Every finding on record at Waters of Lagrange Skilled Nursing Facility, The

Based on observation, interview and record review, the facility failed to assess and evaluate smoking safety for 2 of 3 residents reviewed for accidents (Resident F and Resident H). The facility also failed to ensure the environment was free of accident hazards by not correcting bunched up and uneven carpet in a resident hallway creating a tripping hazard for residents. Findings include:1.a. A report, dated 3/25/26, indicated Resident F had a fall while smoking in the facility parking lot. The fall resulted in nose fractures and hematoma to the right knee. On 3/27/26 at 1:12 P.M., Resident F's record was reviewed. Diagnoses included Alzheimer's disease and nicotine dependence. A quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, indicated Resident F had moderately impaired cognition. Quarterly Smoking Evaluations, dated 9/30/25 and 12/29/25, indicated the resident was not using smoking, nicotine, or tobacco products. Current care plans indicated she was at risk for falls, had impaired cognition due to dementia, at risk for abnormal bleeding due to use of anticoagulant medication, and was at risk for injury related to impaired vision. Interventions included: staff were to anticipate and meet her needs; assess the environment; make modifications as necessary to make the environment conducive to safety & on-going interaction; and keep area free from hazards. A care plan, dated 1/9/26 and revised on 3/29/26, indicated Resident F had a history of nicotine dependence but did not smoke while residing at the facility. She would occasionally smoke when going out with her family. The goal was for her to not smoke at the facility daily. Interventions included to ensure if resident brought in a lighter or cigarettes back from an outing, she would return them to the nurse; and she would be reminded periodically of the smoking policies. The revised care plan, dated 3/29/26, hadn't indicated Resident F was an everyday smoker, was safe to ambulate off the property to smoke, had staff interventions to ensure her safety off site, or observations to be made for continued physically and cognitively safe smoking. A change in condition form, dated 3/14/26 at 10:32 a.m., indicated Resident F had a fall with injuries. The resident indicated she had stood up, felt dizzy, lost her balance, and fell forwards. She was sent to the ER for evaluation and treatment and returned to the facility on 3/14/26 at 1:30 p.m. At the hospital she was diagnosed with facial fractures, traumatic hematoma to her right knee and bruises to her face, scalp, and neck. On 3/27/26 at 1:15 P.M., Resident F was interviewed. She indicated she had gone outside the entrance to the facility to smoke and had been sitting on her rolling walker. She went to stand up, and the pocket of her coat caught on the handle of her walker and she fell forwards, face down. She usually went to smoke across the parking lot to a nearby church, but it had been so windy that day, she had smoked outside the entrance of the building instead. She indicated it was a good thing she was near the entrance and another resident out smoking with her because she didn't know what she would've done without the other resident going in the facility to find someone to help her. She indicated she had smoked for many years and knew the facility was non-smoking. She had no issue with going across the parking lot to smoke off the property. A pack of cigarettes was observed sitting on the end table beside the resident. 1.b. On 3/30/26 at 2:05 P.M., Resident H's record was reviewed. Diagnoses included paralysis of lower extremities. An admission MDS assessment, dated 3/13/26, indicated Resident H was cognitively intact and did not use tobacco. An admission smoking evaluation, dated 3/6/26, indicated Resident H was not using smoking, nicotine, or tobacco products. A significant change smoking evaluation, dated 3/13/26 and signed off on 3/30/26, indicated Resident H was using tobacco products including cigarettes and vape pen. A care plan, dated 3/14/26, indicated Resident H had the potential for safety hazard and injury related to smoking. He was a smoker and the facility had a non-smoking policy. The goals were for the resident to not cause injury to himself or others due to smoking and to not smoke on facility grounds. Interventions included to provide the resident with a copy of the facility smoking policy and store smoking materials per facility policy. Resident H was observed several times during the survey, propelling himself in his wheelchair, up and down the halls and to the front of the facility entrance. During observations, he always had an odor of cigarette smoke about him. Leave of Absence sign in/out forms for Resident H were provided by a nurse on 3/30/26 at 2:25 P.M. The forms indicated beginning 3/10/26, the resident signed himself out multiple times per day, for approximately 20 minutes each time, to go smoke. On 3/30/26 at 2:25 P.M., Certified Nurse Aid (CNA) 5 was interviewed. When asked, she indicated on her hallway, there were 3 residents who smoked. Residents weren't allowed to smoke on the property because it was a non-smoking facility. Residents who smoked, would go across the facility parking lot, over to the next-door church parking lot to smoke. CNA 5 indicated the 3 residents were to sign themselves in/out on the LOA book and get their smoking materials from the nurse. She indicated the residents were to give back their smoking materials upon return and they weren't allowed to be kept in their rooms. When asked, she indicated sometimes residents hadn't returned their smoking materials and staff were to report it to the nurse. On 3/30/26 at 2:45 P.M., the Social Services Director (SSD) and Director of Nursing (DON) were interviewed. The SSD indicated Resident F had not had a smoking evaluation completed following her fall until 3/29/26. The smoking evaluation indicated the resident was safe to light up her own cigarette, hold it independently, and dispose of the ashes and cigarette safely. The SSD indicated Smoking Contract Agreements were completed with Resident F and Resident H on 3/27/26. The SSD and DON were asked how residents were assessed for safety when leaving to go off the property to smoke with no response. A current smoking policy was provided by the DON on 3/30/26 at 2:50 P.M., which indicated the following: Smoking was not permitted in every facility. If smoking was permitted, residents were to smoke only in designated outdoor smoking areas. If smoking was permitted at a facility, staff were to be assigned a time to be responsible for monitoring the smoking area. Staff were to ignite cigarettes for residents and to be present to monitor all residents for safety. Any change in resident competency for smoking was to be reported to the nurse. Smoking was not permitted during mealtimes. The policy hadn't indicated resident safety for going off the property would be assessed or where resident's who signed themselves out to smoke off property were permitted to smoke such as a local business parking lot near the facility. 2. On 3/27/26 at 10:40 A.M., during observation on the northwest rehabilitation hallway, carpeting in the middle of the hallway was bunched up, causing ripples in the carpet and a hazard for tripping. The bunched-up carpet was observed extending from room [ROOM NUMBER] to room [ROOM NUMBER]. 5 rooms were occupied with short-term stay residents. Staff and visitors were observed walking in the hallway with no residents observed. Confidential interviews conducted during the survey, indicated the following:1. The carpet in the hallway had been bunched up for some time and administration staff were aware of the problem.2. A resident had fallen in the hallway, where the bunched-up carpeting was, last year causing severe injuries.3. Mechanical lifts were difficult to get down the hallway because of bunched-up, uneven carpet.4. The bunch-up carpeting caused several people to trip with near falls.5. There was a plan to replace the carpet but the front entrance needed done first. On 3/27/26 at 3:15 P.M., the Administrator was interviewed. He indicated there were plans to replace the carpet but they couldn't do all the proposed changes at one time. He was not aware of any falls occurring in the area where the bunched-up carpet was located but would look into having the carpet stretched until it could be replaced. This Citation relates to Intake 2965357. 410 IAC 16.2-3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure all opened food items were labeled and dated, expired food was discarded, and thermometers were properly maintained in cooled and frozen food storage areas in the kitchen. 71 of 71 residents residing in the facility were served food prepared in the kitchen.During an observation in the walk-in refrigerator, on 09/04/2025 9:28 AM, a Ziploc bag containing pink sliced meat had illegible markings on the package . A plastic sealed bag labeled ham had a date of 8/27/25. A thermometer on an upper shelf had a temperature of 16 degrees. No items in the refrigerator appeared frozen solid or had visible frost. In an interview, on 09/04/2025 9:30 AM, the Dietary Manager (DM) indicated opened items should be used within 3 days or discarded. She indicated the thermometer did not appear to have an accurate reading and replaced the thermometer. In an observation in the walk-in freezer, on 09/04/2025 9:31 AM, no internal thermometer was observed. In an interview, on 09/04/2025 9:32 AM, the DM indicated the thermometer had been present in the freezer on Monday, 3 days prior to the observation. In an observation, on 09/04/2025 9:33 AM, 7 stacked trays of bowls of thick brown substance were covered with plastic wrap in the reach in freezer. No label or date was visible on any bowl, wrapper or tray. A container of mint chocolate chip ice cream had no visible label or date. A jar containing a reddish tan substance with 2025 written on the lid was observed in the back of the freezer. In an interview, on 09/04/2025 9:34 AM, the DM indicated the trays contained bowls of chocolate ice cream was likely dipped that morning, but she did not directly observe the process. She indicated the trays of scooped ice cream should have been labeled and dated at the time of preparation by the staff member performing the task. She indicated the mint chocolate chip ice cream should have been labeled and dated. She indicated the jar contained jam that someone likely bought at the recent craft fair. She indicated it should not have been stored with residents food and should have had a label and date. In an observation, on 09/04/2025 9:36 AM, a plastic scoop was observed in the sugar supply. Loose rice, too many granules to count, was observed on the bottom of a container holding a bag of rice that was tied closed. In an observation, on 09/04/2025 9:37 AM, the reach in refrigerator did not have an interior thermometer. In an interview, on 09/04/2025 9:38 AM, the DM indicated the sugar scoop should not be present in the sugar supply and bins should be clean. She indicated the refrigerator should have an interior thermometer to obtain temperatures. She indicated [NAME] 2 had obtained the temperature readings recorded on the temperature logs in the walk-in refrigerator, walk-in freezer, and reach in refrigerator earlier that morning. In an interview, on 09/04/2025 9:39 AM, [NAME] 2 indicated she did not know where the thermometers were located but she used the thermometers to obtain the temperatures she wrote on the temperature log forms . In an observation, on 09/04/2025 12:19 PM, a bottle of salad dressing was observed in the unit refrigerator on the southwest unit with no label or date. A food storage container containing pasta was observed on a shelf with no label or date. An open water bottle was observed with no label or date in the door of the refrigerator. A wet towel was observed on the bottom shelf of the refrigerator. In an interview, on 09/04/2025 12:20 PM, Licensed Practical Nurse (LPN) 3 indicated she was unable to determine how long unlabeled items had been in the refrigerator. She indicated the salad dressing, bottle of water, and container of pasta should have been labeled and dated. She indicated she did not know why the wet towel was at the bottom of the refrigerator, but indicated it should not have been there. In an interview, on 09/05/2025 9:42 AM, the Director of Nursing indicated all residents residing in the facility were served food prepared in the facility kitchen. A current policy, titled Storage of Dry Goods and Supplies, dated 4/2017, provided by the Regional Nurse Consultant (RNC) on 09/04/2025 11:37 AM, indicated storage bins should be kept clean, labeled and dated. The policy indicated scoops should not be stored in the food bins. A current policy, titled Thermometer Calibration and Use, dated 4/2017, provided by the RNC on 09/04/2025 11:37 AM, indicated thermometers should be calibrated at +/-3 degrees Fahrenheit. The policy indicated the DM should ensure properly calibrated thermometers were in use in refrigerated and frozen food storage areas. A current policy, titled Dating and Labeling, dated 4/2017, provided by the RNC on 09/04/2025 11:37 AM, indicated food labels should include the common name of the food or a statement clearly and accurately identifying the contents. The policy indicated potentially hazardous foods and temperature controlled foods should be stored for a maximum of 7 days after opening, with the count beginning the day the commercial container was opened. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure medications were secured in locked environments when not directly attended for 32 of 71 residents residing in the facility.During an observation on 09/04/2025 11:56 AM the treatment cart and a medication cart on the southwest unit were both unlocked with no staff in the area. One resident was observed propelling her wheelchair in the immediate area of the carts. In an interview, on 09/04/2025 11:58 AM, Licensed Practical Nurse (LPN) 3 indicated the medication cart contained medications in pill and liquid forms and the treatment cart contained medication in liquid, cream and ointment forms. She indicated both carts should be locked when not attended to by staff. In an observation, on 09/04/2025 12:12 PM, the lock on the medication refrigerator in the medication room was not engaged. A vial of lorazepam liquid, a controlled substance was observed in the refrigerator. In an interview, on 09/04/2025 at 12:13 PM, LPN 3 indicated the lock on the refrigerator frequently did not fully engage and sometimes popped open. She indicated the refrigerator contained a controlled substance and should remain behind two locks when not attended, the refrigerator lock and the locked medication room door were the two locks. During an observation, on 09/05/2025 8:47 AM, the treatment cart on the south hall was unlocked. 3 residents were observed propelling their wheelchairs in the immediate area with no staff in the area. Registered Nurse (RN) 4 walked past the unlocked medication cart and went to a workstation about 20 feet away. In an interview, on 09/05/2025 at 8:48 AM, RN 4 indicated the cart contained liquid, cream and ointment medications and should be locked at all times when unattended. A current policy, titled Medication Administration Guidelines, undated, provided by the Administrator on 9/5/25 at 10:48 AM indicated carts containing medications should be locked when not directly attended to. 3.1-25(m)

Based on observation, interview, and record review the facility failed to ensure complete and accurate documentation in 3 of 24 resident records reviewed. (Resident 78, Resident 17, and Resident 42)During an observation, on 9/5/25 at 1:30 PM, the following was observed: A clean and dry dressing covered the insertion site of a Jackson Pratt Drain (JP Drain) on Resident 78's left lateral chest.1. A record review for Resident 78 began on 9/8/25 9:12 AM. Diagnoses included a history of kidney transplant, colostomy, and end stage kidney disease.A review of Resident 78's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 13 (cognitively intact). The MDS indicated the resident had an ostomy present. A review of physician orders, dated 8/30/25, indicated a dressing change to the JP drain was changed every evening. A review of physician orders, dated 8/30/25, indicated the JP Drain was to be drained, and output recorded every shift.A review of physician orders, dated 8/31/25, indicated the colostomy bag was to be emptied daily.A review of physician orders, dated 9/1/25, indicated to cleanse area to buttocks with soap and water, pat dry, and apply barrier cream three times a day for redness.A review of the Task Administration Report, dated 9/1/25 to 9/8/25, indicated there was missing documentation for the JP drain dressing change on 9/2/25 and 9/3/25 at 6:30 PM. Documentation was missing for the JP drain emptying and record of output on 9/2/25 for night shift staff. Documentation was missing regarding emptying the colostomy bag on 9/4/25. Documentation was missing for the cleanse buttocks with soap and water, pat dry, and apply barrier cream three times a day for redness on 9/3/25 at 9:00 PM and 9/4/25 at 5:00 AM.A review of progress notes, dated 9/1/25 to 9/8/25, indicated there was no documentation of refusals or completed tasks for Resident 78 on the missing documentation dates and times.In an interview, on 9/9/25 at 10:17 AM, Resident 78 indicated they had not missed treatments or medications.2. A record review of Resident 42 began on 9/8/25 10:16 AM. Diagnoses included anxiety and Wernicke's Encephalopathy.A review of Resident 42's current quarterly MDS, dated [DATE], indicated their BIMS score was 10 (moderate cognitive impairment). The MDS indicated the resident had a diagnosis of asthma. A review of a physician order, dated 7/8/25, indicated lorazepam 0.5 mg was to be given two times a day for anxiety.A review of Resident 42's Medication Administration Record (MAR), dated 8/1/25-8/31/25, indicated there was missing documentation on 8/7/25 at 4:00 PM.A review of progress notes, dated 8/7/25, indicated there was no documentation of refusal or administration of lorazepam for Resident 42.3. A record review for Resident 17 began on 9/8/25 at 10:25 AM. Diagnoses included diabetes type 2, anxiety, (cardiac) T wave inversion, and chronic obstructive pulmonary disease (COPD).A review of Resident 17's current quarterly MDS, dated [DATE], indicated their BIMS score was 15 (cognitively intact) The MDS indicated a medical history of diabetes, asthma, and respiratory failure. A review of physician orders, dated 2/10/25, indicated alprazolam 0.25 mg was to be given two times a day for anxiety.A review of physician orders, dated 2/11/25, indicated apixaban 5 mg was to be given two times a day for T wave inversion.A review of physician orders, dated 2/10/25, indicated budesonide 0.5 mg/ 2 ml inhale orally was to be given two times a day for COPD.A review of physician orders, dated 2/11/25, indicated magnesium 400 mg was to be given two times a day.A review of physician orders, dated 5/21/25, indicated striverdi respimat inhalation aerosol solution 2.5 mcg/act olodaterol HCL was to be given two times a day for COPD.A review of physician orders, dated 5/12/25, indicated buspirone HCL 5 mg was to be given three times a day for anxiety.A review of the MAR, dated 7/1/25-7/31/25, indicated missing documentation for alprazolam on 7/30/25 at 5:00 PM. There was no documentation for apixaban on 7/30/25 at 4:00 PM. There was no documentation for budesonide on 7/30/25 at 5:00 PM. There was no documentation for magnesium on 7/30/25 at 4:00 PM. There was no documentation for stiverdi respimat on 7/30/25 at 5:00 PM. There was no documentation for buspirone on 7/30/25 at 5:00 PM.A review of the MAR, dated 8/1/25-8/31/25, indicated There was no documentation for alprazolam on 8/4/25 and 8/7/25 at 5:00 PM. There was no documentation for apixaban on 8/7/25 at 4:00 PM. There was no documentation for budesonide on 8/4/25 and 8/7/25 at 5:00 PM. There was no documentation for magnesium on 8/7/25 at 4:00 PM. There was no documentation for stiverdi respimat on 8/4/25 and 8/7/25 at 5:00 PM. There was no documentation for buspirone on 8/4/25 and 8/7/25 at 5:00 PM.In an interview, on 9/9/25 at 10:33 AM, LPN 6 indicated an open box on the Administration Record Report would mean the medication wasn't given, or it was not signed as given. She indicated would report missing medications to the unit manager. The missed medications would not have appeared on the software program for the next shift to administer.In an interview, on 9/09/2025 at 12:50 PM, the Director of Nursing provided signed statements dated 9/9/25 indicating medications were given as ordered but not signed on the MAR or TAR. She indicated an investigation by the facility staff indicated treatments and meds were completed but not documented after completion. A current policy, dated July 2024, provided by the Administrator indicated that after each medication pass, the person administering the medication is to review the MAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.16.2-3.1-50(a)(1)(2)

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 4 of 4 residents reviewed (Resident K, Resident L, Resident M, and Resident N). The deficient practice was corrected on 1/22/25 prior to the start of the survey and was therefore past non-compliance. Findings include: A facility-reported incident was submitted to the Indiana Department of Health on 1/10/25, which indicated potential misappropriation of resident property had occurred and the facility was investigating the allegation. On 2/3/25 at 3:10 P.M., the Director of Nursing (DON) was interviewed. She indicated she had been conducting routine compliance audits of controlled medication records when she noticed a pattern of administration. Licensed Practical Nurse 5 (LPN) administered opioid pain medications to residents with as needed orders for pain medication consistently and without assessment of pain prior to administration. The DON indicated LPN 5's documentation of administration was not completed according to facility policy and the administration records hadn't matched the controlled medication records but should have. During the compliance audits, the DON was notified, 1 opioid medication for Resident N hadn't been accounted for and the controlled medication record was off by 1 pill. 1. On 2/3/25 at 2:15 P.M., Resident K's record was reviewed. Diagnoses included status post pelvis fracture (9/24) and dementia. A physician order, dated 9/30/24, was for Oxycodone 5 milligrams (mg)-give 2 tablets every 4 hours as needed for moderate to severe pain. A Controlled Drug Record, initiated 10/18/24, indicated Oxycodone had been administered as ordered, 1 time on 10/23/24 by LPN 2. LPN 5 administered Oxycodone as ordered on 10/23/24, 11/3, 11/16, 11/20, 12/4, 12/7, 12/9, 12/15, 12/18, 12/23/24, 1/6/25, and 1/8/25. No other nurses administered Oxycodone to the resident. The Medication Administration Records (MAR), dated October 2024, November 2024 and December 2024 had no documentation to indicate Oxycodone had been administered to Resident K on dates the medication was signed out on the controlled drug record by LPN 5. 2. On 2/3/25 at 2:30 P.M., Resident L's record was reviewed. Diagnoses included heel wound. A physician order, dated 12/6/24, was for Hydrocodone-Acetaminophen 5-325 mg tablets-take 1 tablet every 6 hours as needed for moderate pain. A Controlled Drug Record, initiated 12/16/24, indicated LPN 5 administered Hydrocodone as ordered on 12/28/24 at 8:00 a.m., 1/6/25 at 8:00 a.m. and 1:30 p.m., and on 1/8/25 at 7:30 a.m. Medication Administration Records, dated December 2024 and January 2025, had no documentation to indicate Hydrocodone had been administered to the resident on dates the medication was signed out on the controlled drug record by LPN 5. Resident L was interviewed by staff and police during the investigation. The resident indicated he hadn't asked for pain medication on 1/6/25 and hadn't remembered getting any. He indicated he only requested pain medication in the evenings/night time due to pain in his heel during those times. 3. On 2/3/25 at 3:00 P.M., Resident M's record was reviewed. Diagnoses included arthritis and chronic pain. A physician order, dated 3/1/23, was for Hydrocodone 10-325 mg-give 1 tablet by mouth every 4 hours as needed for moderate pain. A Controlled Drug Record, initiated 12/31/24, indicated Hydrocodone had been administered by LPN 5, on 1/8/25 at 3:30 p.m. A MAR, dated January 2025, had not indicated on 1/8/25 Hydrocodone had been administered by LPN 5. The MAR indicated no doses of Hydrocodone had been administered on 1/8/25. When questioned by staff, Resident M indicated she had not been give Hydrocodone on 1/8/25. Her last dose had been given on 1/7/25 around 9:00 p.m. by Nurse 3. The MAR and Controlled Drug Record indicated Hydrocodone had been signed out and administered on 1/7/25 at 9:07 p.m. 4. On 2/3/25 at 3:48 P.M., Resident N's record was reviewed. Diagnoses included pressure wound to back and buttocks. A physician order, dated 11/16/24, was for Norco 5-325 mg tablets-give 1 tablet every 8 hours as needed for severe pain. A Controlled Drug Record, initiated 11/22/24, indicated LPN 5 signed out Norco 1 tablet at 8:00 a.m. and 1:00 p.m. on 1/6/25 and on 1/8/25 at 10:30 a.m. The record indicated on 1/6/25 at 1:00 p.m., a Norco tablet was dropped and then wasted. LPN 5 signed their name but there was no second nurse signature as required for disposing of a controlled substance. An email sent to the DON, dated 1/9/25, indicated LPN 7 worked on 1/6/25 and had counted the controlled medications with off-going nurse, LPN 5. LPN 7 indicated the record had been off for Resident N's Norco. There were supposed to be 25 tablets but there were only 24 tablets in the card holding the medication. LPN 7 questioned LPN 5 about the discrepancy. She indicated she wasn't sure if she'd accidentally pulled it and given to someone else in place of theirs but all other narcotics were accounted for. LPN 5 indicated to LPN 7 she would just write that it had been dropped and ask the unit manager or DON to sign for it later. Both the unit manager and DON were seated at the desk by the medication cart where the 2 nurses were counting but LPN 5 hadn't asked either to sign for her at that time. LPN 7 reported the discrepancy to the DON and unit manager after LPN 5 left the building. A MAR, dated January 2025, had not indicated Norco had been administered by LPN 5 on 1/6/25 at 8:00 a.m. or at 1:00 p.m. The MAR hadn't indicated Norco had been administered by LPN 5 on 1/8/25 at 10:30 a.m. as signed out on the controlled drug record. On 2/3/25 at 3:59 P.M., the Administrator was interviewed. He indicated the DON had notified him of the discrepancy with the controlled medication count and the pattern of administration by LPN 5. The police were contacted and report completed. LPN 5 was immediately suspended. The facility pharmacy conducted a facility wide reconciliation of all controlled medications on all units/residents with no further discrepancies found. A current facility policy, titled Abuse Prevention Program, provided by the DON on 2/3/25 at 3:46 P.M., indicated: It is the policy of this facility to prohibit and prevent .misappropriation of resident property .is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongs or money without the resident's consent The past non-compliance deficiency began on 1/10/24 and deficient practice corrected on 1/22/25 after the facility suspended LPN 5, then reported the incident to IDOH as required. Resident K, Resident L, Resident M, and Resident N were assessed for pain with no adverse effects, all nursing staff were inserviced on misappropriation of property, reporting, and drug diversion and quality monitoring initiated to prevent recurrance. This Citation relates to Complaint IN00451002. 3.1-28(a)

Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 1 of 3 residents reviewed (Resident J). The deficient practice was corrected on 1/22/25 prior to the start of the survey and was therefore past non-compliance. Findings include: A facility reported incident to the Indiana Department of Health, dated 1/21/25, indicated an allegation of verbal abuse had occurred and was being investigated by the facility. The allegation involved verbal abuse from a Certified Nurse Aid (CNA) to a resident. On 2/3/25 at 12:53 P.M., Resident J's record was reviewed. Diagnoses included Alzheimer's disease with late onset. A significant change Minimum Data Set assessment, dated 1/8/25, indicated the resident had severely impaired cognition and required maximal to dependent care for her activities of daily living. She had no behaviors or rejection of care. A care plan, dated 1/8/25, indicated Resident J had cognitive impairments related to dementia and short term memory loss. Her goals were to have her needs met and anticipated. Interventions included: if upset/or distressed check for any unmet needs; give resident two choices when presenting decisions; and observe and report changes in cognitive status. On 2/3/25 at 12:30 P.M., the Administrator was interviewed. He indicated on 1/21/25, he was notified that CNA 8 had been overheard by staff, being rude to Resident J and calling her a bitch in front of her. CNA 8 was asked to write and sign a statement and immediately suspended pending investigation. Resident J was assessed, found with no injury, and was monitored for psychosocial distress. The Administrator interviewed witnesses and contacted the police. A thorough investigation was completed, the facility reeducated all staff and began quality reviews to prevent further verbal abuse. A current facility policy, titled Abuse Prevention Program, provided by the Director of Nursing on 2/3/25 at 3:46 P.M., indicated: It is the policy of this facility to prohibit and prevent resident .Verbal abuse: any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability The past non-compliance deficiency began on 1/21/24 and deficient practice corrected on 1/22/25 after the facility suspended CNA 8's employment, reported the incident to IDOH as required, re-inserviced all staff on abuse prevention, and began quality monitoring to prevent recurrance. Resident J was assessed for injury with none found and psychosocial monitoring put into place. This Citation relates to Complaint IN00451712. 3.1-27(a)(b)

Based on interviews and record review, the facility failed to ensure sufficient nursing staff to meet the anticipated and unanticipated needs for 82 of 82 residents residening in the facility receiving nursing services. Findings include: An Indiana Department of Health complaint intake, dated 9/10/24 at 8:14 PM, indicated on 9/10/24 one nurse, one QMA, and one CNA were scheduled in the building for the evening shift. The complaint indicated CNAs frequently work on a hall by themselves with over 30 residents to assist to bed. An as worked schedule form, verified by payroll records, dated 9/10/24, indicated one certified nurse aide worked between 6:30PM and 10:00 PM for a total of 89 residents. One QMA worked on the Southwest Unit with 38 residents, one LPN worked on the Northwest Unit with 22 residents, and one LPN worked on the dementia unit with 18 residents. An Indiana Department of Health complaint intake, dated 9/18/24 at 7:32 AM, indicated one CNA was present in the building to assist residents to get up and dressed for breakfast. She indicated 80 residents were in the building. An as worked schedule form, verified by payroll records, dated 9/18/24, indicated one CNA worked from 6:02 AM to 6:30 PM. No additional CNAs were on the schedule until 1:22 PM. An Indiana Department of Health complaint intake, dated 9/20/24 at 7:28 AM, indicated the dementia unit had been staffed with one staff member for 18 residents to provide all nursing and aide care. The complainant indicated they were unable to complete all needed services for the residents and feared risking injury to themselves or residents. An as worked schedule form, verified by payroll records, dated 9/20/24 indicated three certified nurse aide worked between 7:00 PM and 10:00 PM. The schedule indicated the CNA from the dementia unit had been pulled from the unit to help on the other units. An Indiana Department of Health complaint intake, dated 9/24/24 at 2:34 PM, indicated on 9/21/24 there were no aides during the first and second shifts for one hall, and on 9/22/24 there was one aide for 36 residents on one hall. On 9/22/24 evening shift there was one aide on one hall for the second and third shift and no aides on the other hall. An as worked schedule form, verified by payroll records, dated 9/21/24 indicated two CNAs were scheduled between 6:00 PM and 10:00 PM. One CNA was scheduled for the night shift. An as worked schedule form, verified by payroll records, dated 9/22/24 indicated two CNAs were present from 6:00 AM to 6:00 PM, with an additional aide working 6:00 AM to 2:00 PM for the Southwest and Northwest units. No CNAs were scheduled on the dementia unit for the day, evening, or night shift. The dementia unit was staffed with an LPN for 15.53 hours and a QMA for 10.25 hours in the 24-hour period. The Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the facility's fiscal year third quarter of 2024 from April 1 - June 30 was reviewed. The PBJ triggered a one-star staff rating (the star rating system was 1-5 with nursing homes with 5 stars considered much above average quality and nursing homes with 1 star considered much below average quality). During an observation and interview, on 9/26/24 at 6:36 PM, the dementia unit halls and lounge were dimly lit. Qualified Medicine Aide (QMA) 21 indicated some of the residents who had been up for days without sleep had finally gone to sleep, so the staff tried to keep the unit darker and quiet to provide a good sleeping environment. 5 residents were seated in recliners in the resident lounge that was also dimly lit. QMA 21 indicated she and a nurse were working on the dementia unit that evening. She indicated the building had better staffing than usual that evening. She indicated most evenings she had to put her residents to bed quickly and then go out to the outer units and assist other halls with putting people to bed, leaving the unit unattended. She indicated staff started getting residents up between 6 and 6:30 in the morning, but since so many residents go to bed so early, they get up around 2:00 AM. She indicated the night shift has one staff member on the unit most of the time. See F689 for additional information on an accident occurring on the dementia unit involving an unattended resident falling in the shower while only one certified nurses' aide was present on the unit. In an interview, on 9/26/24 at 12:05 PM, CNA 35 indicated Resident 32 was unsupervised in the shower room due to low staffing. CNA 35 indicated the unit had been short staffed for a few months. CNA 35 indicated the unit was often staffed with 1 CNA and 1 Qualified Medication Aide (QMA) (a CNA with medication training). CNA 35 indicated the unit QMA was on a break due to having stayed over from night shift. CNA 35 indicated the facility management was aware of the short staffing issues. CNA 35 indicated the corporate office would not allow the facility to use a staffing agency due to the cost. CNA 35 indicated CNAs in training were not supposed to provide resident care. CNA 35 indicated the Unit Manager had directed the CNA in training to provide direct care to residents due low staffing. CNA 35 indicated the Unit Manager had directed the unsupervised shower of Resident 32. In an interview, on 9/26/24 at 1:50 PM, the Maintenance Director (40) indicated The Maintenance Director indicated many staff members had left the facility recently. The Maintenance Director indicated the staff members who remained were overworked and the new staff members didn't know what they were doing yet. During an observation and interview on 9/26/24 at 6:43 PM, Licensed Practical Nurse (LPN) 25 and Registered Nurse (RN) 46 were each at separate medication carts placing pills in medication cups. LPN 22 was observed talking with a resident near the southwest lounge area across from the nurse's station. LPN 22 indicated she came on duty at 6:00 pm and had not been able to attend to shift report because the unit had been so busy. She indicated one CNA was on duty and 2 Basic Nurse Aides (BNA)s were on duty for the evening shift. She indicated this evening was better staffed than usual. She indicated she had come in on several shifts where no second shift CNAs were present, and she was responsible for all the needs of the 38 residents on the unit. She indicated she had called the scheduler for assistance, but did not receive a response. During an interview, on 9/26/24 at 6:49 PM, LPN 23 indicated she was working on the northwest unit with 2 CNAs. She indicated she normally worked with 1 CNA. She indicated nine residents on the unit required a full body sling lift, requiring two staff to perform the lift. She indicated when she assisted the CNA with the lift, there were no staff on the unit available to watch the residents on the unit who were at high risk for falls. She indicated one CNA on the unit was not enough to meet the anticipated and unanticipated needs of the resident on the unit. During an interview, on 9/26/24 at 6:58 PM, CNA 24 indicated he came in to work early at 4:00 PM to assist on an understaffed shift. He indicated staffing at the facility on second shift had been very bad in the last few months. He indicated staff had not called and not come to work and continue to work for the facility. He indicated he had not heard of any disciplinary action being taken on habitual offenders who violate the attendance policy. He indicated employees who had terminated employment continued to be placed on the schedule for weeks after they no longer work for the facility. He indicated people were added to the schedule on their days off without their knowledge. See F689 for additional information on a resident residing on the northwest unit eloping from the facility and falling in the parking lot. During a confidential interview, on 9/26/24 at 10:10 AM, a staff member indicated they did not have sufficient staff to monitor residents when they were wandering. During an interview, on 9/26/24 at 7:04 PM, LPN 25 indicated she had worked the day shift and was supposed to leave at 6:30 PM. She indicated there were two nurses and one CNA on the unit on the day shift, so much of her day was consumed with answering call lights, toileting residents and other immediate care needs. She indicated she was finishing passing medications that were overdue because she had fallen so far behind. During an interview, on 9/26/24 at 7:06 PM, LPN 23 indicated she was on the hall with 38 residents and no aide on 9/23/24. She indicated a resident had fallen behind the doors and she had no one on the unit to monitor the residents on the unit while she enlisted help from another hall to help her get the resident up off the floor. She indicated names were placed on the schedule for people who no longer work in the facility. She indicated 7 residents on the unit required the use of a mechanical lift and two assist to transfer. She indicated when she reports to work and does not have an aide to work with, the facility management would only give her suggestions of people to call and ask if they are willing to pick up a shift. She said the responsibility to call people in lies on the employees in the building who are already struggling to provide care for the residents. See F677 for more information on a resident not receiving showers as scheduled due to low staffing. In an interview, on 9/26/24 at 7:06 PM, Licensed Practical Nurse (LPN) 22 indicated evening shift showers were not being done consistently for the prior few months due to lack of staff to complete them. See F689 for more information on a resident requiring two staff to assist to transfer being lowered to the floor due to only one staff member being present on the unit. A fall investigation, dated 9/17/24 at 9:20 PM, indicated Resident 64 was sitting in the recliner in the lounge with her feet up and scooted down to the foot of the recliner. The CNA on duty attempted to scoot the resident back in the chair but was alone on the hall with no one to assist her so she had to lower the resident to the floor. During an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she indicated staffing was her biggest concern in the building. She indicated some CNA staff had returned to school and were unable to work, many nurse aides in training had quit during their training and others had not completed their certification as anticipated. She indicated the facility had been using agencies in the past, but their corporate office had not allowed any staffing use since June 2024. The Facility Assessment Tool, last updated 6/26/24-6/28/24, was reviewed during Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee. The Facility Assessment Tool indicated an average daily census of 77-85; the facility consisted of 100 licensed beds with 16 beds in memory care. Current census was 82. Staffing included: Projected needed hours per day: CNA Day Shift 60-75 hours CNA Eve Shift 45-67.5 hours CNA Night Shift 22.5-30 hours 3-4 Hours worked as verified per as worked schedule and payroll records indicated the following: 9/1/24 Day shift: 38 hours Evening shift: 20.25 hours Night shift: 0 hours 9/2/24 Day shift: 31.5 hours Evening shift: 39.25 hours Night shift: 7.5 hours 9/3/24 Day shift: 30.75 hours Evening shift: 25 hours Night shift: 7.5 hours 9/4/24 Day shift: 15.5 hours Evening shift: 18 hours Night shift: 7.5 hours 9/5/24 Day shift: 32 hours Evening shift: 30.5 hours Night shift:0 hours 9/6/24 Day shift: 37.75 hours Evening shift: 28 hours Night shift: 22.5 hours 9/7/24 Day shift: 36.25 hours Evening shift: 22 hours Night Shift: 7.75 hours 9/8/24 Day shift: 30.25 hours Evening shift: 25.75 hours Night shift: 15 hours 9/9/24 Day shift: 38 hours Evening shift: 27.5 hours Night shift: 5 hours 9/10/24 Day shift: 30 hours Evening shift: 23 hours Night shift: 15.75 hours 9/11/24 Day shift: 38 hours Evening shift: 38.5 hours Night shift: 18.5 hours 9/12/24 Day shift: 38.5 hours Evening shift: 27.75 hours Night shift: 7.5 hours 9/13/24 Day shift: 39 hours Evening shift: 15.5 hours Night shift: 7.5 hours 9/14/24 Day shift: 45.25 hours Evening shift: 29.75 hours Night shift: 7.5 hours 9/15/24 Day shift: 30.25 hours Evening shift: 44.75 hours Night shift: 15 hours 9/16/24 Day shift: 26 hours Evening shift: 27.75 hours Night shift: 7.5 hours 9/17/24 Day shift: 28.75 hours Evening shift: 12.75 hours Night shift: 0 hours 9/18/24 Day shift: 15 hours Evening shift: 22.25 hours Night shift: 15.5 hours 9/19/24 Day shift: 30 hours Evening shift: 42.75 hours Night shift: 15 hours 9/20 /24 Day shift: 53 hours Evening shift: 31.25 hours Night shift: 15 hours 9/21/24 Day shift: 37.5 hours Evening shift: 27.25 hours Night shift: 7.5 hours 9/22/24 Day shift: 31 hours Evening shift: 18.25 hours Night shift: 0 hours 9/23/24 Day shift: 47.25 hours Evening shift: 36.5 hours Night shift: 0 hours 9/24/24 Day shift: 37.5 hours Evening shift: 24 hours Night shift: 8 hours 9/25/24 Day shift: 30 hours Evening shift: 33 hours Night shift: 15 hours 9/26/24 Day shift: 45 hours Evening shift: 38.25 hours Night shift: 14.5 hours 9/27/24 Day shift: 38 hours Evening shift: 37.25 hours Night shift: 15.25 hours The Facility Assessment Tool, last updated 6/26/24-6/28/24, reviewed during Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee, was provided by the Executive Director on 9/25/24 at 9:30 AM. The tool indicated resources necessary to care for residents competently during day-to-day operation and emergencies. The tool is used to make decisions concerning the direct care of staffing needs to ensure residents are provided care, so residents maintain and or attain their highest practicable physical, mental and psychosocial well-being. The tool included a staffing plan based on a resident daily census between 77-85 and included a budgeted and staffing plan. This citation is related to complaints IN 00443025, IN00443527, IN00443716 and IN00443976. 3.1-17(a)

Based on observation, record review, and interview, the facility failed to ensure a process was in place to identify and correct deficiencies from re-occurring for 82 of 82 residents residing in the facility Findings include: The facility annual survey completed on 12/1/2023 identified noncompliance regarding failure to report, failure to investigate incidents, failure to follow care planned interventions to prevent accidents, failure to maintaining minimum staffing levels to ensure safety, and failure to investigate and identify underlying causes of resident specific behaviors. The facility indicated the noncompliance would be corrected by 1/8/2024. In an interview, on 9/30/24 at 11:40 AM, the Administrator indicated Resident 19's elopement had not been reported to the proper agencies. See F609 for additional information about failure to report incidents requiring reporting. In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find the Resident 19 (through half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through anti-room, through second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision) and was not investigated as an elopement. See F610 for additional information about failure to investigate incidents. In an interview, on 9/30/24 at 2:50 PM, the DON indicated Resident 32 should not have been unsupervised in the shower room. The DON indicated Resident 32's Care Plan should have included interventions for fall precautions. The DON indicated fall risk precautions should have been included on the resident's Kardex. During an interview, on 9/30/24 at 1:34 PM, the Social Services Director (SSD) indicated upon admission, when a resident had a history of smoking, a smoking evaluation should be performed by therapy. The resident's ability to open and close the facility door and handle smoking materials appropriately would be assessed. The SSD indicated staff was aware of who smoked by common knowledge and by reading the Kardex. Residents must follow smoking assessment recommendations to be allowed to continue to smoke. She indicated a care plan should be in place to inform the staff of a resident's smoking status and any special instructions, such as signing out of the building to smoke, care of smoking materials and any devices needed to smoke safely See F689 for additional information about failure to follow care planned interventions to prevent accidents. In an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she was aware that Resident 64 fell from the recliner twice in the same day. She indicated short staffing was a factor in the falls. During an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she indicated staffing was her biggest concern in the building. She indicated some CNA staff had returned to school and were unable to work, many nurse aides in training had quit during their training and others had not completed their certification as anticipated. She indicated the facility had been using agencies in the past, but their corporate office had not allowed any staffing use since June 2024. See F725 for additional information on failure to maintain minimum staffing levels to ensure safety. In an interview on, 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between another resident and Resident 49 on 9/18/24 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated the other resident was a willing participant. The SSD indicated although Resident 49 has displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and the resident was now easily redirected. See F744 for additional information about failure to investigate and identify underlying causes of resident specific behaviors. A QAPI (Quality Assurance Performance Improvement) committee list was provided by the Executive Director (ED) on 9/25/24 at 9:15 AM. The member list included the Administrator, Director of Nursing, Medical Director, MDS coordinator, Housekeeping Supervisor, Business Office Manager, Social Service Director, Unit Managers, Dietary Manager, and Therapy Lead. The QAPI Plan, dated 8/2024, was reviewed. The QAPI Plan indicated concerns including falls, pressure ulcers, and other matrix related tops were recommended for review by the electronic medical record reporting system. In an interview on, 10/1/24 at 2:05 PM, the Administrator indicated he began work in the building in mid-August, identified staffing as the most critical problem in the facility and directed his team to direct their energies toward ensuring enough staff was always in the building to care for the residents. He initiated a program to meet each morning and check for staffing needs as a management team prior to any manager beginning their workday. He indicated he was beginning attendance accountability for the staff. He indicated use of agency to fill staffing needs began on 9/29/24. Additional QAPI focus areas were not available for review due to the critical nature of the staffing concerns. The facility failed to ensure identification of trends, and implement interventions to prevent repeat concerns related to Reporting abuse allegations (F609), investigating Abuse allegations and accidents (F610), Preventing accidents (F689), Maintaining staffing to esure the anticipated and unanticipated needs of the resident scould be met (F725) and implement dementia care interventions (F744). A current policy titled Clinical Policy and Procedure Quality Assurance/Performance Improvement Program (QAPI), last revised 3/9/22, indicated the QAPI program should provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. 3.1-52

Based on observation, interview and record review the facility failed to ensure adequate supervision to prevent resident elopement, falls and ensure safe smoking for 4 of 6 residents reviewed (Residents 32, Resident 19, Resident 64 and Resident 76). Findings include: 1. On 9/26/24 at 11:12 AM, a voice was heard calling for help. A staff member was observed entering the shower room. A voice was heard asking who the nurse was. The Director of Nursing (DON) entered the shower room. A voice was heard saying they were unable to stand the resident up. An overhead page was heard summoning the maintenance staff to the unit STAT (immediately). On 9/26/24 at 11:55 AM, Resident 32 was observed leaving the unit on a gurney escorted by 2 paramedics. Resident 32 was covered with a blanket. In an interview, on 9/26/24 at 11:57 AM, Certified Nurse Aide (CNA) 30 indicated they had started working at the facility on 9/12/24 and they were being trained by CNA 35. CNA 30 indicated they entered the shower room after hearing the resident call for help. CNA 30 observed Resident 32 sitting on the floor in the shower room with their right arm stuck in the handrail. CNA 30 indicated they were unable to remove Resident 32's arm from the handrail. CNA 30 indicated Resident 32 had been in the shower room alone since 10:55 AM. CNA 30 indicated they were directed by CNA 35 to place Resident 32 in the shower unsupervised. CNA 30 indicated they were not permitted to provide direct care to the residents until their training was complete but had been providing direct care due to a staffing shortage. CNA 30 indicated they were directed by CNA 35 to provide direct care due to low staffing. In an interview, on 9/26/24 at 12:05 PM, CNA 35 indicated Resident 32 was unsupervised in the shower room due to low staffing. CNA 35 indicated the unit had been short staffed for a few months. CNA 35 indicated the unit was often staffed with 1 CNA and 1 Qualified Medication Aide (QMA) (a CNA with medication training). CNA 35 indicated the unit QMA was on a break due to having stayed over from night shift. CNA 35 indicated the facility management was aware of the short staffing issues. CNA 35 indicated the corporate office would not allow the facility to use a staffing agency due to the cost. CNA 35 indicated CNAs in training were not supposed to provide resident care. CNA 35 indicated the Unit Manager had directed the CNA in training to provide direct care to residents due low staffing. CNA 35 indicated the Unit Manager had directed the unsupervised shower of Resident 32. In an interview, on 9/26/24 at 1:50 PM, the Maintenance Director (40) indicated they had been summoned to the shower room to remove a handrail. The Maintenance Director indicated they observed Resident 32 sitting on the floor with their right arm lodged in the handrail. The Maintenance Director indicated they left the unit to get a drill and upon their return, Resident 32's arm was no longer stuck in the handrail. Resident 32's record was reviewed on 9/26/24 at 2:10 PM. Diagnoses included dementia, osteoarthritis and seizure disorder. Resident 32's Annual Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 13 (no cognitive impairment). The MDS indicated the resident required partial to moderate assistance with showering or bathing. The MDS indicated the resident had 2 or more recent falls. The MDS indicated Resident 32 had diagnoses of arthritis, osteoporosis, dementia and seizure disorder. Resident 32's Care Plan, dated 12/28/23, indicated the resident had a self-care deficit. The target goal was for the resident to participate in self-care with supervision through 9/17/24. Interventions included assisting the resident according to the resident's level of need and offering frequent rest breaks. Resident 32's Care Plan, dated 8/22/24, indicated the resident was at risk for falls. The target goal was to reduce risks to avoid significant injury from falls through 9/17/24. Interventions included increasing supervision and referring the resident to therapy. Resident 32's Care Plan, dated 9/7/24, indicated the resident required therapy due to decreased leg strength, impaired balance, decreased walking ability and a recent fall. The target goal was for the resident to receive therapy services through 9/17/24. Interventions included gait training, therapeutic exercise and neuromuscular re-education. An Incident Description, dated 1/8/24 AT 7:00 am, indicated Resident 32 had impaired memory, decreased strength and endurance and had not been using their walker. A Fall Risk Review, dated 1/8/24 at 8:14 AM, indicated Resident 32 had a fall risk score of 12 (a fall risk score 10 or above is high risk). The review indicated Resident 32 required an assistive device to walk. An Interdisciplinary Team (IDT) note, dated 1/8/24 at 9:30 AM, indicated Resident 32 lost their balance and did not have their walker within reach. A new intervention was to place a reminder sign on the resident's walker. A Fall Risk Review dated 8/16/24 at 12:25 AM, indicated Resident 32 had a fall risk score of 9. The review indicated Resident 32 required the use of an assistive device to walk An Incident Description, dated 8/22/24 at 5:50 AM, indicated Resident 32 fell while getting clothes from their closet and had swelling above their right eye. A Fall Risk Review dated 8/22/24 at 7:10 AM, indicated Resident 32 had a fall risk score of 9. The review indicated Resident 32 had a balance problem while standing and walking. An IDT note, 8/22/24 at 9:54 AM, indicated Resident 32 had lost their balance and fell while getting clothes from their closet. A new intervention was to remain with the resident while choosing their clothes. An Incident Description, dated 9/5/24 at 7:30 PM, indicated Resident 32 fell while getting their pajamas. A Fall Risk Review, dated 9/5/24 at 8:00 PM, indicated Resident 32 had a fall risk score of 9. The review indicated Resident 32 had a normal gait, normal balance, required the use of an assistive device to walk. An IDT note, dated 9/6/24 at 9:42 AM, indicated Resident 32 fell while getting night clothes from their closet. A new intervention was for staff to lay out night clothes after supper each night. Resident 32's current Kardex, (care plan summary for CNAs), dated 9/26/24, indicated the resident's preference for bathing was to have a shower. The Kardex indicated Resident 32 required assistance with the application and removal of stockings and to lay out the resident's clothes after supper. The Kardex did not indicate the resident was at risk for falls. The Kardex did not indicate Resident 32 required assistance with walking. The Kardex did not indicate the resident had a seizure disorder. On 9/27/24 at 9:45 AM, purple and blue bruises were observed on Resident 32's right lower forearm. An arm sling was above the resident's elbow. Resident 32 indicated they had moved the sling out of the way. Resident 32 indicated they must have bumped their arm on the table. In an interview, on 9/30/24 at 2:50 PM, the DON indicated Resident 32 should not have been unsupervised in the shower room. The DON indicated Resident 32's Care Plan should have included interventions for fall precautions. The DON indicated fall risk precautions should have been included on the resident's Kardex. 46156 2. Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination. Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated the resident was impaired on 1 side of her lower extremity and used a wheelchair. The MDS indicated she required substantial/maximal assist with rolling left to right, transfers, and toileting. Resident 19's current care plan, initiated 2/12/24, indicated her care plan focus was high risk for elopement/wandering related to her bi-polar disorder. The goal of her focus area was the resident would not wander out of the facility or off the floor with a target date of 11/7/24. Interventions included Wanderguard placed initiated 6/10/24, assess/record/report to Medical Doctor (MD) risk factors for potential elopement initiated 2/12/24, and supervise closely and make regular compliance rounds whenever the resident was in her room initiated 2/12/24. Resident 19's quarterly MDS, dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitive intactness). Care Plan Meeting progress note, dated 5/2/24 at 8:54 AM, indicated when Resident 19 went outside she was to be monitored. The note indicated the resident was not able to physically sign for herself anymore. The note indicated the facility was requesting the MD to evaluate Resident 19 to see if guardianship (a legal process that gives a person or entity the authority to make decisions for another person, called a ward, who is considered incompetent) was appropriate. Resident 19's Elopement Risk Review, dated 5/7/24, indicated there were questions to complete; only one question was completed. The Elopement Risk total score was not determined due to the other questions being left blank; the Elopement Risk total score indicated not applicable (NA). Resident 19's MDS, dated [DATE], indicated her BIMS score was 9 (moderate cognitive impairment). A progress note, dated 6/9/24 at 1:11 PM, indicated Resident 19 was found by activity personnel outside on the pavement of the parking lot lying on her right side. The resident indicated a non-employee let her out of the building. The resident fell from the sidewalk curb and reported hitting her head. Abrasions were found on the resident's left knee, redness found on her right elbow/shoulder, and swelling/discoloration on the right side of her forehead/temple. Resident 19 reported slight pain to her head and right hip immediately after the incident; ice was applied to the area. A Fall Risk Assessment, dated 6/9/24 at 12:54 PM, indicated Resident 19's incident occurred in the morning. The assessment indicated the resident was wheelchair bound, had predisposing factors of mental status changes, impaired memory, depression, decreased safety awareness, and was non-compliant with safety instructions. The assessment indicated the resident was using an electric wheelchair outside without supervision. The resident did not inform nurses she was going outside, the resident did not sign out to go outside, and per the resident a visitor let the resident out of the facility to the outside. An Interdisciplinary Team (IDT) note, dated 6/10/24 at 9:42 AM, indicated the fall incident on 6/9/24 at 12:54 PM, root cause was due to the resident leaving the building without assistance. A Wanderguard was applied to resident. Resident 19's Elopement Risk Review, dated 8/19/24, indicated there were questions to complete, but only one question was completed. The Elopement Risk total score was not determined due to questions not completed. The Elopement Risk total score indicated NA. During an observation, on 9/25/24 at 9:05 AM, the facility was noted to have 3 sets of doors to get to the outside from the resident rooms where Resident 19 lived to the location Resident 19 was found on 6/9/24 on the ground outside. The first set of doors led from the Resident 19's home location in the facility, required a code to be entered into a security numerical code pad or an alarm would sound, had wooden double swing doors, and led to a lounge area. The second set of doors led from the lounge area, had a security numerical code pad (not on during day hours), metal double swing doors, and led to the anteroom ( small room, that led into a larger more important room). The third set of doors allowed exit from the anteroom of the facility, required no code for entrance/exit, had metal double swing door, and led to the outside of the building to sidewalks and the front parking lot. In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find Resident 19 (down half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through the anteroom, through the second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision) and was not investigated as an elopement. A current policy titled, Elopement and Missing Resident Prevention, reviewed 4/20/23, provided by the Registered Nurse (RN) 27 on 9/30/24 at 2:18 PM, indicated all residents would be provided adequate supervision to meet personal and nursing needs and be assessed for behaviors/conditions that put them at risk for elopement. The policy indicated all resident would be assessed for risk of elopement annually, quarterly, and with any significant change which included any attempt or actual elopement. Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination. 46756 3) During an observation, on 9/26/24 at 9:05 AM, Resident 76 was observed seated on a bench, smoking a pipe in front of the building about 50 feet from the front door. During an interview, on 9/26/24 at 10:22 AM, Resident 76 indicated he was required to sign out at the nurses' station each time he goes out to smoke . He indicated he was supposed to turn in his smoking materials for staff to lock up, but he would occasionally keep them in his room when staff was not around or too busy. He indicated he did not have a way to lock the materials up in his room. Resident 76's record was reviewed on 9/26/24 at 10:28 AM. Diagnoses included diabetes mellitus type 2, acute systolic heart failure, and muscle weakness. Resident 76's current quarterly, Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). A smoking assessment, dated 9/5/24, indicated a smoking apron was recommended for Resident 76, he was educated on its use, and he did not wish to use it. Resident 76's current care plan did not include identification of risk factors, gals, or interventions pertaining to Resident 76's smoking activities. During an interview, on 9/30/24 at 1:34 PM, the Social Services Director (SSD) indicated upon admission, when a resident had a history of smoking, a smoking evaluation should be performed by therapy. The resident's ability to open and close the facility door and handle smoking materials appropriately would be assessed. The SSD indicated staff was aware of who smoked by common knowledge and by reading the Kardex. Residents must follow smoking assessment recommendations to be allowed to continue to smoke. She indicated a care plan should be in place to inform the staff of a resident's smoking status and any special instructions, such as signing out of the building to smoke, care of smoking materials and any devices needed to smoke safely. A current policy titled Smoking Policy, dated 6/10/23, provided by Regional Nurse Consultant 27 on 9/30/24 at 2:15 PM, indicated residents should be assessed for safe smoking behavior prior to smoking at the facility. The policy indicated education should be provided to the resident and staff based on the results of the smoking assessment. The policy indicated the care plan and certified nurse aide assignment sheets. 4) Resident 64's record was reviewed on 9/26/24 at 10:51 AM. Diagnoses included dementia, severe with other behavioral disturbances, delusional disorders, major depressive disorders, and muscle weakness. Resident 64's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). The MDS indicated the resident required substantial assistance to move from sitting to standing positions and transferring in and out of a chair. A fall investigation, dated 8/27/24 at 1:21 PM, indicated Resident 64 slid down her wheelchair onto her calf cushion and tipped her wheelchair forward, causing her to change planes. The form indicated Resident 64 had impaired memory and decreased safety awareness. No additional care plan interventions were added on the document. A fall risk review, dated 8/27/24, indicated Resident 64 was at high risk for falls. A fall investigation, dated 9/17/24 at 2:15 AM, indicated Resident 64 was sleeping in a recliner in the lounge when the nurse heard a noise, checked on the resident and found her sitting on the floor in front of the recliner. A fall investigation, dated 9/17/24 at 9:20 PM, indicated Resident 64 was sitting in the recliner in the lounge with her feet up and scooted down to the foot of the recliner. The CNA on duty attempted to scoot the resident back in the chair but was alone on the hall with no one to assist her so she had to lower the resident to the floor. Resident 64's current care plan titled Fall Risk indicated the resident had a problem of being at risk of falls, with a goal date of 10/29/24. No new fall interventions were added after the 8/27/24 fall from the wheelchair. On 9/27/24 an intervention of raising the footrest while the resident was in the recliner was added. No additional interventions were added on 9/27/24. During an observation, on 9/26/24 at 7:01 PM, the recliners were observed located in a lounge located at the end of a short hallway across from the nurses' station. The recliners were not visible from the hallways where the residents on the southwest unit resided. An as worked schedule for 9/17/24, confirmed by payroll records, indicated one CNA was assigned to the Southwest unit at the 9:20 PM when Resident 64 slid down to the end of the recliner in the lounge. In an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she was aware that Resident 64 fell from the recliner twice in the same day. She indicated short staffing was a factor in the falls. A current policy titled Guidelines for Incidents/Accidents/Falls, dated 6/30/23, provided by Regional Nurse Consultant on 9/30/24 at 2:25 PM, indicated each fall should have a new care plan intervention added. 3.1-45(a)

Based on interview and record review, the facility failed to ensure an advance directive (code status) was accurate for 1 of 7 residents reviewed (Resident 4). Findings include: Resident 4's record was reviewed on [DATE] at 10:09 AM. Diagnoses included chronic obstructive pulmonary disease, (emphysema) unspecified dementia, schizoaffective disorder and bipolar disorder. Resident 4's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 15 (no cognitive deficit). The MDS indicated Resident 4 required substantial to maximum assistance for activities of daily living. Resident 4's Care Plan, dated [DATE], indicated their code status was Do Not Resuscitate (DNR). A physician order, revision date [DATE], indicated DNR status had been discontinued. A Cardiopulmonary Resuscitation (CPR) Status Form, signed by Resident 4's representative on [DATE] indicated the resident's code status was to have CPR initiated. Resident 4's physician signed the form on [DATE]. In an interview on [DATE] at 12:01 PM, the DON indicated they were not aware of Resident 4's CPR code status. The DON indicated resident code status should be the same throughout each document in the resident's record. A current undated facility policy, provided by the Regional Nurse Consultant on [DATE] at 11:51 AM, indicated each resident's choice of advance directive would be honored and incorporated into their plan of care. The policy indicated advance directive choices would be reviewed annually and as needed. 3XXX,d+[DATE](d)

Based on interview and record review, the facility failed to ensure family notification of an episode of resident-to-resident contact for 1 of 2 residents reviewed (Resident 63). Findings include: Resident 63's record was reviewed on 9/30/24 at 1:13 PM. Diagnoses included dementia with mood disturbance, Parkinson's Disease, major depressive disorder, anxiety disorder and visual hallucinations. Resident 63's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). The MDS indicated Resident 63 required substantial to maximal assistance to roll left and right, to move from a lying to a sitting position and to move from a sitting to a standing position. Resident 63's Care Plan, dated 12/8/23, indicated the resident did not participate in many activities. The Care Plan Indicated Resident 63 mostly sat in the background and watched others. The target goal was for the resident to participate in activities of interest at least 2 times a week through 12/9/24. Interventions included the determination that religious beliefs and religious activities were important to Resident 63. A Behavior Charting note, dated 9/18/24 at 5:19 PM, indicated Resident 63 kissed another resident (Resident 49) on the lips in the dining room. Separation of the residents was effective. Resident 63's progress notes, dated 9/18/24 through 9/30/24, did not indicate the resident's family representative had been made aware of the resident kissing another resident. The progress notes did not indicate the episode had been reported to the family or the resident's physician. In an interview, on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between Resident 63 and Resident 49 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated Resident 63 was a willing participant. The SSD indicated although Resident 49 currently displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and was now easily redirected. The SSD indicated they were not aware of further information related to the kissing episode as they were not at work that day. The SSD indicated the Administrator may have further information in their office. In an interview, on 10/1/24 at 2:05 PM, the Administrator indicated they had not been made aware of Resident 63 and Resident 49 kissing and did not believe they had any further information related to family and/or physician notification of the incident. A current policy titled, Guidelines for Incidents/Accidents/Falls dated 6/30/23, provided by the Registered Nurse (RN) 27 on 9/27/24 at 11:51 AM, indicated the facility would ensure any incident/accident/fall that met reporting criteria would be identified and reported accurately and timely to appropriate persons and agencies which included follow-up reporting. 3.1-5(a)

Based on observation, interview, and record review the facility failed to ensure contents of a urinary catheter bag were not visible from the hallway for 1 of 2 residents reviewed (Resident 44). Findings include: During an observation, on 9/25/24 at 9:42 AM, Resident 44 was lying in bed in a semi-reclined position with a catheter bag attached to the bedframe and facing the door. Resident 44's door was open, his bag was in plain sight and visible from the hallway. The bag was about half full of yellow liquid. During an observation on 9/26/24 at 6:44 PM, Resident 44 was lying in bed with a catheter bag attached to the bedframe and facing the door with about 200 milliliters of yellow liquid in the bag. The bag was in plain sight from the hallway. During an observation, on 9/27/24 at 2:50 PM, Resident 44 was lying in bed with a catheter bag attached to the bedframe and facing the hallway about two-thirds full of yellow liquid. During an interview, on 9/27/24 at 2:50 PM, Licensed Practical Nurse (LPN) 25 indicated catheter bags should be emptied at the end of the traditional day shift, around 2:00 PM. She indicated catheter bags should be anchored on the other side of the bed so it would not be visible from the hallway, protecting resident privacy. She indicated a privacy cover should be in place on the bag to keep urine from being visible to the casual observer. Resident 44's record was reviewed on 9/27/24 at 3:19 PM. Diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and neuromuscular dysfunction of the bladder. Resident 44's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 7 (cognitively impaired). The MDS indicated the resident used an indwelling urinary catheter. Resident 44's current care plan titled Catheter indicated the resident had a problem of requiring the use of an indwelling catheter, with a goal date of 11/19/24. Interventions included ensuring a dignity bag was in place. In an interview, on 9/27/24 at 3:11 PM, Regional Nurse Consultant 27 indicated the catheter bag containing urine should have been covered and its contents should not be visible from the hallway. A current policy titled Catheters, undated, provided by Regional Nurse Consultant 27 on 9/27/24 at 3:20 PM, did not address providing privacy by covering the catheter bag to prevent visibility of the contents by casual observers. No other policies pertaining to maintaining privacy for a resident requiring an indwelling catheter were available for review. 3.1-3(p)(2)

Based on interview and record review, the facility failed to prevent abuse for 1 of 2 residents reviewed (Resident 41). Findings include: An Indiana State Department of Health Survey Report System Incident Number 189, dated 9/13/24 at 2:45 PM, indicated Resident 41's family member got loud with the resident during a visit at the facility. Immediate action taken was the removal of Resident 41's visitor from the facility. A preventative measure was the visitor not being permitted at the facility during the investigation. Follow up on 9/20/24 indicated on 9/13/24 a verbal altercation was overheard in Resident 41's room. The visitor was identified as Resident 41's Power of Attorney (POA). The visitor seemed intoxicated as evidenced by their appearance and smell. The visitor was asked to leave the facility immediately. Resident 41 voiced concern the visitor would return. Adult Protective Services recommended a visit restriction and a possible guardianship change. Resident 41's visitation was to be monitored for the next 30 days. Resident 41's Care Plan was reviewed and updated. Resident 41's record was reviewed on 9/27/24 at 3:00 PM. Diagnoses included systemic lupus erythema, adult failure to thrive, anxiety disorder, bipolar disorder, schizophrenia, cognitive communication deficit, obsessive compulsive disorder, depression, agoraphobia with panic disorder and posttraumatic stress disorder (PTSD). Resident 41's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 6 (severe cognitive impairment). The MDS indicated Resident 41had a gastrointestinal (g tube) feeding tube. Resident 41's Care Plan, dated 5/22/24, indicated the resident had a history of trauma and Resident 41's triggers were still being determined. Resident 41 coped by speaking with their boyfriend (the visitor and POA who had been restricted from visitation). The target goal was for the resident to feel safe and comfortable through 11/22/24. Interventions included findings things of comfort and encouraging the resident to use them. Resident 41's Care Plan did not indicate Resident 41's visitation was to be monitored. The Care Plan did not indicate Resident's POA could not visit. The Care Plan did not indicate the facility had witnessed the abuse of Resident 41 on 9/13/24. A progress note, dated 9/13/24 at 4:11 PM, indicated Resident 41's boyfriend had been verbally abusive. The boyfriend was noted to use a loud voice and told Resident 41 they should stop crying and to get up and walk. Resident 41 had been crying and reported they were afraid of their boyfriend. The boyfriend left the facility after being asked to calm down. A progress note, dated 9/22/24 at 1:27 PM, indicated Resident 41's POA was observed sitting in a chair in the resident's room while the resident was in the dining room. Resident 41's POA left the facility when reminded they were not allowed to visit. Resident 41's Kardex (care plan summary for direct care staff) did not indicate the resident's visitation was to be monitored. The Kardex did not indicate the resident's POA was not permitted to visit. In an interview, on 10/1/24 at 11:40 AM, Qualified Medication Aide (QMA) 28 indicated they were not aware of Resident 41's visitation monitoring. QMA 28 indicated they did not work Resident 41's unit very often. QMA 28 indicated they were aware of Resident 41's boyfriend being nasty to the resident in the past. In an interview, on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated Resident 41 had an extensive history of trauma that included multiple sexual assaults. The SSD indicated Resident 41's boyfriend had left Resident 41 unattended at home for an undetermined length of time. The SSD indicated Resident 41's boyfriend was their Power of Attorney. The SSD indicated the facility was aware of Resident 41's boyfriend's past abusive episodes at the facility. The SSD indicated the episode on 9/13/24 was the first time Resident 41 had asked for help. The SSD indicated they had provided copies of all Resident 41's documentation available. A current facility policy, dated 10/22/22, indicated the facility would identify residents with increased vulnerability for neglect, abuse or mistreatment. The facility would identify risk factors and incorporate the factors into the care plan to monitor and reevaluate. 3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure unusual incidents were reported to the appropriate agencies for 2 of 2 residents reviewed (Resident 63 and Resident 19). Findings include: 1. Resident 63's record was reviewed on 9/30/24 at 1:13 PM. Diagnoses included dementia with mood disturbance, Parkinson's Disease, major depressive disorder, anxiety disorder and visual hallucinations. Resident 63's Quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). The MDS indicated Resident 63 required substantial to maximal assistance to roll left and right, to move from lying to a sitting position and to move from a sitting to standing position. A Behavior Charting note, dated 9/18/24 at 5:19 PM, indicated Resident 63 kissed another resident (Resident 49) on the lips in the dining room. Separation of the residents was effective. Resident 63's progress notes, dated 9/18/24 through 9/30/24, did not indicate the resident's family representative had been made aware of the resident kissing another resident. The progress notes did not indicate the episode had been reported to the appropriate agencies. Resident 63's Care Plan, dated 12/8/23, indicated the resident did not participate in many activities. The Care Plan Indicated Resident 63 mostly sat in the background and watched others. The target goal was for the resident to participate in activities of interest at least 2 times a week through 12/9/24. Interventions included the determination that religious beliefs and religious activities were important to Resident 63. In an interview on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between Resident 63 and Resident 49 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated Resident 63 was a willing participant. The SSD indicated although Resident 49 currently displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and was now easily redirected. The SSD indicated they were not aware of further information related to the kissing episode as they were not at work that day. The SSD indicated the Administrator may have further information in their office. In an interview, on 10/1/24 at 2:05 PM, the Administrator indicated they were not aware of the kissing episode between Resident 63 and Resident 49 so had not reported it. 46156 2. Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination. Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated she had lost weight of 5% in the last month or 10% in last 6 months and was not on Physician prescribed weight loss regimen. The MDS indicated the resident was impaired on 1 side of her lower extremity and used a wheelchair. The MDS indicated she required substantial/maximal assist with rolling left to right, transfers, and toileting. Resident 19's current care plan, initiated 2/12/24, indicated her care plan focus was high risk for elopement/wandering related to her bi-polar disorder. The goal of her focus area was the resident would not wander out of the facility or off the floor with a target date of 11/7/24. Interventions included wanderguard in placed initiated 6/10/24, assess/record/report to Medical Doctor (MD) risk factors for potential elopement initiated 2/12/24, and supervise closely and make regular compliance rounds whenever the resident was in her room initiated 2/12/24. A Care Plan Meeting progress note, dated 5/2/24 at 8:54 AM, indicated when Resident 19 wouo ld outside she was to be monitored. The note indicated the resident was not able to physically sign for herself anymore. The note indicated the facility was requesting the MD to evaluate Resident 19 to see if guardianship (a legal process that gives a person or entity the authority to make decisions for another person, called a ward, who is considered incompetent) was appropriate. A Progress note, dated 6/9/24 at 1:11 PM, indicated Resident 19 was found by activity personnel outside on the pavement of the parking lot lying on her right side. The resident told the staff a visitor let her out of the building. The resident indicated she fell from the sidewalk curb and reported hitting her head. Abrasions were found on the resident's left knee, redness found on her right elbow/shoulder, and swelling/discoloration on the right side of her forehead/temple. Resident 19 reported slight pain to her head and right hip immediately after the incident; ice was applied to the area. In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find the Resident 19 (through half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through anti-room, through second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and it was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision). In an interview, on 9/30/24 at 11:40 AM, the Administrator indicated Resident 19's elopement had not been reported to the proper agencies. A current policy titled, Guidelines for Incidents/Accidents/Falls dated 6/30/23, provided by the Registered Nurse (RN) 27 on 9/27/24 at 11:51 AM, indicated the facility would ensure any incident/accident/fall that met reporting criteria would be identified and reported accurately and timely to appropriate agencies which included follow-up reporting. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure the elopement of a resident was investigated for 1 of 2 residents reviewed (Residents 19). Findings include: Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination. Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated she had lost weight of 5% in the last month or 10% in last 6 months and was not on Physician prescribed weight loss regimen. The MDS indicated the resident was impaired on 1 side of her lower extremity and used a wheelchair. The MDS indicated she required substantial/maximal assist with rolling left to right, transfers, and toileting. Resident 19's current care plan, initiated 2/12/24, indicated her care plan focus was high risk for elopement/wandering related to her bi-polar disorder. The goal of her focus area was the resident would not wander out of the facility or off the floor with a target date of 11/7/24. Interventions included a wanderguard was placed initiated 6/10/24, assess/record/report to Medical Doctor (MD) risk factors for potential elopement initiated 2/12/24, supervise closely and make regular compliance rounds whenever the resident was in her room initiated 2/12/24. A Care Plan Meeting progress note, dated 5/2/24 at 8:54 AM, indicated when Resident 19 would go outside she was to be monitored. The note indicated the resident was not able to physically sign for herself anymore. The note indicated the facility was requesting the MD to evaluate Resident 19 to see if guardianship (a legal process that gives a person or entity the authority to make decisions for another person, called a ward, who is considered incompetent) was appropriate. A Progress note, dated 6/9/24 at 1:11 PM, indicated Resident 19 was found outside by activity personnel on the pavement of the parking lot lying on her right side. The resident indicated a visitor her out of the building. The resident fell from the sidewalk curb and reported hitting her head. Abrasions were found on the resident's left knee, redness found on her right elbow/shoulder, swelling/discoloration on the right side of her forehead/temple. Resident 19 reported slight pain to her head and right hip immediately after the incident; ice was applied to the area. In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find the Resident 19 (through half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through anti-room, through second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision) and was not investigated as an elopement. A current policy titled, Guidelines for Incidents/Accidents/Falls dated 6/30/23, provided by the Registered Nurse (RN) 27 on 9/27/24 at 11:51 AM indicated the facility would ensure any incident/accident/fall would be identified, reported accurately and timely to appropriate agencies, investigated, and resolved. 3.1-28(c)

Based on interview, and record review the facility failed to ensure showers were consistently offered for 1 of 6 residents reviewed (Resident 76). Findings include: During an interview, on 9/26/24 at 10:08 AM, Resident 48 indicated he was not getting showers on a regular basis. He indicated he was supposed to have a shower on Wednesdays and Saturdays at 3:00 pm. He indicated when staff did not show up to give him a shower, he would frequently go to the nurses' station to find out what was going on and was told they were short staffed. Resident 48's record was reviewed on 9/30/24 at 10:25 AM. Diagnoses included cerebral infarction due to thrombosis of right posterior cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left, non-dominant side, and diabetes mellitus, type 2 without complications. Resident 48's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 48 required moderate assistance with bathing and rejection of care was not exhibited. Resident 48's current care plan titled Preferences indicated Resident 48 expressed choices regarding his personal care was important to him, with a goal date of 10/4/24. Interventions included showering twice weekly around 3:00 PM. Resident 48's current care plan titled ADL (Activity of Daily Living) Self-Care Performance indicated the resident had a problem of a self-care deficit related to a cerebral infarction, with a goal date of 10/4/24. An intervention titled Personal Hygiene Routine indicated the resident prefered being shaved weekly and hands washed. Interventions did not include specifications on assistance provided for showering or any other hygiene. Progress notes, dated 8/6/24 at 6:11 PM, indicated Resident 48's skin was dry over his entire body and at high risk for skin breakdown. The notes indicated Nurse Practitioner (NP) 34 recommended Resident 34 receive good hygiene and skin care to prevent skin breakdown. An undated document titled Southwest Shower List indicated Resident 48 should receive showers on evening shift on Wednesdays and Saturdays. Shower/Skin Alteration Worksheets, dated September 2024, indicated Resident 48 received showers on 9/6/24, 9/11/24 and 9/25/24. A worksheet for 9/15/24 indicated Resident 48 refused his shower. No other showers or offerings of a shower were recorded between 9/11/24 and 9/25/24. A form titled I would like to know . provided by the Director of Nursing on 9/26/24 at 9:10 AM, indicated on 9/5/24, Resident 48 indicated he was concerned about missing showers. The Administrator's response noted on the form, dated 9/9/24, indicated Resident 48 received the first shower that week and had refused the second shower. He indicated the resident should receive showers on Wednesdays and Saturdays and he would review all shower schedules. In an interview, on 9/26/24 at 7:06 PM, Licensed Practical Nurse (LPN) 22 indicated evening shift showers were not being done consistently for the prior few months due to lack of staff to complete them. In an interview on, 10/1/24 at 10:16 AM, the Director of Nursing indicated she could not find any documentation of showers being provided or offered and refused between 9/11/24 and 9/25/24, except for a refusal recorded on a shower worksheet on 9/15/24. She indicated when staff were unable to provide a shower for a resident, it should be offered to the resident as soon as possible. She indicated habitual refusals would have been documented in a progress note and care planned. She indicated she was not aware of habitual refusals by Resident 48. A current policy titled Guidelines for Bathing, provided by the Administrator on 10/1/24 at 1:42 PM indicated bathing should occur to cleanse the skin and promote circulation. This citation is related to complaint IN00443976. 3.1-38(b)(3)

Based on observation, interview and record review the facility failed to ensure supervision and maintain seizure precautions for 2 of 6 residents reviewed (Resident 32 and Resident 5). Findings include: During an observation, on 9/26/24 at 11:12 AM, upon entering the memory Care unit, a voice was heard calling for help. A staff member was observed entering the shower room. A voice was heard asking who the nurse was. The Director of Nursing (DON) wsa observed entering the shower room. On 9/26/24 at 11:55 AM, Resident 32 was observed leaving the unit on a gurney escorted by 2 paramedics. Resident 32 was covered with a blanket. In an interview, on 9/26/24 at 11:57 AM, Certified Nurse Aide (CNA) 30 indicated they had started working at the facility on 9/12/24 and they were being trained by CNA 35. CNA 30 indicated they entered the shower room after hearing the resident call for help. CNA 30 observed Resident 32 sitting on the floor in the shower with their right arm stuck in the handrail. CNA 30 indicated they were unable to remove Resident 32's arm from the handrail. CNA indicated Resident 32 had been in the shower room alone since 10:55 AM. CNA 30 indicated they were directed to place Resident 32 in the unsupervised by CNA 35. CNA 30 indicated they were not permitted to provide direct care to the residents until their training was complete but had been providing direct care due to a staffing shortage. CNA 30 indicated they were directed by CNA 35 to provide direct care due to low staffing. In an interview, on 9/26/24 at 12:05 PM, CNA 35 indicated Resident 32 was unsupervised in the shower room due to low staffing. CNA 35 indicated the unit had been short staffed for a few months. CNA 35 indicated the unit was often staffed with 1 CNA and 1 Qualified Medication Aide (QMA) (A CNA with medication training). CNA 35 indicated the unit QMA was on a break due to having stayed over from night shift. CNA 35 indicated the facility management was aware of the short staffing issues. CNA 35 indicated the corporate office would not allow the facility to use a staffing agency due to the cost. CNA 35 indicated CNAs in training were not supposed to provide resident care. CNA 35 indicated the Unit Manager had directed the CNA in training to provide direct care to residents due to low staffing. CNA 35 indicated the Unit Manager had directed the unsupervised shower of Resident 32. Resident 32's record was reviewed on 9/26/24 at 2:10 PM. Diagnoses included dementia, osteoarthritis, osteoporosis, and seizure disorder. Resident 32's Annual Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 13 (no cognitive impairment). The MDS indicated the resident required partial to moderate assistance with showering or bathing. The MDS indicated the resident had 2 or more recent falls. Resident 32's Care Plan, dated 12/28/23, indicated the resident had a self-care deficit. The target goal was for the resident to participate in self-care with supervision through 9/17/24. Interventions included assisting the resident according to the resident's level of need and offering frequent rest breaks. Resident 32's Care Plan, dated 8/22/24, indicated the resident was at risk for falls. The target goal was to reduce risks to avoid significant injury from falls through 9/17/24. Interventions included increasing supervision and referring the resident to therapy. Resident 32's Care Plan, dated 9/7/24, indicated the resident required therapy due to decreased leg strength, impaired balance, decreased walking ability and a recent fall. The target goal was for the resident to receive therapy services through 9/17/24. Interventions included gait training, therapeutic exercise and neuromuscular re-education. Resident 32's Care Plan did not address their diagnosis of a seizure disorder. An Incident Description, dated 5/5/24 at 4:45 PM, indicated Resident 32 had a seizure while walking in the dining room. A Fall Risk Review, dated 5/6/24 at 12:50 PM, indicated Resident 32 had a fall risk of 10. The resident had normal gait and balance. An IDT note, dated 5/6/24 at 9:15 AM, indicated Resident 32 had a fall due to increased seizure activity. A new intervention was for the resident to be assisted by a staff member while walking until the resident was evaluated by a neurologist. An Incident Description, dated 7/9/24 at 6:30 PM, indicated Resident 32 had a seizure in their bathroom and had a laceration to their lip. An IDT note, dated 7/9/24 at 12:19 PM, indicated the resident had a fall due to seizure activity. A new intervention was to encourage the resident to call for assistance with toileting. A physician order, dated 5/16/24, indicated Resident 32 may have a camera in their room for safety due to a diagnosis of seizure disorder. Resident 32's physician orders did not indicate they were to have any other seizure or fall precautions. Resident 32's current Kardex, (care plan summary for CNAs), dated 9/26/24, indicated the resident had a camera in their room. The Kardex did not indicate the resident was at risk for falls. The Kardex did not indicate the resident had a seizure disorder or what interventions should be inplace to prevent falls. In an interview, on 9/30/24 at 2:50 PM, the DON indicated Resident 32 should not have been unsupervised in the shower room. The DON indicated Resident 32's Care Plan should have included interventions for seizure and fall precautions. The DON indicated seizure precautions and fall risk precautions should have been included on the resident's Kardex and omplemented from the care plan. An undated current facility policy, provided by the Regional Nurse Consultant on 9/27/24 at 11:51 AM, indicated residents were to never be left unattended in the shower room. A current facility policy, dated 6/20/23, provided by the Regional Nurse Consultant on 9/27/24 at 11:51 AM, indicated internal risk factors for falls included confusion, unstable joints, confusion, and weakness of the legs. The policy indicated external risk factors for falls included wet floors. The policy indicated the resident's Kardex would be updated as indicated. 46756 2) During an observation on 9/26/24 at 6:43 PM, a loud male voice was heard yelling for help. Resident 5 was lying on the floor on his right side next to a piano located across the hall from the dining room at the far end of the hall. Resident 5 was lying on his back turned slightly to the left on the floor with his feet near the piano positioned along the wall, his torso and head positioned toward the hallway. Licensed Practical Nurse (LPN) 22, LPN 25, and Registered Nurse (RN) 46 approached Resident 5 and asked him if he had any pain. Resident 5 indicated he had pain in his bottom. LPN 22, LPN 25, and RN 46 began to assist Resident 5 away from the piano bench, Resident 5 yelled out and complained of pain. Resident 5's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). The MDS indicated the resident required moderate assistance to mobilize his wheelchair 50 feet with two turns and substantial assistance to mobilize his wheelchair 150 feet. Resident 5's current care plan, titled Pain indicated the resident had a problem of pain/discomfort, with a goal date of 11/5/24. Interventions included assess pain, notify physician as needed, acknowledge presence of pain and discomfort, listen to the resident's concerns, and document and report complaints and nonverbal signs of pain. Progress notes, dated 9/26/24 at 8:31 PM, indicated Resident 5 was heard yelling down the hall. He was found lying on the floor by the dining room with his head toward the dining room doors and feet toward the piano in lounge area. The notes indicated the resident was assessed for injuries with none found and assisted by 3 staff back into his chair. The resident was then assisted to the nurses' station for close monitoring. Vital signs and neurological checks were normal for the resident. The physician, family and Director of Nursing were notified. Progress notes, dated 9/27/24 at 1:49 PM, indicated two nurses attempted to assist Resident 5 to the toilet. When he stood while receiving the usual amount of assistance, he yelled out complaining of pain and indicated the pain was in his right hip. The physician was contacted with orders received to send to the emergency room for evaluation and treatment. Progress notes, dated 9/27/24 at 9:15 PM, indicated the nurse had received report from the hospital at about 5:00 PM and the resident was expected to return to the facility. The notes indicated the resident returned to the facility with new orders around 8:30 PM. No pain assessments were available for review. Emergency Department (ED) notes, dated 9/27/24 at 1:42 PM, indicated Resident 5 was brought into the ED with a complaint of right hip pain after a fall the previous evening. A hospital Xray report, dated 9/27/24 at 2:30 PM, indicated Resident 5 had a comminuted nondisplaced fracture of the right ischial tuberosity (part of the bone in the lower pelvis). No progress notes or assessments related to pain interventions between 9/27/24 and 9/28/24 were available for review. Progress notes, dated 9/29/24 at 4:46 PM, indicated Resident 5 had a fractured pelvis. No pain assessments were available for review. A medication administration record (MAR), dated 9/29/24 at 2:52 PM, indicated Resident 5 received a one-time dose for oxycodone 5 mg, one tablet by mouth for pain. No pain assessment was available for review. Progress notes, dated 9/30/24 at 5:51 PM, indicated Resident 5 had increased pain and discomfort. New orders for oxycodone 5 mg, two tablets by mouth every four hours as needed for pain was received. Resident 5's record was reviewed on 10/1/24 at 11:15 AM. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, vascular dementia, and impulse disorder. In an interview, on 10/1/24 at 11:30 AM, LPN 47 indicated residents should be checked for injuries prior to moving when found on the floor. When a resident would report pain, the doctor would be notified, and his orders should be followed before moving the resident. A current policy titled Guidelines for Incidents/Accidents/Falls, dated 6/30/23, provided by Regional Nurse Consultant 27 on 9/30/24 at 2:25 PM, indicated upon the occurrence of a fall, a nurse should assess the resident for pain and notify the provider. The policy indicated documentation of the resident's physical and mental status should be completed at least every shift over the next 72 hours or until the condition improved. 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide trauma informed care by identifying triggers to minimize re-traumatization for 1 of 2 residents reviewed (Resident 41). Findings include: Resident 41's record was reviewed on 9/27/24 at 3:00 PM. Diagnoses included systemic lupus erythema, adult failure to thrive, anxiety disorder, bipolar disorder, schizophrenia, cognitive communication deficit, obsessive compulsive disorder, depression, agoraphobia with panic disorder and posttraumatic stress disorder (PTSD). Resident 41's Quarterly Minimum Data Set, (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 6 (severe cognitive impairment). The MDS indicated Resident 41had a gastrointestinal (g tube) feeding tube. Resident 41's Care Plan, dated 5/20/24, indicated the resident had a diagnosis of PTSD. The target goal was for Resident 41 to be symptom free through 11/22/24. Interventions included sensitivity to the resident's feelings, encouragement of healthy coping strategies, open discussion, administration of psychoactive medications, observance and documentation of behaviors. The Care Plan did not indicate potential triggers for behaviors. The Care Plan did not indicate specific PTSD symptoms. Resident 41's Care Plan, dated 5/22/24, indicated the resident had a history of trauma. Resident 41's triggers were still being determined. Resident 41 coped by speaking with their boyfriend. The target goal was for the resident to feel safe and comfortable through 11/22/24. Interventions included findings things of comfort and encouraging the resident to use them. A Trauma Screening, dated 5/21/24, indicated Resident 41's trauma score was 4. The screening indicated the score was determined by the number of yes answers. The screening indicated a score of 5 or more was high risk for trauma related symptoms. A progress note, dated 5/28/24 at 9:40 AM, indicated Resident 41 had a history of tobacco use, alcohol use and elicit drug use. Resident 4 1 had been found in an unresponsive state at home by their boyfriend. Resident 41 had been covered with urine and stool for an unknown amount of time. A progress note, dated 9/13/24 at 4:11 PM, indicated Resident 41's boyfriend had been verbally abusive. The boyfriend was noted to use a loud voice and told Resident 41 they should stop crying and to get up and walk. Resident 41 had been crying and reported they were afraid of their boyfriend. The boyfriend left the facility after being asked to calm down. Adult Protective Services (APS) were notified. Resident 41's Kardex (care plan summary for direct care staff) did not indicate the resident had PTSD. The Kardex indicated Resident 41 would be symptom free through 11/22/24. Interventions included being sensitive to feelings, encouraging healthy coping mechanisms, acknowledgment by the resident of safety, open discussion by the resident, psychoactive medications and observation and documentation of behaviors. A progress note, dated 924/24 at 2:40 AM, indicated Resident 41 had been calling out for their boyfriend. A progress note, dated 9/20/24 at 2:42 PM, indicated Resident 41had been lying in bed yelling out. Resident 41 was calling for help and had stated he said I am going to lose my apartment if I don't go home and work. A progress note, dated 9/15/24 at 11:16 AM, indicated Resident 41 had been screaming and crying. Resident 41 kept referring to a traumatic event that had occurred on Friday. A new medication for panic disorder was ordered by the Psychiatric Nurse Practitioner. On 9/27/24 at 3:00 PM, Resident 41 was observed sitting in their wheelchair near the nurse station crying. Resident 41 indicated they did not have a car and asked to borrow a car or get a ride with someone to leave the facility. In an interview, on 10/1/24 at 11:40 AM, Qualified Medication Aide (QMA) 28 indicated they were not aware of Resident 41's visitation monitoring. QMA 28 indicated they did not work Resident 41's unit very often. QMA 28 indicated they were aware of Resident 41's boyfriend being nasty to the resident in the past. In an interview, on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated Resident 41 had an extensive history of trauma that included multiple sexual assaults. The SSD indicated Resident 41's boyfriend had left Resident 41 unattended for an undetermined time. The SSD indicated they were not aware of any specific triggers or stressors. The SSD indicated the facility was aware of Resident 41's abusive episodes in the past. The SSD indicated Resident 41's boyfriend was the resident's Power of Attorney (POA). The SSD indicated the episode on 9/13/24 was the first time Resident 41 had asked for help. The SSD provided Resident 41's Adult Protective Services (APS) Case Manager contact information. The SSD indicated they had provided copies of all Resident 41's documentation. A current facility policy, dated 12/6/16, provided by the Regional Nurse Consultant on 9/30/24 at 9:30 AM, indicated all individuals should be treated as if they may have experienced trauma. The policy indicated trauma is primary to the development of addiction and mental health problems. The policy indicated the facility must ensure culturally competent, trauma informed care with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization.

Based on observation, interview and record review, the facility failed to ensure specific resident behaviors were identified, investigated and communicated with individualized interventions for a resident with dementia for 1 of 1 resident reviewed (Resident 49). Findings include: On 9/26/24 at 11:15 AM, Resident 49 was observed standing up from dining room table. Resident 49 was observed walking while pushing their locked wheelchair. Resident 49 spoke in an agitated voice when they were being followed. Resident 49's record was reviewed on 9/27/24 at 11:36 AM. Diagnoses included alcohol dependence with alcohol induced dementia, anxiety disorder, major depressive disorder, psychotic disorder with hallucinations and mild cognitive impairment. Resident 49's Admission Minimum Data Set (MDS), dated [DATE], indicated Resident 49's Brief Interview for Mental Status (BIMS) was 10 (moderate cognitive impairment). The MDS indicated Resident 49 required partial to moderate assistance with mobility, bathing and dressing. The MDS indicated Resident 49 had diagnoses of non-Alzheimer's dementia, anxiety and depression. Resident 49's Care Plan, dated 7/29/24, indicated the resident displayed behaviors of hitting, kicking, pinching, throwing things, delusions, hallucinations, raising of voice, making sexual comments, irritability, lashing out and being nervous around other people. The target goal was the resident would have no side effects from medications and their needs would be met without injury to self or others through 12/10/24. Interventions included calling family, minimize private interactions with another specific resident, redirection, watch TV, discuss archery and play music. Resident 49's Care Plan did not include resident specific stressors or triggers to their behaviors. The Care Plan interventions did not include attempting to identify resident specific triggers or stressors. Resident 49's Care Plan did not address their diagnosis of dementia. An Incident Description, dated 7/14/24 at 7:00 AM, indicated Resident 49 allegedly touched another resident's breast. A facility staff member indicated Resident 49 had adjusted the other resident's blanket. A Resident Witness indicated Resident 49 had indicated the resident had pulled the other resident's shirt to expose them. A Resident Witness indicated Resident 49 was touching the other resident's breasts. Camera footage indicated Resident 49 had adjusted the other resident's blanket. An Incident Description, dated 7/15/24 at 2:00 PM, indicated Resident 49 had punched a staff member in the ear. Resident 49 had been delusional thinking another resident was being killed by visitors. An Interdisciplinary (IDT) Note, dated 7/22/24 at 9:01 PM, indicated Resident 49 had been triggered at the same time of day (3-5 pm), but the trigger had been unknown at that time. A new intervention was for activity staff to engage with resident during the trigger time. Resident 49's Kardex (summary care plan for direct care staff) indicated the resident resided on a secure dementia unit. The Kardex did not indicate the resident displayed behaviors of hitting, kicking, pinching, throwing things, delusions, hallucinations, raising of voice, making sexual comments, irritability, lashing out and being nervous around other people. The Kardex indicated staff were to minimize private interactions with another specific resident. A progress note, dated 8/11/24 at 3:22 PM, indicated Resident 49 thought they were having a mental breakdown no intervention was documented. A progress note, dated 9/4/24 at 11:19 PM, indicated Resident 49 was found in bed with a female resident. Resident 49 was only wearing a brief. A progress note, dated 9/5/24 at 4:51 PM, indicated Resident 49 had placed their hand on their penis and stated the penis had different flavors for different staff. A progress note, dated 9/13/24 at 5:01 PM, indicated Resident 49 had become agitated at another resident due to the other resident attempting to push the resident's wheelchair. Resident 49 pushed the other resident's hands away. An IDT note, dated 9/16/24 at 11:17 AM, indicated Resident 49 believed their personal space was being invaded on 9/13/24 when they pushed another resident's hands away. A progress note, dated 9/18/24 at 5:14 PM, indicated Resident 49 had kissed another resident on the mouth in the dining room. In an interview on, 10/1/24 at 11:40 AM, Qualified Medication Aide (QMA) 28 indicated direct care staff members were made aware of only new behaviors during shift report. QMA 28 indicated the facility learned the residents' specific behaviors as they got to know the residents. QMA 28 indicated they had not been educated to observe for specific events or stressors that had happened prior to resident behaviors. In an interview on, 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between another resident and Resident 49 on 9/18/24 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated the other resident was a willing participant. The SSD indicated although Resident 49 has displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and the resident was now easily redirected. A current facility policy, dated 8/18/23, provided by the Regional Nurse Consultant on 9/30/24 at 9:30 AM, indicated the facility would investigate resident behaviors in an effort to determine the root cause of the behavior. An undated current facility policy, provided by the Regional Nurse Consultant on 9/30/24 at 9:30 AM, indicated the facility memory care unit could not accept residents who displayed behaviors that may result in harm to self or others. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure nursing staffing numbers including the facility name, date, facility census, total number and actual hours worked per shift by licensed and unlicensed direct care staff were posted in an area accessible to residents and visitors. for 82 of 82 residents resided in the building. Findings include: During an observation, on 9/25/24 at 1:00 PM, a plastic document holder was observed in the front lobby area next to postings of Resident Rights and names, addresses and phone numbers of state agencies. A set of doors at the end of the lobby were locked with a push- button activator to open the doors leading to the area of the building where residents resided. The doors required a keypad code to be entered to reach the lobby area from the area where the residents resided. An additional door was observed, with a keypad entry and exit code required, which lead to the locked dementia unit. During an interview, on 9/25/24 at 3:29 AM, the Administrator indicated the signs had been recently moved to their current location. He was unsure of the location of the posting of nursing hours, but indicated he would find out. During an observation and interview, on 9/25/24 at 3:53 PM, the Administrator pointed to the empty plastic document holder near the resident rights posting and indicated the nursing hours should be posted in that location, and he would provide a copy. During a record review, on 9/25/24 at 3:57 PM, a document titled daily staffing 9/26/24 was reviewed. The document indicated the census was 80, but no nursing hours were indicated on the form. During an interview on 9/25/24 at 4:20 PM, the Director of Nursing indicated the Daily Staffing form posted in the lobby was dated 9/26/24, indicated the next day's date and a census of 80, which should have reflected a census of 82. During an observation, on 9/30/24 at 11:51 AM, a staffing notice, dated 9/27/24, was posted in the lobby. A current undated policy titled BIPA Staffing Posting Requirement indicated the facility specific shift schedule for the 24-hour period should be posted. The policy indicated the post should include the number and category of nursing staff employed or contracted by the facility for each 24-hour period, as well as the number of hours worked by licensed staff and staff who are directly responsible for resident care. The policy indicated the data must be in a conspicuous, prominent location, accessible to residents and visitors.

Based on observation, interview, and record review, the facility failed to ensure staff effectively identified skin impairment on the left inner calf from friction and shear was correctly identified as a pressure injury, failed to ensure a physician's order was received prior to the use of a medical device, and failed to ensure a resident with a history of pressure injuries received effective treatment and services to prevent the wound from deteriorating, from developing infection, or to prevent the development of a second wound for 1 of 1 resident reviewed for wound care. (Resident J) This deficient practice resulted in Wound 1 deteriorating to a stage three pressure injury with infection and required sharp debridement. Findings include: In an interview on 9/3/24 at 12:07 P.M., the Resident Council President (RCP) indicated Resident J, who sat at her table in the dining room, had been taken back to her room, without eating lunch, due to her crying out in pain. The RCP was very concerned for the resident because she had been crying about pain in her left lower leg, foot and toes. In an interview on 9/3/24 at 12:15 P.M., the facility Activity Assistant indicated the resident had been having a bad day and liked to be babied at times. The Activity Assistant indicated she had just come from the resident's room and she had been doing fine. An annual MDS (Minimum Data Set) with Care Area Assessments, dated 6/25/24, indicated Resident J had a BIMS (Brief Interview Mental Status) score of 12 (mildly impaired cognition). Her speech was clear, she was able to make her needs known and was able to understand others. She required substantial assistance with bed mobility, transfers, and toileting. She was frequently incontinent of bowel and bladder and had no identified wounds. Staff would continue to anticipate her needs, provide assistance, and keep her physicians informed of any changes. A skin risk assessment dated [DATE] indicated she was at risk for pressure injuries. There were no other assessments or care plans documented related to the identified risk. A current care plan regarding potential for pain, dated 9/3/23, indicated the resident had the potential for pain and would be free from pain with interventions as needed. Interventions included: medications as ordered; notify doctor of uncontrolled pain; and observe for signs and symptoms of pain. A current care plan regarding at risk for skin breakdown due to edema from heart disease, dated 2/1/24, indicated goals were to provide the resident with preventative measures to avoid skin breakdown and resolution of her edema without complications. Interventions included: float heels while in bed; monitor skin daily during care; mild compression stockings daily-on in the morning and off at night; weekly skin assessment; and observe for any increase in edema. An Incident Report dated 8/8/24 at 9:00 a.m., indicated the resident had a skin tear to her left inner calf with slight bleeding. The skin tear was cleansed and covered with a dry dressing. No other characteristics of the wound had been documented, the physician or family notified. The incident report did not include documentation to determine the root cause of the skin impairment. An Interdisciplinary (IDT) note, dated 8/9/24, indicated the root cause of the left inner calf wound was from the resident rubbing the left leg against an air cast that was applied to the right lower leg. There was no measurement of the area, other characteristics, physician or family notification documented about the skin tear. There was no care plan to address friction and shear related to the air cast. Current physician orders, dated September 2024, did not include an order for the air cast. According to Advances in Skin and Wound Care pg. 222 June 2004 article, friction and shear are mechanical forces contributing to pressure ulcer formation. The tissue injury resulting from these forces may look like a superficial area, yet they often work together to create tissue ischemia (low oxygen) and ulcer development. A nurse progress note, dated 8/11/24 at 4:31 p.m., indicated the resident had a skin tear (stage two pressure ulcer) to her right (sic) (left) lower leg. Her leg was swollen and leaking fluid. The wound was cleaned and her leg wrapped. There was no documentation of how the wound was cleansed, the characteristics of the wound or how the wound had been dressed. A care plan for a skin tear on the right (sic) (left) lower leg, dated 8/12/24, indicated the stage two pressure ulcer on the left lower leg was a skin tear. The goal was to heal without complications. Interventions included: investigate cause of the skin tear; observe for signs/symptoms of infection; take necessary precautions to prevent new areas; and treatments as ordered. There was no assessment or plan of care for pressure risk related to the use of a medical device. A Treatment Administration Record (TAR), dated August 2024, indicated a treatment was ordered on 8/12/24 for a skin tear (ulcer) to the right (sic) (left) lower leg. The skin tear (ulcer) was to be cleansed with soap and water, rinsed, patted dry and dressing applied as needed one time per day. A Daily Skilled Nursing Note, dated 8/13/24 at 11:13 a.m., indicated the stage two pressure ulcer (a partial thickness loss of skin with exposed dermis, presenting as a shallow, open ulcer) identified as a skin tear (ulcer) on her left lower leg continued to drain. There was no documentation of how the wound was cleansed, the specific characteristics of the wound, any drainage associate with the wound or if the wound had been dressed. A Nurse Practitioner note, dated 8/14/24 at 10:29 a.m., indicated the resident reported she was having drainage from her left lower leg. The area was dressed with bandages. She had no excessive warmth, redness, or surrounding swelling, but no other characteristics of the wound had been documented. There was no documentation in the progress notes or wound documentation between 8/14 and 8/26-24 to indicate the facility effectively assessed, monitored, or evaluated the skin impairment. The record contained no documentation, in the progress notes, wound reports, or treatment records, between 8/14/2024 and 8/26/2024, to indicate the facility effectively assessed, monitored, or evaluated the skin impairment including 8/15/24, 8/22/24 and 8/29/24. Care plans, dated August and September 2024, did not contain interventions to remove the air cast, or interventions to provide relief to the wounds on the left lower leg. A Change in Condition form, dated 8/26/24 at 11:17 p.m., indicated the resident had 2 newly identified skin tears (ulcers) on her left lower calf. The form indicated the Left lower leg areas caused her significant pain. New orders were obtained to cover the skin tears on the left lower inner leg and left lower outer leg with Mepitel (a wound dressing to allow drainage to pass on to a secondary dressing, reducing pain) followed by Mepilex (a wound dressing to absorb drainage and protect from damage due to the drainage) until healed every night shift, every 7 days. Resident J was administered pain medication-Tramadol 50 mg 1 tablet by mouth every 8 hours as needed-at 8:18 p.m. for a pain level of 9 out of 10 with 10 being the worst pain. The form did not include sufficient documentation to determine the specific characteristics of the wounds, assessments of the wound, possible root cause. According to Molnlycke.us, Mepitel is a dressing designed to minimize pain and trauma at the dressing site. Mepitel does not adhere to a moist wound so it can be easily removed without damaging the skin. Mepitel is designed to remain in place for 14 days, it protects the skin to support faster healing, and seals the wound to prevent the skin from softening and breaking down related to moisture. According to Molnlycke.us, Mepilex is a dressing designed to designed to minimize pain and trauma at the wound site. It seals the wound and absorbs drainage to protect the wound from breakdown. A Change in Condition follow up note, dated 8/27/24 at 9:39 a.m., indicated skin tears (ulcers) to the residents left lower leg were cleansed and redressed. Her left lower leg was swollen, reddened, tender to touch, and had a moderate amount of bloody drainage. There were no measurements or characteristics of the wound documented. The note did not include documentation to indicate the pain/ tenderness in the left lower leg was effectivly assessed. A new onset pain assessment was not completed to address Resident J's pain/tenderness to the left lower leg. The pain assessments, dated from 8/8/24 to 8/31/24 did not include documentation to indicate a pain assessment was completed on 8/27/24. A Medication Administration Record (MAR) dated August 2024 indicated the resident was not provided any pain medication on 8/27/24. An untimed physician's order, dated 8/27/24, indicated to cover the skin tears (ulcers) on the left lower inner leg (Wound 1) and left lower outer leg (Wound 2) with Mepitel followed by Mepilex until healed every night shift, for 14 days to be discontinued on 9/3. A Wound Nurse Practitioner (NP) note, dated 9/3/24 indicated Wound 1 measured 3.5 cm Length (l) X 2 cm Width (w) with moderate bloody drainage. No further assessment of the area had been documented. Wound 2 measured 1 cm (l) X 1 (w) cm in a V shape with moderate bloody drainage, but no further assessment of the area was documented. An Incident Note, dated 8/28/24 at 8:05 p.m., indicated the residents dressings had been changed per wound orders and she was to be seen by the wound NP the following day (8/29/24). There was no measurement or description of the wound areas or characteristics in the note. An Incident Note, dated 8/29/24 at 2:19 a.m., indicated the dressings to the residents skin tears (ulcers) were intact and there were no signs/symptoms of infection observed. There was no measurement or description of the wound areas or characteristics in the note. The Wound NP progress notes and the Physician progress notes, dated between 8/27/24 and 8/31/24, did not include documentation to indicate Wound 1 or Wound 2 was evaluated on 8/29/24. A Daily Skilled Nursing Note, dated 8/31/24 at 5:47 a.m., indicated the resident complained of pain in her left foot. There was no documentation completed of the wound site, the measurements of the wounds, swelling in the leg or condition of dressings. There was no pain assessment completed nor pain medication administered. The note did not include documentation to indicate Wound 1 or Wound 2 was evaluated on 8/31/24. There was no documentation of wound evaluations, treatments, monitoring, or pressure relief between 8/31 and 9/3/24. During an observation from the hallway outside Resident J's room, on 9/3/2024 at 2:20 P.M., Resident J was heard crying out in pain. She was observed lying in her bed with her legs flat on the mattress, covered with a sheet and blanket. She was anxious, grimacing, moaning, and calling out. She was crying and indicated her left leg hurt terribly. Licensed Practical Nurse (LPN) 3 was observed to enter the room and indicated the resident had her left leg wound debrided (physical removal of necrotic tissue with use of scalpel and forceps) before lunch. LPN 3 indicated Resident J had been administered Tylenol after the procedure but needed something stronger for the pain. LPN 3 was observed to administer Tramadol (pain medication used for moderate to severe pain) 50 mg (milligrams) 1 tablet by mouth for the leg pain. After she took the medication, she began to yell for her leg to be elevated. LPN 3 placed pillows below her legs to elevate them. After the medication administration, Resident J was observed to yell for the left leg to be elevated and LPN 3 was observed to place pillows under the resident's legs. A care plan for skin impairment, dated 9/3/24, indicated Resident J had a wound to her left posterior calf and skin tear (ulcer) to her left lower leg. Goals were for the wound to show signs of improvement, be free from infection, and her skin tear to heal. Interventions included: encourage the resident to elevate her legs; provide wound care as ordered; evaluate and change treatment as needed; monitor for signs/symptoms of pain, administer medications, and re-assess as needed; measure wounds at regular intervals; and monitor signs of healing or wound declining. On 9/4/24 at 9:44 A.M., Resident J was observed in her room, seated in her wheelchair, with both leg pedals slightly elevated, but low to the floor. Her left leg was wrapped from mid foot to top of her calf with an ace wrap bandage. The toes of her left foot were uncovered. The toes were red in color. She was feeling better on this day but indicated the day prior (9/3/24), had been a rough day. The Wound Nurse Practitioner (NP) had been in to visit to treat the wound on her left calf. The wound was painful during the treatment and worsened as the day wore on. She indicated she had been given stronger pain medication. The medication had provided relief from the pain. A Wound NP progress note, dated 9/3/24, indicated the resident was being seen to evaluate skin tears (ulcers) to her left lower extremity. She was observed to have a 1 cm x 1 cm x 0.1 cm V shaped laceration-type skin tear (ulcer) to the left anterior calf (Wound 2) with a non-viable flap and a 3.5 cm x 3.5 cm x 0.4 cm full thickness ulceration to the left medial part of her posterior lower left calf (Wound 1) which appeared consistent with a venous ulcer. There was slough observed to wound (Wound 1) which required sharp debridement to clearly assess the wound. The resident had no documented history of venous stasis disease but had chronic edema to her lower legs due to extensive history of CHF. The resident indicated she had pain at rest in her left lower leg. The tissue around the wound to the left anterior calf (Wound 2) was intact but fragile and there was a scant amount of serosanguineous (blood and clear fluid) drainage. The resident indicated no pain at rest with this wound. The wound to her left posterior lower calf (Wound 1) was 80% covered with slough (dead skin cells) (Stage 3 pressure area presents as a full-thickness loss of skin. Slough may be visible, but does not obscire the depoth of tissue loss) . Tissue around the wound was fragile and there was a heavy amount of serous (clear/cloudy) drainage. The resident complained of severe pain during removal of the bandages and indicated she had severe pain at rest with this wound. Both wounds were numbed and debrided which the resident tolerated without pain. New treatment orders were given to cleanse both wounds, apply calcium alginate (a dressing to promote fliud and enzyme stasis with a wound) to base of wounds, secure with a dressing and rolled gauze, every other day and as needed, followed by compression with Ace wrap to the left lower extremity. Recommendation was made to obtain venous reflux imaging to confirm the diagnosis of venous stasis ulcer to the left medial posterior calf. Intermittent leg elevation, at or above the heart level, was to be completed as tolerated. There was no documentation related the the air cast on the right lower leg. The results of the venous imaging were not available related to the test not having been completed at the time of the survey. Care plans did not reflect they had been updated to include the addition of the Calcium alginate. A Daily Skilled Nursing Note, dated 9/3/24 at 7:40 p.m., indicated the resident's wound showed signs and symptoms of infection and new orders were received to start Keflex (antibiotic) 500 mg by mouth, 3 times per day for 10 days. The note did not include sufficient documentation to determine the signs/symptoms exhibited. On 9/3/24 at 2:36 P.M., LPN 3 was interviewed. She indicated she'd asked the wound NP to check on Resident J's skin tears (ulcers) while she was in the facility on 9/3/24, seeing other residents. She indicated the resident's wounds looked bad and she was complaining of pain to the area. She indicated the resident had skin tears (ulcers) since the beginning of August but didn't have treatments or follow up documentation completed. Resident J was to wear compression stockings daily but hadn't been wearing them due to her wounds leaking fluids. LPN 3 did not indicate how long the wounds had been leaking, what was the facility's response was, or any interventions implemented. On 8/31 and 9/1/24, LPN 3 had wrapped the residents 's legs with ace wraps because her legs were too swollen for the compression stockings. When asked, she was unsure how the resident got the skin tears (ulcers) but thought the resident may have hit her calves on the wheelchair pedals or sides of the chair. In an interview on 9/4/24 at 10:19 AM, the Regional Nurse Consultant indicated she was unable to find any further documentation of the skin tear (ulcer) on the left lower leg, identified on 8/8/24 nor was there further documentation of the skin tear (ulcer) on the right lower leg which had been identified on 8/12/24. There were no observations for signs/symptoms of infection, no investigation for cause of the skin tears (ulcers), no documentation of interventions put into place to prevent further skin tears (ulcers) and no documentation of the wound being healed. The Regional Nurse Consultant indicated she was unable to find any further documentation of the skin tear (ulcer) on the right lower leg, and there was no documentation of the skin tear (ulcer) on the right lower leg being healed. On 9/4/24 at 11:10 A.M., the Wound NP was interviewed. She indicated she visited the facility on Tuesdays for wound rounds. She would see residents with different types of wounds, upon notification from staff. She indicated, there was no designated nurse to complete wound rounds with and would speak with the nurse caring for the resident on the day of her visits. On 9/3/24, she was notified by LPN 3, of the skin tears (ulcers) Resident J had. She had last seen the resident on 8/6/24 for follow up to a pressure wound she'd acquired while hospitalized in July 2024. The pressure wound was healed and required no further treatment. She indicated she hadn't been made aware of the resident's skin tears/wounds to her right or left lower extremities prior to 9/3/24. She indicated the resident complained of much pain when her left calf was lifted up and old dressings removed because of the swelling to her calf. She had proceeded with the debridement of both wounds following numbing the area and resident's comfort determined. The resident had tolerated the procedure without complaints of pain but had pain when the calf was re-dressed. The nurse gave the resident Tylenol after the procedure was completed. When questioned, she indicated residents with painful wounds should be pre-medicated with pain medication prior to her visits and treatments. She had not been told the resident had severe pain following the debridement procedure. When questioned regarding a visit to have been done on 8/29/24, she indicated her partner completed wound rounds on that day and their progress notes had not indicated Resident J was to be visited so she was not. On 9/4/24 at 10:19 A.M., the Regional Nurse Consultant indicated there was no facility policy specific to skin tears but provided a current copy of their policy monitoring skin and weights (S.W.A.T.) program. The policy indicated: Skin alterations such as the following will appear on the weekly skin assessments and will be followed by the clinical management staff for progress. These conditions/alterations will be care planned and managed and treated as per physician order. any concerns with progress and/or healing will be reported to the physician for guidance, recommendations, and/or orders .These areas are non-Pressure Ulcers or Pressure injuries and are therefore not routinely reviewed/discussed at the S-W-A-T meetings. a. skin tears .f. lacerations .m. other On 9/4/2024 at 12:09 P.M., Resident J was observed in the dining room, seated in her wheelchair with her legs slightly elevated but low to the floor. She wore a frown on her face and her eyes were partially closed. When questioned, she indicated she was fine but was observed to be intermittently grimacing. This Citation refers to Complaint IN00440946. 3.1-40

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's care plan was comprehensive and had been updated with new interventions to prevent the development of two new pressure ulcers. the facility further failed to accurately document pressure ulcer assessments. This deficiency affected 1 of 3 residents reviewed for pressure ulcer development, and resulted in the resident developing a new stage three pressure ulcer and a new stage 2 pressure ulcer. (Resident #59) Findings include: On 8/24/16 at 1:43 P.M. Resident #59 was observed lying in bed. On 8/25/16 at 9:15 A.M. Resident #59 was observed sitting up in his wheelchair. On 8/25/16 at 10:00 Resident #59 was lying in bed. On 8/25/16 at 2:30 P.M. Resident #59 was observed lying on his back in bed. On 8/25/16 at 3:30 P.M. Resident #59 was lying in bed slightly turned on his right side. On 08/26/2016 at 4:30 P.M. Resident #59 was observed lying on his back in bed. On 08/24/2016 at 10:12 A.M., during a staff interview, LPN #2 indicated Resident #59 had a stage 3 pressure ulcer on his right buttock. LPN #2 indicated the pressure ulcer on the resident's right buttock had been closed, but opened back up because the resident chose to sit in his chair for long periods of time. On 8/25/2016 at 10:19 A.M., Resident #59's clinical record was reviewed. Diagnose's included, but were not limited to, history of spinal cord tumor, neoplasm of unspecified behavior of endocrine glands and other parts of the nervous system, [MEDICAL CONDITIONS], and acute embolism and [MEDICAL CONDITION] of unspecified deep veins of unspecified distal lower extremity. An interview on 08/30/2016 at 9:43 AM with the Minimum Data Set Assessment Nurse indicated the care plans were updated a minimum of every 3 months and if a significant change was noted. On 7/19/16 a Pressure Ulcer note indicated the reopening of the right buttock stage 3 pressure ulcer that measured 0.8 x 1.2 x 0.1 cm. On 7/20/16, a new physician's orders [REDACTED]. On 7/30/16, a Pressure ulcer note indicated Resident #59 had a new stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle was not exposed. Slough may be present, but does not obscure the depth of tissue loss) identified on his right buttock that measured 5.0 x 3.2 x 0.2 cm (centimeters) and a new stage 2 pressure ulcer (Partial thickness loss of dermis, which presents as an intact or open/ruptured serum filled blister) on his left buttock that measured 4.0 x 2.0 x 0.1 cm. On 7/31/2016, a Pressure ulcer note indicated Resident #59 ' s reopened stage 3 pressure ulcer was non-healing and measured 1.0 x 1.4 x 0.3 cm. A Nursing Care Plan created on 6/17/14 and revised on 7/19/16, indicated Resident #59 had the potential for skin breakdown. It indicated Resident #59 was non-compliant with attempts to relieve pressure. The goal indicated Resident #59 would be provided with preventative measures in an attempt to avoid skin breakdown. Current interventions included, but were not limited to, air mattress to bed; dated 1/14/16, and Provide pressure reducing device to chair dated 8/26/16. A plan of care created on 6/17/14 and revised on 8/24/16, indicated Resident #59 had a wound and actual skin breakdown to the right and left upper buttocks. The goal, revised on 7/20/16 indicated the wounds would show reduction in size/stage of pressure ulcer and show no signs of infection. Interventions included: Apply barrier cream per MD order dated 8/4/16; Follow interventions list on 'Potential for skin breakdown problem dated 5/17/14; Nurse to measure/assess weekly & notify family & physician as needed dated 6/17/16; Resident to have air mattress to bed dated 8/4/16; On 8/26/16 at 12:00 PM, Resident #59's wound care was observed with RN #5, LPN #4, and CNA #6. Resident #59 had the following wounds observed: 1. Stage 3 pressure area to the coccyx/right upper buttock which had been identified on 12/30/15, closed on 6/22/16 and documented as reopening on 7/19/16. 2. Stage 3 pressure area to the right lower buttock. 3. Stage 2 pressure area to the left lower buttock. Additionally, a new stage 2 pressure ulcer was noted to the outer left lower buttock. On 8/26/16 at 1:50 P.M., during an interview with the Director of Nursing Service and RN #5, RN #5 indicated the left buttocks was 80% red and 20% slough. RN #5 indicated the wound assessments to left and right upper buttocks were documented wrong in the weekly assessments from 7/30/2016 through 8/24/16. RN #5 indicated the right buttocks was actually the left buttocks and the left buttocks was the right buttocks. On 6/2/16 the right upper buttocks wound closed and there was a preventative treatment in place. RN #5 indicated on 7/19/16 the right upper buttocks reopened and a treatment to pack the wound bed with Keltostat and cover with [MEDICATION NAME] was ordered on [DATE]. There were no additional care plan interventions initiated from 7/20/16 through 7/30/16 to address prevention of additional pressure ulcers. On 08/29/2016 10:50 A.M. interview with CNA #6 indicated the resident can help take off his shirt, use the trapeze, turn with extensive assist, and can use the head board to turn. CNA #6 indicated the resident is encouraged to turn all the time but he refuses and turning is very uncomfortable for the resident. CNA #6 indicated a Hoyer lift is used to transfer the resident to the chair and we get the resident up in his wheelchair for 1 to 1 and 1/2 hour then we put him back to bed after meals. CNA #6 indicated the resident does not like to turn at all while he is in bed. 3.1-40(a)(1)(2)

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent an accident that resulted in a femur fracture requiring hospitalization and surgical intervention for one of three resident reviewed for accidents. (Resident #26) Finding includes: On 9-24-2014 at 10:25 A.M., Resident #26 was observed in bed. Resident #26 was looking out the window and did not make eye contact when spoken too. On 9-24-2014 at 11:15 A.M., a record review was conducted of Resident #26's chart. Resident #26 was admitted on [DATE], to the locked dementia unit. [DIAGNOSES REDACTED]." The MDS assessment (Minimum Data Set-a assessment tool), dated 5-15-2014, indicated a BIMS (Brief Interview for Mental Status) of 4 out of a possible 15, severe cognitive impairment. Physicians medication orders included, "Aspirin tablet delayed release 81 mg (milligram) Give one tablet by mouth one time a day." The Occurrence Initial Assessment, dated 7-28-2014, indicated "...Date and time of occurrence 07/28/2014 at 0045 (12:45 A.M.)...Fall with injury...CNA (Certified Nursing Assistant) heard resident yelling out, checked on resident and noted her sitting on her floor in her room. Upon entering room writer noted resident sitting on her bottom next to her bed with her legs straight out in front of her. Writer assessed resident and noted abrasions on her right upper calf area and her right ankle. Bright red blood noted to both areas. Resident stated that she slid out of bed and hit her head on her nightstand. Writer noted a slightly raised area 1.5 cm (centimeters) round on her forehead...." The Occurrence Initial Assessment, dated 8-5-2014, indicated "...Date and time of occurrence 08/05/2014 at 0645 (6:45 A.M.)...Fall with no injury...Writer heard loud thump, upon investigation, Resident noted to be sitting on buttocks on the floor directly in front of her closed door, with legs straight out in front of her. Resident's roommate stated she witnessed fall, that Resident was stepping sideways at end of bed when she lost balance, her back sliding down end of bed, her buttocks hitting floor, ending up with back against closed room door. Roommate and Resident stated Resident did not hit head. Wearing non-skid shoes, call light within reach, but rolling walker across room out of reach...Stated mild tenderness to left knee and mid back. No redness or visible injuries noted at this time...Will request therapy screen and med review with Dr. (Medical Directors name) during rounds this evening...Neuro checks started due to hitting head or unwitnessed fall...NO...." A Progress Note, dated 8-5-2014 at 6:17 P.M., indicated "...Resident was seen today for her continued anxiousness and sleeplessness and falls. medications and treatments reviewed...PT/OT (physical therapy/occupational therapy) eval (evaluation) and treat...." A Progress Note, dated 8-6-2014 at 12:24 P.M., indicated "...OT skilled services for 5x (times) 1 week x4 weeks for ADL (Activities of Daily Living} training, neuro re-ed (education), there (therapeutic) exercise and there activities...." A Progress Note, date 8-6-2014 at 6 P.M., indicated "...Physical therapy 5 times per week for 4 weeks, for therapeutic exercises therapeutic activities, neuro (neurological)- re-education and gait training...." The Occurrence Initial Assessment, dated 8-7-2014, indicated "...Date and time of occurrence 08/07/2014 at 0445 (4:45 A.M.)...Fall with injury...Writer heard loud bang coming from residents room and immediantly (sic) went to check on resident. Upon entering room writer noted resident lying on her back on the floor near the foot of her bed. Resident was not incontinent and was wearing gripper socks. Floor was dry and free of debris. Residents right leg was rotated outward. Resident was stating extreme pain when right hip area was touched. No swelling noted to area. No further injuries noted. NW (North West) nurses placed resident on sliding board and onto her bed. Writer phoned physician and received order to send resident to (name of local hospital) ER (emergency room ) for evaluation and treatment per ambulance...." On 9-29-2014 at 12 P.M., an interview was conducted with LPN #4. LPN #4 indicated, "...She (Resident #26) was admitted to Country Meadows (locked dementia unit) in 2013. She fell there and went to the hospital on 8-7-2014 with a hip fracture, she had surgery to fix it and was readmitted on [DATE] to the facility on a different unit because she needed more assistance...." On 9-29-2014 at 1 P.M., record review of Resident #26's care plans was conducted. Fall risk care plan, dated 6-5-2013, indicated, "...Fall Risk characterized by risk factors decreased safety awareness due to Alz (Alzheimer's) Dementia, History of fall with fracture to lower arm...Interventions...Encourage resident to use handrails or assistive devices properly (created on 6-5-2013)...Reassess fall risk factors at least quarterly (created 6-5-2013)...Monitor for changes in gait/positioning (created on 6-5-2013)...Call light within reach. Explain use of it upon admission and reinforce as needed. (created on 6-5-2013)...Encourage and assist with wearing non-skid foot-wear before getting out of bed. (created on 4-22-2014)...Non-skid strip on the floor next to the bed. (created on 7-30-2014)...." On 9-29-2014 at 1:15 P.M., review of the "Incident/Accident Report Procedure & Form" dated 12-6-2013, received on 9-26-2014 at 11:30 A.M., from the DON (Director of Nursing), indicated "...3. PROCEDURE:...A. ASSESSMENT AND INVESTIGATION:...V. If there is any evidence of fracture or severe head trauma, do not more resident until emergency services arrive....VII. If the fall was not witnessed and the resident is unable to accurately inform staff that they did not hit their head, begin neurological assessment. Assess neurological system during assessment of injuries for all un-witnessed falls...C. DOCUMENTATION REQUIREMENTS:...II. Complete the fall assessment at the bottom of the "occurrence initial" assessment if the patient had a fall...." On 9-29-2014 at 3:30 P.M., during an interview, the DON (Director of Nursing) indicated, "... it would not be appropriate for a resident with a BIMS of 4 to have an intervention on their care plan that would be a reminder to use their call light...I should have checked the incident with an IDT (Interdisciplinary Team) form that I am supposed to be filling out...I did not know I was supposed to and none has been filled out since this spring...." There was no documentation to indicate the care plans were updated to include increased supervision or other interventions to prevent falls. 3.1-45(a)(2)