused, the aides were to notify the nurse. During an interview, on 07/17/25 at 12:25 P.M., CNA 2 indicated, a couple of weeks ago, in regard to the day in question, she was going to assist Resident B with a shower. CNA 2 left the resident’s room and went to get the shower chair. CNA 3 was in the room with the resident. When CNA 2 came back, the resident was mad at CNA 3 and said she did not want CNA 3 to give her a shower. CNA 2 told the resident she was going to give the resident the shower, not CNA 3. The resident was super mad; she kept saying things. CNA 2 could not recall what she was saying, she was just trying to calm the resident down. CNA 3 remained in the resident’s room. At some point the resident grabbed CNA 3’s breast. The CNAs had to remove the resident’s hand from CNA 3’s breast. The resident was still in bed, and the CNAs were putting the mechanical lift pad under the resident. The resident was holding on to the bed railing. They told her to let go of the railing. CNA 2 removed the resident’s fingers from the railing. She could not remember what the resident was saying, she kept saying she didn’t want CNA 3 to give her a shower. The CNAs got the resident into the shower chair. The resident said she was going to yell all the way down the hall to the shower room, and she did. Once CNA 2 got the resident into the shower, she was fine. She was able to shower the resident and wash her hair without difficulty. She assisted the resident with combing her hair after the shower. During an anonymous interview, a staff member indicated residents were not allowed to refuse care. Staff were not allowed to document that a resident refused care. The staff member thought residents had the right to refuse, but there had been instances when they were told they had to provide care even if the resident refused. The current facility policy, titled GUIDELINES FOR OBSERVING AND IMPLEMENTING - RESIDENT RIGHTS, dated 07/12/23, was provided by the Regional Director of Operations on 07/18/25 at 2:07 P.M. The policy indicated, .7) It is important that staff be aware of the RESIDENT RIGHTS to include but not limited to: A dignified existence - resident being treated with dignity in all situations . Residents are to have their well-being and self-esteem, and self-worth enhanced during all care and services interactions .1. Staff will treat each resident with respect and dignity .3. Staff will not use any profanity or vulgar words in the presence of the resident and under no circumstances directed at the resident . 2a. During an interview, on 07/18/25 at 10:45 A.M., Resident K indicated he was missing a blue blanket with sharks on it that his family brought him. He was unsure if the blanket was on an inventory list. The resident’s clinical record was reviewed on 07/17/25 at 1:48 P.M. A Quarterly MDS assessment, dated 04/15/25, indicated the resident was moderately cognitively impaired. The resident’s diagnosis included, but were not limited to, stroke, hemiplegia, and malnutrition. The resident’s record lacked an inventory list of personal items. 2b. During an interview, on 07/17/25 at 2:11 P.M., Resident C indicated she had a name brand purse that was missing. Her family member had hung the purse out of view in the back of the closet. She realized it was gone a few weeks ago. The clinical record for Resident C was reviewed on 07/17/25 at 12:29 P.M. A Quarterly MDS assessment, dated 06/03/25, indicated the resident was cognitively intact. The resident’s diagnoses included, but were not limited to, stroke, hypertension, diabetes, and depression. The resident’s record lacked an inventory list of personal items. 2c. During an interview, on 07/17/25 at 2:55 P.M., Resident L indicated she was not missing any personal items. Staff labeled clothing with residents’ names. She did not think the facility made an inventory list of her belongings when she was admitted . Resident L’s clinical record was reviewed on 07/18/25 at 1:10 P.M. An admission MDS assessment, dated 04/14/25, indicated the resident was severely cognitively impaired. The resident’s diagnoses included, but were not limited to, stroke, hypertension, and diabetes. The resident’s record lacked an inventory list of her personal items. During an interview, on 07/18/25 at 11:31 A.M., the Housekeeping Supervisor indicated she could not find inventory lists of residents’ belongings. The previous Housekeeping Supervisor, that left a few months ago, was supposed to be taking care of inventory lists. All resident records should be in the computer; they didn’t have hard charts. She could find no documentation of any resident’s belongings. Inventory lists of residents’ belongings, should include, but would not be limited to, clothing, purses, shoes, personal electronics, etc. The current, undated facility policy, titled “Policy and Procedure, Resident Personal Clothing and Belongings Handling” was provided by the DON on 07/18/25 at 2:07 P.M. The policy indicated, “…To ensure that all resident’s clothing are identified, stored, and laundered appropriately…Personal Belonging are to be listed on the Belongings List in the resident’s chart…” This citation relates to Complaints 2561987 and 2560828. 3.1-3(t) 3.1-9(g)

Based on observation, interview, and record review, the facility failed to treat and identify pressure ulcers in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident C)Findings include:During an observation, on 07/18/25 at 10:19 A.M., Qualified Medication Aide (QMA), answered Resident C's call light. The resident indicated she needed to get off the bed pan. The Assistant Director of Nursing (ADON) assisted the QMA to get the resident off the bed pan. The ADON cleansed the resident and left the room. She returned with a cream and applied it to the resident's bottom. She told the resident she didn't put the cream on her wounds just around them because the wounds would need a treatment put in place. The resident had a wound to the right posterior thigh that was pink in color with to drainage. The wound was pea size and did not have a dressing in place. The resident also had a wound on the coccyx that was a slit that was approximately the size of pencil lead. The wounds were shown by the ADON. The staff applied a brief and dressed the resident with pants. The staff told the resident that they would let the Certified Nurse Aides (CNA)'s know that she was ready to get up. They left the room and alerted the CNA's that the resident was ready to get up. The resident's wounds did not have treatments in place before the QMA and the ADON left the room, and the resident was left laying on her back.During an observation, on 07/18/25 at 11:01 A.M., the ADON returned to Resident C's room and indicated that she was going to apply a dressing to her wounds. The resident was rolled to her left side, her pants and brief were removed, and a treatment was applied to the resident's right posterior thigh. The resident's brief was reapplied, her shorts were pulled up, and the resident's full body mechanical lift pad was hooked up to the lift. The nurse was questioned about the coccyx wound not having a treatment in place at that time.During an interview, on 07/18/25 at 11:08 A.M., the ADON indicated she was unsure if the resident had an order for the coccyx wound. If she did, she must have missed it when she checked the orders. If she did have an order, then she would wait and apply the dressing after lunch. The resident had a pressure reducing cushion in her wheelchair. The ADON went to the resident's room and asked the resident if she was ok to wait for a minute so she could recheck her orders for a treatment to her coccyx. She indicated to the resident that she didn't want her sitting up without a treatment in place.During an interview, on 07/18/25 at 11:11 A.M., the ADON indicated the resident had a treatment to the coccyx and she would get the supplies and apply it before she got out of bed.During an observation, on 07/18/25 at 11:15 A.M., the ADON returned to the resident's room and applied the treatment to the coccyx. The clinical record for Resident C was reviewed on 07/17/25 at 12:29 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 06/03/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, hypertension, diabetes, and depression. The resident was at risk for pressures ulcer with no pressure ulcers identified at the time of the assessment.A Facility Weekly Skin Check, dated 07/15/25, indicated the resident had an existing area of loss but did not have any new skin loss of skin integrity.A Shower Sheet, dated 07/14/25, indicated the resident had no new skin concerns.A Wound Nurse Practitioner (NP) Wound Assessment Report, dated 07/16/25, indicated the resident had a facility acquired Stage 3 (Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss.) pressure ulcer to the right posterior thigh, that was acquired on 07/15/25.During a family interview, on 07/17/25 at 1:50 P.M., they indicated that the resident would frequently go without treatments to their wounds.During an interview, on 07/18/25 at 10:06 A.M., CNA's 6 and 7 indicated they would monitor resident's skin daily during care and during their showers. If they noticed any skin concerns, they would alert their nurse. The only place they had to documented skin concerns was on their shower sheets.During an interview, on 07/18/25 at 10:09 A.M., Licensed Practical Nurse (LPN) 4 indicated resident's skin assessments were completed weekly by the nurse and the CNAs would monitor it during care daily. If she was aware of a new skin impairment then she would assess it, notify the wound nurse, and retrieve new orders.During an interview, on 07/18/25 at 1:31 P.M., the Director of Nursing (DON) indicated the thigh wound for the resident was identified by the Wound NP. The staff should have potentially saw the wound before it was a Stage 3.The current facility policy, dated 10/09/23, titled GUIDELINES FOR PREVENTION/TREATMENT OF PRESSURE INJURIES policy, indicated .The policy indicated, .based on resident assessment, the facility will ensure .A resident receives care, consistent with professional standards of practice; to prevent pressure ulcers .A Risk Assessment is considered the starting point for prevention of pressure injury .It is important to note and at risk resident can develop a pressure injury within hours of the onset of pressure. For this reason, the at risk resident must be identified, and have specific interventions put promptly in place and care planned to prevent formation of a pressure injury .This citation relates to Complaint 2561987.3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 2 of 2 wound care observations. (Residents C and F) Findings include:1.During an observation, on 07/18/25 at 11:01 A.M., the Assistant Director of Nursing (ADON) entered Resident C’s room and indicated that she was going to apply a dressing to her wounds. The resident was rolled to her left side, her pants and brief were removed, and a treatment was applied to the resident’s right posterior thigh. The resident’s brief was reapplied, her pants were pulled up, and the resident’s full body mechanical lift pad was hooked up to the lift. The nurse was questioned about the coccyx wound not having a treatment in place at that time. The ADON nor the Certified Nurse Aide (CNA) in the room had donned gowns prior to the treatment of the right posterior thigh wound. During an observation, on 07/18/25 at 11:15 A.M., the ADON returned to the resident’s room and applied the treatment to the coccyx. The ADON nor the CNA had donned gowns prior to the treatment of the wound. The resident lacked a sign on her door indicating she was on EBP during the survey from 07/17/25 through 07/18/25. The clinical record for Resident C was reviewed on 07/17/25 at 12:29 P.M. The record lacked a physician's order for EBP. 2. The clinical record for Resident F was reviewed on 07/18/25 at 11:45 A.M. A Quarterly MDS assessment, dated 06/05/25, indicated the resident was severely cognitively impaired. The residents’ diagnoses included, but were not limited to, hypertension, dementia, anxiety, and depression. The resident had a chronic pressure wound on her right heel. The clinical record lacked a physician’s order for the resident to be in EBP for wound care. During an observation, on 07/18/25 at 12:55 P.M., Licensed Practical Nurse (LPN) 4 entered the resident’s room, donned gloves, pulled back the heel dressing and exposed a small pinpoint sized wound. She placed the dressing back in place and pulled a sock over the resident’s heel and ankle. The LPN failed to wear a gown during the wound care. The resident’s door lacked a sign indicating she was in EBP. There was no PPE, other than gloves, outside or inside the resident’s room. During an interview, on 07/18/25 at 1:31 P.M., the Director of Nursing (DON) indicated residents with significant or chronic wounds, urinary catheters, and any indwelling tubes should be in EBP. Residents C and F should have been in EBP because they had chronic pressure wounds. The current facility policy titled, Guidelines for Enhance Barrier Precautions, was provided by the Director of Nursing on 06/03/25 at 3:18 P.M. The policy indicated, .It is the policy of the facility to ensure that additional and appropriate PPE [Personal Protective Equipment] is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms .Enhanced Barrier Precautions are defined as the use of PPE [gowns and gloves] during high-contact resident care activities . This citation relates to Complaint 2561987. 3.1-18(b)

Based on record review and interview, the facility failed to obtain a STAT x-ray in a timely manner for 1 of 3 residents reviewed for radiology services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/16/25 at 5:30 P.M. A Quarterly Minimum Data Set (MDS) Assessment, dated 04/11/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, and malnutrition. A Progress Note, dated 05/23/25 at 6:15 P.M., indicated the resident was noted to have some swelling and discoloration to the right lower leg. The Nurse Practitioner (NP) was notified, and a new order was obtained for a STAT (immediately) x-ray of the knee, ankle, and extended tibia/fibula. A Progress Note, dated 05/24/25 at 12:40 P.M., indicated the resident's x-ray was obtained and a new order was received to send the resident to the local emergency room. A Radiology X-Ray Report, dated 05/24/25 at 12:23 P.M., indicated the resident had a two view, right tibia and fibula x-ray. During an interview, on 06/26/25 at 6:58 P.M., RN 3 indicated she was working the night the NP ordered a STAT x-ray for Resident B. She had been working all night until 6:00 A.M. the next morning and the technician never came on her shift. She had instructed that the staff to not get the resident out of bed due to not having the x-ray completed. She believed over 12 hours was an unacceptable time frame for a STAT x-ray to be completed. During an interview, on 06/17/25 at 10:40 A.M., Licensed Practical Nurse (LPN) 4 indicated a STAT x-ray should be obtained within a couple of hours. During an interview, on 06/17/25 at 11:39 A.M., the Assistant Director of Nursing (ADON) indicated a STAT x-ray should be obtained within four hours of getting the order. The NP ordered a STAT x-ray for Resident B on 05/23/25 around 6:00 P.M. and the technician did not come until the next day. The current facility policy titled, Guidelines for Diagnostic Services, dated 07/14/23, was provided by the ADON on 06/17/25 at 1:37 P.M. The policy indicated, .It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource . This citation relates to Complaint IN00460383. 3.1-49(a)

Based on record review and interview, the facility failed to provide medications in a timely manner for 1 of 3 residents reviewed for pharmacy services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/16/25 at 5:30 P.M. A Quarterly Minimum Data Set (MDS) Assessment, dated 04/11/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, and malnutrition. A physician's order, dated 04/16/24 through 05/29/25, indicated the staff were to administer the resident's Cyproheptadine (an antihistamine) 4 milligrams, three times a day for itching. The May 2025 Electronic Medication Administration Record indicated the resident did not receive the medication on the following dates and times due to it nor being available: From 05/19/25 through 05/23/25 for the 8:00 A.M. dose and the 2:00 P.M. dose. The clinical record lacked documentation that the physician was notified that the resident's medications were not available. During an interview, on 06/17/25 at 06/17/25 at 12:10 P.M., Licensed Practical Nurse (LPN) 2 indicated when a resident was out of a medication, she would call the pharmacy to see if they could get it out of the facility's emergency drug kit. If the medication was not available in the emergency drug kit, she would document in the EMAR that the medication was not administered due to it being unavailable, document that she spoke with the pharmacy, and let the physician know. The current facility policy titled, PHARMACY HOURS AND DELIVERY SCHEDULE, dated July 2024, was provided by the Assistant Director of Nursing (ADON) on 06/17/25 at 1:37 P.M. The policy indicated, .is open 24 hours/365 days a year. New orders and refill requests may be faxed or sent electronically at any time .0 The current, undated, facility policy titled, PHYSICIAN-ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the ADON on 06/17/25 at 11:35 A.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-25(a)

Based on observation, record review, and interview, the facility failed to ensure staff supervised a resident that resided on a secured unit when off the unit for 1 of 3 residents reviewed for accident hazards. (Resident C) Findings include: Upon entering the facility on 06/16/25 at 4:25 P.M., on the first floor of the facility, there were no staff observed anywhere on or near the outside of the locked unit. There were three residents sitting in the dining room, outside the locked unit, including Resident C. There was an exit door approximately 10 feet to the right of where Resident C was sitting. During an observation, on 06/16/25 at 4:30 P.M., Dietary Staff 15 knocked on the dementia unit door and no staff answered the door. The door had a window that was approximately four feet by four feet and was 4.5 feet high. The dietary staff member indicated she was unsure of what the code was to get into the locked unit. The dietary staff left the area and then went upstairs to the second floor. Resident C was still sitting in the dining room outside the dementia unit with no staff present. During an observation, on 06/16/25 at 4:45 P.M., there were two visitors leaving the dementia unit when Resident C had gotten up from her chair and asked them to hold the door open to the dementia unit so she could enter. Resident C walked into the dementia unit. The clinical record for Resident C was reviewed on 06/16/25 at 5:00 P.M. A Quarterly Minimum Data Set Assessment, dated 04/30/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, Alzheimer's disease, non-Alzheimer's dementia, and diabetes. The census report indicated the resident resided on the locked dementia unit. A current open-ended physician's order, with a start date of 04/25/24, indicated the resident may reside on a secured unit. A Wandering Risk Assessment, dated 04/11/25, indicated the resident was at a moderate risk for wandering. During an interview, on 06/16/25 at 5:23 P.M., Licensed Practical Nurse (LPN) 2 indicated Resident C was able to be off the locked dementia unit with staff supervision. She should have had a staff member's supervision when she was sitting outside of the locked unit. The facility could not provide a policy related to resident supervision. The current facility policy titled, Guidelines for Incidents/Accidents/Falls, was provided by the Regional Director of Plant Operations on 06/16/25 at 6:02 P.M. The policy indicated, .It is the policy of the facility to ensure that any incident/accident .is reported immediately to the nurse or appropriate person designated to be in charge . 3.1-45(a)(2)

Based on record review and interview, the facility failed to document a resident's behaviors for 1 of 3 residents reviewed for medical records. (Resident B) Findings include: During an interview, on 06/16/25 at 6:46 P.M., Certified Nurse Aide (CNA) 5 indicated Resident B had been having more behaviors during care for the last two to three weeks related to kicking her legs. The CNAs didn't have access to document a resident's behaviors. The CNAs had to let the nurse know and the nurse would document on the resident's record. She had told Licensed Practical Nurse (LPN) 4 and LPN 6 about the resident's behavior related to kicking her legs. During an interview, on 06/17/25 at 10:40 A.M., LPN 4 indicated the resident had some behaviors of kicking during care. The resident behaviors would be documented in the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) or a progress note. During an interview, on 06/17/25 at 11:39 A.M., the Assistant Director of Nursing (ADON) indicated after interview staff, from 05/24/25 through 05/29/25. It was determined the resident was having increased behaviors during care and was kicking during care. She was unsure if the behaviors were documented. The CNAs were not able to document resident behaviors and should have told the nurse. The nurse would document resident behaviors in a progress note. The clinical record for Resident B was reviewed on 6/16/25 at 5:30 P.M. A Quarterly Minimum Data Set (MDS) Assessment, dated 04/11/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, and malnutrition. A physician's order, dated 12/22/23 through 06/17/25, indicated the staff were to monitor the resident's behavior every shift. The May 2025 EMAR/ETAR indicated to see the Progress Notes on the following dates and times: - On 05/03/25 at night, - On 05/04/25 at night, - On 05/08/25 at night, - On 05/09/25 at night, - On 05/13/25 at night, - On 05/14/25 at night, - On 05/17/25 at night, - On 05/18/25 at night, and - On 05/21/25 at night. The May 2025 Progress Notes lacked any documented behaviors for the resident. The current facility policy titled, Guidelines for Addressing/Managing Resident Who-----Refuse Care or Who Are NON-ADHERENT TO THEIR CARE PLAN dated 10/11/2024, was provided by the ADON on 06/17/25 at 1:39 P.M. The policy indicated, .DOCUMENT DOCUMENT DOCUMENT .It cannot be stressed enough that THROUGH DOCUMENTATION IS CRITICAL . The current facility policy titled, Guidelines for Handling and Addressing Behavioral Emergencies, dated 03/18/23, was provided by the ADON on 06/17/25 at 11:35 A.M. The policy indicated, .Documentation .Record specifics related to the behavior incident .Documentation in the clinical record should include facts as related to time, possible causative factors, actual behavior with the consequences, interventions and outcomes . This citation relates to Complaint IN00460383. 3.1-50(a)(2)

Based on interview, and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed. (Resident D) Finding included: A Progress note, dated 04/13/25 at 5:58 P.M., indicated Resident D was hitting, pinching, and spitting at staff during care. The resident was wanting to be left alone. The resident was cleaned up and the call light was given to the resident. A Significant Change Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, anxiety, and depression. The current Care Plan, dated 4/25/22, indicated Resident D was declining. The resident had episodes of declining resident care, medications, treatments, and refused showers. The interventions included, but were not limited to the following: - If resident continues to decline have another staff member approach. - if resident declines, make resident safe and leave; and reapproach in five minutes. During an interview, on 05/16/25 at 2:06 P.M., Certified Nurse Aide (CNA) 2 indicated Resident D was resistive and combative. CNA 2 and CNA 3 continued to provide care to the resident. During an interview, on 05/16/25 at 2:23 P.M., CNA 3 indicated she went in to check on Resident D and asked CNA 2 for help. Resident D was being resistive to care by hitting, pinching, and spitting. CNA 3 and CNA 2 continued to provide care to the resident. Staff failed to allow an upset and combative resident time to calm down prior to providing care. During an interview on 05/16/25 at 3:20 P.M., CNA 5 indicated if a resident was resistive to care you should make sure they are safe, walk away, approach them later, or have another staff member approach them. The current facility policy titled GUIDELINES FOR OBSERVING AND IMPLEMENTING - RESIDENT RIGHTS, was provided by the Corporate Clinical Support on 05/16/25 at 3:42 P.M., dated 07/12/23. The policy indicated, 7) It is important that staff be aware of the RESIDENT RIGHTS to include but not limited to: A dignified existence - resident being treated with dignity in all situations . Residents are to have their well-being and self-esteem, and self-worth enhanced during all care and services interactions .1. Staff will treat each resident with respect and dignity .3. Staff will not use any profanity or vulgar words in the presence of the resident and under no circumstances directed at the resident . This deficient practice was corrected, on 04/14/25, prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan of all residents assessed, re-educated staff on dignity and respect, and implemented a monitory system. This citation relates to Complaints IN00457440 and IN00457734. 3.1-3(t)

Based on record review, and interview, the facility failed to ensure a maintenance staff removed lye-based chemical drain cleaner from the bathroom of vulnerable resident for 1 of 3 residents reviewed for accidents. (Resident C) This deficient practice resulted in the resident ingesting the chemical liquid and sustaining low-grade esophageal injury and moderate-grade gastric injury that required intensive care at an acute care hospital. Findings include: A Quarterly Minimum Data Set (MDS) assessment, dated 11/27/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hypertension, and paranoid schizophrenia (a subtype of schizophrenia characterized by persistent delusions and hallucinations). The resident had no documented behaviors of inattention, disorganized thinking or altered level of consciouness. She had symptoms of feeling down or depressed a total of three time during the assessment review. The resident had no prior history of consuming harmful chemicals. A Progress Note, dated 01/07/25 at 11:23 A.M., indicated Resident C was sent to the emergency room after ingesting the drain cleaner. During an interview on 01/31/25 at 11:02 A.M., the Maintenance Director indicated that he had gone into Resident C's room to unclog her toilet. He knelt in front of the resident's toilet with a plastic garbage bag and a container of drain cleaner. He then realized the toilet was clogged with brown paper towels; he removed the clog and placed the towels into the plastic bag. He thought he placed the bottle of drain cleaner into the same plastic bag since the drain cleaner bottle was nearly empty. Within a few minutes after the Maintenance Director walked out of the resident's room the resident walked out into the hallway and handed a staff member the drain cleaner bottle. During an interview, on 02/03/25 at 8:46 A.M., Qualified Medication Aide (QMA) 2 indicated Resident C brought the drain cleaner out to QMA 2. The resident started complaining of her throat hurting, so QMA 2 immediately took the resident to the nurse. A Hospital Discharge Summary Document, dated 01/12/25, provided by the Director of Nursing (DON), on 01/31/25 at 12:15 P.M., indicated Resident C consumed a bottle of [NAME] Lye drain opener which was left unattended by staff. Resident C was admitted to the intensive care unit for monitoring. An Esophagogastroduodenoscopy (imaging test for examining the lining of the esophagus, stomach, and the first part of the small intestine) with esophageal evaluation showed low grade injuries, but gastric evaluation shows moderate-grade injuries from lye ingestion. The Safety Data Sheet (SDS) for Instant Power [NAME] Lye was provided by the Administrator, on 01/31/25 at 1:20 P.M. The SDS indicated the chemical was harmful if swallowed and should be kept out of reach of children. The current facility policy titled, Chemical Safety and Storage, with a review date of 12/05/24, was provided by the Administrator on 01/31/25 at 1:20 P.M. The policy indicated, .Hazardous chemicals should be kept in a locked area inaccessible to residents . The current undated facility policy titled, Resident Rights was provided by the DON on 01/31/25 at 1:20 P.M. The policy indicated, .The facility must provide a safe, clean, comfortable, home-like environment . This deficient practice was corrected on 01/09/25 after the facility implemented a systemic plan of all resident environments assessed and all staff were educated on chemical safety and storage. This citation relates to Complaint IN00450781. 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure adequate monitoring and treatment was in place for a diabetic resident that resulted in a change in mental status and hospitalization for 1 of 19 residents reviewed for quality of care. (Resident 36) Findings include: The clinical record for Resident 36 was reviewed on 09/26/19 at 11:23 [NAME]M. The resident was admitted from the hospital and had a prior history of uncontrolled blood sugars and [MEDICAL CONDITION]. The EMAR (Electronic Medication Administration Record) indicated the resident's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].before meals and at bedtime for DM (diabetes melitus) . The insulin sliding scale was as follows: .if (blood sugar) 70-130 = (give) 0 units; 131-180 = 2 units; 181-240 = 4 units; 241-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401 + = 12 units .over 400 give 12 units and call MD .' The EMAR was initialed by RN 6 on 07/14/19. The medication administration documentation areas for the scheduled and sliding scale insulin that was due at 7:00 [NAME]M., on 07/14/19, had the number 5 documented, which indicated Hold/See Nurse Notes according to the EMAR Staff Administration Legend. There was no indication in the EHR (Electronic Health Record) that Resident 36's blood sugar was assessed, or that insulin was administered before breakfast on 07/14/19. The EMAR indicated RN 6 administered insulin to Resident 36 at 12:00 P.M. but did not indicate the amount or the resident's blood sugar assessment reading. A Progress Note, dated 07/14/19 at 2:43 P.M., indicated .res (resident's) blood sugar read hi (sic) given insulin and notified dr (Doctor) .with orders to give 20 units and recheck sugar at 4 pm . A Progress Note, dated 7/14/2019 at 4:23 P.M., indicated the resident was noted with high blood sugars throughout the day. The resident was mumbling incoherently, his blood sugar was rechecked at 3:50 P.M., and his blood sugar registered high on the glucometer. Family was present and very concerned. The resident was sent out to the local emergency room for evaluation and treatment. A Progress Note, dated 7/15/2019 at 3:08 [NAME]M., indicated the resident was admitted to the local hospital's Intensive Care Unit with DKA (Diabetic ketoacidosis, a serious complication of diabetes that could occur with elevated blood sugars). During an interview on 09/27/19 at 3:12 P.M., RN 6 indicated she was familiar with Resident 36 and the events of 07/14/19 as she received disciplinary action from the facility. She was not made aware that the resident was diabetic or that he required insulin when she received shift report from the off going nurse the morning of 07/14/19. There was a document available that listed residents that needed blood sugar checks and insulin. The resident was not listed on the document. There was a QMA (Qualified Medication Aide) assigned to administer medications to the residents that resided in the locked unit where Resident 36 lived, and she was administering medications to residents that resided on another unit in the facility. She was not sure when she was made aware of the resident's elevated blood sugars or insulin orders. When she observed the resident around noon, he was alert; he was confused but not lethargic or sleepy. When they (nursing staff) checked the resident's blood sugar it was high. She administered the lunchtime dose of insulin due for blood sugar readings over 401 based on the ordered parameters and notified the doctor. The doctor ordered an additional 20 units of insulin, which she administered as well. They (nursing staff) were to recheck the resident's sugar at 4:00 P.M. The resident's blood sugar was not checked nor did he receive any insulin on 07/14/19 until the afternoon. The current, undated facility policy, titled Physician Orders--(Following Physician Order), was provided by the Administrator on 09/27/19 at 2:08 P.M. The policy indicated .It is the policy of the facility to follow the orders of the physician . 3.1-37(a)

Based on record review and interview, the facility failed to ensure foot pedals were in place when a resident was propelled in a wheelchair by a staff member. This deficient practice resulted in a fall with a [MEDICAL CONDITION] and 13 sutures for 1 of 2 residents reviewed for accident hazards. (Resident E) Findings include: The clinical record for Resident [NAME] was reviewed on 07/01/19 at 12:13 P.M. A Progress Note, dated 05/26/19 at 12:18 P.M., indicated .Resident (E) had fall out of wheelchair this shift, during staff assist propelling in wheelchair. Resulted in skin tears to right cheekbone, right elbow, right shoulder, and laceration to right forehead, was uncontrolled bleeding from laceration with pressure applied. Res (Resident) on eliquis (a blood thinner medication) BID (twice a day). Sent to ER (emergency room ) . writer educated staff member on resident safety during propelling in wheelchair . A Progress Note, dated 05/26/19 at 2:33 P.M., indicated .Received a call from ER. Resident (E) has been admitted with mechanical fall with right [MEDICAL CONDITION], head injury, and [MEDICAL CONDITIONS] with exacerbation with [MEDICAL CONDITION] Res has 13 stitches in right [MEDICAL CONDITION] . A hospital Admission Information, dated 05/26/19, indicated Resident E's chief complaint on admission was a fall. Resident [NAME] had an accidental fall out of the wheelchair, face forward, hitting his forehead, with a laceration to the forehead, that was sutured in the emergency department. During an interview on 07/02/19 at 2:07 P.M., the DON (Director of Nursing) and MDS (Minimum Data Set) Nurse 2, indicated on 05/26/19, Resident [NAME] (who resided in the Ross building) was the last resident in the dining room and had asked the dietary personnel to take him back to his room. She had propelled him in his wheelchair, without asking for assistance from nursing staff, down the hallway with the resident holding his feet up. The resident had suddenly put his feet on the ground which caused him to fall face first out of the wheelchair. The resident had sustained skin tears to his right cheekbone, right elbow, right shoulder, and a laceration to the right forehead. The resident was sent to the hospital but was alert and oriented the whole time at the facility before being transferred to the hospital. The resident normally did not have foot pedals on his wheelchair because he normally propelled himself around the building. The dietary personnel should have asked nursing staff for assistance with propelling residents around the building. The DON did not believe the dietary staff was educated on propelling residents in the facility. During an interview on 07/02/19 at 9:42 A.M., COTA (Certified Occupational Therapy Assistant) 4, who provided therapy services in the Ross building, indicated Resident [NAME] had been working on dressing, bathing, hygiene, transfers, and walking. The resident propelled his self in the wheelchair around the facility without foot pedals, but they were available in his room based on the resident's fatigue. The resident had moments when he needed to be propelled by staff. If the resident wanted assistance with propelling in his wheelchair, then the foot pedals should have been applied and everyone knew they were in the room. Prior to the resident's fall, he probably only asked for assistance to be propelled in his wheelchair 10 percent of the time. An Admission MDS assessment, dated 04/07/19, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. During an interview on 07/02/19 at 3:35 P.M., the Cooperate Administrator indicated there was no policy related to the use of foot pedals on wheelchairs. This Federal tag relates to Complaint IN 436. 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide supervision, safety interventions, and monitor for reoccurrence of self-harm for a resident with known behaviors of wrapping a call light cord around the neck for 1 of 1 residents with a known history of self-harm. (Resident 46) Based on observation, interview, and record review, the facility failed to monitor residents following falls related to neurological assessments and to revise the Care Plan for 4 of 7 residents reviewed for accident hazards. (Residents 24, 32, 42, and 2) This deficient practice resulted in an Immediate Jeopardy. The Immediately Jeopardy began on 08/28/18 at 01:45 A.M. when the facility failed to implement safety interventions, and supervision for a resident with a history of self-harm. The Executive Director and Director of Nursing were notified of the Immediate Jeopardy on 09/10/18 at 04:50 P.M. Findings include: 1. The clinical record for Resident 46 was reviewed on 09/10/18 at 11:42 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/30/18, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. No behaviors were identified during the seven day look back period. A Care Plan for being at risk for a decline in mood related to a [DIAGNOSES REDACTED]. The care plan focus was revised on 06/05/18 to include attempted to wrap call cord around her neck and revised on 08/28/18 to include Placed call cord around neck. The interventions for the 06/05/18 focus revision date included remove call light cord replace with a call bell, 15 minute monitoring and Send to psych unit on 06/06/18. The interventions for the 08/28/18 focus revision date included one on one supervision, sending to a local hospital emergency room , and sending to a neuro-psychiatric hospital on [DATE]. A progress note for Resident 46, dated 08/28/2018 at 02:53 A.M., indicated Resident 46 had repeatedly been using her call light and yelling out, stating I don't want to be here. I'd rather die. I'm going to kill myself. RN 2 indicated she had attempted to verbally calm the resident to no avail. She entered Resident 46's room at 01:45 A.M. to see Resident 46 with the call light cord wrapped around her neck two times. RN 2 wrote that she remained in the resident's room for several minutes to attempt to calm and reassure the resident, again to no avail. RN 2 indicated she returned to Resident 46's room at 02:20 A.M. to find her with the call light cord wrapped around her neck twice again. At that time Resident 46 was brought to the nurse's station for 1:1 supervision. A progress note for Resident 46, dated 08/29/18 at 03:05 P.M., indicated Resident leaving at this time for neuro-psych. A progress note for Resident 46, dated 06/05/18 at 02:21 A.M., indicated Resident 46 was upset and complained of being unable to sleep. res (resident) grabbed call light cord and attempted to wrap it around her neck with writer present, writer took call cord from resident and gave her a bell to use for needs. During an interview on 09/10/18 at 02:41 P.M., RN 2 indicated, during the early morning of 08/28/18, Resident 46 had been saying she didn't want to be here and she didn't want to live. The resident's call light went off at 01:45 A.M. She walked into the room and saw Resident 46 with the call light cord wrapped around her neck. She spoke with the resident about not wrapping the cord around her neck. CNA (Certified Nurse Aide) 3 informed RN 2 that this resident had been sent out in the past for placing the call light cord around her neck. RN 2 told CNA 3 when the call light goes off again she would answer it. At 02:20 A.M. RN 2 answered the call light to find the call light cord wrapped around Resident 46's neck again. RN 2 consulted with the nurse on the locked unit who instructed her to bring Resident 46 out of her room and place her on 1:1 supervision. RN 2 further indicated she didn't have a reason for not removing the call light cord after the first time Resident 46 wrapped the call light cord around her neck. She thought talking to the resident took care of the issue. During an interview on 09/10/18 at 02:26 P.M., LPN (License Practical Nurse) 4 indicated the call light was taken away from Resident 46 on 06/05/18 at the time of the incident of placing the call light cord around her neck and was given a hand held bell. Two weeks after Resident 46 returned from the psych hospital her call light was returned because she had shown no verbal threats of self harm. During an interview on 09/10/18 at 02:03 P.M., the Director of Nursing indicated the every 15 minute checks were one of the interventions that were put into place and should have been completed. She could not provide any documentation for the every 15 minute checks for Resident 46. The current facility policy titled Guidelines For Handling And Addressing Behavioral Emergencies was provided by the MDS Coordinator on 09/11/18 at 10:06 A.M. The policy indicated .if it appears that the resident is likely to harm themselves or others call a Code Gray .Stay in the room or the area with the resident in case the resident would need immediate help or intervention .Continue 1:1 supervision and observation until the episode is resolved/managed .Be sure that sharp or dangerous objects are moved out of the vicinity . The Immediate Jeopardy that began on 08/28/18 was removed on 09/12/18 at 11:48 A.M. when the facility completed inservices and educated staff on how to identify and act upon residents who verbalize or show intent to harm themselves. The non-compliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had completed education on identifying residents with intent to self-harm. This visit resulted in substandard quality of care and an extended survey. 2. Resident 24's clinical record was reviewed on 09/11/18 at 02:14 P.M. A progress note, dated 07/02/18 at 05:35 P.M., indicated the resident had a witnessed fall at 05:15 P.M. The resident hit her face on her walker, broke her glasses, and had the left ear frame piece .hanging out of left side of face . This occurred while the resident was walking to the dining room. No neurological checks were initiated at that time. A progress note, dated 07/03/18 at 10:19 A.M., indicated the resident complained of pain to the left side of her forehead. It was swollen and discolored. Neurological checks were initiated at that time. The Admission MDS (Minimum Data Set) assessment for Resident 24, dated 07/07/2018, was reviewed on 09/07/18 at 10:38 A.M. The assessment indicated the resident was moderately cognitively impaired and needed extensive assistance of one staff member for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident was frequently incontinent of bowel and bladder. [DIAGNOSES REDACTED]. The resident received [MEDICAL CONDITION], physical therapy, and occupational therapy. During an interview, on 09/11/18 at 02:22 P.M., RN 12 indicated when a resident falls and hits their head, neurological checks should be started at that time. If the fall was unwitnessed, neurological checks should be completed whether the resident indicated they had hit their head or not. 3. The clinical record for Resident 32 was reviewed on 09/06/18 at 10:48 P.M. The Quarterly MDS assessment, dated 07/16/18, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. The resident needed limited assistance of one staff member for transfers, walking in the room and corridor, and toilet use. The resident needed extensive assistance of one staff for personal hygiene, used a walker and a wheelchair, was not steady walking, and was frequently incontinent. Neurological Assessment forms for Resident 32 were provided by Medical Records on 09/06/18 at 03:23 P.M. Assessments were incomplete for falls on the following dates and times. The 8 hour assessment on 08/28/18 at 05:15 A.M. The 2 hour assessment on 08/18/18 at 09:00 P.M. The 4 hour assessment on 08/01/18 at 02:15 A.M. The 4 hour assessment on 08/01/18 at 06:15 A.M. The 8 hour assessment on 08/02/18 at 02:15 A.M. The 4 hour assessment on 07/09/18 at 10:15 P.M. The 4 hour assessment on 07/10/18 at 02:15 A.M. During an interview, on 09/10/18 at 01:59 P.M., the DON (Director of Nursing) indicated if a resident refused to allow neurological checks to be completed, it should have been written on the neurological check form. 4. The clinical record for Resident 42 was reviewed on 09/10/18 at 09:50 A.M. The most recent Quarterly MDS assessment, dated 07/26/18, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. She had impairments to one side of her upper and lower extremities and required extensive assistance of two staff members for transfers. During an interview, on 09/05/18 at 10:37 A.M., Resident 42 indicated she had fallen a couple of times. A progress note, dated 07/05/18 at 07:19 A.M., indicated .Housekeeper notified writer that she heard resident yelling for help and then noted her lying on the floor on her left side. Stated she hit her head when she fell out of her w/c (wheelchair) The Neurological Assessment Form, dated 07/06/18, indicated no neurological assessment was completed on 07/07/18 at 05:20 A.M. A progress note, dated 08/30/18 at 04:59 P.M., indicated the resident was sitting on floor in front of her bed, resident stated, I fell getting my drink from my table. The Neurological Assessment Form, dated 8/30, indicated the following assessments were incomplete: 08/30/18 at 04:45 P.M., 05:00 P.M., 05:30 P.M., and 06:00 P.M., 09/01/18 at 12:00 A.M. During an interview, on 09/10/18 at 01:59 P.M., the DON indicated neurological checks should be completed. If the resident refuses them, then it should be marked on the sheet. The current facility policy titled Head Injuries/Neurological Assessment was provided by the MDS Coordinator on 09/11/18 at 10:06 A.M. The policy indicated Assessments are to be done when it is suspected or known that a resident has had a blow to the head. Any resident who has had an unwitnessed fall and sustained a possible blow to the head (has a hematoma or a bump) should be sent to the emergency room for evaluation .Monitor the resident for 48 hours .Vital signs and Neurological signs as indicated: BP (blood pressure) & P (pulse) q (every) 15 minutes x (times) 4; check pupils BP & P q30 minutes x 2; check pupils Complete vital signs and neurological signs q 1 hour X2; then q2 hours X 2 hours; then q4h (hours) X 4hours; and every 8 hours X 4 .Utilize Neurological Assessment form to document findings . 5. The clinical record for Resident 2 was reviewed on 09/06/18 at 03:32 P.M. A Quarterly MDS assessment indicated the resident was moderately cognitively impaired. [DIAGNOSES REDACTED]. The resident required extensive staff assistance with bed mobility, transfers, toileting, and personal hygiene. Resident 2 had two or more falls without injury since the last assessment and utilized a chair alarm daily. The resident had multiple Fall Assessments documented in the clinical record. A progress note, dated 07/11/18 at 03:19 P.M., indicated Resident 2 was found in her room on the floor by an aide. The resident was laying on her back with her wheelchair on top of her. The resident indicated she was trying to get a drink. The resident was assessed, with no bruising or open areas noted. Neurological checks were initiated. The family and appropriate staff members were notified. There was no fall assessment documented for this fall. A progress note, dated 07/14/18 at 07:58 A.M., indicated Resident 2 was observed on the floor in her bathroom sitting upright next to the commode. A full assessment was completed and the resident was at her baseline. The resident denied any new pain or discomfort. Neurological checks were initiated, family and appropriate staff members were notified. There was no fall assessment documented for this fall. A progress note, dated 07/28/18 at 04:03 P.M., indicated full assessment completed. Resident transferred to wc (wheelchair) with assist x 2 (assistance of two staff members). Neuro checks (neurological assessments) initiated and WNL (within normal limits) per baseline. ROM (range of motion) upper and lower ext (extremities) WNL, no outward rotation noted, legs symmetrical. There was no fall assessment documented for this fall. During an interview, on 09/10/18 at 02:16 P.M., the Dementia Unit Coordinator indicated when a resident had a fall, staff were to assess the resident, create an incident report in risk management, and document the fall in the resident's progress notes. The nursing staff were to complete a fall assessment for every fall. Resident 2's Care Plans included, but were not limited to, Potential for Falls Care Plan, initiated on 09/05/16, related to [MEDICAL CONDITION], impaired cognition, and history of falls. During an interview, on 09/10/18 at 01:54 P.M., the DON indicated if a resident had a fall, staff were to create an incident report in Risk Management. Documentation of an actual Fall Assessment was encouraged, but not required to be completed for every fall. The Department heads reviewed all falls in their daily meetings. Care plans should be updated with a new intervention after each fall. There were no updates to Resident 2's fall care plan for the falls that occurred on 07/11/18, 07/14/18, and 07/28/18. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to properly assess a resident with a [DIAGNOSES REDACTED]. This deficient practice resulted in harm in that the resident was transferred from the facility unresponsive to the hospital (Resident D). Findings include: Resident C's closed clinical record was reviewed on [DATE] at 12:02 p.m. [DIAGNOSES REDACTED]. A current care plan for Resident C indicated, Focus: Has DX (diagnosis): Arrhythmia .Interventions: .Labs per order .Monitor vital signs as needed .Observe for any c/o (complaint of) chest pain, cardiac distress, [MEDICAL CONDITION] or chest pain. A current care plan for Resident C indicated, Focus: Resident has a (sic) implantable cardioverter-defibrillator at risk for cardiac distress .Interventions: .observe labs and VS (vital signs) as ordered .Update MD of any changes as needed . A current care plan for Resident C indicated, Focus: Resident has [DIAGNOSES REDACTED].labs as ordered .observe for SOB (shortness of breath), increased [MEDICAL CONDITION], increased weakness, rapid resp (respirations) . A Physician/Nurse Practitioner (NP) Progress Note for Resident C, dated [DATE], indicated, .Acute visit: .report pt (patient) 'raspy' (lungs) .Physician Examination: Pulse: 71. BP (blood pressure) ,[DATE]. RR (respiratory rate) 14. O2 (oxygen) sa (saturation) 98% (on) 2 L (liters) (oxygen) .Resp: crackles L (left) base .Ted hose not on .[MEDICAL CONDITION] - [MEDICAL CONDITION] (up arrow) but weight (down arrow). CXR and BNP (lab to assess for presence of [MEDICAL CONDITION] exacerbation) today . Physician's Orders for Resident C, dated [DATE], indicated, .CXR today .BNP today. Call me (with) results of above today. Resident C's Nursing Progress Note, dated [DATE] at 2:52 p.m., indicated, (NP) here to see .new orders rec'd (received) for cxr and bnp today and call with results, cxr (and) bnp done awaiting results . Portable Chest X-Ray Results for Resident C, indicated the report was finalized on [DATE] at 5:16 p.m. The report indicated, Impression: sizable bilateral pleural effusions .with .other infiltrate including pneumonia . The hand-written documentation on the faxed report indicated, Reported to MD on [DATE] (at) 1pm Give 40mg [MEDICATION NAME] on top of 20 mg already received today . Resident C's BNP results were received [DATE] at 1:18 p.m. and indicated a result of and flagged as high. Nursing Progress Note for Resident C, dated [DATE] at 2:41 p.m., indicated, cxr (results) called into (NP) per request, and bnp, new orders received give extra [MEDICATION NAME] 40 mg daily for 5 days tomorrow . Resident C's Nursing Progress Note, dated [DATE] at 3:10 a.m., indicated, res up at night stating (he/she) cannot breath, HOB (head of bed) elevated and O2 at 2 lpm (liters per minute) 96% (oxygen saturation) skin pink and dry . Resident C's Nursing Progress Note, dated [DATE] at 3:13 p.m., indicated, 98.6 (T: temperature) 70 (P: pulse) 20 (RR: respiratory rate) ,[DATE] (BP: blood pressure) 92% (oxygen saturation) ora (on room air), sleeping a lot, nonproductive congested cough scattered rhonchi per ausc (auscultation), res hangs (his/her) head to the right fluid pocket noted to right upper eyelid, lab done this am, (NP) notified . The following Nursing Progress Note for Resident C, dated [DATE] at 6:59 p.m., indicated, Message left for (NP) about Bmp (lab) results. Physician/NP Progress Note for Resident C, dated [DATE], indicated, Follow up visit .Pulse: 72. BP: ,[DATE], RR 14, O2 Sa 97% (on) 2L (O2) .Ted hose not on .[MEDICAL CONDITION]: [MEDICATION NAME] (up arrow) for 5 days. Infiltrate (pneumonia) vs. [MEDICAL CONDITION]. BNP 0 (elevated to indicated [MEDICAL CONDITION] exacerbation) . The following Nursing Progress Note for Resident C, dated [DATE] at 10:21 a.m., was related to medications and did not include vital signs or resident assessment. The following Nursing Progress Note for Resident C, dated [DATE] at 1:59 a.m., indicated, res in bed with HOB elevated 45 degrees O2 at 2lpm. quiet resp pink skin voiced no c/o pain or discomfort . The documentation did not include vital signs, respiratory, or other nursing assessment. The following Nursing Progress Note for Resident C, dated [DATE] at 8:45 a.m., indicated, Resident unresponsive, no gag reflex noted, shallow breathing noted, o2 sats 76 (%) with o2 on 2l ,[DATE], h 56, r 16, t 98 .new order to send to ER (emergency room } . The last vital signs documented anywhere in Resident C's clinical record before the resident left the facility unresponsive on [DATE] were on [DATE]. On [DATE] at 12:39 p.m., the DON provided an internal document and indicated it showed Resident C was being assessed, despite the lack of documentation in the clinical record. The only additional vital signs were dated [DATE] and indicated, (T) 99.1 (elevated), 90% (O2 saturation. Does not indicated whether the resident was on oxygen), (RR) 24 (elevated). (P) 114 (elevated). (BP) ,[DATE] (elevated for resident). There was no documentation provided to indicate these abnormal vital signs were re-checked, followed up, or reported to the provider. Emergency Department Report for Resident C, dated [DATE] at 10:20 a.m., indicated, .presents via EMS (ambulance) .with decreased level of consciousness and decreased saturations of oxygen .recently had a chest x-ray .showed pneumonia as well as increased [MEDICAL CONDITION] .Patient with acute mental status changes and right-sided pleural effusion with mildly elevated troponin .Primary Diagnosis: [REDACTED]. Add'l Diagnosis: [REDACTED].elevated troponin. Record review indicated the resident was admitted to the hospital on hospice care expired on [DATE]. Resident C's hospital Death Summary, dated [DATE], indicated, Cause of Death: Patient was admitted with a myocardail infarction ([MEDICAL CONDITION]). (He/She) had an underlying [DIAGNOSES REDACTED] and severe dementia. Patient Active Problem List: [MEDICAL CONDITION] .[DIAGNOSES REDACTED] .Acute and chronic [MEDICAL CONDITION] .Advanced dementia. On [DATE] at 2:02 p.m. the ED indicated Resident C did not have any breaks in his/her stay at the facility since the last documented Skilled Nursing Assessment on [DATE]. The ED indicated it was strange there were no nursing assessments documented. LPN #1 was interviewed on [DATE] at 11:26 a.m. She indicated she was Resident C's nurse during day shift on [DATE], beginning at 6:00 a.m. LPN # 1 indicated, We got (him/her) up to the breakfast table .not quite (his /herself) .breathing was labored .not responding to us much .(he/she) had (his/her) head down at the (breakfast) table. LPN # 1 indicated she assisted the resident back to bed and placed the resident on oxygen, which did not improve oxygen saturation. The resident continued to decline, and LPN#1 called the provider. On [DATE] at 11:05 a.m., the ED indicated the facility NP had expressed concerns related to labs/x-rays not being done as ordered and results being reported as ordered. On [DATE] at 11:40 a.m., the DON indicated the facility NP reported concerns related to labs and x-rays not being done as ordered and not being reported as ordered. The DON indicated there were no issues and had disproven (sic) the NP's concerns. The Director of Nursing (DON) was interviewed on [DATE] at 11:49 a.m. He indicated the results were not reported to the NP as ordered because the facility did not receive them until the next day. The DON indicated if the provider ordered lab or x-ray results the same day they were ordered the staff should clarify whether or not the provider wanted the test ordered STAT (immediately) and, if the provider did require the results the same day, order the test STAT. The DON indicated he was unable to provide documentation to indicate Resident C had received a Skilled Nursing Assessment since [DATE] or an assessment other than vital signs since [DATE] (above). The DON indicated, The vital signs went above and beyond (to monitor Resident C). The DON indicated Resident C did not require a daily nursing assessment related to the primary diagnoses/acute illness. He indicated, It depends on the payment source, so (he/she) didn't fall into that category (of requiring a daily skilled nursing assessment). The DON indicated nursing staff relied on physician orders to determine the frequency of assessments, type of assessments, and frequency of vital signs. The DON indicated when there were no specific physician orders, Assessments would be monthly with weights. The DON indicated he was not aware of, and could not provide any, specific policies or procedures or guidelines for nursing regarding skilled nursing assessments, decline in condition, or monitoring residents being treated for [REDACTED]. Resident C's Physician's Orders did not indicate an order specifically related to frequency of obtaining vital signs or nursing assessments. A copy of the current Change in Resident's Condition or Status Policy and Procedure was provided by the ED on [DATE] at 11:02 a.m. The document indicated, .to ensure that the resident's attending physician .is notified of changes in the resident's condition and/or status .The Nurse will notify the .physician when: .There is a significant change in the resident's physical, mental and psychological status .Deemed necessary or appropriate in the best interest of the resident . A copy of the current Laboratory Tests Policy and Procedure was provided by the ED on [DATE] at 10:02 a.m. The document indicated, Guideline: It is the intent of the facility that Laboratory tests are completed on all residents as ordered by the physician . A copy of the current Laboratory Tracking Guidelines Policy and Procedure was provided by the ED on [DATE] at 10:02 a.m. The document indicated, .Center (facility) will establish, maintain and monitor a lab tracking system .will enter lab orders into PCC (electronic medical record system) .the licensed nurse will validate when labs are drawn .labs not documented on will display as missed documentation to be completed prior to the end of the shift .the center is responsible for contacting the lab for any results not received when expected. Labs not drawn as ordered are reported to the attending physician for further direction and reported through the incident management program . On [DATE] at 12:02 p.m., the ED indicated she was not able to locate any policies and/or procedures or guidelines related to skilled nursing assessments, assessments with decline in condition, monitoring residents being treated for [REDACTED]. The Corporate Clinical Consultant (CCC) was interviewed on [DATE] at 12:07 p.m. The consultant indicated the facility had a quality assurance tool by which management could monitor ordered labs and x-rays and make sure each resident's care plan was being followed. The nursing staff was responsible for making sure each resident's care plan was being followed. The CCC indicated she would expect residents with a primary [DIAGNOSES REDACTED]. This Federal tag relates to Complaint IN 336. 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to ensure a resident was free from physical and verbal abuse related to staff grabbing a resident's arm, leaving bruises and verbally threatening the resident for 1 of 36 residents reviewed for abuse. (Resident #76) Findings include: During an observation and interview with Resident #76 on 07/06/2016 at 4:21 P.M., two bruises, slightly larger than quarter size, were noted on the resident's right wrist. The resident indicated the bruises were a result of a disagreement with a staff member. During an interview on 07/07/2016 at 4:33 P.M., LPN (Licensed Practical Nurse) #7 indicated Resident #76 summoned her into her room on the morning of July 4, 2016. Upon entering the room the resident asked LPN #7 if she would help with an experiment and had the nurse put her hand around the resident's right wrist. Following the experiment, the resident concluded the spots on her right wrist were bruises made by the fingers of LPN #6 who pried the resident's fingers open to retrieve a pill. Resident #76 further indicated to LPN #7 that LPN #6 threatened that she would get the resident, kicked out of the place. LPN #7 indicated she called the DON (Director of Nursing) and reported the occurrence. LPN #7 further indicated she seen three bruises on the resident's wrist that day and by the next day, July 5, two of the bruises had joined into one. Record review of an interview conducted by the ADON (Assistant Director of Nursing) with Resident #76, dated July 4, 2016, indicated the incident happened on Friday night, July 1, 2016. The record indicated Resident #76 stated the nurse arrived with her eight o'clock pills and her ten o'clock pills at 9:00 P.M. The resident explained that she took her ten o'clock pills out of the cup because they were, too early. The resident indicated the nurse asked for the ten o'clock pills back because she could not leave them in the room without seeing the resident swallow them. The resident stated that after telling the nurse she would not give the pills back to her, the nurse became angry and threatened to have her, kicked outta here and tried to take them from me. Resident #76 described that she held the medication in her fist, as tight as I could, and then the nurse grabbed her arm with one hand and tried to, rip pills out of my hand with her other hand. Resident #76 then pointed to four small discolorations on her right arm and said, look, she did this to me. Resident #76 stated she would have reported it earlier but she had not notice the marks until the morning of July 4, 2016. The Wound Management form, provided by the Administrator on 07/07/2016 at 11:26 A.M., and dated 07/04/2016, indicated Resident #76 had three discolored areas on the medial wrist of the right arm, one measured 2-1/2 cm (centimeter) in diameter, one measured 2 cm in diameter, and one measured 1-1/2 cm in diameter. The Guidelines for Abuse Investigation form, provided by the Administrator on 07/07/2016 at 11:26 A.M., and dated 07/04/2016, indicated under the Conclusion heading that bruises were on Resident #76's wrist and the allegation was determined to have occurred. The current Abuse Prevention Program policy was provided by the Administrator on 07/07/2016 at 9:10 A.M., and reviewed at that time. The policy indicated, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or treatment by anyone, including staff members . 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who indicated they wished to be a full code status. This deficient practice affected 1 of 3 residents reviewed for resuscitation. (Resident #A) Resident #A went into cardiopulmonary arrest, did not have CPR performed, and died . Findings include: Resident #A's record was reviewed on [DATE] at 10:30 a.m. The record indicated the [DIAGNOSES REDACTED]. A form titled "Code Status Consent Form:" for Resident #A indicated "I (family member), have discussed with the attending physician, the general nature of my/the resident's condition, the procedure, material risks, expected outcome and reasonable alternatives of the procedure and grant my consent to place myself or the resident on a specified code status...(marked with an X) 2. Full Code: a. Cardio-pulmonary resuscitative measures will be instituted in the event of [MEDICAL CONDITION] and/or respiratory arrest. CPR will be utilized," signed by Responsible Party on [DATE], signed by Facility Representative, dated [DATE]. The admission physician orders, dated for [DATE] through [DATE], indicate a full code. Social Service Progress notes, noted an assessment reference date of [DATE] 5d (day)/adm (admission) resident interview. The note indicated, "...BIMS score 15...Cognitive status is intact, was able to repeat the 3 words...on 1st attempt, stated the year '2013,' the month 'March' & the day of the week 'Thursday,' was able to recall the three words...Advance directive & Code status; Code status: Full Code, family member is POA (power of attorney), has a living will...." Nurses' Notes indicated: "[DATE] at 9:25 p.m.,...(symbol for no) S/S (signs and symptoms) distress. [DATE] at 11:00 p.m., right knee pain...PRN (as needed) pain med given... [DATE] at 5:45 a.m.,...c/o chest pain., (symbol for no) relief (symbol for after) 1:1 attempt to relax, M.D. notified N.O. rec (received) @ this time. [DATE] at 6:00 a.m., received PRN nitro ([MEDICATION NAME]) @ 548 a (5:45 a.m.) (symbol for with) (symbol for no) relief. Rec 2nd dose @ 5:56 a.m., C/O (complaint of) pain (arrow up) 911 called for transport to (local hospital) ER (emergency room ) ...6:10 a.m. Rec. dose #3 @ 601 a (6:01 a.m.) C/O chest pain cont (continues) ...in bed with (arrow up) anxiety @ this time. Went out of room preparing for transport. 615 a (6:15 a.m.) returned to res room, res noted (symbol for with) (symbol for no) pulse, (symbol for no) respirations. Skin W/D (warm/dry). 620a (6:20 a.m.) call placed to daughter to notified (sic) of death. 7am MD notified of res death (symbol for with) order to release body to funeral home." A form titled "Resident Transfer" indicated, "...Date of Transfer: [DATE]...Condition/Reason for Transfer: C/O (complaint of) chest pain NTG ([MEDICATION NAME]) given 5:48 AM, 5:56 AM & 6:01 AM,...Resuscitation status...(a box was marked to indicate) Full Resuscitation...." Two care plans were located in the chart regarding the resident's code status. The first was dated [DATE], and indicated "Problem/Need: Code status, full code; Goal/Target Date: Wishes will be honored QD (every day) -TNR (unknown abbreviation); Approaches: Notify MD and family of any changes in condition, Wishes will be honored." The second care plan, dated [DATE], indicated "Problem/Need: Code Status-Full Code; Goal/Target Date: Wishes will be honored QD-TNR; Approaches; Notify MD & family of any changes in condition, wishes will be honored." A policy and procedure was received on [DATE] at 10:30 a.m. from the Administrator, as the current policy, titled "Cardio-Pulmonary Resuscitation (CPR)." The policy indicated, "Guideline: It is the intent of the facility to ensure that all residents suffering a cardiac or respiratory arrest will receive the treatment of [REDACTED]..2. Residents request FULL CODE STATUS will receive CPR if they arrest...Procedure: 1. Check chart for code status. 2. Assess resident to determine if respirations have ceased...3. If a resident who wishes to be resuscitated appears to be having an arrest, the licensed nurse will assess the resident for absence of heartbeat using a stethoscope or palpate pulses and assess for absence of respirations. Call for assistance. 4. If the resident has a cessation of heartbeat or a cessation of respiration and if the resident wished to be resuscitated delegate a person to page for assistance, call 911. 5. All available licensed nurses and staff trained in CPR will respond promptly to the Code and assist as needed...10. Maintain basic life support until ambulance arrives to transport to hospital...." Documentation from the EMT run sheet, dated [DATE] (no time noted), indicated, "...upon arrival in scene we were pointed to her room, nobody else aside of pt (patient) in room. Pt's eyes open staring non reactive no rise & fall of chest, male nurse had followed us into room...no movement of pt, addressed nurse that pt had been deceased . Nurse stated that she had been alive abt (about) 5 min prior, he went to bedside, checked pulse, no pulse, checked with eyeglasses for breathing (fog glasses) negative, glasses clear, Asked if pt was a DNR, Nurse #1 confirmed passing of Pt. No pt contact." An interview with Nurse #1 on [DATE] at 12:28 p.m., indicated he was "called into the resident's room due to chest pain." Vital signs were taken, nitro was provided with no relief, and 911 was called from the desk. "Then I went back into the room for transfer. EMS came into the room; she had passed away. I checked her pulse. The ambulance asked if she was a full code. They said nothing could be started since it was not already started. I should have started it." An interview with Nurse #2 on [DATE] at 9:30 a.m., indicated when she came on the day shift, "the night nurse said he was getting ready to send a resident out. I asked if I could help. He said it was not needed that he thought things were covered. I thought things were under control. The EMTs went into the room with the night shift. I know CPR was not initiated. The EMTs said there is nothing more they can do." An interview with QMA #1 on [DATE] at 12:20 p.m., indicated "I came in early to get papers ready for a hospital visit for Resident #A. The nurse gave the resident nitro; it did not work. The nurse was in the room with the resident and stepped out to call 911. He went back in the room and the resident was gone." An interview with CNA #2 on [DATE] at 12:30 p.m. indicated, "I was not there long. I answered the call light. She was having chest pain. I ran out and got the nurse I left 5 minutes later. My shift is over at 6 a.m." An interview with the local ambulance company, on [DATE] at 12:45 p.m., indicated, "when we go somewhere and the resident has passed, we do not start CPR unless we are told to." An interview with the Administrator and the ADON (Assistant Director of Nursing) on [DATE], indicated, "(Nurse #1) has been on suspension since the incident and will be terminated today ([DATE]), for not meeting professional standards." A Facility Investigation handwritten note, dated [DATE] (not timed), signed by Nurse #1, indicated, "...I had been out of the room for two to three minutes to check on status of staff preparing paper work for transfer to hospital and notification about condition and pending transportation. When I started back to her room I saw the ambulance personnel in hall and directed them to the room. On entering the room I noticed resident with no respirations and checked for a pulse and found none. Staff from life squad stated they would not be able to initiate CPR since it hadn't been started before they arrived and resident already had no pulse and no respirations. They asked code status and I said 'I believe she is a full code.'" A Facility Investigation note, dated [DATE] (not timed), signed by Nurse #1 indicated, "...Resident had complained about chest pain and received nitro, after administering second dose I called 911 for transportation. I then gave a third dose and checked her vital signs a second time. I left her room to inform the oncoming nurse of her condition and to check and see if paperwork was being prepared and if hospital was notified. I saw the life squad in the hall and directed them to the resident's room, I entered the room with the three EMS staff and we noticed she had no respirations. I checked for a pulse and found none. Staff from the ambulance personnel asked what her code status was I answered 'I believe she is a full code.' The oncoming nurse confirmed her status. I expected EMS would initiate CPR assuming they had the necessary equipment with them, and stepped back. They said they 'couldn't' touch her since nothing had been started before they arrived. This led me to the conclusion they would be of no assistance." A Facility Investigation note, dated [DATE], signed by CNA #1, indicated "Came into work [DATE] 5:50 a.m. to copy papers for pt going to go to appt (appointment) @ hosp was @ the desk copying papers when Nurse (#1) came said pt C/O of chest pain gave NTG X3 still C/O came out to call 911-Nurse (#1) called 911 went back into rm (symbol for with) pt came back out said pt expired 911 was in rm told that she was full code." A Facility Investigation note, dated [DATE], signed by Nurse #2 indicated "Ambulance arrived @ 615 am (Nurse #1) went to the room and I followed. Resident was already gone. I stated 'she is gone.' EMT also stated she is gone and there is nothing that can be done. So squad left. I did not state that she was a DNR. Nurse #1 did not state in the room that she was a DNR." A review of an American Heart Association Basic Life Support for Healthcare Providers Course Roster, Date: [DATE], for Course: Healthcare provider CPR/AED (automatic external defibrillator), indicated Nurse #1 under course participants, 96% complete. This federal tag relates to complaint IN 288. 3XXX,[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure a resident at risk for elopement was supervised to prevent elopement. The deficient practice affected 1 of 3 residents reviewed related to wandering and potential for elopement in a sample of 3. (Resident B) Resident B sustained a fracture to the right ankle and suspected fracture to the right ribs when he eloped through a window on the secured unit. Findings include: During Initial Tour on 11/26/12 at 10:45 a.m., Resident B was observed seated in a recliner in the lobby area of the secured Reflections unit. The resident's eyes were closed and respirations even. The resident's legs were elevated, and a cast was on the resident's right leg. During interview at this time, Director of Nursing (DON) #1 indicated the resident had broken his ankle when he left the building through a window in an unoccupied resident room on the secured unit. DON #1 did not indicate the date the resident exited the facility. DON #1 indicated before admission, the resident lived at home and walked 15 to 16 miles per day, and the police would bring him home. DON #1 indicated the resident begged to go home every time his wife came to visit. DON #1 indicated the resident was "seen in the lobby (of the Reflections unit) at 6:45 p.m.," and when the nurse went to the resident's room at 7:00 p.m. to administer routine medications, the resident was not in his room. DON #1 showed the room and window Resident B exited through. She indicated all windows in the facility are "now screwed shut." The window was observed to be above ground level and led into an enclosed courtyard with a high wooden fence. The gate leading out of the courtyard was observed to have two boards nailed across the opening. DON #1 indicated the gate was nailed shut after Resident B's elopement. DON #1 indicated Resident B was found "down the street" and had walked "about a half a mile" when found. During Initial Tour, DON #1 indicated the facility did not use a Wander Guard system. On 11/26/12 at 12:40 p.m., the Administrator provided a file pertaining to Resident B's elopement. During interview at this time, the Administrator indicated the resident eloped from the building on Veteran's Day. She indicated staff called her at home, and she came to the facility and accompanied the resident to the hospital. She indicated she thought the resident might have gone to the American Legion and was concerned because it was getting dark and cold that evening. She indicated the resident was sitting in a chair down the street. She pointed to a plastic baggie containing coins on her desk and indicated the resident had the money in his pocket and his coat on when he was found. The elopement file included a copy of the "Initial with Follow-up" report to the Indiana State Department of Health. The report indicated, "Brief Description of Incident: Resident was admitted to facility on 10/26/12 to the facility (sic) from home due to the inability of wife to care for him in the home setting. Resident has a [DIAGNOSES REDACTED]. Resident ambulates on his own and does walk up and down the hallway. Resident was placed on 15 minute behavior monitoring due (to) identifying the keypad code to the door on 11/9/12. The code to the key pad was changed at that time.....Resident was found down the street at 7:20 p.m. When asked what he was doing, the resident stated, "I was going for a walk but my ankle hurts. I think I twisted it when I went out the window." Resident returned to facility and complete assessment of resident was completed. Resident stated his ankle was sore and was sent to ER (emergency room ) for evaluation...." The elopement file included a copy of a Missing Person Report Form indicating the resident was last seen in his room (sic) on 11/11/12 at 6:45 p.m. The form indicated, "...History of previous elopements and intervention plan: none (a large question mark was handwritten next to the entry); Suspected mode of leaving facility: Out window...Potential outside safety concerns for resident (traffic, lakes): lake, traffic...." Post Elopement Information on the form indicated the resident was noted missing by the nurse on the resident's unit at 7:00 p.m. and was found by the local police at 8:00 p.m. The elopement file also included a copy of an ambulance run report, dated 11/11/12, indicating the following: The call for the ambulance was received at 7:57 p.m., and police were on the scene. The "Narrative" indicated, "Responded emergent to an elderly male dementia pt (patient) that was found near machine shop that had wandered away from nursing home. Pt. was at the garage belonging to the (name) on a dead end street. Pt c/o (complained of) pain in R (right) ankle. Tenderness noted upon palpation....Pt. stated he was on his way to (name of nearby town)....Pt stated, 'I climbed out the window, my wife is expecting me to call her @ 8 p.m.' Pt. was last seen @ nursing home at 6:45 p.m. Blankets placed on pt due to pt shivering....Transported pt to (name of local hospital)...." The elopement file also included a copy of a Visit Summary Report for the local hospital emergency room . Nurses Notes on 11/11/12 at 8:45 p.m., indicated, "...Pt reported to be a resident of Waters of Dillsboro. It is reported that pt frequently tries to escape. Pt reports jumping out of the window '8 to 10 feet'...." The elopement file also included copies of "Resident Location Monitoring" logs indicating the resident was monitored by staff every 15 minutes from 10/25/12 at 2:00 p.m. through 11/12/12 at 11:00 p.m. "OOF" (out of facility) was indicated from 7:00 p.m. until 11:00 p.m. on 11/11/12. The clinical record for Resident B was reviewed on 11/26/12 at 12:05 p.m. The Admission-Face Sheet Information indicated the resident was admitted from a local hospital on [DATE]. The hospital History and Physical for the admission on 10/17/12 indicated, "Past Psychiatric History: ...He also has a hospitalization in July of 2012. At that time, the patient was wandering from his house...." An assessment by Social Services, dated 10/25/12, indicated "Yes" to the following questions: Resident is ambulatory or self-mobile in wheelchair; Resident is cognitively impaired, with poor decision-making skills, and/or pertinent diagnosis; Resident has a history of wandering; Lingering around exit doors, attempting to exit with visitors without authorization; Utilize wander detection system and careplan for risk of elopement, contact DON (Director of Nursing) and/or Obtain physician's orders [REDACTED]. The resident's care plan, dated 10/25/12, indicated, "Problem/Need/Concern: Dementia (with) secondary agitation wandering." The Goal indicated, "Will be easily redirected without frustration TNR (through next review)." No care plan related to elopement was indicated until 11/11/12. A care plan, dated 11/11/12 indicated, "Problem/Need/Concern: Elopement." The Goal indicated, "Will remain on secured unit to maintain safe environment TNR." During interview on 11/28/12 at 4:30 p.m., the Social Services Director (SSD) indicated a care plan related to potential for elopement had not been developed until the resident eloped. When interviewed in regard to care when the resident expressed the need to go outside the secured unit, the SSD showed on the care plan for "Dementia with secondary agitation and wandering" that she had added on 11/8/12 that the therapists would take the resident outside for therapy sessions. Nurse's Notes included, but were not limited to, the following on the dates and times indicated: 10/25/12 at 9:42 p.m., "...ambulating self about unit (with) steady gait noted, stopping staff periodically asking 'Can you please help me get out'...." 10/26/12 at 12:02 a.m., "...Res conts (continues) to ambulate about unit staying primarily in dining room to listen to the radio....Sat on porch (with) writer for about five minutes & stated, 'I need to get back in now. I can't hear the radio out here....(no) attempts to leave unit/facility so far this shift." 10/26/12 at 8:40 p.m., "Wandering all shift....Repeatedly asking for everyone to give him code & let him out. Threatened to leave 'even if I have to break a window & climb out.' Touching staff & visitors to stop them & ask them to 'let me out of here.' Redirected repeatedly." 10/27/12 at 11:00 a.m., "...wanders from hall to hall...." 10/27/12 at 10:10 p.m., "...wandering during evening hours...." 10/28/12 at 9:30 a.m., "Res wanders in & out of room and (up and down) both halls asking staff to help him get outside he wants to walk. Staff reminds res it's getting colder out...." 10/28/12 at 10:00 p.m., "State 'enjoys walking.' Wandering during eve (evening) hrs. (hours)...." 10/29/12 at 1:26 p.m., "Wandering around unit (with) jacket on requesting that staff & visitors let him outside. Unable to redirect." 10/29/12 at 4:30 p.m., "...Wandering per usual...." 10/29/12 at 3:00 a.m., "...Resd (resident) wandered most evening...." 10/30/12 at 10:00 a.m., "...Has been up & about wandering in the hall...." 10/30/12 at 8:00 p.m., "...resident continues to exit seek...." 10/31/12 at 11:30 a.m., "...wandering (up and down) halls (with) no goal." 10/31/12 at 12:30 p.m., "...Now wandering around unit...." 10/31/12 at 6:00 p.m., "....ambulates about unit....Resident continues to wander unit...." 10/31/12 at 6:30 p.m., "Resident (with) (increased) wandering & attempting to open doors. At this point resident became very agitated grabbing door handles & pounding on glass repeatedly over and over." A physician's orders [REDACTED]." The Medication Administration Record (MAR) for October 2012 indicated one dose was administered on 10/31/12 at 7:30 p.m. 11/1/12 at 8:30 p.m., "...Wandering most of shift....Repeatedly asking staff & family member to let him out of facility. Continually going to outside door to see if it will open...." 11/1/12 at 11:15 p.m., "Res was wandering in dining room...." 11/1/12 at 12:30 p.m. (sic), "Res (up) & pacing hallways & asking to get out to several staff members...." 11/2/12 at 7:00 p.m., "Will cont. (continue) to monitor resident for exit seeking behavior." 11/3/12 at 8:58 a.m., "...has attempted to get out several X's (times) unable to redirect several X's. Finally redirected with snack." A physician's orders [REDACTED]." The MAR for November 2012 indicated the Xanax 0.5 mg was administered at 4:00 p.m. on 11/3/12. 11/3/12 at 5:50 p.m., "Res (up) wandering...wanting to walk outside & leave to go home attempted to get out several X's. Also ask writer & other staff to give him code...." 11/4/12 at 2:00 p.m., "Res (up) wandering wanting to get out...." 11/5/12 at 4:00 p.m., "Resident (with) (increased) wandering (with) several attempts to get out doors. Slapped staff during an attempt to go out door. This nurse took resident to vending machine for snack, which he received & returned to unit (without) further incident...." 11/5/12 at 7:30 p.m., "Resident again @ doors pounding on windows & wanting off unit...." The MAR for November 2012 indicated Xanax 1 mg was administered on 11/5/12 at 8:00 p.m. 11/6/12 at 11:00 a.m., "...asks staff to let him out so he can walk..." 11/7/12 at 8:30 a.m., "Res (up) & states 'I need to find a way out of here. It's making me nervous'...." The Medication Administration Record (MAR) for November 2012 also indicated the Xanax 1 mg was administered on 11/7/12 at 8:30 a.m., and at 9:30 a.m., the reverse side of the MAR indicated, "Eff (effective). Calmer." A physician's orders [REDACTED]." 11/9/12 at 12:45 p.m., "...attends therapy. After that resident wanted to leave unit (with) therapy staff...." 11/10/12 at 5:30 p.m., "...(up) per usual ambulating per self...." 11/11/12 at 2:00 a.m., "...Ambulates when (up) during evenings (without) problems...." 11/11/12 at 6:45 p.m., "Res in room (sic) sitting on bed...." 11/11/12 at 7:00 p.m., "Went to resident's room to give him his routine meds (medications). Res not in room. Staff on floor alerted & all areas checked for resident. Not found." 11/11/12 at 7:05 p.m. All other units notified of resident not on unit window was found (with) screen out & open in room (number of unoccupied resident room)...." 11/11/12 at 11:25 p.m., "Res returned per EMS (Emergency Medical Service) to DM (Dillsboro Manor) Res (with) Fx (fracture) R ankle, ribs R...." 11/13/12 at 9:45 a.m., "When resident was taken back to his room after breakfast he looked at the window & said I shouldn't jumped out that window & was rubbing his R side." A report of x-ray results for the right ankle, dated 11/11/12, indicated, "Findings...three view imaging of the right ankle demonstrates an acute, complete, oblique fracture through the distal shaft of the right fibula...." Preprinted hospital discharge instructions, dated 11/11/12, indicated, "Ankle Fracture" and "Rib Fracture." Handwritten next to "Rib Fracture" was "Suspect, non-displaced rib fracture." During interview on 11/26/12 at 2:25 p.m., RN #6 indicated Resident B now seems frustrated, because he is non-weight bearing on his ankle and wants to walk. On 11/28/12 at 11:15 a.m., the window the resident eloped through was observed from the double doors leading from the unit into the fenced courtyard. A long sloped ramp led from the doors down to the ground level. Visible beneath the window used for the elopement was a concrete foundation wall approximately 6 to 8 feet high. At the Exit Conference on 11/28/12 at 5:30 p.m., the Administrator indicated she was sure the resident's care plan for therapy included taking the resident outside for walks, because the therapists had asked her if that was okay to do. She indicated she would forward therapy notes indicating out of doors activities for the resident. On 11/29/12 at 11:47 a.m., copies of physical therapy (PT) notes for Resident B were received by e-mail. The PT Daily Therapy Notes indicated the resident received services outside the secured unit, including exercise outside the facility on some dates: 11/1, 11/6, 11/7, 11/8, and 11/9/12. "Additional Assessment Comments" on the 11/1/12 PT Daily Therapy Note indicated, "Pt (patient) is not really interested in participating in exercises unless it has to do with walking around and trying to figure out a way to leave the facility." This federal tag is related to Complaint IN 553. 3.1-45(a)(2)