Every finding on record at Waters of Scottsburg, The

Based on interview and record review, the facility failed to ensure physician ordered parameters were followed for 1 of 3 residents reviewed for quality of care (Resident C). Findings include:The clinical record for Resident C was reviewed on 7/14/26 at 9:55 a.m. The resident's diagnosis included, but was not limited to, hypertension (a condition where the force of blood against the artery walls is consistently too high, forcing the heart to work harder).The physician's order, dated 4/17/26, indicated the resident was to receive Coreg (medication for high blood pressure) 6.25 mg (milligrams) twice daily, in the morning and evening. The medication was to be held if the resident's systolic blood pressure (SBP) was less than 110.Review of the May 2026, June 2026 and July 2026 medication administration record indicated the resident received the medication on the following dates:- On 5/06/26, the resident received the evening dose with a SBP of 98.- On 5/14/26, the resident received the evening dose with a SBP of 108.-On 5/27/26, the resident received the morning dose with a SBP of 109.- On 6/08/26, the resident received the morning dose with a SBP of 109.- On 6/10/26, the resident received the evening dose with a SBP of 109.- On 6/15/26, the resident received the evening dose with a SBP of 107.- On 6/16/26, the resident received the morning dose with a SBP of 107.- On 6/24/26, the resident received the evening dose with a SBP of 103.- On 6/25/26, the resident received the morning dose with a SBP of 103.- On 7/04/26, the resident received the morning dose with a SBP of 98.- On 7/13/26, the resident received the morning dose with a SBP of 104. The physician's order, dated 4/17/26, indicated the resident was to receive Hydralazine (medication for high blood pressure) 50 mg three times a day, in the morning, afternoon and evening. The medication was to be held if the resident's systolic blood pressure was less than 110.Review of the May 2026, June 2026 and July 2026 medication administration record indicated the resident received the medication on the following dates:- On 5/06/26, the resident received the evening dose with a SBP of 98.- On 5/14/26, the resident received the afternoon dose with a SBP of 108.- On 5/14/26, the resident received the evening dose with a SBP of 108.- On 5/27/26, the resident received the morning dose with a SBP of 109.- On 5/28/26, the resident received the evening dose with a SBP of 101.- On 6/08/26, the resident received the morning dose with a SBP of 109.- On 6/10/26, the resident received the evening dose with a SBP of 109.- On 6/13/26, the resident received the morning dose with a SBP of 108.- On 6/15/26, the resident received the evening dose with a SBP of 107.- On 6/16/26, the resident received the morning dose with a SBP of 107.- On 6/24/26, the resident received the evening dose with a SBP of 103.- On 6/25/26, the resident received the morning dose with a SBP of 103.- On 6/28/26, the resident received the morning dose with a SBP of 102.- On 7/04/26, the resident received the morning dose with a SBP of 98.- On 7/13/26, the resident received the morning dose with a SBP of 104.- On 7/13/26, the resident received the afternoon dose with a SBP of 104. During an interview, on 7/14/26 at 11:44 a.m., Registered Nurse (RN) 4 indicated the physician set parameters should be followed. On 7/14/26 at 10:40 a.m., the Clinical Nurse Consultant provided a current copy of the document titled Medication Administration Policy Guideline dated 1/25/19. It included, but was not limited to, Policy.Medications are administered as prescribed, in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the attending physician. This Citation relates to Intake 3029909410 IAC (Indiana Authorization Code) 16.2-3.1-37

Based on observation, interview and record review, the facility failed to ensure food temperatures were maintained for 1 of 1 lunch observation. Findings include:During a telephone interview, on 7/14/26 10:15 a.m., the complainant indicated the food was not warm when she received her meal trays. During an interview, on 7/14/26 at 10:22 a.m., Resident C indicated she received her meals in her room. Her food had not been warm when she received it. During an interview, on 7/14/26 at 10:29 a.m., Resident E indicated she ate all of her meals in her room and the food was cold when served. On 7/14/26 at 12:57 p.m., on the Eagle-[NAME] Hallway, the food temperatures, obtained by the outsourced Dietary Manager, were observed as follows:-Chile - 138.4 Farhenheit-Pureed Chile - 113.2 Farhenheit-Carrots - 125.2 Fahrenheit During an interview, on 7/14/26 at 1:00 p.m., the outsourced Dietary Manager indicated she did not understand how the food temperatures were not maintained at 135 degrees Fahrenheit. On 7/14/26 at 2:54 p.m., the Executive Director provided a current, undated copy of the document titled Food Temperatures at Point of Service. It included, but was not limited to, Food will be prepared, held, and served in a manner that preserves nutritive value and palatability .Procedure .Hot foods will be held at temperatures 135 degrees or above This Citation relates to Intake 3029909,410 IAC (Indiana Authorization Code) 16.2-3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure a resident's narcotic count sheet was available for review, failed to ensure administered narcotic pain medication was documented on the medication administration record, and failed to ensure insulin administration was documented timely for 2 of 3 residents reviewed for Resident Records. (Resident B and Resident C) Findings include:1. The clinical record for Resident B was reviewed on 7/14/26 at 8:44 a.m. The resident's diagnoses included, but were not limited to, diabetes (a chronic condition where the body cannot process blood sugar properly) and depression (a common, serious mood disorder that causes persistent feelings of sadness, emptiness, and loss of interest in activities).The physician's order, dated 4/17/26, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed for pain.The pharmacy packaging slip, dated 4/20/26, indicated the facility received 30 tablets of the Hydrocodone-Acetaminophen 5-325 mg for the resident.The clinical record lacked documentation of a controlled drug record for the narcotic pain medication delivered on 4/20/26 for administrations between 4/23/26 through 5/8/26.During an interview, on 7/14/26 at 2:04 p.m., the Director of Nursing indicated they could not locate the controlled drug record.Review of the controlled drug record for April 2026 and May 2026 indicated the medication was administered on the following dates and times: 4/17/26 at 8:00 p.m., 4/18/26 at 8:00 p.m., 4/19/26 at 8:00 p.m., 4/20/26 at 8:00 p.m., 4/21/26 at 6:00 a.m. and 8:00 p.m., 4/22/26 at 8:00 p.m., 5/09/26 at 8:00 p.m., 5/11/26 at 8:00 p.m., 5/12/26 at 8:00 p.m., 5/14/26 at 6:30 p.m., 5/15/26 at 12:00 a.m. and 7:00 p.m., 5/16/26 at 8:00 p.m., 5/17/26 at 7:30 p.m., and 5/19/26 at 7:00 p.m.The April 2026 and May 2026 medication administration record lacked documentation of the administration of the narcotic pain medication on the above dates.The physician's order, dated 5/10/26, indicated the resident was to receive Humalog (slow-acting insulin), 8 units subcutaneously with meals at 7:00 a.m., 11:00 a.m. and 5:00 p.m.The May 2026 medication administration record indicated the insulin was administered on the following dates and times:- On 5/11/26, 7:00 a.m. scheduled dose administered at 10:14 a.m.- On 5/13/26, 7:00 a.m. scheduled dose administered at 10:21 a.m.- On 5/14/26, 7:00 a.m. scheduled dose administered at 10:08 a.m.- On 5/14/26, 11:00 a.m. scheduled dose administered at 12:48 p.m.- On 5/15/26, 7:00 a.m. scheduled dose administered at 8:32 a.m.- On 5/16/26, 7:00 a.m. scheduled dose administered at 8:41 a.m.- On 5/17/26, 7:00 a.m. scheduled dose administered at 8:38 a.m.- On 5/17/26, 11:00 a.m. scheduled dose administered at 12:31 p.m.- On 5/18/26, 7:00 a.m. scheduled dose administered at 10:40 a.m.- On 5/18/26, 11:00 a.m. scheduled dose administered at 12:28 p.m.- On 5/19/26, 7:00 a.m. scheduled dose administered at 11:37 a.m.- On 5/19/26, 11:00 a.m. scheduled dose administered at 3:12 p.m.- On 5/20/26, 7:00 a.m. scheduled dose administered at 12:22 p.m.- On 5/20/26, 11:00 a.m. scheduled dose administered at 12:49 p.m.- On 5/21/26, 7:00 a.m. scheduled dose administered at 9:11 a.m.- On 5/22/26, 7:00 a.m. scheduled dose administered at 10:08 a.m. During an interview, on 7/14/26 at 11:44 a.m., Registered Nurse (RN) 4 indicated medications with a scheduled time should be administered an hour before or an hour after the scheduled time and documented at that time.On 7/14/26 at 2:42 p.m., the Regional Nurse Consultant provided a current copy of the document titled Confidentiality of Medical Records dated 6/26/23. It included, but was not limited to, Policy.It is the facilities responsibility for safeguarding both the resident's medical record and its information against loss.On 7/14/26 at 10:40 a.m., the Clinical Nurse Consultant provided a current copy of the document titled Medication Administration Policy Guideline dated 1/25/19. It included, but was not limited to, Policy.Medications are administered as prescribed.Procedure.Medications are administered in accordance with written orders of the attending physician.Medications are administered within 60 minutes of scheduled time.The resident's MAR is initialed by the person administering a medication. 2. The clinical record for Resident C was reviewed on 7/14/26 at 9:55 a.m. The resident's diagnoses included, but were not limited to, fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain) and depression (a common, serious mood disorder that causes persistent feelings of sadness, emptiness, and loss of interest in activities).The physician's order, dated 5/14/26, indicated the resident was to receive Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed for pain.Review of the May 2026, June 2026 and July 2026 controlled drug records indicated the resident received the pain medication on the follow dates and times: 5/16/26 at 6:00 p.m., 5/18/26 at 12:00 a.m., 5/19/26 at 12:00 a.m., 5/20/26 at 12:00 a.m., 5/22/26 at 8:00 p.m., 5/23/26 at 8:00 p.m., 5/24/26 at 8:00 p.m., 5/25/26 at 8:00 p.m., 5/28/26 at 7:00 p.m., 5/29/26 at 12:00 a.m., 5/29/26 at 7:00 p.m., 6/01/26 at 7:30 p.m., 6/02/26 at 12:30 a.m., 6/02/26 at 8:00 p.m., 6/03/26 at 8:00 p.m., 6/04/26 at 8:30 p.m., 6/07/26 at 5:45 p.m., 6/08/26 at 8:00 p.m., 6/09/26 at 7:30 p.m., 6/10/26 at 8:00 p.m., 6/11/26 at 11:00 p.m., 6/15/26 at 7:00 p.m., 6/15/26 at 11:00 p.m., 6/16/26 at 8:00 p.m., 6/17/26 at 8:00 p.m., 6/18/26 at 11:00 p.m., 6/20/26 at 1:45 a.m., 6/22/26 at 6:30 p.m., 6/23/26 at 7:00 p.m., 6/24/26 at 7:00 p.m., 6/25/26 at 8:00 p.m., 6/28/26 at 7:26 p.m., 6/29/26 at 9:00 a.m., 7/01/26 at 9:00 p.m., 7/02/26 at 9:00 p.m., 7/06/26 at 7:30 p.m., 7/09/26 at 7:00 p.m., 7/10/26 at 7:00 p.m., and 7/11/26 at 12:00 a.m. The resident's May 2026, June 2026 and July 2026 medication administration record lacked documentation of the above administrations. This Citation relates to Intake 3029909,410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(1)410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place when a resident (Resident B) with impaired cognition and risk for elopement was left outside without staff supervision. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/25/26 when Resident B, with cognitive impairment and elopement risk, propelled himself from the facility grounds to a heavily traveled road where the resident fell out of his wheelchair landing on the pavement in the emergency lane which was 0.2 miles from the facility. The resident was sent to the emergency room and treated for an abrasion to his right foot and right hand. The Executive Director (ED) and Director of Nursing (DON), Regional Director of Operations (RDO) and Regional Nurse Consultant (RNC) were notified of the Immediate Jeopardy on 4/28/26 at 3:33 p.m. Findings include:The clinical record for Resident B was reviewed on 4/28/26 at 11:18 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), right dominant side hemiplegia and hemiparesis (neurological condition affecting one side of the body caused by a brain injury such as a stroke) secondary to a cerebral infarction, cognitive communication deficit (communication impairment) and aphasia (disorder caused by brain damage). The progress note, dated 4/8/26 at 3:35 p.m., indicated the resident was admitted to the facility, the resident was alert to self, unable to understand most things, was able to propel himself in his wheelchair and had a white board for communication. The progress note, dated 4/23/26 at 8:27 p.m., indicated the resident returned from the hospital and a wander guard was placed to his right ankle. The progress note, dated 4/24/26 at 2:25 p.m., indicated the location of the resident's wander guard was changed from the resident's right lower ankle to the left upper wrist. The progress note, dated 4/24/26 at 4:08 p.m., indicated the wander guard was in place to the resident's left wrist. The resident had removed the wander guard once today. The resident was monitored throughout the shift. The care plan, dated 4/24/26, indicated the resident was at risk for elopement related to periods of confusion, the inability to verbally express needs, not wanting to be at the facility and making statements that he was going to leave and go home. The police report, dated 4/25/26 at 7:59 p.m., indicated a call was received for a medical issue on a busy road 0.2 miles from the facility. The hospital emergency department record, dated 4/25/26 at 9:00 p.m., indicated the resident presented to the emergency department after eloping and flipping out of his wheelchair. The resident was non-verbal, had a history of a stroke and had abrasions on his right foot and right hand. The IDT (interdisciplinary team) note, dated 4/27/26 at 3:57 p.m., indicated the following:-Resident had demonstrated a consistent pattern of expressing a desire to leave the facility, which included gesturing and behaviors indicative of exit-seeking-On 4/19/26, the resident left the faciity on LOA (leave of absence) with a family friend. The resident did not return until the next day. Upon return, the resident initially refused to exit the vehicle and required assistance and EMS (emergency medical services). The resident was sent to the hospital for evaluation and returned to the facility the following day.-The resident continued to express his desire to leave the facility and exhibited ongoing exit-seeking behaviors.-The resident was later (4/25/26) identified off facility grounds and at approximately 8:06 p.m., was located on the roadside. The resident was evaluated and observed to have an abrasion to the right foot and hand. The incident report, dated 4/28/26, indicated Resident B attempted to leave the facility on 4/25/26 by exiting the front doors and propelling himself off the property. The resident fell out of his wheelchair. During an observation, on 4/29/26 at 8:50 a.m., Resident B was observed with an abrasion to the right palm, between the thumb and forefinger. The second toe and fourth toe of the right foot had one small, scabbed area. The right great toe had an abrasion that measured 1.2 cm (centimeters) in width and 3 cm in length. During an interview, on 4/28/26 at 11:07 a.m., the Director of Nursing indicated on 4/25/26 at 6:00 p.m., a group of residents, including Resident B, were sitting on the front porch. There were two staff from the oncoming night shift Certified Nursing Assistants (CNA 5 and CNA 6), who were sitting outside at a table prior to the start of their shift when the residents had come out to the front porch. Activity Aide 7 had walked out of the facility after clocking out and sat at the table waiting for her ride home. CNA 5 and CNA 6 went inside the facility to clock in for work. CNA 5 and CNA 6 were unaware the Activity Aide 7 had clocked out to go home and was waiting for her ride home. At 6:45 p.m., Qualified Medication Aide (QMA) 9 exited the facility through the front doors and did not see any residents or staff outside at that time. Speech Therapist 8 had left the facility for the evening and, at 8:06 p.m., notified the facility of the resident's elopement. During an interview on 4/29/26 at 1:18 p.m., Speech Therapist 8 indicated she had left the facility at around 8:00 p.m. on 4/25/26. When she had gotten up to the main road, she planned to turn right. She looked to the left and then turned right onto the road, however, she turned around in a parking lot on the left side of the road because she had seen a person lying on the side of the road. She pulled up and had gotten out of her car where she saw two middle-aged men and a woman. The two men had gotten the male up off of the ground and into his wheelchair. She spoke to one of the gentlemen who reported that he had called 911. She asked the gentleman if she could speak with the male to make sure it was not a resident from where she worked. She asked the male if she could take a picture of him and he shook his head yes. She took the picture and sent it to her manager and asked if the resident belonged to their facility. Her manager sent her a text back and told her he was a resident of the facility. EMS and the police had arrived by then. Not long after that, multiple staff members from the facility had gotten to the scene. During an interview, on 4/29/26 at 3:29 p.m., Activity Aide 7 indicated on 4/25/26, she had been sitting outside waiting for a ride and there were residents outside. When she left at 6:00 p.m., Resident B was still sitting outside. Activity Aide 7 was unaware that Resident B was an elopement risk. On 4/28/26 at 1:18 p.m., the Administrator provided a current, undated copy of the document titled Policy and Procedure Regarding Missing Residents and Elopement. It included, but was not limited to, Policy Statement.It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. The past non-compliance Immediate Jeopardy that began on 4/25/26. The Immediate Jeopardy was removed and corrected by 4/26/26 after the facility implemented a systemic plan that included the following actions: All staff were educated on the elopement policy and procedure with emphasis an elopement prevention (4/25/26); Elopement assessments were completed on all residents residing in the facility and care plans updated as needed (4/25/26); Elopement binders were updated and current (4/25/26); Implementation of weekly reviews of elopement risk assessments for four weeks, then monthly for five months to ensure any resident with high risk scores have appropriate safety precautions in place (4/26/26). This Citation relates to Intake 2996030 410 IAC (Indiana Administrative Code) 3.1-45(a)(2)

Based on interview and record review, the facility management failed to timely report an incident to the Indiana Department of Health when a cognitively impaired resident (Resident B) with a high risk for elopement exited the facility grounds, without supervision, for 1 of 3 residents reviewed for reportable incidents. Findings include:The clinical record for Resident B was reviewed on 4/28/26 at 11:18 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction (stroke), aphasia, cognitive communication deficit and altered mental status. The incident report, dated 4/28/26, indicated on 4/25/26, Resident B attempted to leave the facility, against medical advice, by exiting the front doors. Resident B propelled himself, in his wheelchair, off of the property and fell out of the wheelchair. The admission BIMS (Brief Interview of Mental Status) assessment, dated 4/10/26, indicated the resident had a cognitive impairment. Residents with impaired cognition cannot leave a facility against medical advice. The elopement risk assessment, dated 4/24/26 at 1:23 p.m., indicated Resident B was a high risk for elopement. The care plan, dated 4/24/26, indicated the resident was at risk for elopement related to periods of confusion, inability to verbally express needs and making statements that he wanted to leave and go home. Review of the requested State reportable incidents lacked documentation of Resident B's elopement from the facility. During an interview, on 4/28/26 at 11:25 a.m., the Administrator indicated she had spoken with the corporate team. She was advised to do a re-assessment of Resident B's BIMS score, which was 12 (impaired cognition). Since it was a 12, she was told not to report the incident. During an interview, on 4/29/26 at 8:32 a.m., the Regional Director of Operations indicated the facility follows the State guidance on reporting incidents. On 4/29/26 at 8:49 a.m., the Regional Director of Operations provided a copy of the Indiana Department of Health Policies and Procedures titled Long-Term Care Abuse and Incident Reporting. It included, but was not limited to, Purpose .To facilitate compliance with state and federal law and regulation, as applicable, related to reporting of .incidents in licensed long-term care facilities in Indiana .Elopement .Elopement occurs when a resident without decision making capacity leaves the premises or a safe area without authorization .and/or any necessary supervision to do so OR a resident with decision making capacity leaves the premises or a safe area, without facility knowledge This Citation relates to Intake 2996030 410 IAC (Indiana Authorization Code) 16.2-3.1-28(c)

Based on observation, interview and record review, the facility failed to ensure catheter care was in place for a resident (Resident C) with an indwelling catheter for 1 of 1 residents reviewed for urinary catheters. Findings include:The clinical record for Resident C was reviewed on 4/29/26 at 12:07 p.m. The resident's diagnosis included, but was not limited to, Stage 4 pressure ulcer (severe, full thickness wound involving extensive tissue loss, exposing muscle, tendon or bone) to the sacrum. On 4/29/26 at 8:50 p.m., the resident was observed with an Indwelling urinary catheter in place. The physician's order, dated 4/8/26, indicated the resident was to receive catheter care every shift. The clinical record lacked documentation of catheter care provided to the resident between 4/9/26 and 4/29/26. During an interview, during the survey period, Staff Member 13 indicated indwelling urinary catheter care should be provided every shift and documented. On 4/30/26 at 4:00 p.m., the Regional Director of Operations provided a current copy of the document titled Guidelines for Indwelling Foley Catheter Care dated 10/16/24. It included, but was not limited to, Purpose.The main purpose of proper indwelling foley catheter care is to prevent catheter associated urinary tract infections. Trained clinical staff.will conduct indwelling foley catheter care. This Citation relates to Intake 2996274 410 IAC (Indiana Authorization Code) 16.2-3.1-41(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident C) IV (intravenous) antibiotic therapy was reflected on the medication administration record, as ordered by the physician, for 1 of 3 residents reviewed for IV medication administration. Findings include:The clinical record for Resident C was reviewed on 4/29/26 at 12:07 p.m. The resident's diagnosis included, but was not limited to, osteomyelitis (a serious bone infection causing inflammation and potential tissue death, usually triggered by bacteria spreading from nearby wounds, surgery, or the bloodstream). During an observation, on 4/29/26 at 8:50 a.m., Resident C was observed with a PICC (peripherally inserted central catheter) line to the right upper extremity. The physician's order, dated 4/8/26, indicated the resident was to receive Vancomycin (A powerful antibiotic used to treat serious infections) HCl (hydrochloride) 1.25 grams, intravenously two times a day at 8:00 a.m. and 8:00 p.m. for osteomyelitis. The April 2026 medication administration record lacked documentation of the administration of the antibiotic at 8:00 a.m. on 4/23/26 and 4/27/26. The physician's order, dated 4/20/26, indicated the resident was to receive Cefazolin Sodium (antibiotic used for bone/joint infections) 2 grams, intravenously, every 8 hours at 6:00 a.m., 2:00 p.m. and 10:00 p.m. for osteomyelitis. The April 2026 medication administration record lacked documentation of the administration of the antibiotic on 4/23/26 at 2:00 p.m. During the survey period, Staff Member 14 indicated the medication administration record should be signed off by the nurse administering the medication. On 4/30/26 at 4:00 p.m., the Regional Director of Operations provided a current, undated copy of the document titled Medication Administration Guidelines. It included, but was not limited to, The Right Documentation.Sign MAR immediately after administering the medications. This Citation relates to Intake 2996274 410 IAC (Indiana Authorization Code) 16.2-3.1-47(a)

Based on interview and record review, the facility failed to ensure behavior monitoring was in place for a resident (Resident B) with exit-seeking behaviors for 1 of 3 residents reviewed for behaviors. Findings include:The clinical record for Resident B was reviewed on 4/28/26 at 11:18 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain) and cognitive communication deficit (communication impairment).The care plan, dated 4/24/26, indicated the resident was at risk for elopement related to periods of confusion, unable to verbally express needs, making statements that was going to leave and go home and did not want to be at facility. The IDT (interdisciplinary team) note, dated 4/27/26 at 3:57 p.m., indicated the following:-Resident had demonstrated a consistent pattern of expressing a desire to leave the facility, which included gesturing and behaviors indicative of exit-seeking-On 4/19/26, the resident left the faciity on LOA (leave of absence) with a family friend. The resident did not return until the next day. Upon return, the resident initially refused to exit the vehicle and required assistance and EMS (emergency medical services). The resident was sent to the hospital for evaluation and returned to the facility the following day.-The resident continued to express his desire to leave the facility and exhibited ongoing exit-seeking behaviors.-The resident was later (4/25/26) identified off facility grounds and at approximately 8:06 p.m., was located on the roadside. The clinical record lacked documentation of the implementation of behavior tracking monitoring for the resident's exit-seeking behaviors. During the survey period, Staff Member 17 indicated the resident had exit-seeking behaviors prior to the day he had eloped. During an interview, on 4/30/26 at 12:16 p.m., the Social Services indicated Resident B should have behavior monitoring in place for exit-seeking behaviors. On 4/30/26 at 12:41 p.m., the Regional Director of Operations provided a current copy of the document titled Behavior Management Program dated 5/20/24. It included, but was not limited to, Purpose.Each resident of the facility identified as exhibiting problematic behavior will be observed in a manner to identify the casual factor, if possible, of the behavior as well as seek approaches/interventions appropriate for the same.Policy.It is the policy of this facility to assess those residents exhibiting problematic behavior.Initiation of Behavior Management Logbook.The record should list behaviors and interventions specific to the resident.Procedure.Each resident who exhibits problematic behaviors will have a form for monitoring his/her status. This Citation relates to Intake 2996030 410 IAC (Indiana Authorization Code) 16.2-3.1-37

Based on observation, interviews, and record review, the facility failed to ensure food was stored and prepared in a sanitary manner during 3 of 3 kitchen observations. This deficient practice had the potential to affect 63 or 63 residents. Findings include: During the initial tour of the kitchen, on 4/7/26 at 10:23 a.m., while accompanied by the Dietary Manager, the following concerns were observed:-The left-side metal table near the dishwasher in the dish room had a large accumulation of brown water with egg particles floating in the water.-The outside of three glass coffee decanters sitting on the coffee pot bases were covered with a white sticky film.-The floor had a dried sticky spill in front of the long metal prepping table.-The floor had a dried sticky spill at the entrance to the kitchen. -The stovetop burners had a heavy accumulation of black crust on them.-There was a large accumulation of debris and dust underneath the food storage shelving in the dry storage room.-The walk-in freezer had a condenser pipe wrapped in a foam tube and covered with black tape. There was a silver bucket sitting on a shelf on top of a cookie sheet to collect water if it began leaking. The bucket had a small amount of water in it. On the lower shelf below, there was an opened box of single yogurts, a box of frozen chicken meat, and a box of Salisbury steak meat.During an interview, 4/7/26 at 10:25 a.m., the Dietary Manager indicated the pipe in the walk-in free would freeze at times and the bucket was to collect leaking water. He indicated that maintenance was aware of the occasional leaking.During an observation, 4/7/26 at 11:35 a.m., the Robot Coupe (used to create smooth purees, sauces, and baby food) was used to puree beef stroganoff, broccoli, and rolls. The lid was cracked in one area from the edge to the center of the lid. 2. During the second observation of the kitchen, while accompanied by the Dietary Manager, on 4/9/26 at 1:00 p.m., the following concerns were identified:-The same issues identified on 4/7/26 at 10:23 a.m., remained a concern except for the standing brown water with egg particles on the metal table in the dish room.-There was a large accumulation of breadcrumbs on the prepping table, near the toaster and on the floor.During an interview with the Administrator and Maintenance, on 4/8/26 at 10:37 a.m., the Maintenance Director indicated that he had been letting the kitchen verbally tell him if the pipe was leaking. He would put a new work order into the electronic system for repairs. He was waiting for defrost mode to work on the pipe.During an interview with the Dietary Manager, on 4/9/26 at 1:00 p.m., he was unsure when the lid cracked on the Robot Coupe, but did verbalize that it was after he started working at the facility a year ago. The Dietary Manager indicated at this time that Maintenance had fixed the condenser pipe in the walk-in freezer.During an interview, on 4/9/26 at 1:30 p.m., the Administrator indicated that on 4/8/26 a lid was purchased for the Robot Coupe. The administrator indicated that a work order had been placed on 4/8/26 for Maintenance to repair the condenser pipe in the walk-in freezer. She indicated the freezer was original to the building with older parts to repair.During an interview with the Dietary Manager, on 4/10/26 at 9:05 a.m., he indicated on 4/9/26 the steam table looked dirty to him due to a staff member resigning the previous evening who would have cleaned it.During a record review of the daily cleaning schedule, on 4/9/26 at 2:00 p.m., the document indicated many kitchen tasks were to be completed daily. The following tasks were completed and initialed on 4/6/26, 4/7/26, and 4/8/26. -Mopping and sweeping kitchen-Toaster cleaned.-Steam tables drained and wiped out at the end of the day-Dry storage area organized and swept-Stovetop/range/grill cleaned and scrubbed at the end of the day. 3. During the third observation of the kitchen, while accompanied by the Dietary Manager, on 4/13/26 at 9:00 a.m., the following was identified: continued use of the Robot Coupe until it would be replaced. The condenser pipe in the walk-in freezer remained intact with the foam tube and heat tape. The was no bucket to catch potential leaking water. The current policy, titled Sanitation was provided by the Administrator on 4/9/26. The policy indicated, but was not limited to, .The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean. 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the residents' medication status for 1 of 21 resident MDS reviewed for accuracy of assessments. (Resident 10).Findings include: The record for Resident 10 was reviewed on 4/7/26 at 1:14 p.m. The diagnosis included, but was not limited to, moderate depressive disorder, recurrent (a serious, common mental health condition characterized by persistent sadness, loss of interest in activities and low energy which lasted at least 2 weeks).The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had slight impairment in cognition, frequently felt down or depressed and felt tired. The MDS, medication section, indicated the resident was marked as not having used any anti-depressants.A physician's order, dated 11/24/25, indicated the resident was to take 1 tablet of mirtazapine (Remeron - anti-depressant medication) tablet 15 milligrams (mg) at bedtime for depression.An interview with the MDS Coordinator, on 4/13/26 at 10:30 a.m., she indicated that if she had not already transmitted the information, then she would go back and correct the areas needed. If the MDS was already transmitted, then she would complete a correction MDS. On 4/10/26 at 2:15 p.m., the Executive Director indicated there was no specific policy on MDS coding, but the MDS coding followed the Resident Assessment Instrument (RAI) instructions.410 IAC (Indiana Administrative Code) 16.2-3.1-31(h)410 IAC 16.2-3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure documentation on the Controlled Drug Receipt/Record/Disposition Form of administered narcotics for 2 of 46 residents observed for pharmacy services. (Residents 7 and 68) Findings include: 1. During an observation, on 4/9/26 at 10:25 a.m., the Controlled Drug Receipt/Record/Disposition Form indicated Resident 7's Pregabalin (used to treat anxiety and neuropathic pain) was documented as administered on 4/9/26 at 8:00 a.m., by Licensed Practical Nurse (LPN) 4. The count on the sheet indicated 25 capsules left. The medication card indicated 26 capsules left. During an interview, on 4/9/26 at 10:28 a.m., LPN 4 indicated she thought she had administered the medication that morning. She could not explain why the count was off. At 10:48 a.m., LPN 4 indicated the administration range of Resident 7's Pregabalin was between 7:00 a.m. and 11:00 a.m., and she had not administered the medication, so she wasn't late to administer it. She then indicated she should not have signed the narcotic out before administering it, because the count would be off. The record for Resident 7 was reviewed on 4/9/26 at 2:47 p.m. The diagnosis included, but was not limited to, neuralgia (severe, sharp stabbing or burning pain) and neuritis (swelling of nerves causing numbness or muscle weakness). The physician's order, dated 7/29/25 at 7:00 a.m., indicated the nurse was to administer 300 milligrams (MG) of Pregabalin to the resident, two times a day for neuropathy between 7:00 a.m. and 11:00 a.m.The care plan, dated 12/16/25 and last revised 2/23/26, indicated the resident was at risk for adverse effects related to opioid medication use for pain management. The interventions, dated 12/16/25, included, but were not limited to, administer medications as ordered, monitor vital signs as needed, particularly respirations, and observe for effectiveness of medications. The April 2026 Medication Administration Record (MAR) indicated the nurse was to administer 300 milligrams (MG) of Pregabalin to the resident, two times a day for neuropathy between 7:00 a.m. and 11:00 a.m.2. During an observation, on 4/9/26 at 10:58 a.m., the Controlled Drug Receipt/Record/Disposition Form indicated Resident 68's Hydrocodone-Acetaminophen (Norco) had a count of 11 tablets documented. There were 10 tablets left on the medication card. The 5-325 mg Norco was documented as last administered by LPN 5 on 4/8/26 at 8:00 p.m.During an interview, on 4/9/26 at 11:00 a.m., LPN 6 indicated she forgot to sign out the Norco. She got distracted by another resident. She should sign out narcotics when she administered them. The record for Resident 68 was reviewed on 4/10/26 at 11:00 a.m. The diagnosis included, but was not limited to, chronic pain syndrome (pain lasting longer than 3 to 6 months with emotional or functional issues). The care plan, dated 1/14/26, indicated the resident had a diagnosis of chronic pain syndrome and was at increased risk for alteration in pain or discomfort and was at risk for adverse effects from opioid drug use. The interventions, dated 1/14/26, included, but were not limited to, medications per order, to notify the physician for any new complaints of pain, monitor for signs or symptoms of pain to obtain new order for medication regimen or break-through pain management, and observe for effectiveness of pain relief. The physician's order, dated 2/11/26 at 8:00 p.m., indicated the nurse was to administer 5-325 mg of Hydrocodone-Acetaminophen (Norco) two times a day for pain. The April 2026 MAR, indicated the resident received 5-325 mg Norco on 4/8/26 at 8:00 p.m. by LPN 5. The current Guidelines for Controlled Substance Medications - An overview policy, included, but was not limited to, . Responsibilities of the Nurse Who Receives/Takes Possession of/Accepts-Delivered Controlled Drugs. Verify drug strength and number received. Sign the Controlled Medication Delivery Manifest, verifying receipt of the medication (both quantity and strength). 410 IAC (Indiana Administrative Code) 16.2-3.1-25(b)(1)(c)

Based on observation, record review, and interview, the facility failed to ensure glucometers were cleaned per guidelines for infection control when obtaining blood sugar readings for 2 of 3 residents observed. (Residents 29 and 7) Findings include:1. During an observation, on 4/9/26 at 8:05 a.m., Resident, 29's accu check (glucometer - machine used for blood sugar monitoring) was completed by Licensed Practical Nurse (LPN) 4. The resident's blood sugar was 254 milligrams per deciliter (mg/dL). The LPN brought the glucometer back to the medication cart and placed it into the resident's case without cleaning it. LPN 4 obtained the insulin and administered it to the resident. She then went onto her computer to check off the medication and went on to her next resident. The record for Resident 29 was reviewed on 4/10/26 at 10:09 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus (high blood sugar) with diabetic neuropathy (nerve damage caused by long-term high blood sugar). The physician's order, dated 11/11/25, indicated staff were to perform accu checks two times a day for type 2 diabetes mellitus. 2. During an observation, on 4/10/26 at 9:01 a.m., Resident 7's blood sugar was obtained from the right index finger by LPN 4. The resident's blood sugar reading was 215 mg/dL. The resident required sliding scale Humalog. The LPN placed the glucometer in the resident's glucometer case without cleaning it. The LPN then administered the Humalog required. The record for Resident 7 was reviewed on 4/9/26 at 2:47 p.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated 4/1/26 at 7:00 p.m., indicated staff were to monitor the resident's blood sugar for visible signs or symptoms of hypoglycemia or hyperglycemia. If symptoms are apparent, check the blood sugar and follow the prn blood sugar flowchart. During an interview, on 4/10/26 at 9:06 a.m., LPN 4 indicated if the glucometer was shared with other residents, they were cleaned after each use. But the glucometer that was stored individually in the cases, would not need to be cleaned. The shared glucometer would be cleaned after each resident, to prevent germs from being passed on to another resident. She should wrap the glucometer in the Sani-Cloth (Wipes were used by the facility to disinfect high risk areas) for 2 minutes. She was unsure how long to let the glucometer dry after that. The LPN indicated she could not find any Sani-wipes in her cart or in storage. During an interview, on 4/10/26 at 9:13 a.m., the Director of Nursing (DON) indicated the glucometer should be cleaned after every use even if they were used only for one resident. They should be cleaned to prevent bacteria for infection control. The Sani-Cloth containers were readily available in the storage room. She indicated she knew who had not been cleaning the glucometers after each use. The current Cleaning/Disinfecting/Maintaining Glucose Meters policy included, but was not limited to, The Glucose meters will be disinfected between each resident use to prevent the spread of microorganisms including blood borne pathogens. Disinfection of the machine will be completed with PDI Super Sani Germicidal wipes or Bleach Wipes as per guidelines of the manufacturer of the glucometer. Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and the second wipe for disinfecting. Note: always create a dry 'barrier' between the meter and any surface on which it is placed during actual use or cleaning. Paper towels are commonly used. Procedure: Cleaning and Disinfecting 4. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 5. Dispose of the towelette. 6. Obtain a second towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood borne pathogens. The meter must be maintained wet for 2 minutes with the Super Sani cloth wipe. 7. Once the exterior of the glucose meter has remained wet for the appropriate contact time, the meter may be wiped dry with a dry cloth. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(2)

Based on interview, the facility failed to ensure Saturday's mail was delivered to the residents upon arrival to the post box. This deficient practice had the potential to affect 63 of 63 residents currently residing in the facility.Findings include:During the Resident Council meeting, on 4/10/26 at 10:00 a.m., with 6 residents who were alert and oriented per the Assistant Activity Director, the residents indicated they were not getting their Saturday mail as no Activity Staff was there on the weekends. They were the ones who usually passed it out. The residents indicated they had seen the mail be delivered to the outside mail box but no one went and got it. During an interview with the Activities Director, on 4/13/26 at 12:45 p.m., she indicated there was no one assigned to pass the mail on Saturdays. Human Resources would retrieve it first thing Monday morning from the mail box, sort through the bills and other important mail she needed to address and then bring the rest of the residents' mail to her to pass out. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(s)(1)

Based on observation, interview and record review, the facility failed to ensure facial hair covering were in place for staff while working for 1 of 2 kitchen observations. Findings include:Upon entrance into the kitchen, on 3/15/26 at 12:14 p.m., signage on the kitchen door indicated staff must have hairnets in place and beard guards in place to enter the kitchen. During an observation on 3/15/26 at 12:16 p.m., Dietary Aide (DA) 6 and Dishwasher 7 both had 1/2 inch or longer facial hair on their lip and chin area. The DA 6 and Dishwasher 7 were observed in the kitchen dish and food prep areas without beard guards in place. During an interview, on 3/15/26 at 12:19 p.m., the Dietary Manager indicated they had just run out of the beard guards, however, it was the facility policy for beard guards to be in place while in the kitchen. On 3/15/26 at 3:00 p.m., the Executive Director provided a current copy of the document titled Proper Use of Hairnets and [NAME] Guards for Food Safety Compliance which was last reviewed on 6/2/25. It included, but was not limited to, Purpose .To ensure all personnel maintain proper hygiene and prevent contamination of food products .General Requirements .All personnel must wear approved .beard guards when in food preparation, processing, or storage areas .beard gaurds must be worn completely covering all .facial hair .beards and facial hair must be fully covered by the beard guard This Citation relates to Intakes 2743395, 2749355, 2799515 and 2803955 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to protect the resident's right to be free from resident to resident abuse for 3 of 4 residents reviewed for abuse. Findings include:1. The clinical record for Resident B was reviewed on 3/15/26 at 2:04 p.m. The resident's diagnoses included, but were not limited to, schizophrenia (chronic, severe brain disorder that affects how a person thinks, feels, and acts), depression, suicidal ideations, and vascular dementia (mental decline). The incident report, dated 3/13/26 at 1:01 p.m., indicated Resident C entered Resident B's room. Resident B, upset, placed hands on Resident C's shoulders to turn her around and slightly pushed her from the back. The progress note, dated 3/13/26 at 1:16 p.m., indicated Resident C entered Resident B's room. Resident B placed his hands on Resident C's shoulder, turned her around and pushed her from the back. During an interview, on 3/15/26 at 12:00 p.m., Staff Member 8 indicated on 3/12/26 in the late afternoon/early evening, she overheard Resident B tell Resident C he was going to kill the resident if she came into his room. Staff Member 8 reported the incident to the Director of Nursing who then told Staff Member 8 to inform Social Services. When Staff Member 8 reported the incident to Social Services, Social Services asked Staff Member 8 what do you want me to do about it. During an interview, on 3/15/25 at 12:05 p.m., Staff Member 9 indicated on 3/13/26 at around 1:00 p.m., Resident C was ambulating down the hallway towards the end of [NAME] Hall. Resident C had not gotten to the end of the hall when Resident B came out of his room. Resident B grabbed Resident C by her neck, twisted her arm behind her back and then pushed her into a geriatric chair that was in the hallway. Resident C tried to get away, but Resident B kept pushing her. Staff Member 9 intervened and assisted Resident C away from Resident B. Staff Member 9 reported the incident to the Director of Nursing and was told it would be reported to the Administrator. During an interview, on 3/15/26 at 1:20 p.m., the Administrator indicated she reported what she had been told. She had not gotten any staff statements on the incident yet. She was unaware that Resident B had threatened Resident C on 3/12/26 prior to the incident on 3/13/26. During an interview, on 3/15/26 at 3:06 p.m., Staff Member 17 indicated on 3/13/26, she was sitting at the nurses' station when Staff Member 9 took off running down the [NAME] Hall. Resident C was walking towards Resident B's room. Resident B grabbed Resident C at the top of her left shoulder area and up on the right side by her neck. Resident B swiveled Resident C around and shoved her three times down the hallway. Staff Member 9 reported to the Director of Nursing exactly what had happened and what Staff Member 17 had witnessed as well. During an interview on 3/17/26 at 2:38 p.m., the Administrator indicated she did not get the whole story on what had happened prior to reporting the incident. She was not sure what the Regional Director of Operations was going to do with regards to the comment Resident B had made to Resident C on 3/12/26. She had been instructed to report that on the five day follow-up. 2.a.The clinical record for Resident C was reviewed on 3/15/26 at 2:17 p.m. The resident's diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage without loss of consciousness, acute pain due to trauma, personal history of traumatic brain injury, affective mood disorder and anxiety. The progress note, dated 3/12/26 at 5:47 p.m., indicated Resident C continued to pace up and down the halls, in and out of residents' rooms, rummaging through their things and disturbing other residents. The resident was very difficult to re-direct and became agitated and loud while swinging her arms at the staff. The incident report, dated 3/13/26 at 1:01 p.m., indicated Resident C entered Resident B's room. Resident B, upset, placed hands on Resident C's shoulders to turn her around and slightly pushed her from the back. 2.b. During an interview, on 3/15/26 at 12:05 p.m., Staff Member 9 indicated on 3/13/26, she had to separate Resident C from Resident D because Resident D had rammed her walker into Resident C's legs and reported the incident to the Director of Nursing. During an interview, on 3/18/26 at 12:04 p.m., Resident D indicated she pushed her walker into Resident C because Resident C had gotten into her personal space on 3/13/26. The incident report, dated 3/15/26, indicated it was reported to the Administrator that on 3/13/26, Resident D made contact with Resident C's legs with Resident D's rollator walker. The progress note, dated 3/12/26 at 5:47 p.m., indicated Resident C continued to pace up and down the halls, in and out of residents' rooms, rummaging through their things and disturbing other residents. 3. The clinical record for Resident D was reviewed on 3/16/26 at 12:30 p.m. The resident's diagnoses included, but were not limited to, history of traumatic brain injury and anxiety. The incident report, dated 3/15/26, indicated Resident D made contact with Resident C's legs using her rollator walker. During an interview, on 3/15/26 at 12:05 p.m., Staff Member 9 indicated on 3/13/26, she had to separate Resident C from Resident D because Resident D had rammed her walker into Resident C's legs and reported the incident to the Director of Nursing. During an interview, on 3/17/26 at 2:38 p.m., the Administrator indicated Resident D admitted that she hit Resident C in the leg with her walker because Resident C was in Resident D's personal space. During an interview, on 3/18/26 at 12:04 p.m., Resident D indicated she pushed her walker into Resident C and hit her legs because Resident C had gotten into her personal space. On 3/15/26 at 2:50 p.m., the Executive Director provided a current copy of the document titled Abuse Prevention Program dated 10/22/22. It included, but was not limited to, Policy.It is the policy of this facility to prevent resident abuse.Each resident receives care and services in a person-centered environment in which all individuals are treated like human beings.Abuse Reporting.This facility will not tolerate resident abuse or treatment by anyone, including.other residents.Abuse.the willful infliction of injury.Physical Abuse.Hitting, slapping, pinching, kicking, etc. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(1)410 IAC 16.2-3.1-27(b)

Based on interview and record review, the facility failed to ensure blood pressure medication was not administered to a resident (Resident K) outside of prescribed parameter blood pressure for 1 of 4 residents reviewed for quality of care. Findings include:1. The clinical record for Resident K was reviewed on 3/17/26 at 11:15 a.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure). The physician's order, dated 2/14/26, indicated the resident was to receive Midodrine 10 mg, via gastrostomy tube, three times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. for hypotension. The medication was to be held (not administered) for a systolic blood pressure (SBP) greater than 110. Review of the February 2026 medication administration record indicated the medication was administered on the following dates and times:-On 2/16/26 at 10:00 p.m., when the resident's SBP was 122,-On 2/17/26 at 6:00 a.m., when the resident's SBP was 126,-On 2/17/26 at 10:00 p.m., when the resident's SBP was 119, and-On 2/19/26 at 6:00 a.m., when the resident's SBP was 119. During an interview, on 3/18/26 at 11:17 a.m., LPN 12 indicated physician's orders should be followed. This Citation relates to Intake 2743395, 2799515 and 2803955 410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on observations, interviews and record review, the facility failed to ensure the hall meal service food was held at an appropriate temperature for 2 of 2 observations; failed to ensure the food was not overcooked for 1 of 2 meal service observations; and failed to ensure residents received adequate portions for 7 of 10 residents reviewed for dietary services. This deficient practice had the potential to affect 73 of 78 residents residing in the facility. Findings include:During a kitchen food service observation, on 3/15/26 at 12:25 p.m., the following was observed:-The meatloaf was observed with blackened areas across the top and along the edges in the pan.-The serving portion of the meatloaf provided to the residents measured 3 inches in length, one inch in width with a depth of one inch. During an interview, on 3/15/26 at 1:20 p.m., the Executive Director indicated she was going to have the outsourced Dietary Manager re-educate the kitchen staff on portion sizes. During an interview, on 3/16/26 at 11:40 a.m., Resident E indicated the food served was generally cold, especially breakfast. Last night (3/15/26) for supper, they served soup and the bowl was only filled up a quarter of the way. This morning (3/16/26), he was served one hash brown and 2 sausage links which were cold when it was served to him. During an interview, on 3/16/25 at 10:35 a.m., Resident N indicated after every meal, everyone in still hungry. The portion sizes were so small. This past Sunday, she received a piece of meatloaf, which was equivalent to three bites. For dinner Sunday, they were served a bowl of soup which was only filled up a quarter of the way. If you eat in your room, the food was always cold when you get it, especially the eggs. On 3/17/26 at 8:24 a.m., a random food tray was selected during a food temperature check on the [NAME] Hall with the following temperatures:-Scrambled eggs temperature was 98.8 degrees Fahrenheit-Oatmeal temperature was 149.2 degrees Fahrenheit-Sausage link temperature was 86.4 degrees Fahrenheit During an interview, on 3/17/26 at 10:40 a.m., Resident O indicated the food was cold all the time. This past Sunday, he received a sliver (very small size) of meatloaf that was way overcooked. The food served was not fit for a dog. During an interview, Resident P indicated the food was horrible and they do not give you enough. The portions they serve the residents here were equivalent to what you would serve a young child. During an interview, on 3/17/26 at 10:44 a.m., Resident Q indicated for most of the residents, the meals are the highlight of the day. The quality and quantity the facility served the residents dampens that highlight. The facility kitchen staff just don't give you enough food and the quality of the food was very poor. During an interview, on 3/18/26 at 10:53 a.m., Resident R indicated, twice, the facility had served undercooked food. The portion sizes were so small that she was still hungry after she ate. The meatloaf served on Sunday was equivalent to two or three bites for her. They did not serve the residents enough food. During an interview, on 3/18/26 at 10:55 a.m., Resident S indicated the cafeteria food service was horrible. The quantity served was so small and the food served to the residents' in their rooms was always cold. If it was not for the staff buying other food for us, we would starve. On 3/17/26 at 7:59 a.m., the Executive Director provided a current, undated copy of the document titled Food Temperatures. It included, but was not limited to, Policy.Temperatures of TCS (temperature controlled for safety) foods shall be recorded before being served from the steam table.Hot foods will be held at temperatures 135 degrees or above. This Citation relates to Intakes 2743395, 2749355, 2799515 and 2803955 410 IAC (Indiana Administrative Code) 16.2-3.1-21(a)(1)410 IAC 16.2-3.1-21(a)(2)

Based on observation, interview and record review, the facility failed to ensure a variety of snacks and snacks with nutritional value were available for the residents for 4 of 7 residents reviewed for dietary services. This deficient practice had the potential to affect 73 of 78 residents residing in the facility. Findings include:During an observation of the snack pantry on 3/15/26 at 11:00 a.m., the following was observed:-One jar of peanut butter on the counter next to the refrigerator-There was no bread in the pantry-A tray with 4 peanut butter sandwiches and 2 peanut butter and jelly sandwiches in baggies. The crust of the bread was hard. There were no other snacks observed in the pantry for the residents except what the residents had purchased for themselves. On 3/15/26 at 11:05 a.m., small bags of cheez-its were the only snacks observed on the snack cart. During an interview, on 3/16/26 at 10:35 a.m., Resident N indicated they don't have snacks all the time and sometimes don't get offered snacks at night because the staff do not have anything to give them. They had peanut butter and jelly sandwiches the other day and there was barely anything between the two slices of bread. When she pulled the bread apart, one side had a tan color, the other side purple color. It was spread so thin that the peanut butter and jelly had saturated into the bread, which was hard. There was no substance to the sandwiches. During an interview, on 3/16/26 at 11:40 a.m., Resident E indicated the only snacks available were peanut butter sandwiches on hard bread with barely any peanut butter on them. On 3/17/26 at 9:40 a.m., the following was observed of the snack sandwiches sent to the nutrition pantry from dietary for the residents with Staff Member 13: -On the snack tray were 6 peanut butter sandwiches and 2 peanut butter and jelly sandwiches in sandwich bags. The bread crust was hard on all the sandwiches.Staff Member 13 pulled apart the slices of bread of each sandwich, at that time, the peanut butter was so minimal that it saturated into the bread as well as the sandwiches with peanut butter and jelly. There was no substance to the sandwiches. Staff Member 13 indicated that dietary had sent down peanut butter sandwiches, on multiple occasions, with a small clump of peanut butter, no bigger than the size of a quarter, just placed in the middle of the bread and had not been spread. During an interview on 3/17/26 at 10:40 a.m., Resident O indicated the facility doesn't have snacks all the time and snacks don't get offered because they do not have anything to give us. During an interview, on 3/18/26 at 10:53 a.m., Resident S indicated the nursing staff had to go out and buy peanut butter and bread so the residents could have snacks to eat because the dietary department rarely sends any snacks out for the residents. On 3/15/26 at 3:00 p.m., the Executive Director provided a current, undated copy of the document titled Frequency of Meals. It included, but were not limited to, Policy.Each resident shall receive at least three (3) meals daily, as well as an evening or bedtime snack.Procedure.Between-meal snacks are available to those residents who request them. The policy, titled Between Meal Snacks included, but was not limited to, Policy.Between meal snacks are available for all.residents.Procedure.A variety of snacks of high nutritional value will be stocked in each service area by dining services. This Citation relates Intakes 2743395, 2749355, 2799515 and 2803955 410 IAC (Indiana Administrative Code) 16.2-3.1-21(e)

Based on interview and record review, the facility failed to ensure a resident (Resident E) was informed of a decrease in pain medication; failed to ensure a resident's (Resident M) representative was notified of the discontinuation of therapy services; and failed to ensure a resident's (Resident E) follow-up appointment for suture removal status post amputation was set-up for 2 of 3 residents reviewed for resident rights. Findings include:1 The clinical record for Resident E was reviewed on 3/15/26 at 2:27 a.m. The resident's diagnoses included, but were not limited to, orthopedic after care following surgical amputation, diabetes, chronic pain, depression, acquired absence of left leg above knee and myalgia (pain). The admission MDS (Minimum Data Set) assessment, dated 2/2/26, indicated Resident E's cognition was intact. The hospital history and physical note, dated 1/29/26, indicated Resident E had a left above knee amputation on 1/16/26. The hospital discharge orders, dated 1/29/26, indicated the resident had a follow-up appointment with the vascular nurse practitioner on 2/16/26 The physician's order, dated 2/6/26, indicated the resident was to receive Oxycodone-Acetaminophen (narcotic pain medication) 7.5-325 mg (milligrams) every 6 hours for pain. The physician's order, dated 3/9/26, indicated the resident's order from 2/6/26 was discontinued with a new order for Oxycodone-Acetaminophen 5-325 mg every 6 hours for pain. The clinical record lacked documentation of notification to Resident E about the follow-up appointment, a need to reschedule the follow-up appointment or the decrease of the resident's pain medication. During an interview, on 3/15/26 at 1:17 p.m., Resident E indicated he was not aware that he had a follow-up appointment on 2/16/26. Resident E's social worker from the veteran's administration had visited him and asked him about his follow-up appointment. Resident E told him he had not been to any follow-up appointments. The social worker from the veteran's administration spoke to the staff and he did finally get a follow-up appointment earlier that month. It took the doctor a while to remove his sutures as they were embedded in the skin. Last week, his pain medication had been decreased without his knowledge. The only reason he found out that it had been changed was the pain medication was a different color. When he asked about the medication, he was told by the nurse that the nurse practitioner had decreased it. During an interview, on 3/17/26 at 3:32 p.m., the vascular center indicated Resident E had surgery on 1/16/26. The patient had a follow-up appointment on 2/16/26 which was sent to the facility on discharge. The facility made no contact to reschedule the appointment, and the resident was listed as a no call no show on 2/16/26. The social worker from the veteran's administration had gotten involved and the appointment was rescheduled for 3/5/26 at 1:00 p.m. The resident did not arrive until 3:00 p.m., however, the physician did go ahead and see the resident because he had sutures that needed removed. During an interview, on 3/18/26 at 11:08 a.m., Licensed Practical Nurse (LPN) 10 indicated when there were changes in a resident's medication or care, the resident and/or resident representative should have been informed of those changes. 2. The clinical record for Resident M was reviewed on 3/17/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to, dementia (mental decline) with other behavioral disturbances and lack of coordination. During an interview, on 3/16/26 at 3:23 p.m., Resident M's representative indicated she had requested for therapy to work with her father to help increase his strength and was told they would. She had been to the facility multiple times, for extended periods, and had not seen any therapist work with her father. She had no idea what was going on and had not been notified of anything related to his therapy. During an interview, on 3/17/26 at 9:40 a.m., physical therapist 14 indicated he had worked the Resident M for about a month with max potential reached and the resident was discharged from therapy. He did not notify the family because he had given the orders to the nursing staff and the nursing staff were to notify the family. The clinical record lacked documentation of resident or the representative notification related to the resident's discontinuation of therapy. On 3/18/26 at 9:54 a.m., the Executive Director provided a current, undated copy of the document titled Resident Rights. It included, but was not limited to, Policy.It is the policy of the facility to observe and implement RESIDENT RIGHTS as dictated by CMS.Each resident has the right to be treated with dignity and respect.The preferences and goals of the resident should be honored as much as possible and the resident's comfort, safety and overall welfare must be promoted.and enhanced at all times. This Citation relates to Intakes 2743395, 2799515 and 2803955 410 IAC (Indiana Administrative Code) 16.2-3.1-3(h)(2)410 IAC 16.2-3.1-3(h)(3)

Based on interview and record review, the facility failed to ensure complete and accurate information was provided to the abuse coordinator for an allegation of resident-to-resident abuse; failed to ensure an allegation of resident-to-resident abuse was reported to the abuse coordinator; and failed to ensure an allegation of verbal abuse was reported, in a timely manner, for 3 of 4 residents reviewed for abuse. (Resident B, Resident C and Resident D) Findings include:1.On 3/15/26 at 12:00 p.m., Staff Member 8 indicated on 3/12/26 in the late afternoon/early evening, Staff Member 8 overheard Resident B tell Resident C he was going to kill her if Resident C came in his room. Staff Member 8 reported the incident to the Director of Nursing who then told Staff Member 8 to inform Social Services. When Staff Member 8 reported the incident to Social Services, Social Services asked Staff Member 8 what do you want me to do about it. On 3/15/25 at 12:05 p.m., Staff Member 9 indicated on 3/13/26 at around 1:00 p.m., Resident C was ambulating down the towards the end of [NAME] Hall. Resident C had not gotten to the end of the hall when Resident B came out of his room, grabbed Resident C by her neck, twisted her arm behind her back and then pushed her into a geriatric chair that was in the hallway. Resident C tried to get away, but Resident B kept pushing her. Staff Member 9 intervened and assisted Resident C away from Resident B. Staff Member 9 reported the incident to the Director of Nursing and was told it would be reported to the Administrator. On 3/15/26 at 3:06 p.m., Staff Member 17 indicated on 3/15/26, she was sitting at the nurses' station when Staff Member 9 took off running down the [NAME] Hall. Resident C was walking towards Resident B's room. Resident B grabbed Resident C at the top of her left shoulder area and up on the right side by her neck. Resident B swiveled Resident C around and shoved her three times down the hallway. Staff Member 9 reported to the Director of Nursing exactly what had happened and what Staff Member 17 had witnessed as well. The incident report, dated 3/13/26 at 1:01 p.m., indicated Resident C entered Resident B's room. Resident B, upset, placed hands on Resident C's shoulders to turn her around and slightly pushed her from the back. During an interview, on 3/15/26 at 1:20 p.m., the Administrator indicated she reported what she had been told. She had not gotten any staff statements on the incident yet. She was unaware that Resident B had threatened Resident C on 3/12/26. On 3/17/26 at 2:38 p.m., the Administrator indicated she did not get the whole story on what had happened prior to reporting the incident. She was also unaware of the incident between Resident D and Resident C. She was not sure what the Regional Director of Operations was going to do with regards to the comment Resident B had made to Resident C on 3/12/26. 2.During an interview, on 3/15/26 at 12:05 p.m., Staff Member 9 indicated on 3/13/26, she had to separate Resident C from Resident D because Resident D had rammed her walker into Resident C's legs and reported the incident to the Director of Nursing. During an interview, on 3/17/26 at 2:38 p.m., the Administrator indicated Resident D admitted that she hit Resident C in the leg with her walker because Resident C was in Resident D's personal space. During an interview, on 3/18/26 at 12:04 p.m., Resident D indicated she pushed her walker into Resident C and hit her legs because Resident D had gotten into her personal space. The incident report, dated 3/15/26, indicated it was reported to the Administrator that on 3/13/26, Resident D made contact with Resident C's legs with Resident D's rollator walker On 3/15/26 at 2:50 p.m., the Executive Director provided a current copy of the document titled Abuse Prevention Program dated 10/22/22. It included, but was not limited to, Policy.It is the policy of this facility to prevent resident abuse.Each resident receives care and services in a person-centered environment in which all individuals are treated like human beings.Identification .Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations .of potential mistreatment. Upon learning of the report, the Administrator or in the absence of the Administrator, the person in charge of the facility shall initiate and incident investigation . 410 IAC (Indiana Administrative Code) 16.2-3.1-28(a)410 IAC 16.2-3.1-28(c)

Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place when a resident (Resident G) with impaired cognition and risk for elopement exited the front doors without staff supervision. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/7/23. Resident G is a [AGE] year-old male with severely impaired cognition and risk for elopement that had resided on the dementia unit since 7/12/23. The resident was admitted to a psychiatric hospital on 11/22/23. He readmitted to the facility on [DATE] at 11:30 a.m., off the dementia unit, as a trial for the safety of the other residents on the dementia unit. The resident exited the facility through the front doors on 12/7/23 between 5:20 p.m. and 5:30 p.m. when a visitor exited the facility. At 5:43 p.m. on 12/7/23, the visitor returned and informed the facility she thought she had let a resident out of the facility. The resident was found by the maintenance director 0.8 miles from the facility. The path the resident took was a busy highway without sidewalks. The resident was returned to the facility and placed on the secured unit. The resident had an abrasion to his right knee and a hematoma to his right hand from a fall while out of the facility unsupervised. The resident was not placed on any increased supervision upon behavioral hospital return until after the elopement. The Executive Director (ED) and Director of Nursing (DON) and Regional Nurse Consultant were notified of the Immediate Jeopardy on 12/11/23 at 4:00 p.m. The Immediate Jeopardy was removed on 12/12/23 at 4:35 p.m., but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy. On 12/11/23 at 11:30 a.m., Resident G was observed sitting at a table in the dining room of the dementia unit. His right hand was observed to be extremely swollen. The clinical record for Resident G was reviewed on 12/11/23 at 10:11 a.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety, violent behavior, wandering, impulsiveness and glaucoma. The quarterly MDS (Minimum Data Set) Assessment, dated 11/22/23, indicated the resident's cognition was severely impaired. Resident G's hospital admission record, dated 5/10/23, indicated the resident admitted from home with a previous diagnosis of dementia, aggressiveness towards his spouse, and eloped from his home. During an interview of 12/11/23 at 9:29 a.m., the ED indicated she had an incident occur last Thursday evening and reported it. Resident G was readmitted back to the facility after a hospital stay from the behavioral hospital. The resident was placed off the dementia unit due to a positive COVID result. There were a lot of things going on as well as the Christmas dinner for the residents. Resident G exited the facility when Visitor 22 let him out the front doors. Visitor 22 notified the building and the maintenance director found him up by the highway. The facility should have placed him on the secured unit, or the resident should have had a wanderguard (alarm bracelet) on. The care plan, dated 6/9/23 and last reviewed on 9/11/23, indicated the resident was a risk for elopement related to a previous elopement from home. The interventions included, but were not limited to, activities per the calendar, check and maintain code device if applicable, elopement risk assessment quarterly and as needed, and secure with a code device and/or secured unit. The progress note, dated 7/6/23 at 12:00 p.m., indicated the staff were alerted that Resident G was naked outside in the courtyard. The resident was then redirected to the shower room and assisted by a CNA in taking a shower. The progress note, dated 7/12/23 at 10:09 a.m., indicated the family member gave consent for the resident to be moved back to the secured unit related to being intrusive, using the bathroom outdoors, disrobing outdoors and more confused. The physician's order, dated 7/12/23, indicated the resident may reside on the secured unit. Review of the resident's census report indicated Resident G had resided on the dementia unit since 7/12/23. The progress note, dated 11/22/23 at 9:29 a.m., indicated the resident had an altercation with another resident and was placed on one staff member to one resident supervision. The progress note, dated 11/22/23 at 2:00 p.m., indicated the resident had been transported to a behavioral hospital. The IDT (Interdisciplinary Team) note, dated 12/7/23 at 9:30 a.m. (created as a late entry on 12/8/23 at 5:52 p.m.) indicated the IDT team met to review Resident G's placement upon return to the facility from the behavioral hospital. The resident had not had exit seeking behaviors prior to placement on the dementia unit or while on the dementia unit. IDT determined to trial the resident on an open unit upon hospital return related to the safety of the residents on the memory care unit as well as not having a history of exit seeking. The admission elopement risk review assessment, dated 12/7/23 at 11:27 a.m., indicated the resident was an elopement risk. The progress noted, dated 12/7/23 at 11:30 a.m., indicated the resident readmitted from the behavioral health hospital, alert to self, recognized the facility, but not the name of the facility. The progress note, dated 12/7/23 at 12:30 p.m., indicated the resident tested positive for COVID-19 and was moved to another room. The police report, dated 12/7/23 at 5:52 p.m., indicated the police responded to the area at a grocery store parking lot in reference to an elderly man lying face down in the roadway. Dispatch advised they had received two to three calls about the male. Upon arrival, the police spoke with the facility Maintenance Director. He advised the police Resident G was a resident at the facility and should have had a device on to alert staff when a resident wandered away. The Maintenance man indicated Resident G did not have an alert device on. The dispatch narrative on the police report indicated on 12/7/23 at 5:53 p.m. included, but was not limited to, Face down .elderly man .in roadway .had to swerve .adv [advised] people were with him . [the resident was wearing] Blue jeans and a dark sweatshirt .5:56 p.m . employee adv that .the male left .and wondered [sic] off The progress note, dated 12/7/23 at 6:57 p.m., indicated at 5:40 p.m. Visitor 22 approached LPN (Licensed Practical Nurse) 3 at the nurse's station to report a person had exited out of the facility at the time she did earlier. When she returned to the building, she had seen the same person walking up by the new pharmacy. At that point, the visitor thought it may have been a resident. A Code Silver (missing resident) was called at that time. The Maintenance Director left the facility to see if he could locate the resident in the area where he was last seen by the visitor. Staff searched the building and perimeter of the building. The resident was unable to be located. The LPN 3 received a call from the Maintenance Director and informed LPN 3 that the resident had been located. The resident was brought back to the facility by the Maintenance Director. The progress note, dated 12/7/23 at 10:46 p.m., indicated Resident G had a small abrasion to his right knee and a hematoma to top of his right hand, approximately 3 cm (centimeters) in diameter. Ice was applied and his hand elevated on a pillow. The physician was notified with a new order to x ray the right hand. The progress note, dated 12/7/23 at 10:52 p.m., indicated Resident G was moved to the dementia unit. The physician's order, dated 12/8/23, indicated the resident may reside on the secured unit. During an interview on 12/11/23 at 11:24 a.m., the Maintenance Director indicated he was told a resident was missing. He got in his truck, sometime between 5:45 p.m. and 6:00 p.m., to go and look for the resident. It was dark outside. He found the resident at the entrance of a grocery store parking lot. When he got there, two other people were talking to the resident and informed the Maintenance Director that the resident had fallen. After that, the police came to find out what was going on. The police then called EMS (emergency medical services) to check Resident G out before he took the resident back to the facility. During an interview on 12/11/23 at 11:26 a.m., LPN 3 indicated he worked Resident G's Hall on 12/7/23. The resident was originally on another hall, tested positive for COVID-19 and was then moved to LPN 3's hall. He had not realized the resident had vanished. A visitor approached him at the desk and told him a gentleman had walked out the front doors with her when she left, and she thought maybe it was a resident. He called a Code Silver and found Resident G was missing. The Maintenance Director went out and found the resident and he was place on the dementia unit. Resident G was not on 15-minute checks until after the elopement. During an interview on 12/11/23 at 3:20 p.m., Visitor 22 indicated she had left the facility between 5:20 p.m. and 5:30 p.m. As she was leaving, the resident was standing off to the side of the door keypad. He did not look like a resident. She opened the door, and he followed her out. She assumed he was going to smoke out front. She left the parking lot to go back home to pick up her kids. She only lived 5 minutes from the facility. On her way back, she noticed the same guy in front of the new pharmacy. She called her mother who recommended that she let someone know at the facility. She got back to the facility at 5:43 p.m. and told the front desk what had happened, and they started to try and figure out who was missing. On 12/12/23 at 2:43 p.m., Visitor 22 indicated there were no staff down the hallway where the front doors were located on the day Resident G exited out the doors behind her. During an interview on 12/12/23 at 3:25 p.m., the Director of Nursing indicated a wanderguard should have been implemented upon readmission. She was unaware there was not a code alert system on the front doors. If known, she would have implemented 15-minute checks. On 12/11/23 at 4:21 p.m., the ED provided a current, undated copy of the document titled Policy and Procedure Regarding Missing Residents and Elopement. It included, but was not limited to, It is the policy of this facility that all residents are provided adequate supervision .Prevention of Missing Residents and Elopements .Resident that are at risk for elopement will be provided at least one of the following safety precautions .staff supervision of facility exits either directly or by video camera .door alarms on facility exits .a personal safety device that notifies facility staff when the resident attempts to or has left the facility without supervision The Immediate Jeopardy, that began on 12/7/23, was removed on 12/12/23 when the facility conducted the following: The facility reviewed the current elopement risk assessment for every resident; the care plans for at risk residents were reviewed; the Director of Nursing, Infection Preventionist and Administrator were re-trained on the Dementia policy and the Dementia Unit policy with attention to re-admission risk assessment and putting safety measures in place immediately upon identification risk; a wanderguard monitor had been ordered for the front door and staff placed at the front door to prevent elopement until the wander guard device is put in place; all families were contacted and educated to check with nursing prior to letting anyone out the exit door; a greeter will be placed at the front door during events to monitor for residents attempting to exit the facility with visitors; the Regional Nurse conducted training with the Administrator, Director of Nursing and Infection Preventionist on the elopement policy, guidelines for alarms, and admission/readmission checklist; and all staff were educated on the elopement policy-missing resident, guidelines for alarms, admission/readmission checklist, and handling and addressing behavioral emergencies. The Immediate Jeopardy was removed on 12/12/23 but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, because not all staff had been educated on the elopement policy-missing resident, guidelines for alarms, admission/readmission checklist, and handling and addressing behavioral emergencies. 3.1-45(a)(2)

A. Based on observation, record review, and interview, the facility failed to address and manage unstable blood glucose levels for a resident with Diabetes Mellitus and to follow the physician recommendations for care for 1 of 21 residents reviewed for Quality of Care. (Resident 46) B. Based on observation, record review, and interview, the facility failed to ensure the physician was notified and treatment orders were obtained for a new skin impairment for Resident 54. The facility also failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice affected 2 of 21 residents reviewed for Quality of Care. The Immediate Jeopardy began on 11/10/21 when the facility failed to follow physician recommendations to refer the resident to an endocrinologist related to unstable blood glucose levels. The resident's blood glucose levels became progressively unstable. On 12/5/21 the resident was hospitalized due to a change in condition and was hospitalized with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident returned to the facility and has continued to have unstable blood glucose levels with no changes made in his insulin treatment. The Executive Director, Assistant DON (Director of Nursing) and Nurse Consultant were notified of the Immediate Jeopardy on 12/16/21 at 6:45 p.m. The immediate jeopardy was removed on 12/18/21, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A. During an observation on 12/15/21 at 10:53 a.m., Resident 46 was observed walking into the memory care unit dining room. There was a large pool of liquid on the dining room floor. CNA (Certified Nursing Aide) 8 indicated the resident had just had an accident and she had gotten him cleaned up. This had happened for the third time recently and he was urinating quite frequently (common sign of diabetes mellitus). During a continuous observation, on 12/16/21 from 10:15 a.m. to 11:15 a.m., Resident 46 was confused as normal, walking about the memory care unit dining room. He would sit for short periods in the dining room, and then get up and walk around the room. At 10:42 a.m. he sat down in another resident's geriatric wheelchair in the hallway and closed his eyes. CNA 9 assisted the resident to his bed. The clinical record for Resident 46 was reviewed on 12/16/21 at 8:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 11/5/21, indicated the resident was severely cognitively impaired, had diabetes mellitus, and required injections of insulin daily The hospital discharge summary, dated 4/9/21, indicated the resident would need to continue accuchecks (blood glucose monitoring) after meals and at bedtime after discharged and would need to be continued on high dose sliding scale insulin with the nursing home medical doctor to adjust insulin as needed. Orders at the time of discharge to the facility included, but were not limited to, insulin [MEDICATION(S)] 26 units every morning, insulin [MEDICATION(S)] 10 units three times daily every 6 hours and sliding scale as ordered, after giving SSI (sliding scale insulin) do not recheck finger or give more SSI until next scheduled check. Give sliding scale dose based on blood glucose 70 to 150 administer no insulin (none), 151 to 200 give 3 unites, 201 to 250 give 6 units, 251 to 300 give 9 units, 301 to 350 give 12 units, for blood sugars over 350 call the provider. The care plan, initiated on 6/14/21, indicated the resident had type 2 diabetes with risk for [CONDITION(S)] and [CONDITION(S)]. Interventions included, but were not limited to, administer medications and insulins per order, check blood sugar per order and as needed, monitor labs as ordered, notify MD (physician) of blood sugar results outside specified parameters, and offer snacks as needed. The Blood Sugar Summary indicated the resident had multiple blood sugar levels above 350 on the following dates: - April 23 at 7:23 a.m., the resident's blood sugar (BS) level was 389 mg/dL (milliliters per deciliter). - April 24 at 4:39 p.m. and 4:40 p.m., BS level was 567 mg/dL; at 7:51 p.m., BS level was 384 mg/dL. - May 14 at 9:10 a.m., BS level was 397 mg/dL; at 1:24 and 1:25 p.m., BS level was 395 mg/dL; and at 7:44 p.m., BS level was 399 mg/dL. - May 26 at 9:01 p.m., BS level was 558 mg/dL. - June 7 at 10:08 a.m., BS level was 406 mg/dL. - June 8 at 9:30 a.m., BS level was 520 mg/dL; at 10:30 a.m., BS level was 445 mg/dL; at 1:39 p.m., BS level was 353 mg/dL; and at 3:54 p.m., BS level was 463 mg/dL. - June 9 at 7:06 p.m., BS level was 482 mg/dL. - June 10 at 8:19 p.m., BS level was 435 mg/dL. - June 11 at 4:40 p.m., BS level was 449 mg/dL. - June 12 at 4:56 a.m., BS level was 589 mg/d; and at 7:20 p.m., BS level was 545 mg/dL. - June 15 at 12:05 p.m., BS level was 365 mg/dL. - June 17 at 5:02 p.m., BS level was 353 mg/dL. - July 1 at 11:35 a.m., BS level was 513 mg/dL. - July 2 at 9:44 a.m., BS level was 530 mg/dL; at 8:40 p.m., BS level was 452 mg/dL. - July 3 at 8:21 p.m., BS level was 364 mg/dL. - July 10 at 7:47 p.m., BS level was 430 mg/dL. - July 11 at 8:14 p.m., BS level was 450 mg/dL. - July 26 at 11:55 a.m., BS level was 421 mg/dL. - July 29 at 5:24 p.m., BS level was 401 mg/dL. - August 11 at 11:24 a.m., BS level was 391 mg/dL. - August 16 at 5:31 p.m., BS level was 442 mg/dL. - September 3 at 10:49 a.m., BS level was 600 mg/dL. - September 4 at 1:07 p.m., BS level was 371 mg/dL; and at 4:55 p.m., BS level was 347 mg/dL. - September 15 at 8:13 p.m., BS level was 382 mg/dL. - September 18 at 8:26 p.m., BS level was 434 mg/dL. - September 20 at 8:57 p.m., BS level was 369 mg/dL. - September 21 at 10:18 a.m., BS level was 569 mg/dL. - October 2 at 7:47 p.m., BS level was 378 mg/dL. - October 3 at 7:15 p.m., BS level was 500 mg/dL. - October 7 at 10:51 a.m., BS level was 357 mg/dL. - October 10 at 7:56 p.m., BS level was 386 mg/dL. - October 11 at 10:13 a.m., BS level was 416 mg/dL. - October 15 at 12:00 p.m., BS level was 457 mg/dL; and at 4:59 p.m., BS level was 490 mg/dL. - October 16 at 8:45 p.m. and 8:46 p.m., BS level was 380 mg/dL; at 3:38 p.m., BS level was 353 mg/dL; and at 7:45 p.m., BS was 574 mg/dL. - October 17 at 8:00 p.m., BS level was 570 mg/dL. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's [MEDICATION(S)] was increased to 25 units twice daily. There were no other medication changes related to the resident's insulin. The Blood Sugar Summary indicated the resident had multiple blood sugar levels above 400 on the following dates: - October 25 at 7:59 a.m., BS level was 554 mg/dL; and at 12:17 p.m., BS level was 471 mg/dL. The physician's note, dated 10/25/21 at 8:28 a.m., indicated the resident's [MEDICATION(S)] was increased from 25 units twice a day to 30 units in the a.m. and 35 units at h.s. (bedtime). The physician's note, dated 10/26/21 at 12:15 a.m., indicated the physician ordered a onetime dose of Novolog (fast acting insulin) 10 units. - October 27 at 9:17 p.m., BS level was 568 mg/dL. The physician's note, dated 10/27/21 at 11:20 a.m., indicated the resident was discharged to the emergency room and returned at 5:52 p.m. with no new orders at that time. On 10/27/21 at 10:22 p.m., the physician changed the resident's p.m. [MEDICATION(S)] dose to 30 units. The resident received 30 units of [MEDICATION(S)] in the a.m. and at h.s. - October 30 at 4:28 p.m., BS level was 589 mg/dL. The physician was notified with no new orders received. - October 31 at 11:50 a.m., BS level was 459 mg/dL. No physician notification documented. - November 1 at 8:14 p.m., BS level was 514 mg/dL. The physician was notified with no new orders received. - November 2 at 4:42 p.m., BS level was 483 mg/dL. The physician was notified with no new orders received. - November 5 at 1:14 p.m., BS level was 566 mg/dL. No physician notification documented. - November 6 at 6:05 p.m. and at 7:57 p.m., BS level was 500 mg/dL. The physician was notified with no new orders twice in the same day. - November 7 at 7:47 p.m., BS level was 484 mg/dL No physician notification documented. - November 8 at 9:12 p.m., BS level was 560 mg/dL. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Blood Sugar Summary indicated the resident's blood sugar levels were at/or above 500 on the following dates: - November 10 at 8:38 p.m., BS level 500 mg/dL. The physician was notified, advised the facility to set up an appointment with endocrinologist, and to give a onetime dose of 6 units of Novolog. - November 11 at 10:04 p.m., BS level 600 mg/dL. The physician was notified and ordered 8 units of Novolog. - November 13 at 8:25 p.m., BS level 500 mg/dL. No physician notification documented. - November 14 at 8:08 p.m., BS level 500 mg/dL. No physician notification documented. - November 15 at 10:05 p.m., BS level 560 mg/dL. No physician notification documented. - November 16 at 7:39 a.m., BS level 500 mg/dL. No physician notification documented. - November 17 at 10:09 p.m., BS level 516 mg/dL. No physician notification documented. - November 20 at 9:20 p.m., BS level 500 mg/dL. No physician notification documented. - November 21 at 8:23 p.m., BS level 500 mg/dL. No physician notification documented. - November 27 at 8:52 p.m., BS level 600 mg/dL. No physician notification documented. - December 4 at 8:34 p.m., BS level 500 mg/dL. No physician notification documented. The review of the nursing notes, indicated the resident experienced low blood sugars below 60, requiring physician notification on the following dates: - June 24 at 12:45 a.m., BS level was 47 mg/dL, and he required a [MEDICATION(S)] injection. - August 26 at 8:12 a.m., BS level was 47 mg/dL, and he required two [MEDICATION(S)] injections. - September 23 at 8:07 a.m., BS level was 57 mg/dL, and he required a [MEDICATION(S)] injection. - September 29 at 7:32 a.m., BS level was 57 mg/dl, and he required a [MEDICATION(S)] injection. The nursing note, dated 11/6/21 at 11:29 p.m., indicated the resident required frequent checks by staff due to unpredictable increases and drops in blood sugar levels. The resident had gotten up two times during the shift and urinated on the floor, his bowel sounds were hyperactive, his blood sugar had been reading HI since 4:00 p.m. that same day. The resident's physician had been notified twice and had given no new orders. The nursing note, dated 11/10/21 at 8:44 a.m., indicated the resident had altered mental status and was not responding and could not swallow and was sent to hospital. The hospital later called report at 12:19 p.m. to report the resident would be returning to the facility, and that when he had arrived at the hospital his blood sugar had been 26. The nursing note, dated 11/10/21 at 8:25 p.m., indicated the physician was contacted regarding a blood glucose level of HI. The physician advised to set up an appointment with an endocrinologist, and a onetime dose of NovoLog 6 units. The clinical record lacked documentation of any communication or appointments with an endocrinologist following the physician's request on 11/10/21. The nursing note, dated 11/10/21 at 11:35 p.m., indicated the resident's blood sugar was 600 mg/dL and the physician was notified at 8:03 p.m., with orders to administer 8 units of fast acting insulin. The resident's sugar was rechecked at 9:35 p.m. and the resident's blood sugar level was 504 md/dL. The nursing note, dated 11/28/21 at 5:42 a.m., indicated the resident's blood glucose level reading was HI. The physician was made aware, however, the clinical record lacked documentation of any new orders. The nursing note, dated 12/2/21 at 2:30 a.m., indicated the resident's blood glucose level reading was HI. The physician was made aware, however, the clinical record lacked documentation of any new orders. The nursing note, dated 12/5/21 at 1:36 a.m., indicated the resident was wandering in and out of his room with an unsteady gait and confusion, his blood sugar level registered as HI, fluids were given, and vitals were obtained. The resident had a tremor in his hand, and he would not answer questions. The physician was notified with new orders to send to the hospital. The nursing note, dated 12/5/21 at 9:25 a.m., indicated the resident was admitted to the hospital for acute [CONDITION(S)]. The hospital discharge summary, dated 12/7/21, indicated the resident's current problems were acute [CONDITION(S)], dementia, elevated troponin (acute), hyperglycemic hyperosmolar nonketotic coma, [CONDITION(S)], and lactic acid acidosis. He was treated with IV fluids and insulin administration. The resident's insulin order for [MEDICATION(S)] was decreased to 25 units twice daily with instruction to continue to monitor and adjust insulin as needed. The resident returned to the facility on [DATE] in stable condition. The Blood Sugar Summary indicated the resident had continual elevated blood glucose levels above 400 mg/dL upon return to the facility as follows: - December 8 at 11:09 a.m., BS level was 405 mg/dL; and at 4:28 p.m., BS level was 430 mg/dL. - December 9 at 8:31 p.m., BS level was 429 mg/dL. - December 11 at 4:32 p.m., BS level was 428 mg/dL; and at 8:35 p.m., BS level was 483 mg/dL. - December 12 at 4:19 p.m., BS level was 550 mg/dL; and at 8:57 p.m., BS level was 418 mg/dL. - December 13 at 6:02 p.m., BS level was 465 mg/dL; and at 9:33 p.m., BS level was 409 mg/dL. - December 15 at 11:38 a.m., BS level was 501 and 444 mg/dL (both were documented at the same time); at 4:31 p.m., BS level was 500 mg/dL; and at 7:43 p.m., BS level was 600 mg/dL. The clinical record lacked documentation of any orders or administration for sliding scale insulin from the time of readmission, on 12/7/21 until 12/16/21, or any adjustments to the resident's insulin regimen between 12/7/21 and 12/16/21. During an interview on 12/16/21 3:03 p.m., the DON indicated she believed someone had told her the SSD (Social Services Director) had spoken with the family regarding a referral to an endocrinologist for the resident and they didn't want him to see one. During an interview on 12/16/21 at 3:10 p.m., the SSD indicated she had not spoken to the resident's family until this date (12/16/21) and the daughter had indicated she did want him to see an endocrinologist. If it's clinical, it wouldn't be her responsibility. She did not schedule the outside appointments, the bus driver did that. During an interview on 12/16/21 at 3:18 p.m., the DON and ED both indicated the MDS coordinator was currently responsible for scheduling appointments, but prior to two weeks ago the bus driver had been responsible for it. Neither the ED nor the DON personally had any conversations with the resident's family regarding his blood sugar levels. If family were notified of things, it would need to be documented. The DON had spoken with the resident's physician on this date (12/16/21), and he had no changes and planned to see the resident on his next visit to the facility. The ED indicated the resident had not had any endocrinologist appointments made for the resident at this time. During an interview on 12/17/21 at 1:58 p.m., Resident 46's physician indicated he had been caring for the resident for approximately four months. He had brittle diabetes and bounced back and forth from high to low without any medicine. He decided last month to send the resident to an endocrinologist. Whenever someone had brittle diabetes, an endocrinologist should be considered. He gave an order last month for the resident to see an endocrinologist. He was at the point where he thought it might be better to let the resident have high blood sugars than to let him bottom out with low blood sugar. He expected the facility to call the endocrinologist and follow up on it, but indicated what they did, was call him and discussed potential realities. As a temporary situation the resident's sugars were a . a little bit higher . He was the one holding back, but he still felt the resident needed to see an endocrinologist. He was not sure if he documented that conversation. He did not adjust the resident's insulin because he felt they needed to make sure he didn't go into diabetic ketoacidosis (DKA). The resident needed an endocrinologist. He was going to decide on 12/18/21 how to proceed with his care. He indicated he could control the resident's condition. During an interview, on 12/17/21 at 2:40 p.m., Resident 46's physician indicated when the resident was hospitalized on [DATE], it was most important that it was not DKA. Even though his sugars were high, it was not a DKA. The bad one that could kill patients was DKA. He gave an order, and nursing staff had more information than him and told him he needed to adjust his orders. Communication between a doctor and a nurse was mostly verbal. He wasn't sure what he wanted to do and wasn't sure of the right direction. He indicated the resident was on sliding scale insulin, and he was to be notified any time the resident was above 400. If the resident was above 400, he would want him to receive fast acting insulin. There was a change in nurses, who did not know the patients, so he chose to use longer acting insulin because there was less room for error. Agency staff did not know patients. He would rather not give the fast-acting insulin and would rather the patients have high blood sugar. He stated, This delay in making a determination is mine completely, by tomorrow when I come there, you will see a clarity of direction. It won't be I have solved the problem; it will be I will have decided how I hope to solve the problem. Guidance for Hyperosmolar Hyperglycemic Nonketotic Coma (Updated 5/12/21), was obtained on 12/17/21 from the National Institutes of Health website. The guidance included, but was not limited to, Hyperosmolar hyperglycemic syndrome (HHS) is a clinical condition that arises from a complication of diabetes mellitus. HHS is a serious and potentially fatal complication of type 2 diabetes. The mortality rate in HHS can be as high as 20% which is about 10 times higher than the mortality seen in diabetic ketoacidosis. this condition was formerly called . hyperosmolar hyperglycemic non-ketotic syndrome. HHS is a serious and potentially fatal complication of type 2 diabetes. If diabetes is well controlled, the chance of developing HHS is minimal. the glucose level in HHS is usually above 600 mg/dl. Dehydration is usually more severe in HHS as compared to DKA, and there is more risk for cardiovascular collapse. particular attention should be focused on the insulin regimen, missed doses of oral hypoglycemic agents, overconsumption of carbohydrate-rich diet, or simultaneous use of medications that can trigger [CONDITION(S)] or cause dehydration. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to improve patient outcome, an interprofessional approach with good care communication and coordination between the Intensivist, nurse, dietician, and the endocrinologist are necessary. Guidance for NIH Hyperglycemic crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State (Updated 5/9/21), was obtained on 12/17/21 from the National Institutes of Health website. The guidance included, but was not limited to, . Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises' management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis . The mortality rate of HHS is higher, reaching 10-20% depending on associated comorbidities and severity of the initial presentation compared with DKA . and is highest in those with DKA+ [and] HHS . The two most common precipitating factors in the development of DKA or HHS are inadequate insulin therapy (whether omitted or insufficient insulin regimen) or the presence of infection . Over 30% of patients have features of both DKA and HHS with most recent evidence confirming that about 1 out of 4 patients will have both conditions at the time of presentation with hyperglycemic crisis . The cornerstone of DKA and HHS therapy is insulin in physiologic doses . Once DKA has resolved, patients who are able to eat can be started on a multiple dose insulin regimen with long-acting insulin and short/rapid acting insulin given before meals as needed to control plasma glucose . Several studies suggested that the omission of insulin is one of the most common precipitating factors of DKA . Considering DKA and HHS as potentially fatal and economically burdensome complications of diabetes, every effort for diminishing the possible risk factors is worthwhile . The immediate jeopardy, that began on 11/10/21, was removed on 12/18/21 when the DON completed a review of the resident's vitals, glucose monitoring review for the last 7 days, and current medication orders to treat diabetes, the physician adjusted the medication regimen for Resident 54, and the appointment for the resident to see an endocrinologist was scheduled, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because the facility would need to conduct ongoing monitoring of Resident 46, diabetic monitoring compliance audits would need to be conducted, diabetic residents would need continued monitoring, and further staff education would need to be provided. B.1. During an observation, on 12/14/21 at 9:46 a.m., Resident 54 was sitting in his recliner in his room. His right arm was observed to have a large, bordered gauze dressing which had a moderate amount of dried, flaking reddish-brown staining. Below the dressing was a approximately 2 inch by 2 inch piece of duct tape. His pants and shirt were also observed to have dried reddish brown staining on them. The resident indicated he had hit his arm and staff had not done anything about it. The dressing was worn and stained, with the gauze fabric pilling and fraying. During an observation, on 12/14/21 at 1:47 p.m., the resident was out to the dining room. He approached the nurse on the unit and asked her if she was going to help fix his arm. The nurse did not answer the resident's question or assess his arm. She assisted him to sit down at a table. During an observation on 12/15/21 at 9:13 a.m., the resident was sitting in his recliner in his room. The duct tape was no longer in place on the resident's arm, however the bordered gauze dressing remained in place, with dried, flaking reddish brown staining to the gauze. The resident stated, They ain't fixed it! I asked them to fix it and they wouldn't do it! During an observation, on 12/15/21 at 1:00 p.m., the resident was sitting in his recliner in his room. The dressing to the resident's right arm remained unchanged. During an observation, on 12/17/21 at 8:15 a.m., the resident was sitting in his recliner in his room. The dressing to the right forearm was no longer in place. A small, scabbed area to the arm was observed where the dressing had been. The clinical record for Resident 54 was reviewed on 12/15/21 at 10:40 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 10/9/21, indicated the resident's cognition was moderately impaired and he had no skin impairments. The care plan, dated 8/29/19, indicated the resident was at risk for self-abusive acts, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 4/12/21, indicated the resident was at risk for bleeding related to the use of antiplatelet medication. Interventions included, but were not limited to, document abnormal findings and notify the physician. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing note, dated 12/12/21 a 2:30 p.m., indicated the resident appeared to have a small 0.1 cm (centimeter) by 0.5 cm skin tear on his right elbow. Initially he would not allow staff to treat, but when the resident was calm, the area was cleansed with wound cleaner and a border gauze was applied. The resident could not recollect how he obtained the skin tear. The clinical record lacked documentation of any notification to the family, physician, or of any treatment orders for the skin tear. During an interview on 12/20/21 at 12:10 p.m., the DON (Director of Nursing) indicated she had seen the note about the resident's skin tear. When a resident had a new skin impairment, they should open a change in condition note, notify the family and doctor, and ensure treatment orders are in place. 2. During an observation, on 12/13/21 at 10:36 a.m., Resident 51 was observed with long jagged fingernails to his left hand. His left palm and his hand appeared red in color. The clinical record for Resident 51 was reviewed, on 12/18/21 at 1:31 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly MDS assessment, dated 11/10/21, indicated the resident's cognition was moderately impaired. He required extensive assistance of two staff members with ADL's (Activities of Daily Living). The physician's verbal orders, dated of 10/26/21, indicated to apply a prescription barrier cream to the resident's buttocks and groin topically every shift for redness. Apply to palm left hand topically every shift for excoriation and a rolled pillowcase to be placed in palm after cream applied. The nurse's note, dated 10/26/21 at 12:31p.m., indicated during care the resident had excoriated area to the palm of his left hand, which was contracted. He was currently working with therapy per order on brace for the contracture. The physician was notified with new orders for prescription barrier cream to area and apply rolled pillowcase to area every shift. The clinical record lacked documentation indicating the order for a rolled pillowcase to be placed in the resident's left palm was transcribed into the resident's clinical record. During an interview on 12/17/21 at 9:30 a.m., LPN 19 (Licensed Practical Nurse) indicated the resident had a roll that he was supposed to wear all the time for his contracture and moisture. His left hand holds moisture. When a doctor gives a verbal order, it should be added to the clinical record at the time he gave the order. On 12/20/21 at 8:30 a.m., the DON presented a copy of the facility's current policy titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission.2. As assessments are completed, orders will be received from the physician to address significant findings of the assessment. 3.1-37(a) 3.1-37(b)

Based on interview and record review, the facility failed to ensure effective interventions to prevent a delay in staff notification, action, assessment, and medical care for a resident having pain, shortness of breath, and numbness on the left side, resulting in the resident having no pulse, being unresponsive, and death. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when a cognitively intact, male resident, notified the Dietary Manager, he was short of breath and had pain down his left side. The Dietary Manager notified two nursing staff. Neither nurse assessed the resident until he was found face down in the floor. The Health Facility Administrator and Acting Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 1:27 p.m. Findings include: A Progress Noted, dated [DATE] at 11:30 a.m., indicated Resident B had his light on around 10:00 a.m. The resident's vital Signs were obtained and include, but were not limited to, Blood Pressure ,d+[DATE]; Pulse 80; Respirations 20; Oxygen Saturation 97.4 on room air and he voiced a complaint of pain in his right heel. The nurse was in the process of texting the doctor to notify him of the [MEDICATION(S)] needed when the DON (Director of Nursing) came to the desk and stated housekeeping had indicated the resident was on the floor. Upon entering the room, the resident was lying face down on floor beside bed. Resident B had been previously sitting in bed. Resident B was rolled over and assessed. No pulse or respirations noted. CPR immediately started by nurse and Hospice nurse who was on the hall. A Code (cardiopulmonary arrest) was started and 911 was called. CPR continued until EMS arrived and took over care. EMS called the resident's time of death at 10:49 a.m The clinical record for Resident B was reviewed on [DATE] at 10:15 a.m. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact, he had adequate vision and hearing with clear speech, was able to understand and be understood. The resident required the extensive assistance of two physical staff members for mobility, transfer, and ADLs. He was always continent of bladder and bowel. A Care Plan, dated [DATE], indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated [DATE], indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included, but were not limited to, staff were to observe the resident for shortness of breath. A Care Plan, dated [DATE], indicated the resident was at risk for a CVA (stroke). The interventions included, but were not limited to, staff were to observe the resident for signs and symptoms of chest pain, hypertension, shortness of breath, loss of vision, and unresponsiveness. Staff were to notify the doctor with symptoms. A Care Plan, dated [DATE], indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated [DATE], indicated the resident had a Full Code Status. (all resuscitation procedures will be provided). The interventions included, but were not limited to, staff were to notify the doctor and family of any change in condition. During a telephone interview on [DATE] at 10:10 a.m., LPN 2 indicated she last observed the resident when he refused his medication, and she was not sure of the time, but she charted it. Later he was hollering so she went down, and he indicated he was in pain, but he no longer had [MEDICATION(S)] ,d+[DATE] and did not return from the hospital with his original order for [MEDICATION(S)] ,d+[DATE]. He was in bed with the head of the bed raised up. She could not recall the time and that she was not notified the resident was in distress. As far as she knew there was nothing out of the ordinary. She doesn't recall talking with staff at the nurses' station that morning. During an interview on [DATE] at 10:03 a.m., the DON indicated LPN 2 charted Resident B refused medications at 8:26 a.m. During an interview on [DATE] at 1:40 p.m., Housekeeper 5 indicated on [DATE] around 9:30 a.m., she had gone to Resident B's room and he told her to get him some help, that his entire left side was numb, and he was having pain. She went to the nurses station and notified CNA 7. CNA 7 indicated she would find and notify the nurse. Around 10:30 a.m. she was walking down the hallway, at the same time as the Agency CNA, and they saw Resident B face down on the floor. Housekeeper 5 ran down the hall hollering for the nurse. The DON, LPN 2, and CNA 6 responded. LPN 2 called for the crash cart, for staff to call 911, and initiated CPR until the Paramedics arrived and pronounced him dead. During an interview on [DATE] at 3:26 p.m., CNA 4 indicated on the morning of [DATE] she had answered Resident B's call light, he indicated he was sick and he wanted crackers. She returned with graham crackers and gave him a sputum tray since he indicated he didn't feel well. The CNA notified LPN 2 and the LPN said ok. Later she heard hollering and Resident B was found on the floor with his arms at his side, palms up. I don't recall the exact time; I'd rather not guess. During an interview on [DATE] at 3:00 p.m., the Dietary Manager indicated she had checked on Resident B because he was calling for help most of the morning. When she entered the room at 10:10 a.m., Resident B was lying in bed, head of the bed was up, he had his hands up, and was gulping air, he indicated, I can't breathe, gulped more air, and said, get me some help. She notified the CNA 6 and the CNA said she was not going in due to he had cussed her earlier that day. LPN 2 was with another resident when she notified her and so she went to [NAME] Hall and told LPN 3 at 10:15 a.m. During an interview on [DATE] at 2:40 p.m., LPN 3 indicated the Dietary Manager asked me to look at Resident B because he said he was dying or something. When he went to the nurses' station LPN 2 was talking to someone and said his vitals were good, no shortness of breath, and that he just liked to be babied. Later when LPN 2 was at the nurses station charting the DON came up and said to call 911 that Resident B was unresponsive. After the call, he went down, and they were doing CPR. During an interview on [DATE] at 1:35 p.m., LPN 3 indicated he did not actually speak to LPN 2 due to he assumed she was already aware based on the conversation she was having with another staff concerning Resident B's vitals, so he just returned to the [NAME] Hall to finish passing his medications. During an interview on [DATE] at 10:12 a.m., LPN 3 indicated he had been the nurse on [NAME] Hall. He had a cup of pills and a cup of water in his hand when he walked around the nurses station and down the [NAME] Hall. LPN 2 was about half way down that hall. He didn't talk to her because she was telling another staff about Resident B, and he overheard her say his vitals are better than mine. During an interview on [DATE] at 9:40 a.m., the Acting DON indicated she was not in the building on [DATE]. However, based on charting he was non-compliant with care, on [CONDITION(S)], refused medications, and that was all she knew. During an interview on [DATE] at 9:52 a.m., the Administrator indicated [DATE] was her first day in the building and she was not out on the floor. She was not notified of Resident B's passing until after the fact. The current facility policy titled Assessments, and dated [DATE], was provided by the Acting DON on [DATE] at 1:24 p.m. The Policy indicated, .ensure that assessments of the residents take place timely, .Procedure: 1.) Assessments are completed using the Required Nursing Clinical Assessments.when a significant change of condition occurs .2.) Appropriate assessments can and will be completed at times based on the event .D. Resident experiencing Pain .Note: Nurses will perform appropriate assessments of the resident .when a change in condition or circumstance takes place that requires assessment by qualified medical professional . The current facility policy titled Change in Resident's Condition or Status, and not dated, was provided by the Acting DON on [DATE] at 1:24 p.m. The Policy indicated, the resident's attending physician .are notified of changes in the resident's condition or status .Procedure: 1. The nurse will notify the resident's attending physician when: .There is a significant change in the resident's physical .status . The Immediate Jeopardy began on [DATE] was removed on [DATE] when the facility completed staff education on points of the in-servicing for change of condition, medical emergency, neglect, immediate notification and responding timely. Requirements for all staff to work together as needed to meet any resident needs or perform any services timely and appropriately were addressed. How to manage and work with residents who request staff assistance repetitively and effective care planning an monitoring. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on all change of condition points of in-servicing. This Federal tag relates to Complaint IN 797. ,d+[DATE]-27(a)

Based on interview and record, the facility failed to follow policy and procedure on abuse when staff observed a sexual encounter between two cognitively impaired residents (Resident #G and Resident #H) and failed to immediately notify the Administrator. This deficient practice had the potential to affect 1 of 3 sampled residents (Resident H) on a secured unit of 23 residents. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/22/16 at 3:30 a.m. when two staff members observed a sexual encounter between two cognitively impaired residents (Resident #G and Resident #H) and failed to immediately notify the Administrator of the incident. The Health Facility Administrator, Regional Director, Director of Nursing, and Assistant Director of Nursing were notified of the Immediate Jeopardy on 7/7/16 at 4:47 p.m. The Immediate Jeopardy was removed on 7/11/2016 at 4:45 p.m., but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The ISDH (Indiana State Department of Health) reportable, dated 6/22/16, included, but was not limited to, the following: .Incident Date: 06/22/2016 .Incident Time: 03:30AM .Residents Involved .(Resident #H's name) .Diagnosis: [REDACTED].#G's name) .Diagnosis: [REDACTED].Brief Description of Incident .6/22/2016 Resident, (Resident #G) was noted in the bed with . roommate when the C.N.A. (Certified Nursing Assistant) went in to check on the residents. She noted (Resident #G) lying behind (Resident #H) and when she got closer, (Resident #G) had . hand stretched across (Resident #H) waste (sic) and touching (Resident #H) hip and groin area .Follow up added - - 6/27/2016 Upon investigation, the following was noted: At approx. (approximately) 3:30 am, June 22, 2016, (CNA #8) went into (room number) to check on (Resident #G) and (Resident #H). Upon entering, she discovered that (Resident #G) was in (Resident #H) bed, lying behind .(Resident #G) was noted to be pulling at (Resident #H) brief/pull up. (CNA #8) attempted to redirect resident .became combative. She then went to the doorway to summon (CNA #7) to help her. They immediately went together and separated them. (CNA #7) noted that (Resident #H) brief was pulled down on one side and (Resident #G) was touching (Resident #H) on leg/groin area .The CNAs (sic) reported to the night shift nurse (LPN (Licensed Practical Nurse) #9) that (Resident #G) was found in bed with (Resident #H) and was noted to be rubbing .leg/hip area The written statement from CNA #8, undated and untimed, included, but was not limited to, the following: .At around 4 am (sic) (4:00 a.m.) we began to start rounds and I opened the door to (Resident #G's) (plus sign) (and) (Resident #H's) room. When I opened the door (sic) (Resident #G) had .pants off w (with)/nothing on but a shirt and was laying behind (Resident #H) w(with)/ .cheek against (Resident #H's) butt. (Resident #G) was pulling on (Resident #H's) pull up as I was telling .to stop and get up .I stepped in the hallway to get (CNA #7) to come in and help me. When she came in to help me (sic) (Resident #G) had pulled (Resident #H's) pull up down slightly at an angle and .butt was exposed. (Resident #G) was rubbing on .leg and butt/groin area .The nurse was then notified of the situation and said she would document The written statement from CNA #7, dated 6/22/16 and untimed, included, but was not limited to, the following: Around 3:30 a.m. (Resident #G) was got (sic) toileted and layed (sic) down in .own bed. 4:00 a.m. (sic) (CNA #8) went and checked on (Resident #G) to make sure .wasn't going into other resident (sic). (CNA #8) yelled at me while I was standing at the nurse (sic) station to help her with (Resident #G). I walked in (Resident #G's) room and I found (Resident #G) naked beside (Resident #H) with .pull up half way down while (Resident #G) touching (Resident #H's) private parts. (Resident #G) was awake when doing what .was doing. Me and (CNA #8) got (Resident #G), put .clothes on and sent .to the dining room The written statement from RN #9, indicated as verbal to the DON (Director of Nursing), dated 6/22/16 and untimed, included, but was not limited to, the following: The nurse on Onyx night shift, noted (CNA #7 and CNA #8), bringing (Resident #G) out in the hallway. The CNA's reported to (RN #9) that they had seen (Resident #G) (was with a line through it) in bed behind (Resident #H). (Resident #H) had no pants on but he did have a pull up on. (Resident #H) was facing the wall while abed. (Resident #G) was noted to be pulling (Resident #H's) brief at the waist.(RN #9) was unsure if (Resident #G) was (in or out of bed), (sic) (RN #9) told (DON) the CNA's yelled stop that when they saw the resident rubbing on hip .(RN #9) did not witness The written statement from CNA #5, dated 6/22/16 and untimed, included, but was not limited to, the following: I (sic) (CNA #5) was reported .on 6-22-16 By (sic) C.N.A.s (sic) working on onyx that (Resident #G) laying behind (Resident #H). With (sic) all his clothes off and brief off. (Resident #G) had (Resident #H) brief off. (Resident #G) was rubbing (Resident #H) buttox (sic) (buttocks) and his genitalia, they (sic) said they removed (Resident #G) from (Resident #H) bed and they reported this to nurse The written statement from CNA #6, dated 6/22/16 and untimed, included, but was not limited to, the following: I (CNA #6) was reported this on 6-22-16, By (sic) the night shift CNA working on onyx that (Resident #G) was laying behind (Resident #H) with all .clothes off and brief was off (sic) (Resident #G) had (Resident #H's) brief off (sic) (Resident #G) was rubbing (Resident #H's) buttox (sic) (buttocks) and .genetalia (sic) .They said they reported this to there (sic) (their) nurse The nurses note, dated 6/22/16 at 9:09 a.m., included, but was not limited to, the following: ADON (Assistant Director of Nursing) summoned me into his office to report to me that (RN #4) had just reported to him that his CNA's (CNA #5 and #6) got in report that (Resident #G) was noted in the bed with his roommate and touching him inappropriately with his hands During an interview on 7/7/16 at 2:20 p.m., the Administrator indicated CNA #7 and CNA #8 did not tell the nurse the specifics of the incident, only that (Resident #G) was in bed with (Resident #H). The Administrator indicated CNA #7 and CNA #8 told RN #9 (Resident #G) was not sleeping so they were bringing (Resident #G) to the dining room and RN #9 indicated she would watch him/her. The Administrator indicated the day shift CNA's got report from the night shift CNA's, and the day shift CNA's further questioned the night shift CNA's about the incident. The Administrator indicated the day shift CNA's reported the incident to RN #4, the day shift nurse, who reported it to the ADON, who then, reported it to her. The Administrator indicated she and the Director of Nursing were not notified when the incident occurred. The clinical record lacked documentation regarding the incident, when it occurred, on 6/22/16 at 3:30 a.m. until the next shift began at approximately 7:00 a.m. The clinical record also lacked documentation of the notification of the Administrator and/or Director of Nursing regarding the incident, when it occurred, on 6/22/16 at 3:30 a.m. On 7/7/16 at 2:04 p.m., the Business Office Manager provided a current copy of the document titled, Abuse Prevention Program. It included, but was not limited to, the following: Policy .All personnel must promptly report any incident or suspected incident of resident abuse .Procedure .Any alleged violations involving .abuse .MUST be reported to the Administrator and Director of Nursing .Additionally, the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse .The Charge Nurse will immediately report the incident to the Administrator The Immediate Jeopardy that began on 6/22/16 was removed on 7/11/2016 at 4:45 p.m. when the facility completed staff education/inservices on resident rights, abuse policy, reporting witnessed abuse or alleged abuse and residents who require 1:1 supervision of any onset of sexual behaviors. The Immediate Jeopardy was removed on 7/11/16, but noncompliance remained at the lower scope and severity of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on resident rights, abuse policy, reporting witnessed abuse and residents who require 1:1 supervision of any onset of sexual behaviors. This Federal tag relates to Complaint IN 347 3.1-28(a)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent, the potential for, additional sexual encounters to occur, after a resident (Resident #G) returned from a behavioral hospital stay related to sexual misconduct towards another resident (Resident #H). This deficient practice had the potential to affect 1 of 3 sampled residents (Resident H) on a secured unit of 23 residents. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/22/16 at 3:30 a.m. when two staff members observed a sexual encounter between two cognitively impaired residents (Resident #G and Resident #H) and failed to provide adequate supervision to prevent, the potential for, additional sexual encounters to occur, after a resident returned from a behavioral hospital stay related to sexual misconduct towards another resident. The Health Facility Administrator, Regional Director, Director of Nursing, and Assistant Director of Nursing were notified of the Immediate Jeopardy on 7/7/16 at 4:47 p.m. The Immediate Jeopardy was removed on 7/11/2016 at 4:45 p.m., but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The ISDH (Indiana State Department of Health) reportable, dated 6/22/16, was reviewed on 7/6/16 at 11:00 a.m. It included, but was not limited to, the following: .Incident Date: 06/22/2016 .Incident Time: 03:30AM .Residents Involved .(Resident #H's name) .Diagnosis: [REDACTED].#G's name) .Diagnosis: [REDACTED].Brief Description of Incident .6/22/2016 Resident, (Resident #G) was noted in the bed with . roommate when the C.N.A. (Certified Nursing Assistant) went in to check on the residents. She noted (Resident #G) lying behind resident and when she got closer, (Resident #G) had . hand stretched across (Resident #H's) waste (sic) and touching (Resident #H's) hip and groin area .Type of Preventative Measures Taken (.Resident #G) was moved into a different room where .will return upon readmission On 7/6/16 at 9:46 a.m., during initial tour, Resident #G's name and Resident #H's name were observed to be posted on the wall by the door of the same room. On 7/6/16 at 9:50 a.m., Resident #G was observed ambulating independently on the Onyx unit. During an interview on 7/6/16 at 10:46 a.m., CNA #6 indicated Resident #G and Resident #H resided in the same room. During an interview on 7/6/16 at 12:00 p.m., the Administrator indicated the facility just realized Resident #G and Resident #H were residing in the same room. The Administrator indicated Resident #G was moved to a different room the day the incident occurred, prior to discharge to the behavioral hospital. The Administrator indicated RN (Registered Nurse) #4, per their phone conversation, felt it was okay to readmit Resident #G to his original room with Resident #H. The Administrator further indicated RN #4 stated since Resident #G was sent out and treated and Resident #H's POA (Power of Attorney) was okay with Resident #G returning to the same room, there was no issue. The Administrator also indicated RN #4 should not have made that decision without consulting management. The Administrator indicated Resident #G and Resident #H were now in separate rooms. During an interview on 7/6/16 at 12:04 p.m., the DON (Director of Nursing) indicated there was a communication problem regarding the resident's room change. During an interview on 7/6/16 at 4:48 p.m., the Vice President of Clinical Operations indicated Resident #G did not return to the facility with any orders for 15 minute monitoring checks and also indicated Resident #G was not having any behaviors at the time of hospital discharge on 6/27/16. The Social Service note, dated 7/7/16 at 1:48 p.m., included, but was not limited to, the following: F/U (follow up) on adjustment to room change this am (sic) (a.m.) when observed (Resident #G) in the DR (dining room) (sic) mood pleasant & (and) calm. Upon making rounds later in the AM to unit (sic) observed .name on old room with old roommate. Upon speaking with staff (sic) was informed (Resident #G) was moved back into old room upon return from the hospital During a interview on 7/7/16 at 2:15 p.m., the Social Services Director (SSD) indicated, on 6/22/16, only bodies were moved, not belongings. The SSD indicated, for whatever reason, someone took it upon themselves to put Resident #G back in his/her original room. The SSD indicated she did not know why the personal belongings were not moved on 6/22/16. The clinical record for Resident #G was reviewed on 7/6/16 at 10:05 a.m. [DIAGNOSES REDACTED]. The clinical record for Resident #H was reviewed on 7/6/16 at 11:15 a.m. [DIAGNOSES REDACTED]. The nurses note, dated 6/27/16 at 6:48 p.m., included, but was not limited to, the following: Resident (Resident #G) returned to facility from (name of behavior hospital) .Making frequent statements such as we love you. Stated to the female CNA (sic) sit on my head while being weighed The nurses note, dated 6/28/16 at 5:14 a.m., included, but was not limited to, the following: Resident (Resident #G) has been resting quietly .No inappropriate sexual comments or advances; .was repeating the word balls over and over The IDT (Interdisciplinary Team) note, dated 6/28/16 at 11:24 a.m., included, but was not limited to, the following: .Resident (Resident #G) was sent to behavior for sexual behaviors .now on Climara (medication used for sexual behaviors) to prevent further sexual behaviors The IDT note, dated 7/1/16 at 2:04 p.m., included, but was not limited to, the following: IDT team met for weekly behavior meeting. Team reviewed & (and) discussed behavior charted by nursing. (Resident #G) was being verbally sexually inappropriate The June 2016 Behavior Monthly Flowsheet indicated Resident #G had a sexual behavior on 6/28/16. The clinical record indicated behavior monitoring was tracked once per 12 hour shift. The behavior tracking logs for sexual behaviors/remarks were left blank on 6/30/16, 7/1/16, 7/2/16 and 7/4/16. The behavior tracking log for July 2016 also indicated to begin tracking signs of sexual behavior on 7/7/16. The clinical record lacked any documentation of increased monitoring and preventative measures for Resident #G to ensure the safety of Resident #H and other residents residing on Onyx. The Immediate Jeopardy that began on 6/22/16 was removed on 7/11/2016 at 4:45 p.m. when the facility completed staff education/inservices on resident rights, abuse policy, reporting witnessed abuse or alleged abuse and residents who require 1:1 supervision of any onset of sexual behaviors. The Immediate Jeopardy was removed on 7/11/16, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on resident rights, abuse policy, reporting witnessed abuse, and residents who require 1:1 supervision of any onset of sexual behaviors. This Federal tag relates to Complaint IN 347 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident, admitted with no pressure areas, did not acquire pressure areas for 1 of 3 residents reviewed for pressure ulcers. (Resident #B) Findings include: The clinical record for Resident #B was reviewed on 6/1/16 at 11:15 a.m. [DIAGNOSES REDACTED]. Resident #B was admitted to the facility on [DATE]. The wound sheet for Resident #B, dated 4/22/16 at 5:55 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .23) Coccyx .b. Type of Wound .Pressure ulcer .b1. Stage of Wound .Stage II (2) (Partial thickness loss of dermis) .c. Size of Wound .3 cm (centimeters) x (by) 3 cm (centimeters) .Healing Process .1. New Wound The wound sheet for Resident #B, dated 4/27/16 at 1:52 a.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .23) Coccyx .b. Type of Wound .Pressure ulcer .b1. Stage of Wound .Stage II (2) (Partial thickness loss of dermis) .c. Size of Wound .3 cm (centimeters) x (by) 4.2 cm (centimeters) x (by) 0.2 cm (centimeters) (depth of wound) .Healing Process .1. No Change .Action Taken .8d. No new orders. Continue current treatment plan The wound sheet for Resident #B, dated 5/3/16 at 11:18 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .23) Coccyx .b. Type of Wound .Pressure ulcer .b1. Stage of Wound .Unstageable (Full thickness tissue loss) .c. Size of Wound .9.2 cm (centimeters) x (by) 3.7 cm (centimeters) .Wound Bed .2g. Black/Eschar .Drainage Type .3c .Odorous .3d .Purulent (brownish-yellow) .Healing Process .4. Worsening .Action Taken .8d .No new orders. Continue current treatment plan The wound sheet for Resident #B, dated 5/4/16 at 2:07 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .23) Coccyx .b. Type of Wound .Pressure ulcer .b1. Stage of Wound .Stage III (3) (Full thickness tissue loss) .c. Size of Wound .9.5 cm (centimeters) x (by) 3.0 cm (centimeters) .Wound Bed .2g. Black/Eschar .Drainage Type .3d .Purulent (brownish-yellow) .Healing Process .4. Worsening .Action Taken .8d .No new orders. Continue current treatment plan The wound sheet for Resident #B, dated 4/19/16 at 5:32 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .right heel .b. Type of Wound .Pressure ulcer .b1. Stage of Wound .Unstageable (Full thickness tissue loss) .c. Size of Wound .2.4 cm (centimeters) x (by) 3.0 cm (centimeters) .Wound Bed .2g. Black/Eschar .Healing Process .1. New Wound The wound sheet for Resident #B, dated 4/28/16 at 2:39 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .right heel .b. Type of Wound .Pressure ulcer .b1. Stage of Wound . Stage III (3) (Full thickness tissue loss) .c. Size of Wound .3.8 cm (centimeters) x (by) 6.2 cm (centimeters) x (by) 0.2 cm (centimeters) (depth) .Wound Bed .2d. Red/Beefy .2g. Black/Eschar .2j. Slough (yellow/stringy) .Healing Process .4. Worsening The wound sheet for Resident #B, dated 5/03/16 at 11:19 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .right heel .b. Type of Wound .Pressure ulcer .b1. Stage of Wound . Unstageable (Full thickness tissue loss) .c. Size of Wound .5.3 cm (centimeters) x (by) 8.5 cm (centimeters) .Wound Bed .2g. Black/Eschar .2j. Slough (yellow/stringy) .Drainage Type .3c. Odorous .3d. Purulent (brownish-yellow) .Healing Process .4. Worsening .Action Taken .8d. No new orders. Continue current treatment plan The wound sheet for Resident #B, dated 5/04/16 at 2:06 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .right heel .b. Type of Wound .Pressure ulcer .b1. Stage of Wound . Stage III (3) (Full thickness tissue loss) .c. Size of Wound .8.2 cm (centimeters) x (by) 4.8 cm (centimeters) .Wound Bed .2g. Black/Eschar .2j. Slough (yellow/stringy) .Drainage Type .3c. Odorous .3d. Purulent (brownish-yellow) .Healing Process .4. Worsening The wound sheet for Resident #B, dated 5/04/16 at 2:18 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .Other .right outer foot blister .b. Type of Wound .Pressure Ulcer .c. Size of Wound .2 cm (centimeters) x (by) 2 cm (centimeters) .Wound Bed .2m. Blister .Healing Process .3. No Change .Action Taken .8d. No new orders. Continue current treatment plan There were no other wound sheets provided related to the blister on Resident #B's right outer foot. The wound sheet for Resident #B, dated 4/27/16 at 6:22 a.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .Left heel .blister .b. Type of Wound .Pressure Ulcer .c. Size of Wound .(blank) .Wound Bed .2c. Pink .Healing Process .5. Resolved/Healed There were no other wound sheets provided related to a left heel blister. The wound sheet for Resident #B, dated 4/22/16 at 5:57 p.m., included, but was not limited to, the following: .Resident: (Resident #B's name) .a. Document each wound .Include site .Site .Right buttock .b. Type of Wound .Pressure Ulcer .b1. Stage of Wound .2. Stage II (2) (Partial thickness loss of dermis) . Size of Wound .0.3 cm (centimeters) x (by) 0.5 cm (centimeters) .Wound Bed .2c. Pink .2d. Red/Beefy .Healing Process .1. New Wound There were no other wound sheets provided related to the Stage II pressure ulcer on the right buttock. The clinical record lacked documentation of interventions, provided by staff between 3/24/16 - 5/5/16, to ensure Resident #B did not develop pressure ulcers. The hospital discharge report, dated 5/6/16, included, but was not limited to, the following: .(name of hospital) .(Resident #B's name) .Plan of Care Problems .Wound: Assessment .rt (right) calf outer .Wound Type .Pressure Ulcer .Length (cm) (centimeters) .2.5 .Width (cm) .1.5 .Wound Stage .II (2) .rt inner calf .unopened blister/pressure .Wound Type .ulcer .rt (right) heel .Wound Type .Pressure .General Appearance .Necrotic .Length (cm) .7.5 .Width (cm) .5.5 .Depth (cm) .0.5 .Wound Stage .Unstageable .Wound Bed Assessment .Yellow (Slough) .Black (Eschar) .coccyx/sacrum .Wound Type .Pressure Ulcer .Foul Odor .Length (cm) .17 .Width (cm) .8.5 .Depth (cm) .0.5 .Wound Stage .Unstageable .Wound Bed Assessment .Yellow (Slough) .Black (Eschar) .Surrounding Tissue .Purple .lt (left) heel .Wound Type .calloused with soft mushy skin The Braden Scale Score (assessment of a residents risk for pressure ulcers) for Resident #B, on admission, was 19, which indicated he/she was not at risk for the development of a pressure ulcer. The Braden Scale Score on 2/18/16 and 2/24/16 for Resident #B was 18, which indicated he/she was at risk for the development of a pressure ulcer. The clinical record lacked a Braden Scale Score after 2/24/16. The care plan for Resident #B, initiated on 2/18/16, included, but was not limited to, the following: .Resident at risk for skin breakdown related to cognitive impairment; immobility; incontinence .Resident will have no skin breakdown .Resident to T & R (turn and reposition) self while in bed related to independent with bed mobility The Minimum Data Set assessments, dated 2/24/16, 3/2/16, and 3/16/16 indicated Resident #B was an extensive, 2 person assist with bed mobility. The physician order, dated 5/3/16, indicated to start Zinc Sulfate 220 mg (milligrams) daily, Vitamin C 500 mg a day for wound healing. The physician order, dated 5/3/16, indicated to start Prostat, 30cc (cubic centimeters) three times a day for wound healing. The physician order, dated 5/3/16, indicated to keep heels floated at all times while in bed, every shift, for prevention. During an interview on 6/1/16 at 5:02 p.m., the DON (Director of Nursing)indicated when a resident gets a wound, the Registered Dietician gets involved. The DON also indicated Resident #B could reposition, while abed, independently until the end and then required an assist of 1 with bed mobility. The clinical record lacked documentation from the Registered Dietician after the initial assessment was completed on 2/22/16. During an interview on 6/2/16 at 2:09 p.m., the Therapy Manager indicated, since admission, Resident #B could not turn and reposition independently while in bed. On 6/2/16 at 2:06 p.m., the Administrator provided a copy of the document titled, Braden Scale and Comprehensive Evaluation of Skin Risk Factors, dated 7/1/11. It included, but was not limited to, the following: .Guideline: It is the intent of the facility for a Braden Scale and a Comprehensive Evaluation of Skin Risk Factors to be completed for all residents to assess risk factors for developing pressure sores .Procedure .1. Complete Braden Scale .With a significant change in status (including pressure ulcer or wound development) During an interview on 6/2/16 at 5:45 p.m., the Administrator and DON indicated they were unaware that a Braden Scale had to be completed when new wounds developed. This Federal tag relates to Complaint IN 205 3.1-40(a)(1)

Based on record review and interview, the facility failed to provide the necessary care to maintain the highest practical well-being after recent surgery in that the resident developed a scrotal hematoma 3 days after surgery due to not wearing his scrotal support sling. This resulted in the resident being readmitted to the hospital for further treatment. This deficient practice affected 1 of 1 resident reviewed for after surgery care. (Resident #54) Finding includes: Review of the clinical record for Resident #54 on 4/15/13 at 2:00 p.m., indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a 1/22/13 hospital out-patient surgery note indicated the resident had undergone a hydrocelectomy (removal of fluid and soft swelling in the membrane surrounding the testes). Review of the out-patient instructions indicated the only instructions the physician gave upon return was to change the dressing as needed. A 1/22/13 1:50 p.m. nursing note indicated "...Drsg (dressing) et (and) sling (scrotal support) in place...." Further documentation of the resident wearing his scrotal support sling was lacking. Review of the care plans indicated there was a care plan originally dated 9/12/12 regarding the resident's scrotal swelling and left hydrocele. This care plan was updated on 1/22/13 due to his surgery to repair the hydrocele with new interventions to include: "Antibiotics per order, observe surgical incision, report abnormal findings to MD." Documentation of the intervention regarding the use of the scrotal support after surgery was not included. Documentation was also lacking of the physician having been contacted to clarify use of the sling. On 1/25/13, documentation indicated the resident had a follow-up appointment with the Urologist, per primary physician recommendation, due to scrotal swelling and low grade temperature. The Urologist noted on the visit note that the resident was having pain after surgery from his left testicle. He further noted "Never wore scrotal support." He then sent the resident back to the hospital as a direct re-admit and diagnosed the resident as having a left scrotal hematoma. Review of the 1/25/13 hospital admitting note indicated, "...He underwent a left hydrocele repair on 1/22/13 and really went fine. He apparently went home to his nursing home and no one applied the mesh panties/scrotal support and he subsequently developed a hematoma...given his exam, I thought he needed to be admitted for IV (intravenous fluid) antibiotics. He is aware that if the hematoma infects or this gets worse, he may need a scrotal orchiectomy (removal of the testicle)...." On 1/28/13, the resident was readmitted back the facility after receiving antibiotics in the hospital for three days. No further surgery was necessary. During an interview on 4/16/13 at 3:30 p.m. with the Administrator in Training, Director of Nursing and the MDS (Minimum Data Set) Coordinator, they indicated "the Physician did not indicate on his orders whether he wanted to continue the sling when he came back. They may have just put it on him after surgery and didn't want to continue it. We did not clarify with the Urologist nor his Primary Physician if it was to be continued here at the facility and for how long. We talked with his primary Physician as to what was going on with him and gave us some orders but not specifically about the sling. The urologist was assuming he didn't wear the sling - that's not to say the nurses didn't have it on him. They may have just forgot to chart it. Can't say if it should have been put on the Care Plan as an intervention as we didn't know if the Urologist wanted to continue it or not." 3.1-37(a)

Based on record review and interview, the facility failed to ensure the resident with history of pressure ulcers had a comprehensive plan to prevent recurrence and timely, effective treatment for [REDACTED]. The facility failed to ensure the resident was turned and repositioned in accordance with the care plan. The facility discontinued nutritional supplements and failed to administer other nutritional supplements as ordered. The facility failed to ensure a timely referral to the Registered Dietitian when the resident's wound declined. The deficient practice affected 1 of 3 residents reviewed related to pressure ulcers in a sample of 4. (Resident B) Resident B was readmitted to the facility on [DATE] without pressure ulcers. On [DATE] Resident B had chronic Stage 3 and Stage 4 pressure ulcers. Findings include: During Initial Tour on [DATE] at 11:00 a.m., the Director of Nursing (DON) indicated Resident B had expired about two days earlier after living at the facility for ten years. During interview on [DATE] at 11:40 a.m., the DON indicated the Assistant Director of Nursing is responsible for the facility's wound management program and records. The DON indicated two Assistant Directors of Nursing had worked at the facility recently, and the second had left about two weeks ago during her 90-day probationary period. The DON indicated the DON is responsible for the wound program when there is no Assistant Director of Nursing. The clinical record for Resident B was reviewed on [DATE] at 1:35 p.m. The record indicated the resident was readmitted to the facility after hospitalization on [DATE]. The Nursing Admission Assessment, dated [DATE], indicated in the Narrative Summary section, "Blanchable old area noted to R (right) cease of buttocks. (Symbol for no) redness or drainage noted...." (American Medical Directors Association (AMDA) Clinical Practice Guideline related to Pressure Ulcers in the Long-Term Care Setting describes a Stage 1 pressure ulcer as "Intact skin with nonblanchable redness of a localized area, usually over a bony prominence...." Therefore, the resident was readmitted without a pressure ulcer to the right gluteal area.) A Non-pressure Ulcer Condition Monitoring Sheet, dated [DATE], indicated the resident had an "Abrasion - non-pressure related" wound to the right gluteal fold, 1 cm by 0.5 cm, red in color with no drainage or odor. A notation on [DATE] indicated, "Appears to be opening more due to brief rubbing." A Physician's Telephone Order, dated [DATE], was obtained for "N.O. (new order) apply Purocol Plus (arrow pointing down - lower) R gluteal fold Q (every) shift until healed then D/C (discontinue)." During interview on [DATE] at 10:55 a.m., the DON indicated the nurse used the incorrect form (Non-pressure Ulcer Condition Monitoring Form) for the documentation of the right gluteal wound. She indicated the wound was a pressure ulcer. A Pressure Ulcer Condition Monitoring Sheet, dated [DATE], indicated the wound to the right gluteal fold was 1.8 cm X 1.4 cm X 0.2 cm, brownish in color, with slough and moderate, non-odorous drainage. (AMDA Clinical Practice guideline describes a Stage 2 pressure ulcer as "Partial thickness loss of dermis presenting as a shallow open ulcer wit a red pink ulcer bed, without slough," and a Stage 3 pressure ulcer as "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss...." Therefore, the wound was a Stage 3 ulcer.) A Physician's Telephone Order, dated [DATE], was obtained for "1. Cleanse wound to R buttock (symbol for with) wound cleanser. 2. Apply Mary's Magic Butt Cream around the wound. 3. Apply Santyl oint (ointment) directly to wound bed (approximately a nickel's thickness) q (every) shift & prn (as needed) for soiling or dislodgement, 4. Cover with abd (abdominal) pad. 5. D/C Puracol Plus." A Dietitian's Progress Record, dated [DATE], indicated, "Wound note: Res (resident) has wound that is nonhealing. Currently res is getting Ensure BID (twice daily) & Beneprot (protein supplement) BID. On MVI (multivitamin). Wt (weight) ,[DATE] 96.4 # (pounds), ,[DATE] 98.6 #, ,[DATE] 97.8 #, ,[DATE] 94.8#. Wt. fluctuates. Rec (recommend) d/cing (discontinuing) [MEDICATION NAME] 2 packets/day to help (with) healing. Cont (continue) to encourage intake @ all meals. RD to follow as needed." A lab report, dated [DATE], indicated, "[MEDICATION NAME] 3.3 L (low)" with the Normal Range of 3.5 to 5.0 grams per deciliter. A Physician's Telephone Order, dated [DATE], indicated, "1. D/C Ensure. 2. D/C [MEDICATION NAME] 3. [MEDICATION NAME] 2 pkg (packages) QD (daily) wound healing. 3. Vitamin C tab 500 mg 1 po (by mouth) qd wound healing...." The physician's rewrite orders and Medication Administration Records for August, September, and [DATE] indicated the order originally received [DATE] was for one packet instead of two packets [MEDICATION NAME], and nurses' initials next to the entry for "Juven Revigo Pow (powder) orange, dissolve 1 packet in liquid & take by mouth once daily" indicated the resident received one packet [MEDICATION NAME] daily, instead of the two packets ordered on [DATE] for wound healing. Review on-line on [DATE] at 1:45 p.m. at http://www.abbottstore.com/juven+reg/juven-orange-085-oz-packet-30-pack/invt/ p30 indicated, "Juven is a targeted therapeutic nutrition drink mix that has been clinically shown to support wound healing in as little as 2 weeks and helps build lean body mass (LBM) in as little as 4 weeks. [MEDICATION NAME] twice daily...." Another Physician's Telephone Order, dated [DATE], indicated the physical therapist was to evaluate and treat three times a week for twelve weeks for wound care including electrical stimulation (HVPC - high voltage pulsed current) and sharp mechanical debridement as needed. A Physical Therapy Evaluation Note, dated [DATE], indicated, "Current status includes: Need for wound care management. Pt (patient) was wound free prior to existence of current wound. Pt...referred by nursing for wound care on right ischial tuberosity. Wound is stage 3 completely covered with necrotic tissues. Pt. has advanced [MEDICAL CONDITION] and is completely dependent on all functional skills including bed mobility and transfers. Pt. is non-ambulatory.... Pt. evaluated for wound care on right ischial tuberosity. Pt. developed stage 3 decubitus ulcer measuring 1.8 X 1.5 X 0.3 cm with good pinkish area of skin surrounding wound bed. Wound edges also looks healthy. Wound bed completely covered with necrotic tissues. Sharp/mechanical debridement performed to remove non-viable tissues. Use of HVPC to promote blood flow to wound bed." The Pressure Ulcer Condition Monitoring Sheet indicated the right gluteal fold wound descriptions as follows: [DATE] - 1 X 1 X 0.2 cm., yellow color, no drainage, no odor. [DATE] - 1.7 X 1.8 X 1.6 cm, yellow color, moderate drainage, no odor. [DATE] - 1.3 X 1.9 X 0.3 cm, pink/red color, no drainage, no odor. [DATE] (no measurements indicated from ,[DATE] to [DATE]) - 0.8 X 1.2 X 0.8 cm, pink/red color, scant serosanguineous drainage, description of odor not indicated. [DATE] - 0.8 X 1.2 X 0.8 cm., pink color, scant serosanguineous drainage, description of odor not indicated. [DATE] - 1.8 X 1.8 X 0.8 cm., light pink slough color, moderate green serosanguineous drainage, no odor. During interview on [DATE] at 10:55 a.m., the DON indicated she could not find that the physician was notified of the change in wound drainage on [DATE]. Nurse's Notes for [DATE] did not indicate the physician was notified of the increased size of the wound as measured on [DATE]. [DATE] - 1.6 X 1.4 X 0.8 cm, no color indicated, moderate greenish drainage, description of odor not indicated. On [DATE] a Physician's Telephone Order was obtained to change the treatment to the right gluteal wound to "Clean wound (with) NS (normal saline) to R gluteal fold, apply Santyl 3:1 to wound bed pack (with) calcium alginate cover (with)[MEDICATION NAME] tape (symbol for change) q (every) 3 days and prn." [DATE] - 1.8 X 1.7 X 0.7 cm, eschar pink edges dark wound bed color, no description of drainage or odor indicated. [DATE] - 1.8 X 1.6 X 0.7 cm, eschar pink edge, moderate greenish drainage, no description of odor indicated. A Physician's Progress Note, dated [DATE], indicated, "...R buttock wound - cont (continue) wound care - difficult to heal (secondary to) multiple medical problems & immobility (secondary to) advanced dementia." [DATE] - 1.7 X 1.6 X 0.7 cm, pink edge green inside, green drainage, no description of odor indicated. On [DATE] a Physician's Telephone Order was obtained to discontinue the Santyl treatment and change the treatment to the right gluteal fold to "Wet to dry drsg (dressing) once dly (daily) until healed." [DATE] - 2.3 X 2.0 X 1.3 cm, green color, no description of drainage or odor indicated. On [DATE], a Physician's Telephone Order was obtained to discontinue the wet to dry dressing and "Cleanse area (with) normal saline. Start Santyl to R gluteal fold cover with ABD pad or gauze (symbol for no) tape." [DATE] - 2.3 X 2.0 X 1.3 cm, green black color, green drainage, foul odor. [DATE] - 2.2 X 2.0 X 1.2 cm, green color, drainage description illegible, no description of odor indicated. [DATE] - 2.2 X 2.1 X 1.0 cm, green/yellow color, greenish/yellow drainage, no description of odor indicated. [DATE] - 2 X 2 X 1 cm, yellow color, yellow drainage, no odor. [DATE] - date but no description. [DATE] - 2.5 X 2.3 X 1.5, black/yellow color, yellow - bloody drainage, no odor. Nurse's Notes did not indicate further contact with the physician related to the wound treatment, and physician's orders did not indicate further changes to the wound treatment from ,[DATE] through [DATE] except as follows: On [DATE], a Physician's Telephone Order was obtained to increase the physical therapy visits to five times a week for wound care and electrical stimulation and sharp mechanical debridement. On [DATE], a Physician's Telephone Order was obtained for "Give Mighty Shakes between meals...Give ice cream (with) each meal." On [DATE], Physician's Telephone Orders were obtained for "F/C (Foley catheter) to BSD (bedside drainage) for wound healing." On [DATE], Physician's Telephone Orders were obtained for "Surgical consult for surgical debridement of wound with (name of physician)," and "PT (physical therapy) clarification order: Continue PT skilled service including use of HVPC to right lower gluteal area Stage 4 wound; sharp/mechanical debridement PRN." The Quarterly Nutritional Re-evaluation, dated June (no specific date) 2012 and signed by the Dietary Manager (DM) indicated, "Resident's wt. is stable and intake is good. Will continue to monitor and refer to RD (Registered Dietitian) PRN (as needed)." The evaluation indicated the resident's diet was "Puree, ice cream w/ (with) all meals." A notation by the DM, dated [DATE], indicated, "Resident's wt. is stable at this time. Consumes ,[DATE]% of most meals. Will continue to monitor and refer to RD PRN." The note did not address the resident's pressure ulcer. The next entry by the Registered Dietitian was [DATE], the annual RD Assessment. A PT (Physical Therapy) Recertification Note, dated [DATE], and signed by the physician on [DATE], included, but was not limited to, "treatment plan: [REDACTED]." A Determination of Clinically Unavoidable Skin Condition was signed by the DON on [DATE], and countersigned by the physician on [DATE]. The form indicated the resident was at risk for a clinically unavoidable skin condition, if the resident had two or more of the listed [DIAGNOSES REDACTED]. The form indicated the resident might have [MEDICAL CONDITION]/dehydration based on four lab values. The resident had two of the lab values checked, as follows: "Serum [MEDICATION NAME] below 3.4 g/dl (check what additional protein is being provided)" and HGB (hemoglobin) less than 12 mg per dl." No documentation on the form indicated additional protein was being provided. The serum [MEDICATION NAME] listed was [DATE] at 3.3, and the hemoglobin listed was [DATE] at 10.4. During interview on [DATE] at 10:30 a.m., the Dietary Manager indicated she thought the resident's Mighty Shakes and ice cream were discontinued in [DATE] because she was eating well and gaining weight. She also indicated when she started her job at the facility in [DATE], she noticed a lot of residents received supplements, instead of being provided good nutrition. She indicated she would locate the physician's order related to the discontinuation and subsequently provided a Physician's Telephone Order obtained on [DATE], for "D/C (discontinue) shakes & super pudding @ meals." The Monthly Record of Vital Signs and Weights indicated the resident's 2012 weights were as follows: March: 98.6 pounds, [MEDICAL CONDITION] pounds, [MEDICAL CONDITION] pounds, [MEDICAL CONDITION] pounds, [MEDICAL CONDITION] pounds, [MEDICAL CONDITION] pounds, [MEDICAL CONDITION] pounds, and [MEDICAL CONDITION] pounds with reweight of 103 pounds. The Care plan Worksheet for "(Name of resident) received a puree diet at risk for weight loss," originally dated [DATE], and updated [DATE], [DATE], [DATE], [DATE], and [DATE], indicated the goal of "Consume 75% - 100% of most meals thru next review." Dates for revised interventions were not indicated. The intervention of "Health shakes at all meals" was lined through. The intervention of "Health shakes between meals" was lined through. The most recent update, [DATE], indicated in the problem list: "Puree diet, at risk for wt. loss. Goal: No significant wt. loss thru next review." In the same handwriting was the intervention: "Mighty Shakes TID (three times a day), super cereal @ breakfast, ice cream w/ (with) meals." During interview on [DATE] at 10:15 a.m., in regard to a follow-up [MEDICATION NAME] level after [DATE], the DON indicated she did not know if a repeat lab had been obtained and indicated, "We can only do what the doctor orders." Lab reports in the lab report section of the clinical record did not indicate additional [MEDICATION NAME] levels were obtained. The Registered Dietitian's Assessment, dated [DATE], indicated no [MEDICATION NAME] level after [DATE]. During interview on [DATE] at 11:05 a.m., the DON indicated she did not know when the resident stopped having Mighty Shakes and ice cream. During interview on [DATE] at 11:45 a.m., the DON indicated the resident had lived at the facility for ten years and "she (Resident B) had always had the Mighty Shakes since I've been here (until the supplements were discontinued)." During interview on [DATE] at 11:20 a.m., the DON indicated the health shakes were discontinued on [DATE]. During interview on [DATE] at 11:55 a.m., the Dietary Manager provided a nutritional list for Mighty Shakes. The list indicated the four ounce Mighty Shake provided: 200 calories, 6 grams of fat, and 6 grams of protein. The Care plan Worksheet for Pressure Ulcer Risk, originally dated [DATE], and updated every three months and most recently updated [DATE], indicated, "The resident is at risk for further development of pressure ulcers due to: decreased mobility, incontinence." Dates of updated interventions were not indicated but included "Mighty shakes" and "Juven." Another care plan, dated [DATE], indicated, "I have an open area in the following area: "R gluteal fold." Interventions included, but were not limited to: "Notify MD and responsible party of area....Observe for S/S (signs and symptoms) such as: redness, warmth, odor, drainage, elevated temp (temperature). Notify MD and responsible party of noted signs and symptoms....Dietitian evaluation as indicated...XXX,[DATE](sic)/12 Air mattress [DATE] T& R (turn and reposition) Q (every) 1 (symbol for hour) ,[DATE][MEDICATION NAME] (protein supplement)/MVI (multivitamin). ,[DATE] Dietary to see pt (patient) weekly. ,[DATE] Mighty shake...." Nurse's Notes for ,[DATE] through [DATE] indicated the resident was turned and repositioned every two hours instead of every hour, as planned, except on the following dates/times, when the Nurse's Notes indicated the resident was turned and repositioned every hour: [DATE] at 8:00 p.m., [DATE] at 4:00 a.m. and 8:00 p.m., [DATE] at 4:00 a.m., and [DATE] at 8:00 p.m. Entries on the Treatment Record for August and [DATE] indicated, "Turn & reposition q (every) 2 (symbol for hours)." Nurses' initials indicated the intervention was implemented on the 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. shifts. The Treatment Record for [DATE] indicated, "Turn & reposition q 2 (symbol for hours) FYI (for your information). The entry was not signed by nurses. During interview on [DATE] at 10:30 a.m., the DON indicated no dietary notes indicated the resident was seen weekly. The DON indicated the Dietary Manager was part of the PAR (Patient at Risk) meetings. The DON indicated the PAR meeting information was not part of the clinical record. She provided the PAR information for Resident B. The Patient at Risk (PAR) Tracking Form notes indicated the following for Resident B: [DATE] - "PT (physical therapy) to look at wound - new order." [DATE] - "Tx (treatment) working well - getting smaller...labs - [MEDICATION NAME] level ordered. Res. (resident) gets supplements...." [DATE] - "Res. continues to get supplements.... [DATE] - "D/C (discontinue) shakes & super puddings (with) meals - res. doing better...." The next entry in the record related to nutritional care was the RD assessment dated [DATE], the annual assessment. The RD recommendations included, but were not limited to, "Add double meat @ bkft (breakfast)." The RD Assessment indicated the resident received "Juven 1 pk (package)." The Dietitian's Progress Record, dated [DATE], indicated: "Wound note: See yrly (yearly) assessment sheet for recommendations." During interview on [DATE] at 2:10 p.m., the Dietary Manager provided the resident's tray card and indicated the double meat portion at breakfast had not been added to the resident's nutritional plan. A physician's consult, dated [DATE], indicated, "Reason for Consultation: decubitus....Skin: Reveals a 2.5 X 2 cm deep ischial wound. Some eschar in a portion of the edge of it that is fairly thin with a diffuse exudate and a little bit of devitalized eschar....Impression: Patient with a fairly significant ischial wound that does not appear to be progressing very well. I think given the appearance of this, surgical debridement may be necessary, but I do not think it would be as effective as an aggressive wet to dry dakins mechanical [MEDICATION NAME] dressing change. My goal for this would be to improve the bed of the wound enough to start a wound vac which should increase her rate of healing somewhat. Of note, really as expected, her principal problem is going to be keeping up with the caloric intake and offloading this wound, as well. I think also we need to make sure that she is having no recurrence of her [MEDICAL CONDITION] and that her oxygen delivery is good, as well. I will start the therapies as mentioned and will proceed with that." This federal tag related to Complaint IN 976. 3XXX,[DATE](a) 3XXX,[DATE](b) 3XXX,[DATE](c)

Based on record review and interview, the facility failed to ensure dietary interventions to improve wound healing for 1 of 3 residents reviewed related to pressure ulcers (Resident B) and address weight loss for 1 of 3 residents reviewed related to weight loss (Resident A). The deficient practice affected 2 of 4 residents reviewed related to nutrition in a sample of 4. (Residents A and B) Resident B experienced a decline in a pressure ulcer from no ulcer to a Stage 4 ulcer. Findings include: 1. The clinical record for Resident B was reviewed on 11/2/12 at 1:35 p.m. The record indicated the resident was readmitted to the facility after hospitalization on [DATE]. The Quarterly Nutritional Re-evaluation, dated 3/26/12, indicated, "Resident continues to demonstrate poor appetite. Receives numerous supplements to combat weight loss. Weight stable. Will continue to monitor and refer to RD (Registered Dietitian) PRN (as needed)." The resident's diet was listed as "Puree/Ice cream @ all meals." The next Dietary Note was dated 4/9/12, and indicated, "14 day complete. Will continue to monitor: on weekly weights X 2 more weeks to monitor." A Non-pressure Ulcer Condition Monitoring Sheet, dated 4/17/12, indicated the resident had an "Abrasion - non-pressure related" wound to the right gluteal fold, 1 cm by 0.5 cm, red in color with no drainage or odor. During interview on 11/5/12 at 10:55 a.m., the DON indicated the wound was a pressure ulcer. A Pressure Ulcer Condition Monitoring Sheet, dated 5/8/12, indicated the wound to the right gluteal fold was 1.8 cm X 1.4 cm X 0.2 cm, brownish in color, with slough and moderate, non-odorous drainage. A Dietitian's Progress Record, dated 5/16/12, indicated, "Wound note: Res (resident) has wound that is nonhealing. Currently res is getting Ensure BID (twice daily) & Beneprot (protein supplement) BID. On MVI (multivitamin). Wt (weight) 5/12 96.4 # (pounds), 4/12 98.6 #, 2/12 97.8 #, 11/11 94.8#. Wt. fluctuates. Rec (recommend) d/cing (discontinuing) [MEDICATION NAME] 2 packets/day to help (with) healing. Cont (continue) to encourage intake @ all meals. RD to follow as needed." A lab report, dated 5/17/12, indicated, "[MEDICATION NAME] 3.3 L (low)" with the Normal Range of 3.5 to 5.0 grams per deciliter. A Physician's Telephone Order, dated 5/17/12, indicated, "1. D/C Ensure. 2. D/C [MEDICATION NAME] 3. [MEDICATION NAME] 2 pkg (packages) QD (daily) wound healing. 3. Vitamin C tab 500 mg 1 po (by mouth) qd wound healing...." A Physical Therapy Evaluation Note, dated 5/17/12, indicated, "Current status includes: Need for wound care management....Pt (patient) was wound free prior to existence of current wound. Pt...referred by nursing for wound care on right ischial tuberosity. Wound is stage 3 completely covered with necrotic tissues...." The physician's rewrite orders and Medication Administration Records for August, September, and October 2012 indicated the order originally received 5/17/12 was for one packet instead of two packets [MEDICATION NAME], and nurses' initials next to the entry for "Juven Revigo Pow (powder) orange, dissolve 1 packet in liquid & take by mouth once daily" indicated the resident received one packet [MEDICATION NAME] daily, instead of the two packets ordered for wound healing. Review on-line on 11/9/12 at 1:45 p.m. at http://www.abbottstore.com/juven+reg/juven-orange-085-oz-packet-30-pack/invt/ p30 indicated, "Juven is a targeted therapeutic nutrition drink mix that has been clinically shown to support wound healing in as little as 2 weeks and helps build lean body mass (LBM) in as little as 4 weeks. [MEDICATION NAME] twice daily...." The next note related to nutrition was the Quarterly Nutritional Re-evaluation, dated June (no specific date) 2012, and signed by the Dietary Manager (DM), which indicated, "Resident's wt. is stable and intake is good. Will continue to monitor and refer to RD (Registered Dietitian) PRN (as needed)." The evaluation indicated the resident's diet was "Puree, ice cream w/ (with) all meals." A notation by the DM, dated 6/22/12, indicated, "Resident's wt. is stable at this time. Consumes 75-100% of most meals. Will continue to monitor and refer to RD PRN." The note did not address the resident's pressure ulcer. A Determination of Clinically Unavoidable Skin Condition was signed by the DON on 6/11/12, and countersigned by the physician on 6/23/12. The form indicated the resident was at risk for a clinically unavoidable skin condition, if the resident had two or more of the listed [DIAGNOSES REDACTED]. The form indicated the resident might have [MEDICAL CONDITION]/dehydration based on four lab values. The resident had two of the lab values checked, as follows: "Serum [MEDICATION NAME] below 3.4 g/dl (check what additional protein is being provided)" and HGB (hemoglobin) less than 12 mg per dl." No documentation on the form indicated additional protein was being provided. The serum [MEDICATION NAME] listed was 5/17/12 at 3.3, and the hemoglobin listed was 4/2/12 at 10.4. During interview on 11/5/12 at 10:30 a.m., the Dietary Manager indicated she thought the resident's Mighty Shakes and ice cream were discontinued in June 2012 because she was eating well and gaining weight. She also indicated when she started her job at the facility in June 2012, she noticed a lot of residents received supplements, instead of being provided good nutrition. She indicated she would locate the physician's orders [REDACTED].@ meals." The Monthly Record of Vital Signs and Weights indicated the resident's 2012 weights were as follows: March: 98.6 pounds, April 98.6 pounds, May 96.4 pounds, June 98.2 pounds, July 100.4 pounds, August 95.8 pounds, September 99.6 pounds, and October 90.2 pounds with reweight of 103 pounds. The Care plan Worksheet for "(Name of resident) received a puree diet at risk for weight loss," originally dated 11/10/10, and updated 2/2/11, 11/3/11, 3/26/12, 6/28/12, and 9/27/12, indicated the goal of "Consume 75% - 100% of most meals thru next review." Dates for revised interventions were not indicated. The intervention of Healthshakes at all meals was lined through. The intervention of "Healthshakes between meals" was lined through. During interview on 11/5/12 at 11:20 a.m., the DON indicated the health shakes were discontinued on 6/28/12. The most recent update, 9/27/12, indicated in the problem list: "Puree diet, at risk for wt. loss. Goal: No significant wt. loss thru next review." In the same handwriting was the intervention: "Mighty shakes TID (three times a day), super cereal @ breakfast, ice cream w/ (with) meals." During interview on 11/5/12 at 10:15 a.m., in regard to a follow-up [MEDICATION NAME] level after 5/17/12, the DON indicated she did not know if a repeat lab had been obtained and indicated, "We can only do what the doctor orders." Lab reports in the lab report section of the clinical record did not indicate additional [MEDICATION NAME] levels were obtained. The Registered Dietitian's Assessment, dated 9/21/12, indicated no [MEDICATION NAME] level after 5/17/12. During interview on 11/5/12 at 11:05 a.m., the DON indicated she did not know when the resident stopped having Mighty Shakes and ice cream. She indicated she remembered the resident had stopped receiving them. During interview on 11/5/12 at 11:45 a.m., the DON indicated the resident had lived at the facility for ten years and "she (Resident B) had always had the Mighty Shakes since I've been here (until the supplements were discontinued)." During interview on 11/5/12 at 11:55 a.m., the Dietary Manager provided a nutritional list for Mighty Shakes. The list indicated the four ounce Mighty Shake provided: 200 calories, 6 grams of fat, and 6 grams of protein. The Care plan Worksheet for Pressure Ulcer Risk, originally dated 12/17/08, and updated every three months and most recently updated 9/27/12, indicated, "The resident is at risk for further development of pressure ulcers due to: decreased mobility, incontinence." Dates of updated interventions were not indicated but included "Mighty shakes" and "Juven." The next entry in the record related to nutritional care was the RD assessment dated , 9/21/12. The RD "Evaluation of Needs/Recommendations/Interventions for Nutrition Care" indicated, "Annual assessment completed. Diet puree (with) intake fair to good @ meals. (Symbol for no) chewing or swallowing problems (with) current diet. Wt. very stable X 1 yr. Res has wound abd (sic) folds. Add double meat @ bkft. (breakfast). Cont (continue) to encourage intake @ meals." During interview on 11/5/12 at 2:10 p.m., the Dietary Manager provided the resident's tray card and indicated the double meat portion at breakfast had not been added to the resident's nutritional plan. On 9/24/12, a Physician's Telephone Order was obtained for "Give Mighty Shakes between meals...Give ice cream (with) each meal." On 9/28/12, Physician's Telephone Orders were obtained for "Surgical consult for surgical debridement of wound with (name of physician)," and "PT (physical therapy) clarification order: Continue PT skilled service including use of HVPC (high voltage pulsed current) to right lower gluteal area Stage 4 wound; sharp/mechanical debridement PRN." Another care plan, dated 5/17/12, indicated, "I have an open area in the following area: "R gluteal fold." Interventions included, but were not limited to: "....Dietitian evaluation as indicated....5/[MEDICATION NAME] (protein supplement)/MVI (multivitamin). 9/12 Dietary to see pt (patient) weekly. 8/12 Mighty shake...." During interview on 11/5/12 at 10:30 a.m., the DON indicated no dietary notes indicated the resident was seen weekly. The DON indicated the Dietary Manager was part of the PAR (Patient at Risk) meetings. The DON indicated the PAR meeting information was not part of the clinical record. She provided the PAR information for Resident B. The Patient at Risk (PAR) Tracking Form notes indicated the following for Resident B: 5/16/12 - "Tx (treatment) working well - getting smaller...labs - [MEDICATION NAME] level ordered. Res. (resident) gets supplements...." 5/23/12 - "Res. continues to get supplements.... 6/27/12 - "D/C (discontinue) shakes & super puddings (with) meals - res. doing better...." A physician's consult, dated 10/5/12, indicated, "Reason for Consultation: decubitus....Skin: Reveals a 2.5 X 2 cm deep ischial wound. Some eschar in a portion of the edge of it that is fairly thin with a diffuse exudate and a little bit of devitalized eschar....Impression: Patient with a fairly significant ischial wound that does not appear to be progressing very well. I think given the appearance of this, surgical debridement may be necessary, but I do not think it would be as effective as an aggressive wet to dry dakins mechanical [MEDICATION NAME] dressing change. My goal for this would be to improve the bed of the wound enough to start a wound vac which should increase her rate of healing somewhat. Of note, really as expected, her principal problem is going to be keeping up with the caloric intake and offloading this wound, as well. I think also we need to make sure that she is having no recurrence of her [MEDICAL CONDITION] and that her oxygen delivery is good, as well. I will start the therapies as mentioned and will proceed with that." 2. The clinical record for Resident A was reviewed on 11/2/12 at 1:00 p.m. The record indicated the resident was admitted from another facility on 7/27/12. The resident's [DIAGNOSES REDACTED]. A Dietary Note, dated 8/1/12, indicated, "New admit. Receives a regular diet. Intake is good. (Symbol for no) noted skin issues. Above ideal body wt (weight) BMI (basal metabolic index) 35 weekly wt. X 4 wks. Will monitor and refer to RD for assessment." The RD Assessment, dated 8/10/12, indicated, "New res admitted to facility. Current diet regular (with) intake adeq (adequate). (Symbol for no) chewing or swallowing problems noted. Skin (symbol for no) pressure issues. Res is nutritionally stable at this time. Cont (continue) to monitor. RD to follow as needed." The Resident Care Plan, originally dated 8/4/12, indicated a regular diet, was updated on 9/4/12 to indicate a mechanical soft diet. The Goal included, but was not limited to, "Rd (resident) will have no significant weight change through next review." Interventions included, but were not limited to, "Weights as needed." A Physician's Telephone Order, dated 10/3/12, indicated, "Re: pt (patient) c/o (complains of) bilateral heels hurting. Skin prep to heels q (every) shift." A Care plan Worksheet, dated 10/5/12, indicated a Problem of "Intact blister" with interventions including, but not limited to "Air waffle boots." The Monthly Record of V/S (vital signs) and Weights for 2012 indicated monthly weights as follows: July - 224 pounds August - 220 pounds (1.7% loss in one month) September - 211 pounds October - 203.2 pounds, reweigh 201.9 pounds (9.86% loss in three months) (November weight was not documented at the time of clinical record review.) During interview on 11/5/12 at 2:40 p.m., the DON indicated the Dietary Manager tracks weights, and the resident is placed on weekly weights if a significant weight change is indicated. During interview at this same time, the Dietary Manager indicated she did not have weekly weights tracked for Resident A since the first four weeks after admission. The Dietary Manager indicated the resident "should have triggered," but she did not catch the significant change (from July to October 2012). The Dietary Manager indicated her tracking form only showed the weights for September (211 pounds) and October 2012 (201 pounds). She indicated the change between those two months was not significant. This federal tag related to Complaint IN 976. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure that a resident was readmitted to the facility immediately when a bed was available and upon returning to the facility. The resident was not allowed back into the facility upon arrival and was secluded in the ambulance remaining on a stretcher for a least an additional hour without food, hydration or toileting. This deficient practice affected 1 of 3 in a sample of 5 reviewed for involuntary discharge. (Resident A) Findings include: Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., included [DIAGNOSES REDACTED]. with disturbance of mood and behaviors. On 2/6/2012 at 6:00 p.m., in an telephone interview with Registered Nurse # 3 from the (name of psychiatric hospital), Resident A left their facility at approximately 1:15 p.m., via a transport ambulance to return to Waters of Scottsburg. Registered Nurse #3 (RN) of the (name of psychiatric hospital) called to give report to Waters of Scottsburg on Resident A when she was transferred to the Administrator #1 (ADM), who indicated to RN #3 that they (Waters of Scottsburg) were not going to take Resident A back and that "they would rather take a ding from State then take him back.". The resident was already in transit at this time. On 2/7/2012 at 10:15 a.m., in an interview with the Vice President of Nursing at the hospital indicated at approximately 4:00 p.m., Resident A arrived at Waters of Scottsburg, upon arriving the ambulance crew was met by 4 facility staff members standing outside in front of main doors. On 2/7/2012 at 3:30 p.m., in an interview with the Director of Nursing (DON) #1, the following four people were identified as the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and a staff member heading home identified as the Minimum Data Set Coordinator as the four who met the ambulance. Review of the ambulance run flow sheet, dated 2/6/2012, indicated one of the four members indicated to ambulance staff they were not to take him (resident) off the stretcher and that they would not accept him into their facility. They did not allow the ambulance crew to unload the resident off of the stretcher or out of the ambulance. At approximately 4:55 p.m., the ambulance driver received direction from their supervisor to take Resident A over to the hospital. According to the interview on 2/7/2012 at 10:15 a.m., with the Vice President of Nursing at the hospital, Resident A was transported back to (name of psychiatric hospital) at 10:40 p.m. On 2/7/2012 at 2:00 p.m., in an interview with the DON #1, she indicated that the Waters of Scottsburg follows the Indiana State Department of Health (ISDH) guidelines on bed holds as their policy. On 2/7/2012 at 2:30 p.m., record review of ISDH guidelines on bed holds indicated, but is not limited to; "A nursing facility is required to establish and follow a written policy under which a resident, whose hospital or therapeutic leave exceeds Medicaid coverage limitations, is readmitted to the facility upon the first availability of a bed in a semi-private room...." On 2/6/2012 at 7:30 p.m., record review of the Waters of Scottsburg census indicated that a bed was available on 2/6/2012. On 2/8/2012 at 10:35 a.m., record review of the Waters of Scottsburg 2/6/2012 daily hall assignments indicated that a bed was available on 2/6/2012 at 4:00 p.m. On 2/6/2012 at 6:30 p.m., in an telephone interview with Registered Nurse # 1 she indicated that Resident A was confused about why he "didn't have a place to stay" and why the Waters of Scottsburg was not allowing him to return "home." On 2/7/2012 at 3:45 p.m., in an telephone interview with RN # 4 from the hospital she indicated that he was "frustrated because of the situation." On 2/8/2012 at 11:20 p.m., in an telephone interview with Resident A's sister she indicated that she had gone over to see her brother when he arrived back at (name of psychiatric hospital) and that her brother was "upset over the whole matter." On 2/8/2012 at 10:15 a.m., in an interview with Resident A he indicated "I don't like being here" talking about (name of psychiatric hospital) and "when will I get an answer." Review of the nursing notes, dated 2/7/2012 at 1:15 a.m., from (name of psychiatric hospital) indicated, but not limited to; patient admitted back to facility brought in by ambulance with 2 attendants. "pt (patient) upset and voicing his complaints to staff." Nursing note dated 2/7/2012 at 4:28 a.m., "pt (patient) sat in dayroom for a short time upset with his situation." This Federal tag is related to Complaint #IN 562. 3.1-12(a)(27)(A) 3.1-12(a)(27)(B)

A. Based on record review and interview, the facility failed to ensure that a resident was free from mental abuse and involuntary seclusion related to not allowing the resident back into the facility upon arrival and having him remain on stretcher for a least an additional hour without food, hydration or toileting. This deficient practice affected 1 of 5 residents reviewed for mental abuse and involuntary seclusion in a sample of 5 residents (Resident A) B. Based on record review and interview, the facility failed to ensure residents were free from verbal and physical abuse during episodes of [MEDICAL CONDITION] by Resident #E. This deficient practice affected 1 of 5 residents reviewed for behaviors in a sample of 5 residents. (Resident #E) Findings include: A.1. Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., [DIAGNOSES REDACTED]. with disturbance of mood and behaviors. Record review indicated that Resident A was alert to person, place and time and was aware of his situation and that Resident A was in control of his bladder and bowel functions. On 2/6/2012 at 6:00 p.m., in an telephone interview with Registered Nurse # 3 from the (name of psychiatric hospital), Resident A left their facility at approximately 1:15 p.m., via a transport ambulance to return to Waters of Scottsburg. RN #3 indicated that Resident A indicated that he was "excited to come back home." Review of the ambulance run flow sheet, dated 2/6/2012, indicated at approximately 4:00 p.m., Resident A arrived at Waters of Scottsburg. Upon arriving the ambulance crew was met by four facility staff members standing outside in front of main doors. One of the four members indicated that the ambulance staff were not to take him off the stretcher and that they would not accept him into their facility. They did not allow the ambulance crew to unload the resident off of the stretcher or out of the ambulance. The ambulance drivers confused about the situation drove to the back of the facility's parking lot where they called their supervisor for direction in the matter, who in turn had to call his supervisor. They were in limbo for about 1 hour while waiting for direction in the matter. In an interview on 2/7/2012 at 3:30 p.m., the Director of Nursing (DON) she identified the 4 persons as the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and a staff member heading home identified as the Minimum Data Set Coordinator as those who met the ambulance. On 2/6/2012 at 6:00 p.m., in an telephone interview with Registered Nurse # 3 she indicated that Police were called by the (name of psychiatric hospital) because during a phone conversation that transpired on 2/6/2102 at 1:15 p.m., Registered Nurse #3 (RN) of the (name of psychiatric hospital) called to give report to Waters of Scottsburg on Resident A when she was transferred to the Administrator #1 (ADM), who indicated to RN #3 that they (the facility) were not going to take Resident A back and that "they would rather take a ding from State then take him back". Review of the ambulance run flow sheet, dated 2/6/2012, indicated at approximately 4:30 p.m., the Police came to the Waters of Scottsburg and inquired as to what the situation was. The Police interviewed the facility staff and the ambulance staff. The police decided that they could not get involved because this was an issue between 2 companies. At approximately 4:55 p.m., the ambulance drivers received direction from their supervisor to take Resident A over to the hospital. On 2/6/2012 at 6:30 p.m., in an telephone interview with RN #1 from the hospital, she indicated that Resident A came to the hospital around 5:00 p.m., and that she was told by the ambulance drivers that the facility had "4 nurses standing in parking lot outside bay refusing to let him in." RN #1 indicated that he (resident) was very hungry and thirsty and that they got him a diabetic meal tray and that he finished 100 percent of the food. RN #1 indicated that Resident A was confused about why he "didn't have a place to stay" and why the Waters of Scottsburg was not allowing him to return "home." On 2/7/2012 at 10:15 a.m., in an interview with the Vice President of Nursing (VPN) from the hospital, she indicated that she had called the facility last night and asked why they did not take Resident A in when he arrived. The VPN indicated that the Director of Nursing #1 (DON) had told her that they had discharged him to the (name of psychiatric hospital). The VPN indicated that she then called RN #3 of the (name of psychiatric hospital) and she indicated that Resident A was to go to the Waters of Scottsburg and that they were aware that he was on his way. RN #3 indicated that they had no medical or psychosocial reason to keep him at (name of psychiatric hospital). On 2/7/2012 at 10:40 a.m., in an interview with RN #2 from the hospital, he indicated that Resident A arrived around 5:00 p.m., and that he was calm and understanding of situation and that the Waters of Scottsburg was not allowing him to come in. RN #2 indicated that Resident A was very hungry and thirsty and requested a diet orange juice. RN #2 indicated that Resident A was wet and soiled with a brown spot the size of a half dollar that had begun to dry and spread out on to stretcher. On 2/7/2012 at 10:50 a.m., in an interview with RN #1 from the hospital, she indicated that Resident A drank a 12 ounce diet 7up and 240 milliliters of water and that he did seem very thirsty. On 2/7/2012 at 3:45 p.m., in an interview with RN # 4 from the hospital, she indicated that she took Resident A to the bathroom to clean up and change his clothes. RN # 4 showed Resident A where the bathroom was and gave him clothes and washcloths to clean up. RN # 4 indicated that he had control of his bladder and bowel for the entire stay at the hospital. RN # 4 indicated that he was frustrated because of the situation and he indicated "he wanted his things back" and felt as though the facility had "stole them." Approximate total time on stretcher was 4 hours. Review of the nursing notes, dated 2/7/2012 at 1:15 a.m., from (name of psychiatric hospital) indicated, but not limited to; patient admitted back to facility brought in by ambulance with 2 attendants. "pt (patient) upset and voicing his complaints to staff." Nursing note, dated 2/7/2012 at 4:28 a.m., "pt (patient) sat in dayroom for a short time upset with his situation." Record review from (name of psychiatric hospital), dated 2/7/2012, the Corporate Nurse Consultant and Social Service #3 went to (name of psychiatric hospital) to reevaluate Resident A. Record review of (name of psychiatric hospital) interdisciplinary notes, dated 2/7/2012, indicated, but not limited to questions: *"why he was aggressive..." *"asking him all kinds of questions about his angery (sic) & (and) why he gets so angry" *"pt (patient) was asked questions regarding his aggressive bx (behavior) & (and) consistency c (with) medication" On 2/8/2012 at 12:35 p.m., in an interview with the psychiatric technician from (name of psychiatric hospital) he indicated that staff from Waters of Scottsburg spent about 1 hour with Resident A and questions they asked were: *"why are you so angry and agitated at the facility" *"why didn't you get up for smoke breaks" The Waters of Scottsburg representatives then spoke about the resident to the psychiatric technician in front of the resident. On 2/8/2012 at 10:40 a.m., in an interview with Staff Development Coordinator #1, he indicated that abuse was "anything that would be physically, emotionally, mentally harmful by the person." Sitting on a ambulance stretcher for extended period of time is abuse "if caused anguish to resident." B.1. Review of the clinical record for Resident #E on 2/8/2012 at 11:00 a.m., indicated the resident was discharged to (name of psychiatric hospital) on 10/6/2011. [DIAGNOSES REDACTED]. Review of the nursing notes between March 1, 2010 and October 6, 2011, the following entries were noted: - "9/10/10 - 6 p.m.: Resident got hair pulled & (and) got pulled down on resident. Slapped resident in face. (No) injuries noted. (No) s/s (signs/symptoms) of distress noted." - "9/27/10 - 2:00 a.m.: Res (resident) has been up all night tonight and this nurse was witness to several name calling and threatening remarks to roommate such as '(curse word) devil', 'bubble butt' and telling us that we would find out in the morning. This nurse told resident after approximately ten minutes that she needed to go back to bed..." - "4/10/11 - 10:15 (a.m.): Res increasingly delusional et (and) psychotic. believes she is 'in command of the soldiers surrounding this building' et has ordered them 'to shoot you all'. Screaming at staff to stay away from roommate when feeding her..." The nursing documentation from this date indicated the resident was moved to a room next door to ensure safety. - "6/1/11 - 9:20 a.m.: Writer entered unit @ (at) this x (time). As soon as writer got through door, pt (patient) pushed writer aggressively & tried to exit unit. Writer explained to pt that her behavior was inapp. (inappropriate). Res said '(name of a person) told me to do it'. Res then said 'Do you ever get the urge to bash someone's face in?'" - "7/21/211 - 3:15 p: Res was witnessed striking another res in the side with closed hand..." Review of the psychiatric notes from both in-house and in-patient treatments between 11/2/10 and 8/5/11, the following entries were noted: - "11/2/10 - "(resident) was laying on bed, awake, yelling out for anyone - attn-seeking (attention) bx (behavior), paranoia evident, continues (with) instability of (psychiatric) issues even (after) hospz (hospitalization )..." - "7/22/11 - ...History of Present Illness: The patient was admitted secondary to aggression. She reportedly hit another resident and was exit-seeking....She had been here at (name of psychiatric facility). Also she had been at (names of other psychiatric facilities) multiple times. Well known to us. Currently she is a resident of Waters of Scottsburg and evidently patient's behavior has been escalating. She has been increasingly paranoid, very delusional, very difficult to re-direct, and admitted her for medication stabilization..." - "8/5/11 - History of Present Illness: This is a (age) divorced Caucasian female admitted from (name of facility) for being delusional, threatening to kill a peer and going into the other peer's room. This peer is apparently nonverbal and the patient insists that she is someone that the patient knows from her previous life..." - "9/6/11 - ...Recent in-pt psy (psychiatric). Staff report conts (continues) to seek out peer - who believes she's her sister-in-law - verbal aggression...delusional, paranoid, impulsive, irritable. No improvement (with) in-pt (psychiatric)..." A 4/20/11 Care plan addressed the following problem "Wandering into peers rooms and giving them food and fluids not on their diet". "Goal - will (decrease) wandering into peers rms (rooms) to less than 1x wk (week); will (decrease) episodes of giving peers food and fluids to none by next review". "Intervention: staff to educate PRN (as needed) on risk factors; ensure safety of others; 15 min (minute) safety (checks) PRN; motion sensor to rm to alert staff when up & about." The care plan problem continued to be an issue as it was reviewed on 6/27/11 and 9/8/11. A 9/1/2010 Social Service note indicated the following: "Rec'v (received) call from daughter to inform SSD (Social Service Director) that on Sunday 8/29 (resident) got very upset (with) her and daughter's biological mother & scratched & moved biological mother into the closet & per daughter, has been voicing (increased) paranoia to them about facility, unit & other residents & per daughter had threatened to jump out the window....made LPN aware of above & to get orders to r/o (rule out) medical factors and to notify psych..." "9/2/2010 - No new orders from psych..." On 9/8/10, the resident was moved to a different room due to not getting along with her roommate. On 2/9/11, the resident was moved from the open unit to the secured unit due to safety and trying to exit open unit - very delusional. On 3/9/11, the resident was moved from the secured co-ed unit to the secured female unit as it was necessary for her welfare R/T sexual [MEDICAL CONDITION] & paranoia (with) male peers. On 4/10/11, the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] next door as it was necessary for the welfare of others. Review of the Behavior Monitoring Records between 9/1/2010 and 10/6/2011, the following behaviors towards others were documented: - 9/11/10 - wandering into others rooms, verbally abusive - screamed at others. - 9/12/10 - wandering into others rooms. - 9/20/10 - verbally abusive - screamed at others. - 9/24/10 - verbally abusive - screamed at others. - 9/25/10 - verbally abusive - screamed at others. - 9/27/10 - verbally abusive - threatened others. - 9/29/10 - verbally abusive - screamed at others. - 10/22/10 - verbally abusive - screamed at others. - 10/25/10 - verbally abusive - screamed at others. - 10/27/10 - verbally abusive - screamed at others. - 10/28/10 - verbally abusive - screamed at others. - 11/9/10 - verbally abusive - screamed at others. - 11/10/10 - verbally abusive - cursed at others, physically abusive - hitting others. - December 2010 through May 2011 - behaviors revolved around wandering and looking for an exit. - 6/20/11 - wandering into others rooms. - 6/24/11 - wandering into others rooms, verbally abusive - threatened, screamed and cursed at others. - 6/26/11 - verbally abusive - threatened and screamed at others, physically abusive - hitting and shoving others. - 7/1/11 - physically abusive - hitting others. - 7/7/11 - physically abusive - hitting and scratching others. - 7/8/11 - verbally abusive - threatened others. - 7/9/11 - wandering into others rooms, verbally abusive - threatening others. - 7/13/11 - wandering into others rooms, verbally abusive - threatened, screamed and cursed at others. - 7/21/11 - physically abusive - hitting others. - 8/4/11 - (5 p.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/4/11 - (11 p.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/5/11 - (3 a.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/5/11 - (6 a.m. to 5 p.m.) - verbally abusive - threatened and screamed at others. - 9/1/11 - wandering into others rooms, verbally abusive - threatened, screamed, and cursed at others. - 9/5/11 - wandering into others rooms, verbally abusive - threatened, screamed, and cursed at others. - 9/28/11 - wandering into others rooms. - 10/2/11 - wandering into others rooms, physically abusive - hitting others. - 10/5/11 - wandering into others rooms. - 10/6/11 - verbally abusive - threatened and cursed others. Review of these behaviors sheets also noted cause of behavior was frequently unknown and that the intervention approaches suggested to be tried, were usually unsuccessful. On 10/6/2011, the resident was again sent out for in-patient psychiatric treatment. A 10/7/2011 Social Service note indicated the family was told to look for alternate placement. During confidential interviews on 2/8/2012 and 2/10/2012, they indicated that both Resident #A and #E were not considered appropriate for placement in the facility at the time of initial admission nor after each psychiatric re-admission as they did not feel the residents' needs could be met. They also indicated that this was also one of the reasons Resident #E's family finally moved her from the facility to another facility as she too felt the resident's needs were not being met by the facility. On 2/7/2012 at 2:15 p.m., the Administrator presented a copy of the facility's current policy on "Abuse Prohibition." Review of this policy at this time included, but was not limited to: "Guideline: It is the intent of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse,... involuntary seclusion and misappropriation of their property (collectively, sometimes referred to as "events"). Residents will not be subjected to such events by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the residents...1. Definitions of key terms: a) Abuse: willful infliction of injury, unreasonable confinement...with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being... b) Verbal Abuse: The use of oral, written, or gestured language that willingly includes disparaging and derogatory terms to residents...or within their hearing distance, regardless of their age, ability to comprehend, or disability... d) Physical Abuse: This includes hitting, slapping, pinching and kicking... e) Mental Abuse: This includes, but is not limited to humiliation... f) Neglect: A failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. g) Misappropriation of Resident Property: The deliberate misplacement, exploitation, or, wrongful temporary or permanent use of a resident's belongings...without the resident's consent... 9. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. Care will be monitored to assure that there are not repeated failures to follow the resident's care plan and that no resident harm has occurred..." This Federal tag is related to Complaint #IN 562. 3.1-27(a)(1) 3.1-27(a)(4) 3.1-27(b)

Based on interview and record review, the facility failed to ensure that the resident was free from neglect related to not allowing the resident to be admitted to facility upon arrival and having to endure extended time on the stretcher without food, hydration or toileting. This deficient practice affected 1 of 1 in a sample of 5 reviewed for neglect. (Resident A) Finding include: Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., included [DIAGNOSES REDACTED]. with disturbance of mood and behaviors. Record review indicated that Resident A was in control of his bladder and bowel functions. On 2/6/2012 at 6:00 p.m., in an interview with Registered Nurse #3 from the (name of psychiatric hospital) she indicated that Resident A left their facility around 1:15 p.m., in route to Waters of Scottsburg. Record review of the ambulance run log indicated that Resident A arrived at the facility via transport ambulance around 4:00 p.m., but was not allowed to get off stretcher and/or enter the facility and was held in limbo in the ambulance while drivers received guidance. Resident A was taken to the hospital around 5:00 p.m. On 2/6/2012 at 6:30 p.m., in an telephone interview with RN #1 from the hospital, she indicated that Resident A came to the hospital around 5:00 p.m., and that she was told by the ambulance drivers that the facility had "4 nurses standing in parking lot outside bay refusing to let him in." RN #1 indicated that Resident A very hungry and thirsty and that they got him a diabetic meal tray and that he finished 100 percent of the food. On 2/7/2012 at 10:40 a.m., in an interview with RN #2 from the hospital, he indicated that Resident A arrived around 5:00 p.m. RN #2 indicated that Resident A was very hungry and thirsty and requested a diet orange juice. RN #2 indicated that Resident A was wet and soiled with a brown spot the size of a half dollar that had begun to dry and spread out on to stretcher. On 2/7/2012 at 3:45 p.m., in an interview with RN #4 from the hospital, she indicated that she took Resident A to the bathroom to clean up and change his wet and soiled with stool clothes. RN #4 showed Resident A where the bathroom was and gave him clothes and washcloths to clean up. RN #4 indicated that he had control of his bladder and bowel for the entire stay at the hospital. On 2/7/2012 at 2:15 p.m., the Administrator presented a copy of the facility's current policy on "Abuse Prohibition." Review of this policy at this time included, but was not limited to: "Guideline: It is the intent of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse,... involuntary seclusion and misappropriation of their property (collectively, sometimes referred to as "events"). Residents will not be subjected to such events by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the residents...1. Definitions of key terms: a) Abuse: willful infliction of injury, unreasonable confinement...with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being.. f) Neglect: A failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 9. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. Care will be monitored to assure that there are not repeated failures to follow the resident's care plan and that no resident harm has occurred..." This Federal tag is related to Complaint #IN 562. 3.1-27(a)(3)

A. Based on interview and record review, the facility failed to ensure that they followed their policy and procedure on abuse and neglect of resident related to extended time resident spent on stretcher without food, hydration and toileting. (Resident A) This deficient practice affected 1 of 2 residents in a sample of 5 reviewed for following their policy on abuse and neglect. B. Based on interview and record review, the facility failed to ensure that they followed their policy and procedure on mental abuse related to making the resident feel unwanted. (Resident A) This deficient practice affected 1 of 1 residents in a sample of 5 reviewed for following their policy on mental abuse. C. Based on record review and interview, the facility failed to implement their Abuse policy in order to protect others from verbal and physical abuse when Resident #E experienced delusional and aggressive behaviors. This deficient practice affected 1 of 5 residents reviewed for behaviors in a sample of 5 residents. (Resident #E) Findings include: A.1. Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., included [DIAGNOSES REDACTED]. with disturbance of mood and behaviors. Record review indicated that Resident A was alert to person, place and time and was aware of his situation and that Resident A was in control of bladder and bowel functions. On 2/6/2012 at 6:00 p.m., in an telephone interview with Registered Nurse # 3 from the (name of psychiatric hospital), Resident A left their facility at approximately 1:15 p.m., via a transport ambulance to return to Waters of Scottsburg. Review of the ambulance run flow sheet, dated 2/6/2012, indicated at approximately 4:00 p.m., Resident A arrived at Waters of Scottsburg, upon arriving the ambulance crew was met by 4 facility staff members standing outside in front of main doors. One of the 4 members indicated that the ambulance staff were not to take him off the stretcher and that they would not accept him into their facility. They did not allow the ambulance crew to unload the resident off of the stretcher or out of the ambulance. The ambulance drivers confused about the situation drove to the back of the facility's parking lot where they called their supervisor for direction in the matter, who in turn had to call his supervisor. They were in limbo for about 1 hour while waiting for direction in the matter. At approximately 4:30 p.m., the Police came to the Waters of Scottsburg and inquired as to what the situation was. The Police interviewed the facility staff and the ambulance staff. The police decided that they could not get involved because this was an issue between 2 companies. At approximately 4:55 p.m., the ambulance driver received direction from their supervisor to take Resident A over to the hospital. In an interview on 2/7/2012 at 3:30 p.m., the Director of Nursing (DON), she identified the 4 person's as the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and a staff member heading home identified as the Minimum Data Set Coordinator as who met the ambulance. On 2/6/2012 at 6:30 p.m., in an telephone interview with RN #1 from the hospital, she indicated that Resident A came to the hospital around 5:00 p.m. RN #1 indicated that he was very hungry and thirsty and that they got him a diabetic meal tray and that he finished 100 percent of the food. On 2/7/2012 at 10:40 a.m., in an interview with RN #2 from the hospital he indicated that Resident A was very hungry and thirsty and requested a diet orange juice. RN #2 indicated that Resident A was wet and soiled with a brown spot the size of a half dollar that had begun to dry and spread out on to stretcher. On 2/7/2012 at 10:50 a.m., in an interview with RN #1 from the hospital she indicated that Resident A drank a 12 ounce diet 7up and 240 milliliters of water and that he did seem very thirsty. On 2/7/2012 at 3:45 p.m., in an interview with RN # 4 from the hospital she indicated that she took Resident A to the bathroom to clean up and change his clothes. RN # 4 showed Resident A where the bathroom was and gave him clothes and washcloths to clean up. RN # 4 indicated that he had control of his bladder and bowel for the entire stay at the hospital. Approximate total time on stretcher was 4 hours. On 2/9/2012 at 9:45 a.m., in an interview with Licensed Practical Nurse (LPN) #2, he indicated that his understanding of neglect is "sitting in a wet brief, not changing properly, not eating at scheduled times or having fluids" On 2/9/2012 at 10:30 a.m., in an interview with Administration, she indicated the her interpretation of neglect is "intentional refusal to provide care or assistance." On 2/7/2012 at 2:15 p.m., the Administrator presented a copy of the facility's current policy on "Abuse Prohibition." Review of this policy at this time included, but was not limited to:" a) Abuse: willful infliction of injury, unreasonable confinement...with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being... f) Neglect: A failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." B.1. On 2/6/2012 at 6:00 p.m., in an telephone interview with Registered Nurse # 3 from the (name of psychiatric hospital), RN #3 indicated that Resident A indicated that he was "excited to come back home." Review of the ambulance run flow sheet, dated 2/6/2012, indicated at approximately 4:00 p.m., Resident A arrived at Waters of Scottsburg , upon arriving the ambulance crew was met by 4 facility staff members standing outside in front of the main doors. In an interview on 2/7/2012 at 3:30 p.m., with the Director of Nursing (DON), she identified the 4 person's as the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and a staff member heading home identified as the Minimum Data Set Coordinator as who met the ambulance. On 2/6/2012 at 6:30 p.m., in an telephone interview with RN #1 from the hospital she indicated that Resident A was confused about why he "didn't have a place to stay" and why the Waters of Scottsburg was not allowing him to return "home." On 2/7/2012 at 10:40 a.m., in an interview with RN #2 from the hospital, he indicated that Resident A arrived around 5:00 p.m., and that he was calm and understanding of situation and that the Waters of Scottsburg was not allowing him to come in. Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., he was in control of bladder and bowel functions prior to his ambulance ride. When arriving at the hospital was wet and soiled with stool due to delay in being able to be admitted to Waters of Scottsburg. On 2/7/2012 at 3:45 p.m., in an interview with RN #4 from the hospital, she indicated that she took Resident A to the bathroom to clean up and he was able to do this independently and voiced that he was just frustrated at the whole situation. On 2/7/2012 at 2:15 p.m., the Administrator presented a copy of the facility's current policy on "Abuse Prohibition." Review of this policy at this time included, but was not limited to: "e) Mental Abuse: This includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation." C. 1. Review of the clinical record for Resident #E on 2/8/2012 at 11:00 a.m., indicated the resident was discharged to (name of psychiatric hospital) on 10/6/2011. [DIAGNOSES REDACTED]. Review of the nursing notes between March 1, 2010 and October 6, 2011, the following entries were noted: - "9/10/10 - 6 p.m.: Resident got hair pulled & (and) got pulled down on resident. Slapped resident in face. (No) injuries noted. (No) s/s (signs/symptoms) of distress noted." - "9/27/10 - 2:00 a.m.: Res (resident) has been up all night tonight and this nurse was witness to several name calling and threatening remarks to roommate such as '(curse word) devil', 'bubble butt' and telling us that we would find out in the morning. This nurse told resident after approximately ten minutes that she needed to go back to bed..." - "4/10/11 - 10:15 (a.m.): Res increasingly delusional et (and) psychotic. believes she is 'in command of the soldiers surrounding this building' et has ordered them 'to shoot you all'. Screaming at staff to stay away from roommate when feeding her..." The nursing documentation from this date indicated the resident was moved to a room next door to ensure safety. - "6/1/11 - 9:20 a.m.: Writer entered unit @ (at) this x (time). As soon as writer got through door, pt (patient) pushed writer aggressively & tried to exit unit. Writer explained to pt that her behavior was inapp. (inappropriate). Res said '(name of a person) told me to do it'. Res then said 'Do you ever get the urge to bash someone's face in?'" - "7/21/211 - 3:15 p: Res was witnessed striking another res in the side with closed hand..." Review of the psychiatric notes from both in-house and in-patient treatments between 11/2/10 and 8/5/11, the following entries were noted: - "11/2/10 - "(resident) was laying on bed, awake, yelling out for anyone - attn-seeking (attention) bx (behavior), paranoia evident, continues (with) instability of (psychiatric) issues even (after) hospz (hospitalization )..." - "7/22/11 - ...History of Present Illness: The patient was admitted secondary to aggression. She reportedly hit another resident and was exit-seeking....She had been here at (name of psychiatric facility). Also she had been at (names of other psychiatric facilities) multiple times. Well known to us. Currently she is a resident of (name of facility) and evidently patient's behavior has been escalating. She has been increasingly paranoid, very delusional, very difficult to re-direct, and admitted her for medication stabilization..." - "8/5/11 - History of Present Illness: This is a (age) divorced Caucasian female admitted from (name of facility) for being delusional, threatening to kill a peer and going into the other peer's room. This peer is apparently nonverbal and the patient insists that she is someone that the patient knows from her previous life..." - "9/6/11 - ...Recent in-pt psy (psychiatric). Staff report conts (continues) to seek out peer - who believes she's her sister-in-law - verbal aggression...delusional, paranoid, impulsive, irritable. No improvement (with) in-pt (psychiatric)..." A 4/20/11 Care plan addressed the following problem "Wandering into peers rooms and giving them food and fluids not on their diet". "Goal - will (decrease) wandering into peers rms (rooms) to less than 1x wk (week); will (decrease) episodes of giving peers food and fluids to none by next review". "Intervention: staff to educate PRN (as needed) on risk factors; ensure safety of others; 15 min (minute) safety (checks) PRN; motion sensor to rm to alert staff when up & about". The care plan problem continued to be an issue as it was reviewed on 6/27/11 and 9/8/11. A 9/1/2010 Social Service note indicated the following: "Rec'v (received) call from daughter to inform SSD (Social Service Director) that on Sunday 8/29 (resident) got very upset (with) her and daughter's biological mother & scratched & moved biological mother into the closet & per daughter, has been voicing (increased) paranoia to them about facility, unit & other residents & per daughter had threatened to jump out the window....made LPN aware of above & to get orders to r/o (rule out) medical factors and to notify psych..." "9/2/2010 - No new orders from psych..." On 9/8/10, the resident was moved to a different room due to not getting along with her roommate. On 2/9/11, the resident was moved from the open unit to the secured unit due to safety and trying to exit open unit - very delusional. On 3/9/11, the resident was moved from the secured co-ed unit to the secured female unit as it was necessary for her welfare R/T sexual [MEDICAL CONDITION] & paranoia (with) male peers. On 4/10/11, the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] next door as it was necessary for the welfare of others. Review of the Behavior Monitoring Records between 9/1/2010 and 10/6/2011, the following behaviors towards others were documented: - 9/11/10 - wandering into others rooms, verbally abusive - screamed at others. - 9/12/10 - wandering into others rooms. - 9/20/10 - verbally abusive - screamed at others. - 9/24/10 - verbally abusive - screamed at others. - 9/25/10 - verbally abusive - screamed at others. - 9/27/10 - verbally abusive - threatened others. - 9/29/10 - verbally abusive - screamed at others. - 10/22/10 - verbally abusive - screamed at others. - 10/25/10 - verbally abusive - screamed at others. - 10/27/10 - verbally abusive - screamed at others. - 10/28/10 - verbally abusive - screamed at others. - 11/9/10 - verbally abusive - screamed at others. - 11/10/10 - verbally abusive - cursed at others, physically abusive - hitting others. - 6/20/11 - wandering into others rooms. - 6/24/11 - wandering into others rooms, verbally abusive - threatened, screamed and cursed at others. - 6/26/11 - verbally abusive - threatened and screamed at others, physically abusive - hitting and shoving others. - 7/1/11 - physically abusive - hitting others. - 7/7/11 - physically abusive - hitting and scratching others. - 7/8/11 - verbally abusive - threatened others. - 7/9/11 - wandering into others rooms, verbally abusive - threatening others. - 7/13/11 - wandering into others rooms, verbally abusive - threatened, screamed and cursed at others. - 7/21/11 - physically abusive - hitting others. - 8/4/11 - (5 p.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/4/11 - (11 p.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/5/11 - (3 a.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/5/11 - (6 a.m. to 5 p.m.) - verbally abusive - threatened and screamed at others. - 9/1/11 - wandering into others rooms, verbally abusive - threatened, screamed, and cursed at others. - 9/5/11 - wandering into others rooms, verbally abusive - threatened, screamed, and cursed at others. - 9/28/11 - wandering into others rooms. - 10/2/11 - wandering into others rooms, physically abusive - hitting others. - 10/5/11 - wandering into others rooms. - 10/6/11 - verbally abusive - threatened and cursed others. Review of these behaviors sheets also noted cause of behavior was frequently unknown and that the intervention approaches suggested to be tried, were usually unsuccessful. On 2/7/2012 at 2:15 p.m., the Administrator presented a copy of the facility's current policy on "Abuse Prohibition." Review of this policy at this time included, but was not limited to: "Guideline: It is the intent of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse,... involuntary seclusion and misappropriation of their property (collectively, sometimes referred to as "events"). Residents will not be subjected to such events by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the residents...1. Definitions of key terms: a) Abuse: willful infliction of injury,...with resulting physical harm, pain, or mental anguish. b) Verbal Abuse: The use of oral, written, or gestured language that willingly includes disparaging and derogatory terms to residents...or within their hearing distance, regardless of their age, ability to comprehend, or disability... d) Physical Abuse: This includes hitting, slapping, pinching and kicking...e) Mental Abuse: This includes, but is not limited to humiliation... 9. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. Care will be monitored to assure that there are not repeated failures to follow the resident's care plan and that no resident harm has occurred..." This Federal tag is related to Complaint #IN 562. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a resident was afforded dignity and respect related to blocking a resident from entering the facility and failed to treat the resident with respect during an interview and evaluation. This caused the resident mental anguish. This deficient practice affected 1 of 1 residents in a sample of 5 reviewed for dignity and respect. (Resident A) Findings include: Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., included [DIAGNOSES REDACTED]. with disturbance of mood and behaviors. Record review indicated that Resident A was alert to person, place and time and was aware of his situation and that Resident A was in control of bladder and bowel functions. On 2/6/2012 at approximately 4:00 p.m., record review indicated that Resident A arrived at the Waters of Scottsburg and were met with 4 people standing in bay area blocking entrance door and indicating to ambulance driver that they were not allowed to unload Resident A. This delayed eating supper, having hydration, toileting. Resident A was kept on stretcher for approximately 1 hour beyond the 3 hour ambulance drive from (name of psychiatric hospital) On 2/6/2012 at 6:30 p.m., in an telephone interview with Registered Nurse # 1, she indicated that Resident A was confused about why he "didn't have a place to stay" and why the Waters of Scottsburg was not allowing him to return "home." On 2/7/2012 at 3:45 p.m., in an telephone interview with RN # 4 from the hospital, she indicated that he was "frustrated because of the situation". On 2/8/2012 at 11:20 p.m., in an telephone interview with Resident A's sister she indicated that she had gone over to see her brother when he arrived back at (name of psychiatric hospital) and that her brother was "upset over the whole matter." On 2/8/2012 at 10:15 a.m., in an interview with Resident A, he indicated "I don't like being here" talking about (name of psychiatric hospital) and "when will I get an answer." Review of the nursing notes dated 2/7/2012 at 1:15 a.m., from (name of psychiatric hospital) indicated, but not limited to; patient admitted back to facility brought in by ambulance with 2 attendants. "pt (patient) upset and voicing his complaints to staff." Nursing note dated 2/7/2012 at 4:28 a.m., "pt (patient) sat in dayroom for a short time upset with his situation." On 2/6/2012 at 6:30 p.m., in an telephone interview with RN #1 from the hospital, she indicated that Resident A came to the hospital around 5:00 p.m. RN #1 indicated that he was very hungry and thirsty and that they got him a diabetic meal tray and that he finished 100 percent of the food. On 2/7/2012 at 10:40 a.m., in an interview with RN #2 from the hospital, he indicated that Resident A was very hungry and thirsty and requested a diet orange juice. RN #2 indicated that Resident A was wet and soiled with a brown spot the size of a half dollar that had begun to dry and spread out on to stretcher. Hospital staff got him clean clothes and wash cloths to clean up with. Review of the clinical records from the (name of psychiatric hospital), dated 2/7/2012, indicated the Corporate Nurse Consultant and Social Service #3 from Waters of Scottsburg went to (name of psychiatric hospital) to reevaluate Resident A. Record review of (name of psychiatric hospital) interdisciplinary notes, dated 2/7/2012, indicated, but not limited to questions: "why he was aggressive..." "asking him all kinds of questions about his angery (sic) & (and) why he gets so angry." "pt (patient) was asked questions regarding his aggressive bx (behavior) & (and) consistency c (with) medication." On 2/8/2012 at 12:35 p.m., in an interview with the psychiatric technician from (name of psychiatric hospital) he indicated that staff from (name of facility) spent about 1 hour with Resident A and questions they asked were: "why are you so angry and agitated at the facility" "why didn't you get up for smoke breaks" The (name of facility) representatives then spoke about the resident to the psychiatric technician in front of the resident. This Federal tag is related to Complaint #IN 562. 3.1-3(t)

Based on record review and interview, the facility failed to ensure that it used its administrative resources to prevent neglect, mental, physical and verbal abuse for the well-being of its residents related to admitting residents outside of the level of care the facility could provide. This failure caused multiple discharges and re-admissions resulting in residents not being allowed to return to the facility and with no assistance in finding alternative placement. This deficient practice affected 2 of 2 in a sample of 5 reviewed for level of care. (Resident A) (Resident E) Findings include: 1. Review of the clinical record for Resident A on 2/6/2012 at 6:30 p.m., [DIAGNOSES REDACTED]. with disturbance of mood and behaviors. Review of the clinical record indicated the resident was admitted to the facility on [DATE]; discharged back to the psychiatric unit on 11/15; readmitted to the facility on ,[DATE]; discharged back to the psychiatric unit on 12/8; readmitted to the facility on ,[DATE] and then subsequently transferred from the facility to the psychiatric hospital on [DATE]. The resident was transported from the psychiatric hospital on [DATE] back to Waters of Scottsburg and was met with resistance and not allowed to enter Waters of Scottsburg. The resident was taken back to the psychiatric hospital and currently waiting alternative placement. On 2/6/2012 at 6:00 p.m., in an interview with Registered Nurse #3 from the (name of psychiatric hospital), she indicated that on 2/6/2102 at 1:15 p.m., she called to give report to Waters of Scottsburg on Resident A and she was transferred to the Administrator #1 (ADM), who indicated to RN #3 that they (Waters of Scottsburg) were not going to take Resident A back and that "they would rather take a ding from State then take him back." On 2/6/2012 at 8:45 p.m., in an interview with Administrator she indicated "we could not meet his level of care" On 2/6/2012 at 7:00 p.m., in an interview with Social Services #1 she indicated that "I knew he had a history of [REDACTED]. On 2/8/2012 at 11:00 a.m., in an interview with the Director of Nursing (DON) she indicated that when they accepted him (Resident A) they had made a plan of care to keep others safe from him and when care plan was unsuccessful they sent him out to behavioral unit. On 2/6/2012 at 5:30 p.m., in an interview with Licensed Practical Nurse (LPN) #1, she indicated that "he has a very [MEDICAL CONDITION], one minute he is fine and the next thing aggressive." LPN #1 indicated also that he was a 1:1 (one on one) kind of person. On 2/8/2012 at 10:15 a.m., in an interview with the Corporate Nurse Consultant (CNC), she indicated that Waters of Scottsburg does the review for placement and then if nursing and administration can't agree if the resident is appropriate then she is called in. If she doesn't think the resident is appropriate then the Chief Operations Officer (COO) gets involved and sometimes they (nursing) are over-ruled by administration. The CNC indicated that she "knew we messed up with this and 2 wrongs don't make a right." On 2/8/12, in an confidential interview, the interviewee's indicated that they felt that Resident A should have never been admitted in the first place based on his history of aggressive behavior and the risk it puts on the other residents and staff. 2 . Review of the clinical record for Resident E on 2/8/2012 at 11:00 a.m., [DIAGNOSES REDACTED]. On 9/8/10, the resident was moved to a different room due to not getting along with her roommate. On 2/9/11, the resident was moved from the open unit to the secured unit due to safety and trying to exit open unit - very delusional. On 3/9/11, the resident was moved from the secured co-ed unit to the secured female unit as it was necessary for her welfare R/T sexual [MEDICAL CONDITION] & paranoia (with) male peers. On 4/10/11, the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] next door as it was necessary for the welfare of others. Review of the Behavior Monitoring Records between 9/1/2010 and 10/6/2011, the following behaviors towards others were documented: - 9/11/10 - wandering into others rooms, verbally abusive - screamed at others. - 9/12/10 - wandering into others rooms. - 9/20/10 - verbally abusive - screamed at others. - 9/24/10 - verbally abusive - screamed at others. - 9/25/10 - verbally abusive - screamed at others. - 9/27/10 - verbally abusive - threatened others. - 9/29/10 - verbally abusive - screamed at others. - 10/22/10 - verbally abusive - screamed at others. - 10/25/10 - verbally abusive - screamed at others. - 10/27/10 - verbally abusive - screamed at others. - 10/28/10 - verbally abusive - screamed at others. - 11/9/10 - verbally abusive - screamed at others. - 11/10/10 - verbally abusive - cursed at others, physically abusive - hitting others. -December 2010 through May 2011 - behaviors revolved around wandering and looking for an exit. - 6/20/11 - wandering into others rooms. - 6/24/11 - wandering into others rooms, verbally abusive - threatened, screamed and cursed at others. - 6/26/11 - verbally abusive - threatened and screamed at others, physically abusive - hitting and shoving others. - 7/1/11 - physically abusive - hitting others. - 7/7/11 - physically abusive - hitting and scratching others. - 7/8/11 - verbally abusive - threatened others. - 7/9/11 - wandering into others rooms, verbally abusive - threatening others. - 7/13/11 - wandering into others rooms, verbally abusive - threatened, screamed and cursed at others. - 7/21/11 - physically abusive - hitting others. - 8/4/11 - (5 p.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/4/11 - (11 p.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/5/11 - (3 a.m.) - wandering into others rooms, verbally abusive - threatened others. - 8/5/11 - (6 a.m. to 5 p.m.) - verbally abusive - threatened and screamed at others. - 9/1/11 - wandering into others rooms, verbally abusive - threatened, screamed, and cursed at others. - 9/5/11 - wandering into others rooms, verbally abusive - threatened, screamed, and cursed at others. - 9/28/11 - wandering into others rooms. - 10/2/11 - wandering into others rooms, physically abusive - hitting others. - 10/5/11 - wandering into others rooms. - 10/6/11 - verbally abusive - threatened and cursed others. Review of these behaviors sheets also noted cause of behavior was frequently unknown and that the intervention approaches suggested to be tried, were usually unsuccessful. - "7/22/11 - ...History of Present Illness: The patient was admitted secondary to aggression. She reportedly hit another resident and was exit-seeking....She had been here at (name of psychiatric facility). Also she had been at (names of other psychiatric facilities) multiple times. Well known to us. Currently she is a resident of Waters of Scottsburg and evidently patient's behavior has been escalating. She has been increasingly paranoid, very delusional, very difficult to re-direct, and admitted her for medication stabilization..." During an interview with the Social Worker on 2/8/12 at 3:30 p.m., she indicated the reason the family was told to look for alternate placement after the resident got out of the hospital was because the facility decided they could no longer meet her needs. On 2/8/2012, in a confidential interview, the interviewee indicated that the reason they told family to find alternative placement was because they could not meet her level of care and the interviewee thought that Resident E had never been appropriate for placement to Waters of Scottsburg. This Federal tag is related to Complaint #IN 562. 3.1-13(q)

Based on observations, record review, and interview, the facility failed to provide adequate supervision for a cognitively impaired resident (Resident #57) who was at risk for falls, had a fall which resulted in a fractured hip for 1 of 2 residents reviewed for falls in a sample of 17. Findings include: The clinical record for Resident #57 was reviewed on 1/24/11 at 9:30 a.m. The resident [DIAGNOSES REDACTED]. During the initial tour on 1/23/11 between 12:30 p.m. and 1:30 p.m., LPN #1 indicated Resident #57 had a recent fracture which was an in-house fall. The resident was observed lying in bed with a mat on the floor next to the bed. Nurses Notes included, but were not limited to: 1/10/11 710 A "Hospice CNA called this nurse to resident room. Bruise noted on bilateral hips. L (Left) hip 1/2 dollar size R (right) hip from iliac crest to buttocks (middle) sic Resident stated he fell in room yesterday - Doesn't remember how he got up or approx time he fell ." Documentation lacking for Nurses Notes on 1/09/11. 1/10/11 7:55 a.m. "N.O.N. (New Order Nursing) Xray bilateral hips, L shoulder. Head C.T. (Computerized Tomography) Send to (named hospital) for CT et (and) xrays. Resident stated he fell yesterday...." 1/10/11 0710 "this nurse and nurse (LPN 1) had not made rounds before hospice nurse came to office. Getting report et (and) counting narcs (medications)." 1/10/11 1115 "Dr. from (named hospital) X-ray dept called et reported resident has fx (fracture) of L hip. Displaced fx of femoral neck of L hip." 1/10/11 12 30 "Xray called again. (Named hospital) to send him back so we could give pain med." 1/10/11 1255 "Return from (named hospital) xray dept per EMS (Emergency Medical System) stretcher..." 1/10/11 215 P "Hospice Chaplain here. Found resident on floor. Head to toe exam no new injury noted. " Documentation was lacking if the left leg was immobilized prior to transferring back to bed. 1/10/11 230 P Bed alarm in place now et working." Documentation was lacking of any interventions being in place once the resident returned to the facility with an unrepaired fractured hip. The Falls (interdisciplinary Care Plan) dated 9/9/10 Problem: resident at risk for falls R/T (related to) DX (diagnosis) Parkinson, unsteady gait, narcotic med use and hypertension med use and recent fall; Approach: 6/26/10 Bed alarm to alert staff of attempts to transfer unassisted (Res. able to turn off alarm) 1/10/11 Floor mat by bed @ all x's (times) and low bed." In interview with the Director of Nursing on 1/24/11 at 2:45 p.m., she indicated the bed alarm was not effective. "We've even hidden it." An Investigation report related to the incident, dated 1/10/11, was provided by the Director of Nursing on 1/24/11 at 2:50 p.m. "Spoke with CNA #1 who worked Sunday night. She said she witnessed no fall or injury on the resident Sunday night. She did state that resident cont. to turn off alarm and transfer self unassisted. Mat by bed." "Spoke with LPN #2, who worked all weekend. She witnessed no falls or injuries on resident. Res. unplugs alarm. Alarm maneuvered behind bed. Res. does cont. to find and remove." 3.1-45(a)(2)