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

Based on interview and record review, the facility failed to ensure a resident was transferred according to her plan of care, was free from an injury of unknown origin, and the investigation into the injury contained complete documentation for 1 of 2 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B receiving a mildly impacted and displaced fracture of the proximal right humerus (the ball-shaped upper portion of the arm bone which forms the shoulder joint).Findings include:During a telephone interview, on 6/29/26 at 9:48 a.m., an anonymous interviewee indicated Resident B was injured in the shower. The facility indicated she fell out of bed. Resident B did not fall out of bed.During an observation, on 6/29/26 at 10:05 a.m., Resident B's right arm was noted to be in a sling. The clinical record for Resident B was reviewed on 6/29/26 at 10:58 a.m. The diagnoses included, but were not limited to, dementia and weakness.A care plan, dated 12/9/25, indicated Resident B had impaired cognition/function or impaired thought process related to dementia. Interventions included, but were not limited to, ask yes or no questions to determine needs and to present one thought, question or command at a time.A quarterly minimum data set (MDS) assessment, dated 3/11/26, indicated Resident B was severely cognitively impaired and was either dependent or required substantial to maximum assistance with all transfers and mobility.A physician's order, discontinued 6/11/26, indicated to utilize a stand lift for transfers.A CNA flow sheet (a sheet which provided a summary of diet, transfers, showers and other information) indicated Resident B transferred with a stand lift.The clinical record indicated Resident B had a shower on 6/8/26 at 4:08 p.m.A comprehensive minimum data set (MDS) assessment, dated 6/10/26, indicated Resident B was severely cognitively impaired and was either dependent or required substantial to maximum assistance with all transfers and mobility.A nursing progress note, dated 6/10/26 at 5:45 p.m., indicated the resident had complained of severe right upper extremity/shoulder pain. The physician and family were notified and an x-ray was ordered.There was no prior progress notes documented to indicate Resident B had suffered an injury, had rolled or fallen out of bed, or was found on the floor.A radiology report, dated 6/11/26 at 7:03 a.m., indicated Resident B had a fracture involving the humeral head and neck with displacement.A nursing progress note, dated 6/11/26 at 9:54 a.m., indicated Resident B had reported to the nurse she had fallen out of bed. She had complaints of pain/discomfort in the right arm. The x-ray revealed a mildly impacted and displaced fracture of the proximal right humerus. Resident B was sent to the hospital with the fracture results and recommendations for a CT (computed tomography) scan.There were no progress notes or documentation to indicate how or who removed Resident B from the floor if she had fallen out of bed since Resident B was dependent or required substantial maximum assistance for mobility.A physician's order, dated 6/11/26 at 10:36 a.m., indicated Resident B could be sent to the emergency room for an evaluation and treatment.A facility fall event, dated 6/11/26 at 9:54 a.m., indicated Resident B reported she rolled from bed. It was unwitnessed. She complained of right shoulder pain.A social service note, dated 6/11/26 at 10:51 a.m., indicated Resident B had pain in her shoulder and stated she fell out of bed and that was why it hurt.A nursing progress note, dated 6/14/26 at 5:53 p.m., indicated Resident B had increased anxiety toward rolling and was afraid she was going to fall.A facility obtained witness statement, dated 6/11/26, indicated CNA 4 reported she cared for Resident B, on 6/8/26, and no fall or event had occurred. She did report transferring Resident B with the assist of two when the resident's legs gave out. She had no knowledge of Resident B rolling out of bed.A facility obtained witness statement, not dated, indicated QMA 6 reported Resident B had complained of pain before her shower. After the shower, at dinner, Resident B complained of more pain. No incidents were reported to QMA 6.A facility obtained witness statement, dated 6/11/26, indicated RN 7 reported Resident B had stated she fell out of bed.A facility obtained witness statement, not dated, indicated CNA 3 reported on 6/8/26 after Resident B's shower, she was transferred with a two person assist. A noise was heard and the CNAs thought Resident B's shirt had ripped. Resident B was placed back in her wheelchair with no complaints.A facility obtained witness statement, dated 6/11/26, indicated LPN 8 reported Resident B had stated she had fallen out of bed but could not recall what day.A facility obtained witness statement, not dated, indicated RN 9 reported on 6/10/26 Resident B complained of right shoulder pain. She obtained an order for an x-ray. She did not witness any incidents.The facility investigation did not contain documentation to indicate how or who removed Resident B from the floor if she had fallen out of bed since Resident B was dependent or required substantial maximum assistance for mobility.During an interview, on 6/29/26 at 2:01 p.m., CNA 3 indicated she completed Resident B's shower on 6/8/26. The resident did not report pain until she was dressed and placed back into her wheelchair. Resident B was to be transferred with a mechanical stand-up lift (a machine which helped the resident stand up), but there was a concern with the lift. CNA 4, who assisted with the transfer, lifted the resident, without using the mechanical lift or a gait belt, while CNA 3 undressed her for the shower. After the shower had been completed, the same transfer method was used again. CNA 4 lifted the resident without any assistive device while CNA 3 dressed the resident. CNA 3 indicated during the transfer, she heard a ripping sound and thought the resident's clothing had ripped, but she did not investigate to see if the clothing had ripped.During an interview, on 6/29/26 at 2:09 p.m., CNA 4 indicated CNA 3 was in Resident B's room trying to get her on the stand-up lift, but Resident B kept putting her feet outside of the flat surface on the lift. There were no safety straps for the legs on the lift. When they got the resident to the shower, CNA 4 decided to stand her up so CNA 3 could undress her. She did not use the lift or a gait belt. She lifted the resident from under her arms and CNA 3 undressed her. CNA 4 indicated she asked CNA 3 to use the call light when the shower was completed, and the resident was ready to transfer back into her wheelchair. When the shower was completed, CNA 4 lifted Resident B without any assistive devices while CNA 3 dressed her and then the resident was transferred into her wheelchair. CNA 4 indicated she did not use the lift because she did not feel it was safe without the leg strap. She indicated she had worked a double (evening and night shift) and Resident B did have complaints of discomfort on the night shift.During an interview, on 6/30/26 at 10:21 a.m., Physical Therapist 5 indicated if a mechanical stand-up lift was not safe, the CNA should inform the nurse and utilize the full body mechanical lift (a lift which had a sling and used to lift the whole body). Resident B had utilized a mechanical stand-up lift for transfers since May of 2023. If a gait belt was used to transfer Resident B, it would most likely require two, maybe even three staff as the resident was a larger person.A current facility policy, titled Policy and Procedure for Mechanical Lift Transfer Usage, undated and received from the Executive Director on 6/30/26 at 11:54 a.m., indicated .All residents determined to require a two-person transfer will be transferred with the use of a Mechanical Lift or a Sit-Stand Lift.This citation relates to Intake 3045109.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure neurological assessments were completed and documented after an unwitnessed fall for 1 of 2 residents reviewed for quality of care. (Resident B)Findings include:During a telephone interview, on 6/29/26 at 9:48 a.m., an anonymous interviewee indicated neurological checks and fall follow-up monitoring were not completed for Resident B.During an observation and interview, on 6/29/26 at 10:05 a.m., Resident B's right arm was noted to be in a sling. The clinical record for Resident B was reviewed on 6/29/26 at 10:58 a.m. The diagnoses included, but were not limited to, dementia, heart failure and weakness.A nursing progress note, dated 6/10/26 at 5:45 p.m., indicated Resident B complained of right upper extremity/shoulder pain. The physician and family were notified and an x-ray was ordered.A nursing progress note, dated 6/11/26 at 9:54 a.m., indicated Resident B had reported to the nurse she had fallen out of bed and had complaints of pain/discomfort to the right arm. The x-ray revealed an impacted and displaced fracture of the upper end of the humerus (upper arm bone).The clinical record did not contain documentation follow-up assessments and neurological checks had been completed for 72 hours after the unwitnessed fall.The last 72-hour fall follow-up assessments were charted in March 2026.During an interview, on 6/30/26 at 9:25 a.m., LPN 2 indicated when a resident had an unwitnessed fall, fall follow-up assessments and neurological checks needed to be completed for 72 hours.During an interview, on 6/30/26 at 12:09 p.m., the Executive Director indicated the facility did not have documentation neurological checks for Resident B were completed.A current facility policy, titled NEURO CHECKS, undated and received from the Executive Director on 6/30/26 at 11:54 a.m., indicated .Neuro checks will be performed for a minimum of 72 hours post incident.ALWAYS DO NEURO CHECKS IF THE FALL WAS UNWITNESSED.EVEN IF THE RESIDENT THEMSELVES.STATE THAT THE RESIDENT WHO FELL DID NOT HIT THEIR HEAD BEFORE AFTER OR DURING THE FALL.Observe the resident for the first 72 hours.This citation relates to Intake 3045109.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure the privacy and confidentiality of a resident's medical record was maintained for 1 of 3 residents reviewed for resident rights. (Resident C)Findings include:During an interview, on 5/26/26 at 10:25 a.m., Resident B's representative indicated he had received the medical records of Resident C, including a summary of episode, with his father's medical record. He was concerned the facility had included another resident's private information with his father's documents. The clinical record for Resident C was reviewed on 5/26/26 at 1:10 p.m. The diagnoses included, but were not limited to, chronic systolic congestive heart failure, dementia, and depression.A summary of episode notes, dated 5/1/26, indicated it was created by medical records on 5/1/26 at 3:19 p.m. It included, but was not limited to, the resident's date of birth , medical diagnoses, medications, and current care plan. During an interview, on 5/27/26 at 11:40 a.m., the Medical Records Director indicated requests for medical records must be made in writing. Once requested, she created the record on the computer. It was then reviewed and approved by management. Once reviewed, she printed the document. Once printed, it was prepared for the representative to pick it up. She tried to make sure there were no other documents in the packet, but multiple documents were printed on the same printer. If the printing of the medical record was interrupted for any reason, another printing request could have been printed within the original request. She attempted to go through the large document to make sure it did not contain other items, but it was very difficult to be sure. It was not supposed to have another resident's information in it. She did not know the facility's policy or process for providing a resident's information to an unapproved person.A current facility policy, titled Medical Records Request, dated 6/26/23 and provided by the ED (Executive Director) on 5/27/26 at 11:05 a.m., indicated .The facility shall ensure that any resident representative has the proper authorization to review.the resident's medical record.HIPPAA requirements will be maintained for medical records.A current facility policy, titled Resident Rights, undated and provided by the ADON (Assistant Director of Nursing) on 5/27/26 at 10:55 a.m., indicated .You have the right of privacy over your personal and clinical records.A current facility document, titled Your Rights and Protections as a Nursing Home Resident, undated and provided by the ED on 5/27/26 at 11:05 a.m., indicated .As a nursing home resident.you have the right to.have your personal information kept private. This citation relates to Intake 3016906. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(o)

Based on interview and record review, the facility failed to ensure residents were administered the correct medications for 2 of 4 residents reviewed for significant medication errors. (Resident B and C) The deficient practice was corrected on 5/11/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 5/14/26 at 8:11 a.m., the Director of Nursing (DON) indicated two medication errors occurred recently. Resident B had been administered Resident D's medications and Resident C had been administered Resident E's medications. Resident B was observed overnight in the emergency room, and Resident C was monitored at the facility. 1. The clinical record for Resident B was reviewed on 5/14/26 at 10:15 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, a history of falling, anxiety disorder, dementia, unsteadiness on feet, and pulmonary fibrosis. A facility document, titled Medication Error, dated 5/8/26 at 7:04 p.m., indicated Resident B had been administered medications which were not prescribed to her. She was sent to the hospital for evaluation. She was kept overnight for observation and sent back to the facility in the morning on 5/9/26. The medications she received which were not ordered for her were:a. Lyrica (a controlled substance medication used to treat seizures or nerve pain) 50 milligrams (mg).b. Zyprexa (an atypical antipsychotic used to treat mental health conditions such as; schizophrenia and bipolar disorder) 2.5 mg.c. Trazadone (an antidepressant medication also used to treat insomnia) 50 mg.d. Metoprolol (a medication used to treat high blood pressure which slows the heart rate and decreases the force of the heart's contractions) 12.5 mg.e. Eliquis (an anticoagulant medication which thins the blood) 2.5 mg.The Electronic Medication Administration Record (EMAR) for Resident B, dated May 2026, did not indicate Lyrica, Zyprexa, trazadone, metoprolol or Eliquis were her prescribed medications. The clinical record indicated, from 2/13/26 to 5/15/26, Resident B's pulse (measure of heart rate) typically ran from 55 bpm (beats per minute) to 88 bpm. Resident B's pulse had dropped down to 55 and 58 two (2) times then the rest of the time her pulse ranged 60 to 88 bpm.A hospital document, titled ED Physician Progress Note, dated 5/9/26 at 7:06 a.m., indicated Resident B was transported to the emergency room for evaluation and treatment after a medication error. She was accidentally administered medication which was meant for another resident. Resident B was administered Eliquis 2.5 mg, Lyrica 50 mg, metoprolol 12.5 mg, trazadone 50 mg, and Zyprexa 2.5 mg. At her baseline, she was only routinely oriented to person. The physician observed bradycardia on the physical exam as well as the resident was drowsy but awoke to stimuli. The physician called the Indiana Poison center, who indicated there was no specific therapy and they would not expect her to have any substantial complications. Their recommendation was to observe her. The resident was observed in the emergency room until 7:00 a.m., on 5/9/26, on a heart monitor. She slept all night. She was bradycardic in the upper 40's to 50's. She had some hypotension in the middle of the night. Her vital signs ranged from 46 to 53 bpm and her blood pressure dropped to as low as 80/46 while being monitored. The resident woke up to verbal stimuli but quickly fell back to sleep. The discharge diagnosis was medication administered in error. Patient education included accidental overdose of an adult. During a telephone interview, on 5/15/26 at 4:36 p.m., LPN 2 indicated she was passing medications when a resident began yelling and screaming. She put Resident D's medications in the cart after marking the cup with her first and last initial. After she took care of the resident, she went back to her cart and picked up the medication cup. She took the medications and administered them to Resident B instead of Resident D. The Nurse Practitioner was notified of the error and ordered an evaluation at the emergency room because she was concerned about the Zyprexa medication Resident B received.2. The clinical record for Resident C was reviewed on 5/14/26 at 12:20 p.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, major depressive disorder, unsteadiness on feet, muscle weakness, and metabolic encephalopathy. A telehealth note, dated 4/27/26 at 1:00 a.m., indicated Resident C had been administered medications in error by a nurse. The diagnosis was accidental medication error. The clinician ordered Resident C's vital signs to be checked every two hours for 24 hours and to notify the clinician of any change in condition. The medications included:a. atorvastatin (a medication used to decrease cholesterol levels).b. Plavix (an antiplatelet medication)c. Metoprolol (a medication used to treat high blood pressure which slows the heart rate and decreases the force of the heart's contractions) The Electronic Medication Administration Record (EMAR) indicated Resident C was administered Plavix 75 mg, buspirone (a medication used to treat anxiety) 15 mg, metformin (a medication used to lower blood sugar levels in someone with diabetes mellitus) 500 mg (2 tablets), metoprolol, and duloxetine (an antidepressant medication) 40 mg. Resident C was administered 1000 mg of metformin without a physician's order and without a diagnosis of diabetes mellitus. There was no documentation in Resident C's clinical record to indicate her blood sugars were monitored after receiving an incorrect medication of metformin. During a telephone interview, on 5/15/26 at 5:37 p.m., QMA 3 indicated she administered Resident E's medication to Resident C. She was a new Qualified Medication Aide (QMA). It was her first time out of orientation and the first time she had passed medications in that hallway. The internet went down when she was passing medications and she did not know what to do. So, she passed the medications based off the resident's roll of medications in the drawer. She had the residents mixed up and administered Resident C, Resident E's medication.A current facility policy, titled Six Rights of Medication Administration, dated September 2013 and provided by the Executive Director on 5/15/26 at 11:45 a.m., indicated .before administering the medication.Right RESIDENT-identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as photo on the MAR [Medication Administration Record], asking a resident his/her name, etc. Right MEDICATION-the name of the medication ordered by the physician The deficient practice was corrected by 5/11/26 after the facility implemented a systemic plan that included the following actions: All nursing staff were educated on the administration of medications, the LPN and QMA involved had the medication administration policy reviewed with them and completed a medication administration pass competency. Audits and medication pass competency had begun and continued. This citation relates to Intake 3011150.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident remained safe from accident hazards during incontinence care provided by a staff member for 1 of 8 residents reviewed for accidents. This deficient practice resulted in Resident 63 hitting her head and receiving a head laceration which required six (6) staples.Findings include:The clinical record for Resident 63 was reviewed on 3/23/26 at 8:52 a.m. The diagnoses included, but were not limited to, muscle weakness, Alzheimer's disease, dementia, and muscle wasting and atrophy.A care plan, dated 11/18/25, indicated the resident required assistance with activities of daily living. Interventions included, but were not limited to, ensure proper positioning while in bed.A Minimum Data Set (MDS) assessment, dated 1/28/26, indicated Resident 63 required substantial to maximal assistance to roll from back to side and to return to the back while in bed.A progress note, dated 2/13/26 at 1:10 p.m., indicated a CNA was completing care on Resident 63, rolled the resident toward the wall, bumped the resident's head on the trim of the wall, and caused a laceration to the top of her head.A facility document, titled Skin Integrity Issue-Other than Pressure Ulcer, dated 2/13/26 at 2:10 p.m., indicated while placing the resident back into a low air loss (LAL) mattress with bolsters to perform incontinent ADL care, a staff member placed the resident on her back on the inflated mattress with the bed raised to waist height of the staff member. They started to roll the resident to the right side and bumped her head on the chair railing on the wall which resulted in a laceration to the top of her head.An emergency room physician's note, dated 2/13/26, indicated according to the resident's facility, while the resident was being moved in her bed today, the top of her head hit part of the bed frame. This caused a laceration on the top of her scalp, and she was sent for evaluation and treatment. A laceration repair was performed to a 4.5 cm wound. The wound was reapproximated by utilizing 6 staples.A facility confidential witness statement, signed on 2/13/26 by Licensed Practical Nurse (LPN) 12, indicated she was told by CNA 11, the CNA rolled the resident over in bed to do care, accidentally hit the top of the resident's head on the wall trim, and caused the resident's head to bleed.A facility confidential witness statement, signed on 2/13/26 by CNA 11, indicated CNA 11 placed Resident 63 into bed on her LAL mattress. When she went to change the resident, she rolled the resident towards the wall. While rolling Resident 63, she clipped her head on the wooden strip on the wall.During an interview, on 3/24/26 at 12:07 p.m., the Director of Nursing (DON) indicated CNA 11 had raised the bed to waist height to perform care for the resident. The incident occurred during care. The CNA rolled the resident over too far and the resident's head was hit on the trim of the wall. It was a combination of the LAL mattress being inflated and the CNA rolling over the resident too far which caused the resident's head to hit the trim on the wall.During an interview, on 3/24/26 at 12:07 p.m., the Executive Director (ED) indicated it was a combination of the LAL mattress being inflated and CNA 11 rolled the resident over too far which caused the resident's head to hit the trim on the wall.During an interview, on 3/25/26 at 9:38 a.m., CNA 11 indicated her and another CNA transfered Resident 63 into bed. After transferring the resident into the bed, she then alone performed a brief change for the resident. It was a combination of her rolling the resident too far over and the bed was inflated which caused the resident to roll over even more. Her head was hit on the trim on the wall. Resident 63 cannot roll on her own and needed help from staff to roll over.During an interview, on 3/26/26 at 3:39 p.m., the DON indicated the facility followed all federal and state regulations.During the exit conference, on 3/26/26 at 4:23 p.m., the DON indicated the facility had no additional information to submit for review related to the accident.This citation relates to Intake 2744045.410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident's nutritional status was assessed, risk factors were identified and addressed, interventions were implemented, and the physician was notified of the need to assess a significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 7) This deficient practice resulted in Resident 7 experiencing an approximate 22% weight loss in approximately 4 months. Findings include:During an observation, on 3/19/26 at 12:26 p.m., Resident 7 was not eating her lunch. The CNA charting indicated the resident refused her lunch. No replacement meal or alternatives offered were charted for her lunch, on 3/19/26.During an observation, on 3/20/26 at 12:37 p.m., Resident 7 ate less than half her lunch.The clinical record for Resident 7 was reviewed on 3/24/26 at 9:45 a.m. The diagnoses included, but were not limited to, dementia, major depressive disorder, muscle weakness, muscle wasting and atrophy of the right and left arms, and cognitive communication deficit.A hospital discharge document, dated 11/18/25, indicated Resident 7's current ongoing problems included weight loss and malnutrition and the most recent weight in the last 24 hours was 181 lbs. A care plan, dated 11/21/26, indicated Resident 7 was at risk of malnutrition. Interventions included, but were not limited to, monitor weights as ordered and refer to the Registered Dietician as needed for significant weight loss or observed poor intake.A physician's order, dated 11/18/25, indicated Resident 7 could receive a general diet with regular texture and thin liquids.The facility weight log indicated, on 11/18/25, Resident 7 weighed 180.6 pounds.An admission Minimum Data Set (MDS) assessment, dated 11/21/25, indicated Resident 7 weighed 181 pounds and had no weight loss.A physician's order, dated 12/7/25, indicated to obtain weekly weights for four (4) weeks every dayshift on Sunday for SWAT (skin wound observation team) monitoring.The facility weight log indicated, on 12/8/25, Resident 7 weighed 160 pounds which was a 11.41% weight loss. The admission weight of 180.6 pounds was cancelled as a data entry error by the dietician, on 12/9/25, with no progress note to indicate why the weight was considered invalid and was cancelled.There was no documentation the physician or facility interdisciplinary team was notified of the weight change. A skilled nursing progress note, dated 12/8/25 at 9:25 a.m., indicated the resident weighed 160 pounds.A physician's progress note, dated 12/14/25, indicated Resident 7's weight was 180.6 pounds. There was no indication of concerns or notification of the weight loss documented.A dietician's recommendation report, dated December 2025, indicated the recommendation was to add house shakes three times a day for weight stability.The electronic medical record did not include an order for house shakes in December or January.A review of Resident 7's meal intakes, for December 2025, indicated the resident had refused or eaten less than half of her meal for 14 meals and had eaten 51-75% of her meal for 26 meals in December.A weight summary indicated, on 1/4/26, Resident 7 weighed 149.3 pounds which was a 6.69% weight loss from the 160-pound weight documented on 12/8/25.A skilled nursing progress note, dated 1/4/26 at 9:33 a.m., indicated Resident 7 was fed that morning due to not attempting to feed herself.A physician's progress note, dated 1/6/26 at 8:53 a.m., indicated the physician was new to the resident and had just taken over her care. Her weight was listed at 149.3 pounds. There was no documentation on prior weights or the resident's weight loss.A skilled nursing progress note, dated 1/7/26 at 9:42 a.m., indicated Resident 7's weight was 149.3 pounds. She required verbal cueing at the minimum and was fed that morning due to not attempting to feed herself.A weight log, dated 1/11/26, indicated Resident 7 weighed 146.4 pounds which was an 8.5% loss in a month from the 160 pounds on 12/8/25. A dietary progress note, dated 1/26/26 at 2:06 p.m., indicated Resident 7's weight was 147.5 pounds with a declining weight trend and an 8.9% weight loss with stalled wound healing. The dietician recommended adding house shakes twice a day to enhance intakes. An order for supplemental house shakes was not initiated until 2/18/26.The dietician's weekly nutrition at risk report, dated January 2026, did not have Resident 7 included on the list of residents with weight loss.A review of Resident 7's meal intakes, for January 2026, indicated the resident had refused or eaten less than half of her meal for 28 meals and had eaten 51-75% of her meal for 25 meals in January.A weight record, dated 2/15/26, indicated Resident 7 weighed 143.9 pounds which was a 10.06% weight loss in less than 3 months from the 160 pounds, on 12/8/25.A physician's order, dated 2/18/26, indicated to administer a house shake two times a day for weight stability.A quarterly nutritional risk review, dated 2/18/26 at 10:58 a.m., indicated Resident 7's weight was 143 pounds and there was no weight loss of more than 5% in the last month or a loss of 10% or more in the last 6 months with no issues noted and no referral to the dietician had been performed.A quarterly MDS assessment, dated 2/21/26, indicated Resident 7 weighed 144 pounds which was a significant weight loss while not being on a prescribed weight-loss regimen.A physician's progress note, dated 3/17/26 at 10:05 a.m., did not indicate the facility had notified the physician or Resident 7 was assessed for a significant weight loss.A weight summary, dated 3/23/26, indicated Resident 7's current weight was 140.7 pounds.The documented 181-pound weight, on 11/18/25, and the documented 140.7-pound weight, on 3/23/26, would be an approximate 22% weight loss in approximately 4 months and 5 days. A review of Resident 7's meal intakes, for March 2026, indicated the resident had refused or eaten less than half of her meal for 14 meals and had eaten 51-75% of her meal for 23 meals so far in March.During an interview, on 3/25/26 at 2:45 p.m., LPN 5 indicated Resident 7 needed cueing and encouragement to eat most of the time. Resident 7 did not have any weight loss concerns being monitored by nursing.During an interview, on 3/26/26 at 10:47 a.m., the Director of Nursing (DON) indicated Resident 7 was admitted after having sepsis in the hospital where she had been given a lot of fluids and diuretics, so the facility had expected some weight loss. The facility was not following her for weight loss even after weight loss had continued for months after her hospital discharge and no longer receiving any diuretics.The DON did not provide any documentation or indication the facility was monitoring Resident 7 for weight loss, or the physician had been notified and was evaluating the resident.During an interview, on 3/26/26 at 1:49 p.m., the Assistant Director of Nursing (ADON) indicated she had initiated the house shakes for nutrition in February.A current facility policy, titled GUIDELINES FOR OBTAINING RESIDENTS' WEIGHTS, dated 7/24/24 and provided by the DON on 3/26/26 at 9:40 a.m., indicated .changes in weight can often indicate other medical changes.Compare the obtained to the previous weight. If there is a significant variance.be sure to reweigh the resident to verify the weight. If a weight is found to be incorrect - note this and initial the error - then notify the nurse for guidance.A current facility policy, titled S-W-A-T PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM) WEIGHT MANAGEMENT, dated 10/9/23 and provided by the ADON on 3/26/26 at 1:45 p.m., indicated .assess the.medication with side effect.dx of severe dementia.s/s of depression.s/s constipation.calorie count.diet acceptance.recent notifications made to MD, RD, Family.410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)(2)

Based on observation, interview and record review, the facility failed to ensure puree foods were prepared with methods to conserve nutritive value and flavor and to maintain proper food holding temperatures to ensure safe and appetizing temperatures. This deficient practice had the potential to affect 93 of 93 residents who received food from the facility.Findings include:1. During an observation, on 3/20/26 at 9:54 a.m., [NAME] 2 was pureeing beef pot roast and carrots for seven residents who required a puree diet. [NAME] 2 placed two large scoops of the beef pot roast and an unmeasured amount of hot water into the food processor bowl and turned it on. [NAME] 2 turned the food processor off to check the consistency of the pureed food and determined the beef pot roast was still too thick. [NAME] 2 again added an unmeasured amount of hot water into the food processor and turned it back on to continue to puree the meat. When [NAME] 2 believed the pureed beef pot roast was at an appropriate texture, the food was removed from the food processor bowl and a small scoop of juices from the main roasting pan was added to the pureed portion.During an interview, on 3/20/26 at 10:03 a.m., the Dietary Manager (DM) indicated staff used water as a thinning agent during the pureeing process but would add a small amount of juice from the main cooking pan after the process was complete. She indicated the facility had recipes for all meals the kitchen prepared.A review of the kitchen recipe for beef pot roast indicated to count/measure out the number of portions needed. The food was to be added into the food processor and processed to a smooth consistency by adding juice, milk or broth, whichever was most appropriate for the item being pureed as needed to achieve desired consistency.Cook 2 was not observed utilizing or following the recipe or its instructions.2. During an interview, on 3/19/26 at 10:44 a.m., Resident 12 indicated she ate in the dining room on the second floor and meals were not always hot when served.During an interview, on 3/24/26 at 1:33 p.m., three (3) of the resident council members indicated food served during meal services was cold.A food temperature was requested in the second-floor dining room for the lunch service on 3/20/26 at 12:03 p.m. [NAME] 4 indicated he did not have a food thermometer available in the serving area. Upon returning to the second-floor dining room, after obtaining another kitchen staff member with a food thermometer from the main kitchen, the meal service had started.The food temperatures were obtained, on 3/20/26 at 12:07 p.m., from the second-floor dining room where five (5) food items were being held on the steam table for the lunch service.The following temperatures were obtained:a. The pureed carrots were 128 degrees Fahrenheit.b. The pureed beef pot roast was 103 degrees Fahrenheit.c. The hamburgers (an alternative option) were 119 degrees Fahrenheit.During an interview, on 3/20/26 at 12:09 p.m., [NAME] 4 indicated he believed the holding temperatures would be 160 degrees.During an interview, on 3/20/26 at 12:13 p.m., the Dietary Manager indicated the carrots, pureed beef pot roast, and the hamburgers were not at the appropriate holding temperatures and could not be served.A current facility policy, titled Pureed food preparation, dated as last revised 1/2025 and received from the Administrator on 3/20/26 at 12:00 p.m., indicated .Pureed foods will be prepared and served in a manner that maximized quality of flavor and nutrient content.Standardized recipes will be used to produce pureed food to maintain nutrient content.Milk, broth, soup, gravy, and margarine will be used to thin the pureed food instead of water. Water may only be used if mixed with a commercially available thickening agent to form a slurry.Pureed hot items will be prepared while maintaining a temperature above 135 degrees.A current facility policy, titled Food Temperatures, undated and received from the Administrator on 3/23/26 at 11:27 a.m., indicated .Food temperatures shall be checked at the end of cooking, at the start of service.Hot foods will be held at temperatures 135 degrees or above.prior to serving to maintain food safety.Inappropriate holding temperatures shall be reported to supervisor for corrective action or disposal instruction.Hot Food.Hold at 135 degrees Fahrenheit or greater throughout service process.410 IAC (Indiana Administrative Code) 3.1-21(a)(1)410 IAC (Indiana Administrative Code) 3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR) were resubmitted after psychotropic medications were initiated for newly identified behaviors, prior to the expiration for short term approvals, and for an increase in dosage of psychotropic medications for 4 of 6 residents reviewed for PASARR. (Resident 47, 3, 1 and 10)Findings include:1. The clinical record for Resident 47 was reviewed on [DATE] at 1:46 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anxiety. A hospital document, dated [DATE], indicated Resident 47's wife reported being unable to care for him at home due to his severe dementia. Resident 47 did experience hallucinations but was never violent. Resident 47's hospital discharge medication list did not include a diagnosis of anxiety or medications for anxiety or agitation. A level I PASSAR screen, dated [DATE], indicated Resident 47's only mental health diagnosis was dementia. Resident 47 was prescribed Exelon (a medication used to treat mild-to-moderate dementia) to manage his dementia symptoms. A level II PASSAR was required at that time and if a change occurred or if new information refuted the findings, a new PASSAR must be submitted. The clinical record indicated Resident 47 was admitted to the facility on [DATE]. No behaviors were documented from [DATE] to [DATE]. A behavior note, dated [DATE], indicated Resident 47 had attempted to bust through the fire exit door by forcefully pressing his body against the door and hitting the door in attempt to get out. Interventions by the staff were unsuccessful and the behaviors continued for approximately 1 hour. A behavior note, dated [DATE], indicated Resident 47 was displaying physically aggressive behavior during the shift by yelling, cursing, and threatening to hit staff. Interventions attempted by the staff were unsuccessful and the behaviors continued for approximately 30 minutes. Staff contacted Resident 47's wife and indicated the resident's neurologist would fax a prescription for Valium (an antianxiety medication) to the facility. A behavior note, dated [DATE], indicated Resident 47 was physically aggressive by hitting staff with his walker and pushing the staff. The behavior decreased when his wife came to visit but increased again after his wife left. An interdisciplinary team (IDT) note, dated [DATE], indicated Resident 47 was displaying an increase in behaviors. The facility would evaluate the resident's medication with the psychiatric nurse practitioner and social service was made aware. A physician's order, dated [DATE] to [DATE], indicated to administer Valium 2 milligrams (mg) once a day, as needed, for anxiety and agitation related to dementia. A physician's order, dated [DATE] to [DATE], indicated to administer Valium 2 mg every 12 hours, as needed, for anxiety and agitation related to dementia. A physician's order, dated [DATE], indicated to administer buspirone (a medication used to treat anxiety) 5 mg, three times a day, for anxiety. A physician's order, dated [DATE], indicated to administer Valium 2 mg every 8 hours, as needed, for anxiety and irritability. A physician's order, dated [DATE], indicated to administer Valium 2 mg, at bedtime, for anxiety. A new PASSAR level I screen which included the resident's new diagnosis of anxiety and the new psychotropic medications of Valium and buspirone were not located in the medical record. During an interview, on [DATE] at 12:03 p.m., Resident 47's wife indicated the resident had started experiencing increased anger and his neurologist ordered Valium. During an interview, on [DATE], the Social Service Director indicated a new PASSAR would be submitted for the addition of psychotropic medications and Resident 47 should have had a new PASSAR submitted. 2. The clinical record for Resident 3 was reviewed on [DATE] at 12:35 p.m. The diagnoses included, but were not limited to, major depressive disorder, anxiety disorder, and bipolar disorder. A level I PASSAR screen, dated [DATE], indicated Resident 3's mental health medications included Seroquel (an antipsychotic medication), and a level II evaluation must be conducted. A level II PASSAR, dated [DATE], indicated Resident 3 had a 90-day short-term approval period and the approval period would end on [DATE]. A new level II PASSAR completed prior to the 90-day short-term approval period end date was not located in the clinical record. A physician's order, dated [DATE], indicated to administer buspirone 10 mg, two times a day, for anxiety. A PASSAR which included Resident 3's new psychotropic medication was not located in the clinical record. During an interview, on [DATE] at 4:00 p.m., the Social Service Director indicated a new PASSAR would be submitted for a change in psychotropic medications. When a short-term approval period was ending, the business office manager would be notified so they could start the process of submitting a new PASSAR. Resident 3's PASSAR was expired and should have been resubmitted. The Social Service Director needed to be notified when a short-term approval date was ending so the business office manager could initiate a referral for a new PASSAR. The facility had been trying to determine who would be responsible for ensuring PASSARs were submitted in a timely manner. 3. The clinical record for Resident 1 was reviewed on [DATE] at 11:15 a.m. The diagnoses included, but were not limited to, mild cognitive impairment, essential hypertension, and type 2 diabetes. A PASARR level I screen, dated [DATE], indicated the PASRR level I determination had an approval date of 60 days. The suspected or confirmed PASARR condition was an intellectual disability. If the resident needed to stay longer than the number of approved days listed on the notice, a nursing facility staff member must submit a new level I screen. A PASARR resubmitted after the 60-day approval period was not located in the clinical record. During an interview, on [DATE] at 4:00 p.m., the Social Service Director indicated a new PASSAR would be submitted for a change in psychotropic medications. Before a short-term approval period ends, the business office manager would be notified so they could start the process of submitting a new PASSAR. 4. The clinical record for Resident 10 was reviewed on [DATE] at 2:09 p.m. The diagnoses included, but were not limited to, severe recurrent major depressive disorder without psychotic features, anxiety disorder, and chronic pain. A PASARR, dated [DATE], indicated the resident had diagnoses of depression and anxiety and was taking Cymbalta (a medication used to treat depression). A physician's order, dated [DATE], indicated to administer Cymbalta 40 mg two times a day. A physician's order, dated [DATE] and discontinued [DATE], indicated to administer buspirone (a medication used to treat anxiety) 5 mg twice a day. A physician's order, dated [DATE] and discontinued [DATE], indicated to administer buspirone 10 mg twice a day. A physician's order, dated [DATE] and discontinued [DATE], indicated to administer buspirone 5 mg twice a day. A physician's order, dated [DATE], indicated to administer buspirone 5 mg twice a day. A physician's visit note, dated [DATE], indicated the resident's scheduled current medications included buspirone and Cymbalta. During an interview, on [DATE] at 3:54 p.m., the Social Service Director indicated the facility had recently initiated a new PASARR screen for Resident 10. A new PASARR screen should have been completed when a new medication was started, with a new mental health diagnosis, or when the short-term approval expired. It should also have been initiated if the original PASARR screen was missing information. A current facility policy, titled Guidelines for PASRR Process, dated [DATE] and provided by Unit Manager 7 on [DATE] at 11:36 a.m., indicated PASRR is a federally mandated process that requires all states to pre-screen all residents.PASRR has 3 goals: 1) Identify people.with mental illness.3) To ensure people, (residents), receive the required services for mental illness. 410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)(1)(A) 410 IAC (Indiana Administrative Code) 16.2-3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure medication carts were free from expired medications and medications were properly labeled with a pharmacy label for 2 of 3 medication carts reviewed for medication storage and labeling. (orchard cart and garden cart)Findings include:1. The orchard hall medication cart was reviewed on 3/25/26 at 1:34 p.m. The following were observed:a. In the fifth large drawer, a prescription bottle of levothyroxine (a medication used to treat an underactive thyroid) 200 milligrams (mg) contained several small round pills. The medication bottle had a discard after date of 1/4/25. Expired was written in pink ink on the pharmacy label.During an interview, on 3/25/26 at 1:49 p.m., LPN (Licensed Practical Nurse) 5 indicated she believed expired medications should be taken out of the medication cart.2. The garden hall medication cart was reviewed on 3/25/26 at 1:59 p.m. The following were observed:a. In the first large drawer, a Humalog insulin pen (a rapid acting inulin used to control blood sugar) did not contain a pharmacy label and was in a medication zip-lock bag with another lispro insulin pen. The zip-lock bag contained a pharmacy label for the lispro insulin pen.b. In the fourth large drawer, a single dose of amoxicillin/clavulanate potassium (a combination antibiotic medication), sealed in the manufactures packaging, was sitting loose in the drawer and did not contain a pharmacy label.During an interview, on 3/25/26 at 2:21 p.m., LPN 6 indicated medications should have a pharmacy label. If the pharmacy label came off the medication, the nurse should write the resident's last name, provider's name and see MAR (Medication Administration Record) on the medication packaging.During an interview, on 3/26/26 at 10:19 a.m., Unit Manager 7 indicated the Humalog insulin pen and the single dose of amoxicillin/clavulanate potassium were pulled from the EDK (emergency drug kit). Medications pulled from the EDK did not come with a pharmacy label and should be labeled by the nurse at the time the medication was removed from the EDK with the resident's name, room number, and physician's name.During an interview, on 3/26/26 at 10:22 a.m., Unit Manager 8 indicated when a new order was put into the resident's record, the Unit Manager would sometimes get the medication out of the EDK for the nurse working on the floor. She had pulled 2 doses of amoxicillin/clavulanate potassium sometime before lunch for the afternoon and evening administration times and gave the medications to the nurse.A current facility policy, titled Medication Storage In The Facility, dated 10/2021 and received from Unit Manager 7 at 11:41 a.m., indicated .Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations.Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled, or without secure closures will be immediately withdrawn from the stock by the facility. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists.410 IAC (Indiana Administrative Code) 3.1-25(j)410 IAC (Indiana Administrative Code) 3.1-25(o)

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 4 of 5 residents reviewed for resident records. (Resident 98, 7, 26 and 91)Findings include:1. The clinical record for Resident 98 was reviewed on 3/23/26 at 8:30 a.m. The diagnoses included, but were not limited to, acute respiratory failure, heart failure, and respiratory syncytial virus (RSV) pneumonia. A hospital document, dated 12/27/25, indicated Resident 98 was discharged from the hospital to the facility with diagnoses which included, but were not limited to, pneumonia of the left lower lobe and acute hypoxic respiratory failure. During Resident 98's hospital treatment course, the resident required high oxygen needs and at the time of discharge was utilizing 2 L (liters) of oxygen via nasal cannula. A written physician's telephone order, dated 12/27/25, indicated to administer oxygen at 2 liters per minute as needed for shortness of breath. The telephone order did not include the signature of the nurse who received the order or the date and time the order was received. The order for oxygen was not placed into the resident's electronic health record. An admission assessment, dated 12/27/25, indicated Resident 98 utilized oxygen at 2 liters via nasal cannula. A facility post-admission assessment, dated 12/28/25, indicated Resident 98's most recent oxygen saturation was 97% with oxygen via nasal cannula. The equipment needs were documented as No respiratory support or equipment noted. A care plan, dated 12/29/25, indicated Resident 98 was at risk for impaired gas exchange related to respiratory failure and the use of oxygen. An occupational therapy evaluation note, dated 12/29/25, indicated Resident 98's required oxygen dependance via nasal cannula at 2 liters. The electronic health record indicated Resident 98's oxygen saturations were documented 15 times. Of the 15 documented times, two were documented as room air. A transfer form, dated 1/9/26 at 5:23 p.m., indicated Resident 98 was being transferred to the hospital for respiratory arrest (breathing stopped but a pulse was still present). The vital signs were documented as 24 breaths per minute and an oxygen saturation of 91% with oxygen via nasal cannula. The respiratory devices and treatment section which would indicate if the resident was using oxygen, how many liters of oxygen were being used, and the method of delivery was left blank. A SBAR (situation, background, assessment and recommendation) form, dated 1/9/26, indicated the resident experienced respiratory arrest. Oxygen saturations were 91%. The room-air or oxygen use section was left blank. During an interview, on 3/24/26 at 2:30 p.m., the Director of Nursing (DON) indicated Resident 98 had to have an order for oxygen. She reviewed the physician's orders in the clinical record and indicated the order was missing and she was not sure why the oxygen order was not listed. During an interview, on 3/24/26 at 3:09 p.m., Unit Manager 7 indicated Resident 98 was not discharged from the hospital with an order for oxygen. Resident 98 did require oxygen while in the hospital but was to be weaned off the oxygen at the facility. There was documentation in the record of the resident's oxygen saturations on room air. Resident 98's identification picture in the clinical record showed the resident wearing a nasal cannula but there was no way of knowing if the nasal cannula was attached to an oxygen concentrator. On 1/9/26, Resident 98 became short of breath, the physician came to the facility, placed oxygen on the resident, and ordered Resident 98 be sent to the emergency room for evaluation. A review of the resident identifier picture, located in the clinical record, indicated the picture was taken on 12/29/25, two days after Resident 98 was admitted to the facility. During an interview, on 3/26/26 at 1:42 p.m., Unit Manager 7 indicated when she received a verbal or telephone order from the physician, she would document the date and time the order was given and sign the order form. She would then transcribe the order, give the order form to medical records, and report to the oncoming shift a new order was entered for the resident. 2. The clinical record for Resident 7 was reviewed 3/24/26 at 9:45 a.m. The electronic medical record did not include any record of tuberculosis testing. The facility added the tuberculosis testing to the clinical record on 3/25/26 at 11:10 a.m. The record did not indicate the times when the test was given or read, and it did not include the dates the tests were read. During an interview, on 3/26/26 at 3:05 p.m., the Assistant Director of Nursing (ADON) who served as the facility's Infection Preventionist indicated the tuberculosis tests must be read within 48-72 hours after administration, so she tried to make sure when she documented a test that she included the date and time it was read. The medical record should include the date and time the tests were given and read. 3. The clinical record for Resident 26 was reviewed on 3/24/26 at 2:57 p.m. The testing record indicated the tuberculosis tests were given on 7/21/25 and 7/29/25 at midnight with no indication of the date and time either were read. 4. The clinical record for Resident 91 was reviewed on 3/24/26 at 2:54 p.m. The admission tuberculosis tests were given on 4/18/25 and 7/28/25. The clinical record did not include the date or time either test was read. An immunization report, dated 3/25/26 at 11:04 a.m., was provided by Unit Manager 7 on 3/25/26 at 11:30 a.m., and indicated the tuberculosis tests were given on 4/18/25 and 5/2/25. The medical record did not include the date or time either test was read. The facility did not provide a resident admission tuberculosis policy. A current facility policy, titled Guidelines for Nursing Documentation, dated 5/17/23 and provided by Unit Manager 7 on 3/26/26 at 11:36 a.m., indicated .Be definite in what you record.Use quantifiable date.Be timely in your documentation. It is easy to forget details.Remember If you did not write it down, you did not do it. If you did not do it, you were negligent 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1) 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure an informed consent was obtained prior to initiating psychotropic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 47)Findings include:During an interview, on 3/19/26 at 12:03 p.m., Resident 47's wife indicated after being admitted to the facility Resident 47 experienced an increase in anger and his neurologist ordered Valium (an antianxiety medication). She picked up the prescription from the pharmacy and took the medication to the facility. Resident 47's wife indicated she did not sign an informed consent for the use of the medication and indicated the only person who had asked if she had any questions about the medication was at the pharmacy when she picked up the prescription.The clinical record for Resident 47 was reviewed on 3/23/26 at 1:46 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anxiety.A physician's order, dated 2/28/26 to 3/5/26, indicated to administer Valium 2 milligrams (mg) once a day, as needed, for anxiety and agitation related to dementia.A physician's order, dated 3/5/26 to 3/14/26, indicated to administer Valium 2 mg every 12 hours, as needed, for anxiety and agitation related to dementia.A physician's order, dated 3/9/26, indicated to administer buspirone (an anxiety medication) 5 mg three times a day for anxiety.A physician's order, dated 3/14/26, indicated to administer Valium 2 mg every 8 hours, as needed, for anxiety and irritability.A physician's order, dated 3/18/26, indicated to administer Valium 2 mg at bedtime for anxiety.A signed informed consent for the medication changes related to the administration of Valium was not located in the clinical record.A signed informed consent for buspirone was not located in the clinical record.During an interview, on 3/26/26 at 12:12 p.m., the Social Service Director indicated signed informed consents were needed for all psychotropic medications. Buspirone did not have a black box icon next to the medication, so she did not know the medication needed a signed informed consent. If psychotropic medications needed a new signed informed consent after a dose increased, the nurse would inform the Social Service Director when the dosage increased.During an interview, on 3/26/26 at 3:39 p.m., the Director of Nursing (DON) indicated the facility followed all State and Federal regulations.A current facility policy, titled Guidelines for Behavioral Management, dated 8/18/23 and received from Unit Manager 7 on 3/26/26 at 11:36 a.m., indicated .The purpose is to review residents who have behaviors and who are being monitored for these behaviors.The facility will make every effort to comply with state and federal regulations related to the use of psychoactive medications, to include regular, structured review for continued need, appropriate dose, side effects, risks and benefits.Psychoactive medications include anti-anxiety/hypnotic, anti-psychotic and anti-depressants.Documents discussions with the resident and/or responsible party regarding the risks verses the benefits of the use of these medications to include documented discussion of any black box warning associated with specific medication.410 IAC (Indiana Administrative Code) 3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's significant weight loss for 1 of 3 residents reviewed for notification of change. (Resident 7)Findings include:During an observation, on 3/19/26 at 12:26 p.m., Resident 7 was not eating her lunch. The CNA charting indicated the resident refused her lunch. No replacement meal or alternatives offered were charted for her lunch, on 3/19/26.During an observation, on 3/20/26 at 12:37 p.m., Resident 7 ate less than half her lunch.The clinical record for Resident 7 was reviewed on 3/24/26 at 9:45 a.m. The diagnoses included, but were not limited to, dementia, major depressive disorder, muscle weakness, muscle wasting and atrophy of the right and left arms, and cognitive communication deficit.A hospital discharge document, dated 11/18/25, indicated Resident 7's current ongoing problems included weight loss and malnutrition and the most recent weight in the last 24 hours was 181 lbs. The facility weight log indicated, on 11/18/25, Resident 7 weighed 180.6 pounds.The facility weight log indicated, on 12/8/25, Resident 7 weighed 160 pounds which was a 11.41% weight loss. The admission weight of 180.6 pounds was cancelled as a data entry error by the dietician, on 12/9/25, with no progress note to indicate why the weight was considered invalid and was cancelled.There was no documentation the physician was notified of the weight change. A skilled nursing progress note, dated 12/8/25 at 9:25 a.m., indicated the resident weighed 160 pounds.A physician's progress note, dated 12/14/25, indicated Resident 7's weight was 180.6 pounds. There was no indication the physician was informed of weight loss or the 160-pound weight documented on 12/8/25.A weight summary indicated, on 1/4/26, Resident 7 weighed 149.3 pounds which was a 6.69% weight loss from the 160-pound weight documented on 12/8/25.A physician's progress note, dated 1/6/26 at 8:53 a.m., indicated the physician was new to the resident and had just taken over her care. Her weight was listed at 149.3 pounds. There was no documentation on prior weights, or the facility had informed the physician of the resident's weight loss.A weight log, dated 1/11/26, indicated Resident 7 weighed 146.4 pounds which was an 8.5% loss in a month from the 160 pounds on 12/8/25. A weight record, dated 2/15/26, indicated Resident 7 weighed 143.9 pounds which was a 10.06% weight loss in less than 3 months from the 160 pounds, on 12/8/25.A physician's progress note, dated 3/17/26 at 10:05 a.m., did not indicate the facility had notified the physician or Resident 7 was assessed for a significant weight loss.A weight summary, dated 3/23/26, indicated Resident 7's current weight was 140.7 pounds.The documented 181-pound weight, on 11/18/25, and the documented 140.7-pound weight, on 3/23/26, would be an approximate 22% weight loss in approximately 4 months and 5 days. During an interview, on 3/25/26 at 2:45 p.m., LPN 5 indicated Resident 7 needed cueing and encouragement to eat most of the time. Resident 7 did not have any weight loss concerns being monitored by nursing.During an interview, on 3/26/26 at 10:47 a.m., the Director of Nursing (DON) indicated Resident 7 was admitted after having sepsis in the hospital where she had been given a lot of fluids and diuretics, so the facility had expected some weight loss. The facility was not following her for weight loss even after weight loss had continued for months after her hospital discharge and no longer receiving any diuretics.The DON did not provide any documentation or indication the physician had been notified and evaluated the resident for significant weight loss. The resident had switched physicians in January.A current facility policy, titled S-W-A-T PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM) WEIGHT MANAGEMENT, dated 10/9/23 and provided by the Assistant Director of Nursing (ADON) on 3/26/26 at 1:45 p.m., indicated .assess.notifications made to MD, RD, Family.410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure a physician's order related to a medical condition was obtained for the use of a bed and chair alarm, an initial physical restraint assessment was completed, and an interdisciplinary team (IDT) note which discussed the least restrictive interventions implemented first had failed and to review the use of the devices at least quarterly for 1 of 2 residents reviewed for physical restraints. (Resident 81)Findings include:During an observation, on 3/20/26 at 2:19 p.m., Resident 81 had a pull alarm (a device designed to alarm staff when the resident attempted to get up) connected to the resident and her wheelchair. The resident had a device in her room connected to the bed as well.The clinical record for Resident 81 was reviewed on 3/24/26 at 10:55 a.m. The diagnoses included, but were not limited to, major depressive disorder, muscle weakness, and dementia.A physician's order, dated 9/24/25, indicated to utilize a pull alarm when in the wheelchair every shift.The order had no related diagnosis or indication for use. There was an indefinite end date.A physician's order, dated 9/24/25, indicated to utilize a bed alarm when in bed every shift.The order had no related diagnosis or indication for use. There was an indefinite end date.The clinical record indicated Resident 81 had a fall on 1/26/25 and on 9/24/25. The bed alarm and chair alarm orders were placed after the fall on 9/24/25.Resident 81 had no documented falls after 9/24/25. The facility continued the ordered bed and chair alarm after the resident had gone over 7 months without a recorded fall.An IDT progress note, dated 9/25/25, indicated the IDT team met to discuss the fall which happened on 9/24/25. The resident was found on the floor at approximately 11 a.m. A bruise was noted on her right elbow. The immediate intervention was a pull alarm placed on the wheelchair. The IDT team recommended continuing the alarm at this time with routine evaluations to ensure appropriateness.The IDT team note did not discuss which least restrictive interventions were attempted and failed prior to initiating the alarm.The clinical record did not indicate an initial physical restraint assessment was completed and there was no physical restraint/device assessment completed at least quarterly. During an interview, on 3/24/26 at 10:55 a.m., the Director of Nursing (DON) indicated she understood there was not much documentation in the record about the devices. The facility did reassess the need for the devices and she would work on finding the reassessments.During an interview, on 3/24/25 at 3:50 p.m., the DON indicated she would be providing the device reassessments.A fall assessment for Resident 81 was received from the facility on 3/25/26 at 8:45 a.m. There was no mention of the alarm devices in the fall assessments.During an interview, on 3/25/26 at 3:40 p.m., the DON indicated it did not appear Resident 81 needed the bed and chair alarms.During an interview, on 3/26/26 at 3:39 p.m., the DON indicated the facility followed all federal and state regulations.During an exit conference, on 3/26/26 at 4:23 p.m., the DON indicated the facility had no additional information to submit for review.A current facility policy, titled Guidelines for Physical Restraints/Seclusion, dated 5/17/23 and received from the Executive Director on 3/25/26 at 1:40 p.m., indicated .It is the policy of the facility to use physical restraint only as a last resort and only after every other alternative to a physical restraint (based on assessment) that seemed to have the potential for being used successfully, has been tried, and has failed. The use of a physical restraint and/or device is to enable and promote functioning at the highest practicable physical, mental, or psychosocial well-being. It will be used only after the resident has been assessed and it has been determined by the IDT that the restraint to be used is the least restrictive and for the least amount of time.The resident must have a complete order for the restraint which includes the type of restraint and when it is to be applied/released. The restraint order must include the related medical condition.Procedure A. Complete the initial Physical Restraint Assessment. Note: If a resident is admitted with a physical restraint, a new assessment/order is needed. B. Review contributing factors such as behaviors/mood/fall risk/medical signs and symptoms/diagnosis/cognition/communication and ADL performance abilities. C. IDT to evaluate alternatives to physical restraint use and least restrictive interventions for the least amount of time. D. Explain and document the risks and benefits of treatment options related to physical restraints/devices to the resident as well as the representative (if the resident is not their own responsible party). E. Obtain the consent of the resident or of their representative/POA (if the resident is not their own responsible party). F. Obtain a detailed and specific doctor's order for the physical restraint/device which includes the specific physical restraint/device as well as when it is to be applied and released. J. Complete a new Physical Restraint/Device Assessment at least quarterly or if there is a change in the resident's condition (or if the medical condition for which the physical restraint is being used changes) to see if a lesser restraint can be used-or for possible the discontinuance of the physical restraint if possible.Note: Always try a restraint alternative before using a physical restraint/device 410 IAC (Indiana Administrative Code) 16.2-3.1-26(a)410 IAC (Indiana Administrative Code) 16.2-3.1-26(o)410 IAC (Indiana Administrative Code) 16.2-3.1-26(r)410 IAC (Indiana Administrative Code) 16.2-3.1-26(s)

Based on interview and record review, the facility failed to ensure a bed hold policy was provided to the resident or resident's representative at the time of transfer for 1 of 2 residents reviewed for hospitalization. (Resident 78)Findings include:The clinical record for Resident 78 was reviewed on 3/24/26 at 2:34 p.m. The diagnoses included, but were not limited to, repeated falls, history of falling, and dementia.A progress note, dated 6/25/25, indicated Resident 78 was noted to be on the floor and complained of back pain. The resident was transferred by Emergency Medical Services (EMS) to the hospital.The clinical record did not indicate the bed hold policy was provided to the resident or resident's representative at the time of transfer.During an interview, on 3/26/26 at 9:56 a.m., Social Services14 indicated the staff should document when the bed hold policy was provided to the resident or resident's representative when a resident was transferred to the hospital.During an interview, on 3/26/26 at 10:12 a.m., Social Services14 indicated she found the note about the transfer, but it did not say anything about bed hold information being provided.The facility did not have a policy related to providing bed hold information to the resident and resident's representative at the time of transfer.410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(25)(A)410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(25)(B)410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(26)

Based on observation, interview and record review, the facility failed to ensure mental health services were provided for a resident with several mental health disorders for 1 of 4 residents reviewed for mood and behavior. (Resident 12)Findings include:During an observation and interview, on 3/19/26 at 10:37 a.m., Resident 12 was in bed and indicated she did not receive mental health services but would like to attend therapy sessions.During an observation and interview, on 3/25/26 at 1:57 p.m., Resident 12 was in bed and was thinking about going to the ice cream bar activity downstairs. She indicated staff had not asked if she would like to attend therapy and wished staff would because she could use it.The clinical record for Resident 12 was reviewed on 3/23/26 at 12:36 p.m. The diagnoses included, but were not limited to, bipolar disorder, conversion disorder, anxiety disorder, post-traumatic stress disorder, panic disorder, delusional disorder, and dementia.Resident 12 was admitted to the facility, on 9/5/25, after an extended in-patient stay at a psychiatric hospital.A physician's order, dated 9/5/25, indicated Resident 12 could receive the services of a psychiatrist.A physician's order, dated 9/5/25, indicated Resident 12 could receive counseling and medication management services.A patient registration form indicated consent for behavioral health services was obtained from Resident 12's next of kin on 9/5/25.A care plan, dated 9/8/25, indicated Resident 12 had a diagnosis of anxiety with an intervention of psych per order.A physician's order, discontinued 10/12/25, indicated Resident 12 could be evaluated and treated for psychology and psychiatry services.A level of care document, dated 11/17/25, indicated there were zero days of psychological therapy for Resident 12 by any licensed mental health professional.A PASSAR (Preadmission Screening and Resident Review), dated 11/19/25, indicated the facility was required to provide Resident 12 mental health services such as individual therapy.The clinical record did not contain documentation of mental health services for Resident 12 from 9/5/25 to 1/11/26.A psychiatric note, dated 1/12/26, indicated Resident 12 had a two-way video and audio initial patient visit to evaluate her psychiatric conditions to determine if the mental health services would assist in the management, education, and support of the resident's conditions. The summary of the visit indicated Resident 12 was eligible for behavioral health integration and psychiatric collaborative care management, and a consent to enroll for these services had been signed by the resident.A care plan, dated 2/6/26, indicated Resident 12 had a diagnosis of Post-Traumatic Stress Disorder (PTSD) with an intervention to refer the resident for psychiatric services.A care plan, dated 2/6/26, indicated Resident 12 required the use of antipsychotic medications related to her mental health disorders with an intervention to refer her to psychiatric services.A care plan, dated 2/6/26, indicated Resident 12 had a history of severe, persistent mental illness with an intervention to refer her to appropriate individual counseling or other mental health program.A care plan, dated 2/6/26, indicated Resident 12 had a history of mental illness and mental health needs with interventions to provide initial psychiatric management to monitor psychotropic medications and to help support and enhance structure, inform the psychiatrist of the resident's progress, and to involve the resident in supportive group and/or one-on-one counseling.A psychotherapeutic drug evaluation, dated 3/5/26, indicated Resident 12 was receiving psychiatric services.The clinical record did not contain documentation of mental health services for Resident 12 from 1/13/26 to 3/26/26.A quarterly social service resident interview, dated 3/10/26, indicated during a 7-day look back period from 3/4/26 to 3/10/26, Resident 12 had admitted to experiencing little pleasure in doing things she liked to do, feeling down and depressed, having difficulty falling asleep, feeling tired and having difficulty concentrating. Resident 12's PHQ-9 (a questionnaire which assessed the degree of depression severity) was a 13 out of 27 which indicated moderate depression.An encounter note, dated 3/10/25, from a company which provided on-site care for long-term care residents, indicated Resident 12 was being seen for an initial evaluation of her chronic medical conditions.During an interview, on 3/24/26 at 9:57 a.m., LPN (Licensed Practical Nurse) 9 indicated not all the residents in the facility were seen by the company the facility utilized for on-site care of the residents. The company had their own physicians who come to the facility to see the residents who were members.During an interview, on 3/24/26 at 3:42 p.m., the Social Service Director indicated Resident 12 needed mental health services.During an interview, on 3/25/26 at 10:26 a.m., Unit Manager 7 indicated Resident 12 had been seen by the facility Medical Director who had reviewed the resident's medications but did not want to make changes to her mental health medications until she had been seen by a psychiatric provider. Resident 12 was not currently being seen by a psychiatric provider or receiving mental health services.During an interview, on 3/26/26 at 3:39 p.m., the Director of Nursing indicated the facility did not have a policy regarding mental health services. The facility followed all State and Federal regulations.410 IAC (Indiana Administrative Code) 3.1-43(a)(1)410 IAC (Indiana Administrative Code) 3.1-43(a)(2)

Based on observation, interview and record review, the facility failed to ensure staff followed enhanced barrier precautions and wore personal protective equipment which included a gown during catheter care for 1 of 1 resident randomly observed for infection control. (Resident 93)Findings include:During an observation of catheter care, on 3/24/26 at 11:05 a.m., CNA 13 and Unit Manager 7 were in the room for Resident 93's catheter care. CNA 13 performed catheter care and did not wear a gown during the process.The clinical record for Resident 93 was reviewed on 3/24/26 at 3:26 p.m. The diagnoses included, but were not limited to, benign neoplasm of the bladder, neuromuscular dysfunction of the bladder, and a stroke affecting the left non-dominant side.A physician's order, dated 12/17/25, indicated enhanced barrier precautions every shift for the indwelling catheter.During an interview, on 3/24/26 at 11:16 a.m., Unit Manager 7 indicated a gown should be worn when performing catheter care.During an interview, on 3/24/26 at 12:24 p.m., the Director of Nursing (DON) indicated staff should use a gown when performing catheter care.A current facility policy, titled GUIDELINES for ENHANCED BARRIER PRECAUTIONS-(EBP) An extension of Personal Protective Equipment---(PPE), dated as reviewed December 2022 and received from the Executive Director on 3/26/26 at 8:30 a.m., indicated .It is the policy of the facility to ensure that additional and appropriate PPE (Personal Protective Equipment) is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms also known as MDROs. Enhanced Barrier Precautions (EBP): Enhanced Barrier Precautions are defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of [NAME] in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver.Examples of High Contact Resident Care Activities at which time EBP is to be practiced are.Device Care or Use of to include: Central Lines. Urinary Catheters.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 4 residents reviewed for dignity. (Resident B and C)Findings include:1. During an observation, on 11/11/25 at 3:12 p.m., Resident B had a healed scar from a laceration above her right eyebrow.The clinical record for Resident B was reviewed on 11/11/25 at 10:25 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, generalized anxiety disorder, mood disorder, cognitive communication deficit, major depressive disorder, altered mental status, and dementia.A quarterly minimum data set (MDS) assessment, dated 8/10/25, indicated Resident B had a severe cognitive impairment. The resident required maximal assistance to maintain personal hygiene which included combing hair, shaving, applying makeup, and washing/drying face and hands.A care plan, dated 10/13/25, indicated the resident was at risk of psychosocial distress. Interventions included, but were not limited to, offer reassurance she was safe in the facility.In a facility witness statement, dated 11/3/25, LPN 7 indicated QMA 2 came into the facility, on 11/3/25, and indicated she needed to report something which happened the day before, but she did not know who to tell. LPN 7 told QMA 2 to tell her what happened and she would help direct her. QMA 2 indicated QMA 1 had sprayed Resident B's face with wound cleanser and then marked her forehead with a L. The Executive Director (ED) and Director of Nursing (DON) arrived at the nurse's station and took over the investigation.In a facility witness statement, dated 11/3/25, QMA 2 indicated Resident B was at the nurse's station with LPN 3, CNA 4, and CNA 5. QMA 1 was outside of the nurse's station acting like she was going to spray everyone with a bottle of wound cleanser. QMA 1 sprayed Resident B's hair, and the liquid ran down the resident's face. CNA 4 wiped the resident's face off. QMA 1 then took a marker and scribbled on the resident's forehead. CNA 5 removed the mark from the resident's forehead. The incident happened around 1:00 p.m., on 11/2/25.In a facility witness statement, dated 11/3/25, QMA 1 indicated she had sprayed another staff member with wound cleanser at the nurse's station, on 11/2/25, and it had also gotten on Resident B's face. QMA 1 then placed a mark with a purple/blue colored marker on the resident's forehead. She then wiped it off with wet wipes.In a facility witness statement, dated 11/3/25, CNA 5 indicated she, QMA 1, and CNA 4 were all in the nurse's station, on 11/2/25. QMA 1 sprayed Resident B with wound cleanser on the forehead and another staff member wiped it off. QMA 1 then put a purple/blue mark on the resident's forehead. CNA 5 indicated she wiped the marker off using water a wipe. In a facility witness statement, dated 11/3/25, CNA 4 indicated she had Resident B at the nurse's station while she charted, on 11/2/25. QMA 1 grabbed the water bottle with a pink cap on it and sprayed the resident's hair. CNA 4 then brushed the resident's hair out at the nurse's station. QMA 1 took a purple/blue marker and put a dot on resident's forehead but then washed it off with a wet wipe. CNA 5 was also at the nurse's station.During an interview, on 11/11/25 at 10:00 a.m., the Executive Director (ED) indicated the facility conducted a thorough investigation of the incident with QMA 1 and Resident B. The resident had no signs of distress. She had contacted the police and filed a notice against QMA 1 with the attorney general's office. The investigation revealed QMA 1 sprayed the resident's hair and forehead and then used a marker on the resident's forehead at the nurse's station, on 11/2/25. This was unacceptable behavior and would not be tolerated by the facility.2. During an observation, on 11/12/25 at 10:00 a.m., Resident C was resting in his room and had a full beard and mustache.The clinical record for Resident C was reviewed on 11/10/25 at 2:50 p.m. The diagnoses included, but were not limited to, Parkinson's disease, type 2 diabetes mellitus, dementia with agitation, cognitive communication deficit, Alzheimer's disease, depression, and dysphagia.A quarterly MDS assessment, dated 8/25/25, indicated Resident C had severe cognitive impairment.A facility profile picture of Resident C in the electronic medical record showed the resident with a beard and mustache.In a facility witness statement, dated 11/4/25 at 1:49 p.m., CNA 8 indicated she worked on 8/29/25 from 2:00-6:00 p.m. QMA 1 was in the dining room laughing and asked her how Resident C looked without eyebrows. CNA 8 asked QMA 1 what had happened and QMA 1 indicated she had shaved them off. CNA 8 asked QMA 1 if his Power of Attorney (POA) was going to be upset and QMA 1 indicated his POA never came to the facility. CNA 8 notified RN 9. RN 9 asked Resident C if he had given permission to have his beard and eyebrows shaved and he said no. RN 9 indicated she would tell the DON.In a facility witness statement, dated 11/6/25, CNA 5 indicated she had not worked the day the resident's eyebrows and face were shaved, but when she came to work the next day, the resident's eyebrows and facial hair were all shaved off. LPN 7 indicated to CNA 5 that the resident had been done dirty. The staff routinely used an electric razor to trim and shave Resident C. She did not report it because she believed the nurse was already aware.In a facility witness statement, dated 11/6/25, LPN 7 indicated Resident C had no eyebrows when she saw him. QMA 1 laughed very loud about it and said it was an accident. LPN 7 indicated she had informed the DON at the time, and the DON had said she would investigate it.In a facility documented phone interview, QMA 1 had indicated to the ED, Resident C's daughter requested the staff trim his eyebrows. She had used a comb and an electric razor but did not realize the razor did not have a guard on it and had accidentally shaved 1 eyebrow completely off. She told the nurse on duty, but did not remember who it was, and the nurse told her to match the eyebrows up, so QMA 1 shaved the other eyebrow off. She trimmed his beard and mustache in the shower like they routinely did but decided to shave all his beard and mustache off that day. The daughter had not requested her to shave all his hair off.During an interview, on 11/12/25 at 10:54 a.m., the legal guardian for Resident C indicated she had not seen him for about 6 weeks prior to the end of August. The resident had always preferred to have a mustache and beard. She came in at the end of August to visit and noticed his mustache, beard, and eyebrows had been shaved. She was surprised and asked him what happened. He told her the staff did it but could not say who. Last week, his daughter called her and said Resident C was not happy the staff were still trimming his beard. He had always preferred facial hair and saw the beautician at the facility. The staff could trim it, but under no circumstance should they shave it completely off. The legal guardian did not request anyone to trim his eyebrows. During an interview, on 11/12/25 at 11:15 a.m., CNA 6 indicated the staff would shave Resident C on his shower days. There were disposable twin blade razors in the shower room. She had been employed at the facility for 3 years and Resident C did not have any hair clippers that she was aware of. Resident C always preferred to have facial hair. A current facility document, titled Your Rights and Protections as a Nursing Home Resident, provided by the DON on 11/10/25 at 10:00 a.m., indicated .You have the right to be treated with dignity and respect.This citation relates to Intake 2659059.3.1-3(t)

Based on interview and record review, the facility failed to ensure a person-centered care plan was developed with individualized interventions and reviewed and revised to accommodate the resident's care needs prior to initiating a medication to control behaviors for 1 of 1 resident reviewed for dementia care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 7/17/25 at 10:06 am. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and muscle weakness. A handwritten document, titled Behavior Sheet, dated 6/17/25, indicated Resident C had a sexually inappropriate behavior when he grabbed CNA 1's butt with both his hands. She was standing him up to move him to his wheelchair when he touched her. The CNA provided the resident with instructions or redirected him, which improved the behavior immediately.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/21/25, indicated Resident C inappropriately physically touched CNA 2 during personal care. He tried to kiss the employee. He was redirected and the employee asked him to stop and the behavior gradually improved. The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/22/25, indicated Resident C was touching the inner thighs of CNA 3 inappropriately while she was checking and changing him. She provided instructions to him or redirected him, and his behavior improved gradually.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A nursing progress note, dated 6/22/25 at 3:26 p.m., indicated Resident C was forgetful and confused. At times, he had to be redirected because he went into other residents' rooms and needed friendly reminders of where his room was located. A nursing progress note, dated 6/23/25 at 10:14 a.m., indicated Resident C needed reminders not to touch other residents.A nursing progress note, dated 6/23/25 at 3:19 p.m., indicated Resident C's physician saw the resident and wrote a new order for medroxyprogesterone (a synthetic progestin used in men primarily for treating abnormal sexual behaviors by reducing testosterone levels) 5 mg (milligram) by mouth every day. An initial psychiatry consultation note, dated 6/23/25, indicated the reason for the visit was to assess Resident C's mental illness and manage his medication. He had a history of depression and dementia and presented for an evaluation for increased sexual behaviors. He had been exhibiting increased sexual behaviors, including inappropriate touching of female staff and reports of masturbation in his room. He was not a danger to himself or others. He was having sexual aggression. His Brief Interview for Mental Status (BIMS) assessment, on 5/26/25, score was 10, which indicated a moderately cognitive impairment. He had a diagnosis of dementia with behavioral disturbance. Staff had reported he had increased sexual behaviors and masturbation which were new developments for this resident. Progesterone therapy at 5 mg daily was initiated to manage his sexual behavioral disturbances. A physician's order, dated 6/24/25, indicated to give medroxyprogesterone acetate 5 mg by mouth once a day for inappropriate sexual behaviors. A handwritten document, titled Behavior Sheet, dated 6/25/25, indicated Resident C was touching CNA 4 inappropriately. She provided instructions and/or redirection and used conflict resolution, and his behavior did not improve. The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A nursing progress note, dated 7/8/25 at 6:17 p.m., indicated the nurse was in the dining room prior to dinner attending to another resident. When she turned and looked out into the dining room, she observed Resident C had his outstretched hand patting Resident B's upper chest to lower shoulder area.A nursing progress note, dated 7/8/25 at 6:24 p.m., indicated Residents B and C were in the dining room and fully dressed. Resident C patted Resident B on the upper chest to lower shoulder area.A social service progress note, dated 7/10/25 at 10:02 a.m., indicated the psychiatric hospital had indicated the reason Resident C was not picked up and transported to their facility last evening was because they were calling his spouse, but was unable to receive consent from her to transfer him. The Social Service Director (SSD) and the Admissions Director called the spouse, and she gave her consent by phone for him to be transferred. The psychiatric hospital transported the resident that afternoon. The Electronic Medication Administration Record (EMAR), for June 2025, indicated Resident C received medroxyprogesterone acetate 5 mg on 6/24/25 through 6/30/25. The EMAR lacked documentation the resident was being monitored for inappropriate sexual behaviors.The EMAR, for July 2025, indicated Resident C received medroxyprogesterone acetate 5 mg on 7/1/25 through 7/10/25. The EMAR lacked documentation the resident was being monitored for inappropriate sexual behaviors. Resident C had a care plan which addressed the problem he had socially inappropriate behavior at times such as invading other female resident and staffs' personal space. The interventions included educating Resident C on what was and was not appropriate (the resident had a diagnosis of dementia), psychiatric evaluation as needed and validating his feelings. The care plan and interventions were not initiated until 7/9/25.There was no documentation located in Resident C's record which indicated the facility was monitoring the resident's inappropriate sexual behaviors. The resident's record lacked a behavioral care plan with specific interventions to address inappropriate sexual behaviors prior to the initiation of a medication to control his behavior. During a phone interview, on 7/17/25 at 3:11 p.m., LPN 5 indicated at approximately 5:00 p.m., on 7/8/25, she was at her medication cart in the dining room. She had observed Resident C's hand on the right side of Resident B's chest below her clavicle. She was too far from the residents to see if Resident C had his hand on Resident B's breast or not. She called his name, moved towards the residents, and he took his hand down. She had not observed him have any other sexually inappropriate behaviors toward any female residents. During an interview, on 7/17/25 at 3:30 p.m., the Executive Director indicated that a resident's inappropriate sexual behaviors would be documented in the electronic medical record in the progress notes. During an interview, on 7/18/25 at 3:32 p.m., LPN 6 indicated she had not seen Resident C have any inappropriate sexual behaviors with staff members or female residents. During an interview, on 7/18/25 at 3:42 p.m., CNA 7 indicated once Resident C had touched her outer leg when she was giving him personal care. She directed him to stop, and he did. One evening, Resident C went up to a female resident's table and attempted to touch her arm. A current facility policy, titled Guidelines for Caring for Residents with Alzheimer's and/or Dementia, dated 11/20/24 and provided by the Executive Director on 7/18/25 at 3:30 p.m., indicated .What about care planning for those with Alzheimer's or Dementia? The care plan for those with Alzheimer's or Dementia must be person-centered and must address concerns associated with diagnoses, cognitive and/or physical deficits, medication, nutrition/diet/hydration, activities, any related special programming, any psych services to include and behavioral issues or any sleep issues, ADL'S [Activities of Daily Living] (to include FALL RISK), skin issues, any Advanced Directives any other concerns which are discovered through observation and/or assessment. It is recommended that the care plan includes activities that help the patient/resident stay in touch with their pre-dementia lives-such as watching a favorite TV show or movie--and/or showing them familiar pictures of family members or pets, plus listening to favorite music/songs from their past A current facility policy, titled Guidelines for Use of Unnecessary Drugs to Include Chemical Restraints, dated 3/5/25 and provided by the Executive Director on 7/17/25 at 3:55 p.m., indicated .It is the intent of this facility to ensure that any use of unnecessary meds .This practice is in keeping with the integrity of care provided to the residents who reside here-and as part of our mission A current facility policy, titled Guidelines for Handling and Addressing Behavioral Emergencies, dated 3/18/23 and provided by the Regional Nurse Consultant on 7/18/25 at 12:20 p.m., indicated .The Escalating Resident A. Staff need to be aware of how likely a resident is to lose control and exhibit a behavior.this comes from knowledge obtained on resident assessment as well as the care plan.Immediate Approaches.Any interventions implemented for behavior control will be monitored by nursing staff and/or SSD [Social Service Director] daily until the behavior is considered to be managed .Record specifics related to the behavior incident(s). Include time, place, duration, actions observed by the resident, statements or vocalizations made by the resident, possible causative factors, persons involved other than the resident, witnesses, behavior intensity, interventions, notifications, orders received and resolutions. This documentation should be done on a behavioral occurrence form for review at the CQI meeting and/or the Behavior meetings. 2. Documentation in the clinical record should include facts related to time, possible causative factors, actual behavior with the consequences, interventions and outcomes. D. Follow Up Interventions: 1. Follow up interventions after an acute behavior incident are essential in preventing further behavioral incidents. Interventions will be reduced or removed as able depending on stabilization and assessment. Only the least restrictive physical and/or chemical interventions will be implemented and only for the shortest time frame possible. These will be implemented as a LAST RESORT and only to prohibit harm to the resident's self or others until the resident is able to be transferred to a setting that manages extreme behaviors. A physician's order will be necessary for these interventions/transfers .Be sure that the assessments and care planning and medication reviews as well as the individualized Activity Programs for resident s with behavior issues are done accurately and timely.

Based on interview and record review, the facility failed to ensure an assessment which included prior interventions, risks and benefits, and the clinical rationale for the initiation of a medication to control behaviors was completed and documented for 1 of 3 residents reviewed for unnecessary medications. (Resident C)Findings include:The clinical record for Resident C was reviewed on 7/17/25 at 10:06 am. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and muscle weakness. A handwritten document, titled Behavior Sheet, dated 6/17/25, indicated Resident C had a sexually inappropriate behavior when he grabbed CNA 1's butt with both his hands. She was standing him up to move him to his wheelchair when he touched her. The CNA provided the resident with instructions or redirected him, which improved the behavior immediately.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/21/25, indicated Resident C inappropriately physically touched CNA 2 during personal care. He tried to kiss the employee. He was redirected and the employee asked him to stop and the behavior gradually improved. The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/22/25, indicated Resident C was touching the inner thighs of CNA 3 inappropriately while she was checking and changing him. She provided instructions to him or redirected him, and his behavior improved gradually.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A nursing progress note, dated 6/22/25 at 3:26 p.m., indicated Resident C was forgetful and confused. At times, he had to be redirected because he went into other residents' rooms and needed friendly reminders of where his room was located. A nursing progress note, dated 6/23/25 at 10:14 a.m., indicated Resident C needed reminders not to touch other residents.A nursing progress note, dated 6/23/25 at 3:19 p.m., indicated Resident C's physician saw the resident and wrote a new order for medroxyprogesterone (a synthetic progestin used in men primarily for treating abnormal sexual behaviors by reducing testosterone levels) 5 mg (milligram) by mouth every day. An initial psychiatry consultation note, dated 6/23/25, indicated the reason for the visit was to assess Resident C's mental illness and manage his medication. He had a history of depression and dementia and presented for an evaluation for increased sexual behaviors. He had been exhibiting increased sexual behaviors, including inappropriate touching of female staff and reports of masturbation in his room. He was not a danger to himself or others. He was having sexual aggression. His Brief Interview for Mental Status (BIMS) assessment, on 5/26/25, score was 10, which indicated a moderately cognitive impairment. He had a diagnosis of dementia with behavioral disturbance. Staff had reported he had increased sexual behaviors and masturbation which were new developments for this resident. Progesterone therapy at 5 mg daily was initiated to manage his sexual behavioral disturbances. A physician's order, dated 6/24/25, indicated to give medroxyprogesterone acetate 5 mg by mouth once a day for inappropriate sexual behaviors. The Electronic Medication Administration Record (EMAR), for June 2025, indicated Resident C received medroxyprogesterone acetate 5 mg on 6/24/25 through 6/30/25. The EMAR lacked documentation the resident was being monitored for inappropriate sexual behaviors.The EMAR, for July 2025, indicated Resident C received medroxyprogesterone acetate 5 mg on 7/1/25 through 7/10/25. The EMAR lacked documentation the resident was being monitored for inappropriate sexual behaviors. Resident C had a care plan which addressed the problem he had socially inappropriate behavior at times such as invading other female resident and staffs' personal space. The interventions included educating Resident C on what was and was not appropriate (the resident had a diagnosis of dementia), psychiatric evaluation as needed and validating his feelings. The care plan and interventions were not initiated until 7/9/25.There was no documentation located in Resident C's record which indicated the facility was monitoring the resident's inappropriate sexual behaviors. The resident's record lacked a behavioral care plan with specific interventions to address inappropriate sexual behaviors prior to the initiation of a medication to control his behavior. The resident's record lacked documentation the risks and benefits of the medication to control Resident C's behaviors were discussed the resident's representative. During an interview, on 7/17/25 at 3:30 p.m., the Executive Director indicated that a resident's inappropriate sexual behaviors would be documented in the electronic medical record in the progress notes. During an interview, on 7/18/25 at 3:32 p.m., LPN 6 indicated she had not seen Resident C have any inappropriate sexual behaviors with staff members or female residents. During an interview, on 7/18/25 at 3:42 p.m., CNA 7 indicated once Resident C had touched her outer leg when she was giving him personal care. She directed him to stop, and he did. One evening, Resident C went up to a female resident's table and attempted to touch her arm. A current facility policy, titled Guidelines for Use of Unnecessary Drugs to Include Chemical Restraints, dated 3/5/25 and provided by the Executive Director on 7/17/25 at 3:55 p.m., indicated .It is the intent of this facility to ensure that any use of unnecessary meds .This practice is in keeping with the integrity of care provided to the residents who reside here-and as part of our mission A current facility policy, titled Guidelines for Handling and Addressing Behavioral Emergencies, dated 3/18/23 and provided by the Regional Nurse Consultant on 7/18/25 at 12:20 p.m., indicated .The Escalating Resident A. Staff need to be aware of how likely a resident is to lose control and exhibit a behavior.this comes from knowledge obtained on resident assessment as well as the care plan.Immediate Approaches.Any interventions implemented for behavior control will be monitored by nursing staff and/or SSD [Social Service Director] daily until the behavior is considered to be managed .Record specifics related to the behavior incident(s). Include time, place, duration, actions observed by the resident, statements or vocalizations made by the resident, possible causative factors, persons involved other than the resident, witnesses, behavior intensity, interventions, notifications, orders received and resolutions. This documentation should be done on a behavioral occurrence form for review at the CQI meeting and/or the Behavior meetings. 2. Documentation in the clinical record should include facts related to time, possible causative factors, actual behavior with the consequences, interventions and outcomes. D. Follow Up Interventions: 1. Follow up interventions after an acute behavior incident are essential in preventing further behavioral incidents. Interventions will be reduced or removed as able depending on stabilization and assessment. Only the least restrictive physical and/or chemical interventions will be implemented and only for the shortest time frame possible. These will be implemented as a LAST RESORT and only to prohibit harm to the resident's self or others until the resident is able to be transferred to a setting that manages extreme behaviors. A physician's order will be necessary for these interventions/transfers .Be sure that the assessments and care planning and medication reviews as well as the individualized Activity Programs for resident s with behavior issues are done accurately and timely.

Based on interview and record review, the facility failed to ensure a resident's behaviors were documented in the electronic medical record for 1 of 3 residents reviewed for a complete and accurate clinical record. (Resident C)Findings include:The clinical record for Resident C was reviewed on 7/17/25 at 10:06 am. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and muscle weakness. The following were provided by the Executive Director, on 7/18/25 at 11:00 a.m.:A handwritten document, titled Behavior Sheet, dated 6/17/25, indicated Resident C had a sexually inappropriate behavior when he grabbed CNA 1's butt with both his hands. She was standing him up to move him to his wheelchair when he touched her. The CNA provided the resident with instructions or redirected him, which improved the behavior immediately.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/21/25, indicated Resident C inappropriately physically touched CNA 2 during personal care. He tried to kiss the employee. He was redirected and the employee asked him to stop and the behavior gradually improved. The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/22/25, indicated Resident C was touching the inner thighs of CNA 3 inappropriately while she was checking and changing him. She provided instructions to him or redirected him, and his behavior improved gradually.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/25/25, indicated Resident C was touching CNA 4 inappropriately. She provided instructions and/or redirection and used conflict resolution, and his behavior did not improve. The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. During an interview, on 7/17/25 at 3:30 p.m., the Executive Director indicated that a resident's inappropriate sexual behaviors would be documented in the electronic medical record in the progress notes. A current facility policy, titled Guidelines for Handling and Addressing Behavioral Emergencies, dated 3/18/23 and provided by the Regional Nurse Consultant on 7/18/25 at 12:20 p.m., indicated .Documentation in the clinical record should include facts as related to time, possible causative factors, actual behavior with the consequences, interventions and outcomes

Based on observation, interview and record review, the facility failed to ensure a resident who was severely cognitively impaired and had memory problems, had assistive devices in place to prevent a fall from her moving wheelchair for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B falling forward from her wheelchair and sustaining a subarachnoid hemorrhage with facial, neck, and shoulder bruising which required hospitalization . Finding includes: A document, titled Indiana State Department of Health Survey Report System, indicated Resident B went to the emergency room (ER), on 4/13/24, upon family request after a fall, while being transferred back to her room in her wheelchair. She was sent back to the facility without any injuries. Then on 4/14/24, she had a change in mental status from her baseline, was sent back to the ER, and was admitted to the hospital for an acute subarachnoid hemorrhage. The root cause of the fall was determined to be staff transporting the resident in her wheelchair without foot pedals. The fall intervention put into place by the facility to prevent another fall from her wheelchair while transporting her was to ensure the resident's wheelchair had foot pedals on it when she was being transported. The clinical record for Resident B was reviewed on 4/26/24 at 4:07 p.m. The diagnoses included, but were not limited to, vascular dementia with psychotic disturbance, psychotic disorder with delusions and hallucinations, cognitive communication deficit, and difficulty in walking. A Significant Change Minimum Data Set (MDS) assessment, dated 4/4/24, indicated Resident B required substantial/maximal assistance for mobility. A fall risk care plan, dated 2/3/24, indicated Resident B was at risk to experience falls, had difficulty rising from a chair, had poor vision, had a history of falls, and required assistance with mobility. The plan included, but was not limited to, interventions to tilt the wheelchair seat back in addition to using anti-roll back and anti-tip equipment. On 4/26/24 at 12:20 p.m., Resident B was observed sitting at a dining room table eating her lunch in a standard wheelchair with foot pedals on it. Her standard wheelchairs did not have a back on them which could be tilted backwards. A psychiatry note, dated 4/9/24, indicated Resident B had a severe cognitive impairment and impaired memory. A facility document, titled Basic Investigation Form, undated, indicated Resident B had a fall on 4/13/24, which resulted in an injury. The fall occurred in the hallway involving CNA 1. Mealtime had happened just prior to the event. The adaptive device being used was the resident's wheelchair. CNA 1 was transporting Resident B in her wheelchair when she fell forward out of her chair. The investigation indicated the resident was believed to have possibly put her feet down during the transport, but it was not actually seen. A nursing note, dated 4/13/24 at 12:17 p.m., indicated a nurse was called to the hallway to assess Resident B. A CNA was pushing the resident in her wheelchair when the resident fell forward out of the wheelchair. She landed on the floor hitting the left side of her forehead, leaving a baseball sized hematoma. She had a skin tear to her elbow, which measured 5 cm (centimeters) by 2 cm. The resident was taken to the ER by her son to be evaluated. The CT of the cervical spine without Intravenous contrast, dated 4/13/24 at 1:33 p.m., indicated the resident had a left frontal scalp hematoma. A nursing note, dated 4/14/24 at 11:10 a.m., indicated the resident had bruises on her left shoulder and left knee. She was observed to be very sleepy. She was sitting up in her recliner. A nursing note, dated 4/14/24 at 2:53 p.m., indicated Resident B was lethargic (very tired, without energy, and hard to arouse) and was unable to hold a conversation while staying awake. She had an increase in her mood. One minute she would be ok, then the next minute she was mean. Her son transported her to the ER for evaluation and a CT scan due to her lethargy. The CT scan of the head without Intravenous contrast, dated 4/14/24 at 5:53 p.m., indicated the resident had a trace traumatic subarachnoid hemorrhage along the left lateral frontal cortex of the brain. She also had a left frontal scalp laceration and a contusion with hematoma. An Interdisciplinary Team (IDT) note, dated 4/15/24 at 12:18 p.m., indicated the resident had a witnessed fall on 4/13/24 at 11:38 a.m. The CNA was pushing her down the hallway in her wheelchair and she leaned forward in the wheelchair causing her to fall out. A head-to-toe assessment was completed, a hematoma was observed on her forehead, and a skin tear to her left elbow. Her son opted to take her to the ER to get her evaluated. The root cause of the fall was her wheelchair did not have foot pedals in place during the transfer. The immediate intervention was to ensure foot pedals were on her wheelchair when transporting the resident. A facility document, titled Confidential Witness Statement, dated 4/15/24, indicated during a phone interview CNA 1 indicated she was transporting Resident B in her wheelchair when she fell forward out of the chair. The resident had been wheeling herself around in her wheelchair all morning. A hospital discharge summary, dated 4/17/24, indicated Resident B was admitted to the hospital on 4/14/24. The reason for her visit was encephalopathy likely worsened by concussion and urinary tract infection. Her hospital course was due to her falling out of her wheelchair at the facility. She was drowsy but arousable. The medical decision making was based off her presenting to the ER due to increasing drowsiness/lethargy. She had a trace traumatic subarachnoid hemorrhage identified on imaging. Her case was discussed with a neurosurgeon, who indicated the resident was a poor neurosurgical candidate due to her advanced age and history of severe dementia. Palliative care or hospice was offered to the family due to her significant health decline since a week or two ago. The family would consider both and let the physician know. A nursing note, dated 4/18/24 at 10:25 a.m., indicated dark purple bruising was observed to the resident's face, neck, and shoulder. She had a large hematoma on the left side of her forehead. She complained of a headache of a 5 on a pain scale of 0-10 with 0 being no pain and 10 being the worst pain. The resident was medicated for her headache. A facility document, titled Record of Conversation, dated 4/19/24, indicated CNA 1 was involved in an accident with a resident, which resulted in a fall with an injury. The action taken was CNA 1 was educated on ensuring safe transfers with residents in wheelchairs and keeping her eyes on the resident and his/her extremities while transporting the resident in a wheelchair to ensure his/her safety. A nursing note, dated 4/25/24 at 3:37 p.m., indicated the resident was disoriented and forgetful. She had bruising in multiple stages of healing observed on her face, head, neck, and shoulders. A facility document, titled Weekly Wound Evaluation, dated 4/25/24, indicated the resident had a hematoma with an abrasion to the left of her forehead which was identified on 4/19/24. The measurements of the wound were length-1.8 cm, width-2.1 cm, and depth-0.1 cm. The wound color was pink and red with some redness and warmth surrounding the wound. A facility weekly wound evaluation document, dated 4/25/24, indicated the resident had a hematoma with an abrasion to the left of her forehead which was identified on 4/19/24. The abrasion measured 1.8 cm (centimeters) L (length) by 2.1 cm W (width) by 0.1 cm D (depth) with a pink wound bed and red/warm peri wound. During an interview, on 4/26/24 at 1:24 p.m., the Executive Director (ED) indicated she would try to locate documentation to show the facility had effectively assessed the wheelchair and safety needs of Resident B prior to 4/13/24. On 4/26/24 at 12:20 p.m., Resident B was observed to have a small area of purple and yellow bruising under both her eyes, purple with yellow bruising on her left forehead, and a knot the size of a golf ball, which was purple in color and had a scab the size of a quarter above her left eye. She had purple bruising along the left side of her face by her ear and into her hairline extending onto her left side of her neck. She indicated she received the bruising and goose egg on her head from an accident from her wheelchair. She fell out of her wheelchair, but she did not remember how. During that time, the resident's son (POA) indicated he did observe her use her hands and arms to wheel herself, but he had not observed her to use her feet to propel herself with her wheelchair. During an interview, on 4/26/24 at 12:26 p.m., the Executive Director (ED), Director of Nursing (DON) and Assistant Director of Nursing (ADON) were in attendance. The DON indicated Resident B was just weighed in the dining room and was being taken back to her room when CNA 1 stopped at the nurse's desk to report her weight and the resident fell out of her wheelchair. Prior to her fall, on 4/13/24, she did not have foot pedals on her wheelchair because she propelled herself with her feet. She had a small subarachnoid hemorrhage of the brain and spent two days in the hospital after the fall. During an interview, on 4/26/24 at 3:37 p.m., Resident B's family indicated she did not see her mother propel her wheelchair with her feet. During an interview, on 4/29/24 at 10:22 a.m., the Rehabilitation Program Manager indicated there was an area in the facility where wheelchairs were kept. When a resident needed a wheelchair, the aides went to retrieve a wheelchair for the resident. The Rehabilitation Department did not fit residents for their wheelchairs. On 4/29/24 at 10:30 a.m., Resident B was in the therapy department working with a therapist. She was observed to propel herself in her wheelchair with her hands on both wheels. Her foot pedals were on at that time. The foot pedals were removed from the wheelchair, and she was asked to propel herself with her feet and she was unable to touch the floor with her feet. She was asked to hold her legs and feet up with her foot pedals removed from her chair and she was able to do so for 46 seconds before her feet dropped. She had been medicated for pain earlier according to her therapist. Her therapist indicated being medicated for pain would make a difference on how long she was able to hold her feet up due to pain in the hip she broke. During a phone interview, on 4/29/24 at 4:25 p.m., CNA 1 indicated, on 4/13/24, she and CNA 2 transferred Resident B from her recliner into her wheelchair, so she could take her to get her weight, then to the dining room to eat. She was pushing the resident down the hallway in her wheelchair when the resident threw herself out of her wheelchair. She did not have foot pedals on her chair. When asked why she did not let the resident propel herself to get weighed, CNA 1 indicated she was in a hurry, it was around mealtime, and she was trying to get her weight, then to the dining room for lunch. During an interview, on 4/29/24 at 4:45 p.m., the ED indicated the facility did not have a wheelchair transfer policy. She had already provided the policy the facility had regarding wheelchairs, and there was no wheelchair assessment found for Resident B. During a confidential interview, a confidential interviewee indicated the resident had fallen in March 2024, and had broken her hip, so she had not been able to propel herself in her wheelchair with her feet because her legs had not been strong enough. She propelled herself in her wheelchair by using her hands on the wheels and moving her chair with her arms. She typically had foot pedals on her wheelchair when she was being transported out of her room. A current policy, titled Policy and Procedure Wheelchair Usage, undated and provided by the ED on 4/26/24 at 1:24 p.m., indicated .to provide appliances to residents that will enable them to attain and maintain their highest level of practicable functioning in relation to their medical condition including to wheelchairs .Any resident requiring a wheelchair or Geri chair will be assessed prior to application/use to determine the most effective appliance to be used. Physical Therapy will be responsible to ensure the appropriate fit and additional appliance application to the chair . According to the facility's wheelchair usage policy, Physical Therapy (PT) was responsible to ensure the appropriate fit and additional appliance application for the wheelchairs. A current CNA curriculum, titled Procedure #26: Transfer to Wheelchair, undated and provided by the Indiana Nurse Aide Curriculum Appendix A Procedures, indicated .Place wheelchair on resident's unaffected side. Brace firmly against the side of bed with wheels locked and footrests out of way .Align resident's body and position footrests The State Operations [NAME], dated 4/16/21, indicated .Training of staff, residents, family members and volunteers on the proper use of assistive devices/equipment is crucial to prevent accidents. It is also important to communicate clearly the approaches identified in the care plan to all staff, including temporary staff. It is important to train staff regarding resident assessment, safe transfer techniques, and the proper use of mechanical lifts including device weight limitations .Mobility devices include all types of assistive devices, such as, but not limited to, canes, standard and rolling walkers, manual or non-powered wheelchairs, and powered wheelchairs. Three primary factors that may be associated with an increased accident risk related to the use of assistive devices include: 1. Resident Condition. Lower extremity weakness, gait disturbances, decreased range of motion, and poor balance may affect some residents. These conditions combined with cognitive impairment can increase the accident risks of using mobility devices. This citation relates to Complaint IN00432760. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure an unlicensed staff notified a licensed staff member that a dependent resident experienced a fall before transferring the resident from the floor to a wheelchair. This deficient practice resulted in the resident not being immediately assessed for injury by a licensed nurse and the resident experienced bilateral femur fractures. (Resident 2) Finding includes: A document, titled Indiana State Department of Health Survey Report System, dated 12/30/23 at 5:01 a.m., indicated Resident 2 had a witnessed fall on 12/22/23. At the time of the fall, the resident's skin and pain was assessed with no concerns. The physician and family were notified of the fall. The resident was noted to have increased pain on 12/29/23 and the physician was notified. X-rays were ordered on 12/29/23. The family and physician were aware of the femur fracture and resident was sent to the emergency department for evaluation. The record for Resident 2 was reviewed on 1/8/24 at 2:55 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (paralysis and weakness) affecting the right side of the body, cerebral infraction (stroke), and osteoporosis without a pathological fracture (low bone mass which increases the risk of bone fractures/breaks). A quarterly Minimum Data Set (MDS) assessment, dated 10/19/23, indicated the following: a. The resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated she was cognitively intact. b. The resident had an impairment on one (1) side to both her upper and lower extremities. c. The resident was dependent (helper did all the effort) to move from a lying position to sitting on the side of the bed. A care plan, initiated on 08/05/2023 and discontinued on 01/08/24, indicated the resident was a fall risk. There were no nursing notes found in the resident's record to indicate the events which led to the resident having fell or being lowered to the ground on 12/22/23. There was no nursing assessment found in the resident's record to indicate the nurse had assessed the resident after she fell or was lowered to the ground on 12/22/23. The resident's progress notes did not indicate a change in the resident's mental condition from 12/19/23 to 12/22/23. A physician's note, dated 12/22/23, indicated the physician did see the resident for complaints of bilateral knee pain (both knees) and shoulder pain. The resident reported to the physician she had slid off the bed and landed on her knee. The physician's finding was mild tenderness of both knees without significant effusion (fluid gathered in the space). The time of the physician's report was 10:28, without specification of a.m./p.m. There was no documentation of when the physician had assessed the resident only the time of his report, on 12/22/23 at 10:28:13 and another time/date stamp on 12/22/23 at 11:20:24. The Medication Administration Record (MAR) indicated the following: a. The resident had complaints of 4/10 pain, on 12/24/23, and was given acetaminophen 325 milligrams x 2 tablets at 3:09 p.m. b. The resident had complaints of 5/10 pain, on 12/28/23, and was given acetaminophen 325 mg x 2 tablets at 9:56 a.m. c. The resident had complaints of 10/10 pain, on 12/29/23 at 7:40 a.m., and was given acetaminophen 325 mg x 2. There was no entry as to where the resident was experiencing pain noted in the Medication Administration Record or notes. A facility document, titled Basic Investigation Form, undated, indicated Resident 2 had a witnessed fall, on 12/22/23, in her room. CNA 3 was assisting the resident from bed. The CNA sat the resident on the side of the bed, turned her back to get the sit to stand mechanical lift and the resident slid to the floor from the edge of the bed. CNA 3 and QMA 2 assisted the resident from the floor to a wheelchair. The QMA did get the resident's vital signs and they were normal. The resident denied any pain. The physician was notified while he was in the facility making rounds and did see the resident on 12/22/23. The CNA and QMA were suspended pending an investigation. The resident had continued complaints of pain. Orders for x-rays were obtained and the results of the x-ray were bilateral femur fractures. The resident was sent to the hospital for evaluation and treatment. The QMA was terminated for practicing outside of her scope of practice and the CNA was terminated for not following facility policy and procedure. A facility document, titled .Facility Separation Form, dated 1/5/24 and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated QMA 2 was terminated from the facility for performance, gross violation of safety rules, working outside of her scope of practice, not following facility policy and procedure. A facility document, titled .Facility Separation Form, dated 1/5/24 and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated CNA 3 was terminated for performance, violation of safety rules, violation of company policy and /or procedure. CNA did not follow facility mechanical lift policy or reporting incidents/accidents policy. In a facility document, titled Confidential Witness Statement, dated 12/29/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., CNA 3 indicated, on 12/22/23, Resident 2 was sitting on the side of the bed. CNA 3 turned her back to grab the stand-up lift; when she turned back around Resident 2 was starting to fall. CNA 3 had to move the lift, so the resident did not fall on it. The CNA hollered for the QMA. When QMA 2 entered the room, she asked Resident 2 she asked if she was okay. The resident told the QMA she was okay, and then they moved the resident and took her to breakfast. When the CNA was asked why she did not notify the nurse she stated .I don't know, I know I should of I thought [name of QMA 2] did it The Assistant Director of Nursing asked CNA 3 why she was using the stand lift without another staff, CNA 3 indicated .I don't know, I know I am supposed to In a facility document, titled Confidential Witness Statement, dated 12/29/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., QMA 2 indicated, on 12/22/23, the CNA came and got her while she was passing medications. She indicated Resident 2 was on the floor. QMA 2 went into the resident's room, assessed her, and Resident 2 seemed okay. She assisted CNA 3 to put the resident into her wheelchair so she could go to breakfast. The Assistant Director of Nursing asked QMA 2 if she had notified the nurse on duty of the fall. QMA 2 stated to the Assistant Director of Nursing and the Administrator, .No I got busy again with my med pass and forget to tell her The Assistant Director of Nursing asked QMA 2 why she assessed the resident when it was outside of her scope of practice. QMA 2 indicated .I don't know I had a lapse in judgement A facility document, titled Confidential Witness Statement dated 12/31/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., indicated when the Assistant Director of Nursing asked CNA 3 what time the incident happened, she indicated she thought it was around 7:00 a.m. CNA 3 told her she went into the resident's room to get her up. She checked the resident and set her up on the side of the bed. The resident was fine. She pulled the lift to the side of the bed and noticed Resident 2 was starting to slide. She pulled the call light and yelled for QMA 2 to help. By the time QMA 2 got into the room, CNA 3 had pushed the lift out of the way; if it had remained in place, it would have hit the resident. Instead of letting Resident 2 fall, she lowered her to the ground. The QMA came in and assessed the resident, she asked the resident if she was okay, and Resident 2 said yes. The QMA then helped put Resident 2 into the wheelchair and the resident said she was fine. The Assistant Director of Nursing asked the CNA what the resident's position was after she had been lowered to the floor. CNA 3 indicated the resident was kind of sitting up straight. Her back was straight, and her legs were out in front of her. Her legs were not folded/bent in any way. When asked if the CNA had notified the nurse; CNA 3 indicated .No I didn't I'm sorry A facility document, titled Confidential Witness Statement, dated 12/31/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., indicated when the Assistant Director of Nursing asked QMA 2 what happened, she indicated she was out on the medication cart passing medication when CNA 3 came and got her. CNA 3 had informed her; she had slowly put Resident 2 on the floor. QMA 3 entered the room and asked the resident if she was hurt. The resident denied pain at any location on her body. She did not appear to have any red marks or anything. The QMA and the CNA then transferred her into the wheelchair. She asked the resident if she was okay, and the resident said yes. She then took the resident's vital signs. She could not recall the vital signs but indicated her blood pressure was good and she went to breakfast. The resident did not say anything else to her about it the rest of the day. When asked about the position of the resident when the QMA entered the room, she indicated the resident's knees were bent, she had boots on her feet, and she was leaning against the bed on her bottom. The QMA did not administer pain medication to the resident that day. During a telephone interview, on 1/8/24 at 2:43 p.m., QMA 2 indicated she was working on the medication cart on the day Resident 2 fell or was lowered to the ground. She did not witness the incident. She was informed by CNA 3. The incident happened between 7:00 and 8:00 a.m. The CNA told her, she had sat the resident up on the side of the bed, went to get the stand-up lift, and the resident slid to the floor. QMA 2 retrieved the vital sign machine and then went to the room. The resident was found on the floor with her legs extended out in front of her, in a sitting position, with the CNA supporting her. The resident told QMA 2 she was fine. A few minutes later, the CNA took the resident to the dining room. The resident seemed fine. QMA 2 indicated she did tell the nurse of the fall when the nurse came to the unit to administer insulin. She did not know if the nurse assessed the resident. The nurse administered insulin, returned the insulin pens to the medication cart, and then left the unit. Resident 2 used the sit to stand lift for transfers. During a telephone interview, on 1/8/24 at 2:46 p.m., CNA 3 indicated the day of the fall was a normal morning. Resident 2 used a sit to stand mechanical lift, for transfers, and she had not ever had trouble with the resident using the lift before. She sat the resident on the side of the bed and noticed the resident was starting to slip. She turned on the call light and yelled for the QMA in the hall. She lowered the resident very gently to the floor as soft as she could. The QMA came, looked at the resident, and all was okay. The CNA and QMA transferred Resident 2 into her wheelchair and the resident was fine. She indicated the QMA reported the fall to the nurse. The nurse did not assess the resident from the time of the fall to when Resident 2 was transported to the dining room. She understood the resident was to be a one person assist using the sit to stand lift but was informed after the incident the resident required two (2) staff to use the lift. During an interview, on 1/8/24 at 2:57 p.m., the Executive Director indicated QMA 2, nor CNA 3 had notified the nurse of the fall. The QMA cannot assess. The facility policy had not been followed and both the CNA and QMA had been terminated from employment. During an interview, on 01/8/24 at 3:01 p.m., the Executive Director indicated the reason there was not an assessment in the resident's record was due to neither the CNA nor the QMA had reported the fall to the nurse. During a telephone interview, on 1/9/24 at 9:45 a.m., LPN 1 indicated she had not been informed of the fall involving Resident 2 until she returned to work on 12/27/23. She did go to the unit, look at the resident's sliding scale, administer her insulin, return the items back to the medication cart, and then returned to the unit she was working on that day. During the time she spent with Resident 2 on the day of the incident, the resident did not mention she had fallen. During an interview, on 1/9/24 at 10:04 a.m., the Executive Director indicated insulin was administered to Resident 2, by LPN 1, on 12/22/23 at 9:01 a.m. During an interview, on 1/9/24 at 1:02 p.m., the Executive Director indicated the facility found out about the fall, on 12/29/23, when Resident 2 reported pain to QMA 2. Both QMA 2 and CNA 3 were then interviewed about the fall. There was a physician's note related to the fall on that day, but the physician did not notify the facility of the fall. During a telephone interview, on 1/9/24 at 2:00 p.m., Physician 8 indicated he was making rounds in the facility and a nurse informed him Resident 2 wanted to see him because the resident was having knee pain after a fall which occurred that day. He did assess the resident and had low suspicions of any fractures and thought it was a mild injury. He indicated Resident 2 did not fall, she was lowered to the ground. During an interview, on 1/9/24 at 2:08 p.m., the Executive Director indicated the physician did refer to the QMA as a nurse. A facility document, titled Job Description, undated and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated the QMA responsibility was to administer medications under the supervision of a licensed nurse. It did not include assessing residents. A facility policy, titled Policy and Procedure Sit to Stand Lift, undated and received from the Executive Director on 1/9/24 at 3:39 p.m., indicated .The operation of the lift requires a minimum on one trained operator The resident's care plan indicated she was 2-person mechanical lift for transfers. A facility policy, titled Accident Incident Reporting Policy, undated and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated .Any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge .If a resident is involved in an accident/incident an immediate assessment of the resident will be completed The Indiana Department of Health (IDOH) Qualified Medication Aide (QMA) Training Curriculum Student Manual, dated 1/2/24, indicated .Lesson 1: Role and Responsibilities of the Qualified Medication Aide .Tasks the QMA is PROHIBITED from Performing 1. Assess a resident's condition . This Federal tag relates to Complaints IN00425077 and IN00425307. 3.1-37(a)

Based on interview and record review, the facility failed to ensure adequate supervision and staff assistance to prevent falls was provided to a resident who required the use of a mechanical lift and the assistance of two staff during transfers. This deficient practice resulted in Resident 2 experiencing an unwitnessed fall and bilateral femur fractures. (Resident 2) Finding includes: A document, titled Indiana State Department of Health Survey Report System, dated 12/30/23 at 5:01 a.m., indicated Resident 2 had a witnessed fall on 12/22/23. At the time of the fall, the resident's skin and pain was assessed with no concerns. The physician and family were notified of the fall. The resident was noted to have increased pain on 12/29/23 and the physician was notified. X-rays were ordered on 12/29/23. The family and physician were aware of the femur fracture and resident was sent to the emergency department for evaluation. The record for Resident 2 was reviewed on 1/8/24 at 2:55 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (paralysis and weakness) affecting the right side of the body, cerebral infraction (stroke), and osteoporosis without a pathological fracture (low bone mass which increases the risk of bone fractures/breaks). A quarterly Minimum Data Set (MDS) assessment, dated 10/19/23, indicated the following: a. The resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated she was cognitively intact. b. The resident had an impairment on one (1) side to both her upper and lower extremities. c. The resident was dependent (helper did all the effort) to move from a lying position to sitting on the side of the bed. A care plan, initiated on 9/7/17 and discontinued on 1/8/24, indicated the resident had late loss Activity of Daily Living (ADL) and needed total assist with transfers due to hemiplegia. Interventions included, but were not limited to, mechanical lift and to see the CNA assignment sheet for details on the staff assist needed. The care plan did not specify how many staff were needed for total assistance with transfers or the use of the mechanical lift. A care plan, initiated on 8/5/23 and discontinued on 1/8/24, indicated the resident was a fall risk and to use the assist of 2 people with the mechanical sit to stand lift, and do not leave the resident while sitting on the side of the bed. A physician's order, dated 11/24/19, indicated .Assistive device .May use mechanical lift for transfers There were no nursing notes found in the resident's record to indicate the events which led to the resident having fell or being lowered to the ground on 12/22/23. The resident's progress notes did not indicate a change in the resident's mental condition from 12/19/23 to 12/22/23. A physician's note, dated 12/22/23, indicated the physician did see the resident for complaints of bilateral knee pain (both knees) and shoulder pain. The resident reported to the physician she had slid off the bed and landed on her knee. The physician's finding was mild tenderness of both knees without significant effusion (fluid gathered in the space). The time of the physician's report was 10:28, without specification of a.m./p.m. There was no documentation of when the physician had assessed the resident only the time of his report, on 12/22/23 at 10:28:13 and another time/date stamp on 12/22/23 at 11:20:24. The Medication Administration Record (MAR) indicated the following: a. The resident had complaints of 4/10 pain, on 12/24/23, and was given acetaminophen 325 milligrams x 2 tablets at 3:09 p.m. b. The resident had complaints of 5/10 pain, on 12/28/23, and was given acetaminophen 325 mg x 2 tablets at 9:56 a.m. c. The resident had complaints of 10/10 pain, on 12/29/23 at 7:40 a.m., and was given acetaminophen 325 mg x 2. There was no entry as to where the resident was experiencing pain noted in the Medication Administration Record or notes. A facility document, titled Basic Investigation Form, undated, indicated Resident 2 had a witnessed fall, on 12/22/23, in her room. CNA 3 was assisting the resident from bed. The CNA sat the resident on the side of the bed, turned her back to get the sit to stand mechanical lift and the resident slid to the floor from the edge of the bed. CNA 3 and QMA 2 assisted the resident from the floor to a wheelchair. The QMA did get the resident's vital signs and they were normal. The resident denied any pain. The physician was notified while he was in the facility making rounds and did see the resident on 12/22/23. The CNA and QMA were suspended pending an investigation. The resident had continued complaints of pain. Orders for x-rays were obtained and the results of the x-ray were bilateral femur fractures. The resident was sent to the hospital for evaluation and treatment. The QMA was terminated for practicing outside of her scope of practice and the CNA was terminated for not following facility policy and procedure. A facility document, titled .Facility Separation Form, dated 1/5/24 and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated QMA 2 was terminated from the facility for performance, gross violation of safety rules, working outside of her scope of practice, not following facility policy and procedure. A facility document, titled .Facility Separation Form, dated 1/5/24 and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated CNA 3 was terminated for performance, violation of safety rules, violation of company policy and /or procedure. CNA did not follow facility mechanical lift policy or reporting incidents/accidents policy. In a facility document, titled Confidential Witness Statement, dated 12/29/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., CNA 3 indicated, on 12/22/23, Resident 2 was sitting on the side of the bed. CNA 3 turned her back to grab the stand-up lift; when she turned back around Resident 2 was starting to fall. CNA 3 had to move the lift, so the resident did not fall on it. The CNA hollered for the QMA. When QMA 2 entered the room, she asked Resident 2 she asked if she was okay. The resident told the QMA she was okay, and then they moved the resident and took her to breakfast. When the CNA was asked why she did not notify the nurse she stated .I don't know, I know I should of I thought [name of QMA 2] did it The Assistant Director of Nursing asked CNA 3 why she was using the stand lift without another staff, CNA 3 indicated .I don't know, I know I am supposed to In a facility document, titled Confidential Witness Statement, dated 12/29/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., QMA 2 indicated, on 12/22/23, the CNA came and got her while she was passing medications. She indicated Resident 2 was on the floor. QMA 2 went into the resident's room, assessed her, and Resident 2 seemed okay. She assisted CNA 3 to put the resident into her wheelchair so she could go to breakfast. The Assistant Director of Nursing asked QMA 2 if she had notified the nurse on duty of the fall. QMA 2 stated to the Assistant Director of Nursing and the Administrator, .No I got busy again with my med pass and forget to tell her The Assistant Director of Nursing asked QMA 2 why she assessed the resident when it was outside of her scope of practice. QMA 2 indicated .I don't know I had a lapse in judgement A facility document, titled Confidential Witness Statement dated 12/31/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., indicated when the Assistant Director of Nursing asked CNA 3 what time the incident happened, she indicated she thought it was around 7:00 a.m. CNA 3 told her she went into the resident's room to get her up. She checked the resident and set her up on the side of the bed. The resident was fine. She pulled the lift to the side of the bed and noticed Resident 2 was starting to slide. She pulled the call light and yelled for QMA 2 to help. By the time QMA 2 got into the room, CNA 3 had pushed the lift out of the way; if it had remained in place, it would have hit the resident. Instead of letting Resident 2 fall, she lowered her to the ground. The QMA came in and assessed the resident, she asked the resident if she was okay, and Resident 2 said yes. The QMA then helped put Resident 2 into the wheelchair and the resident said she was fine. The Assistant Director of Nursing asked the CNA what the resident's position was after she had been lowered to the floor. CNA 3 indicated the resident was kind of sitting up straight. Her back was straight, and her legs were out in front of her. Her legs were not folded/bent in any way. When asked if the CNA had notified the nurse; CNA 3 indicated .No I didn't I'm sorry A facility document, titled Confidential Witness Statement, dated 12/31/23 and received from the Director of Nursing on 1/9/24 at 10:26 a.m., indicated when the Assistant Director of Nursing asked QMA 2 what happened, she indicated she was out on the medication cart passing medication when CNA 3 came and got her. CNA 3 had informed her; she had slowly put Resident 2 on the floor. QMA 3 entered the room and asked the resident if she was hurt. The resident denied pain at any location on her body. She did not appear to have any red marks or anything. The QMA and the CNA then transferred her into the wheelchair. She asked the resident if she was okay, and the resident said yes. When asked about the position of the resident when the QMA entered the room, she indicated the resident's knees were bent, she had boots on her feet, and she was leaning against the bed on her bottom. The QMA did not administer pain medication to the resident that day. During a telephone interview, on 1/8/24 at 2:43 p.m., QMA 2 indicated she was working on the medication cart on the day Resident 2 fell or was lowered to the ground. She did not witness the incident. She was informed by CNA 3. The incident happened between 7:00 and 8:00 a.m. The CNA told her, she had sat the resident up on the side of the bed, went to get the stand-up lift, and the resident slid to the floor. The resident was found on the floor with her legs extended out in front of her, in a sitting position, with the CNA supporting her. The resident told QMA 2 she was fine. A few minutes later, the CNA took the resident to the dining room. The resident seemed fine. QMA 2 indicated she did tell the nurse of the fall when the nurse came to the unit to administer insulin. She did not know if the nurse assessed the resident. The nurse administered insulin, returned the insulin pens to the medication cart, and then left the unit. Resident 2 used the sit to stand lift for transfers. During a telephone interview, on 1/8/24 at 2:46 p.m., CNA 3 indicated the day of the fall was a normal morning. Resident 2 used a sit to stand mechanical lift, for transfers, and she had not ever had trouble with the resident using the lift before. She sat the resident on the side of the bed and noticed the resident was starting to slip. She turned on the call light and yelled for the QMA in the hall. She lowered the resident very gently to the floor as soft as she could. The QMA came, looked at the resident, and all was okay. The CNA and QMA transferred Resident 2 into her wheelchair and the resident was fine. She indicated the QMA reported the fall to the nurse. She understood the resident was to be a one person assist using the sit to stand lift but was informed after the incident the resident required two (2) staff to use the lift. During an interview, on 1/8/24 at 2:57 p.m., the Executive Director indicated QMA 2, nor CNA 3 had notified the nurse of the fall. The facility policy had not been followed and both the CNA and QMA had been terminated from employment. During a telephone interview, on 1/9/24 at 9:45 a.m., LPN 1 indicated she had not been informed of the fall involving Resident 2 until she returned to work on 12/27/23. She did go to the unit, look at the resident's sliding scale, administer her insulin, return the items back to the medication cart, and then returned to the unit she was working on that day. During the time she spent with Resident 2 on the day of the incident, the resident did not mention she had fallen. During an interview, on 1/9/24 at 1:02 p.m., the Executive Director indicated the facility found out about the fall, on 12/29/23, when Resident 2 reported pain to QMA 2. Both QMA 2 and CNA 3 were then interviewed about the fall. There was a physician's note related to the fall on that day, but the physician did not notify the facility of the fall. During a telephone interview, on 1/9/24 at 2:00 p.m., Physician 8 indicated he was making rounds in the facility and a nurse informed him Resident 2 wanted to see him because the resident was having knee pain after a fall which occurred that day. He did assess the resident and had low suspicions of any fractures and thought it was a mild injury. He indicated Resident 2 did not fall, she was lowered to the ground. During an interview, on 1/9/24 at 2:08 p.m., the Executive Director indicated the physician did refer to the QMA as a nurse. A facility policy, titled Policy and Procedure Sit to Stand Lift, undated and received from the Executive Director on 1/9/24 at 3:39 p.m., indicated .The operation of the lift requires a minimum on one trained operator The resident's care plan indicated she was 2-person mechanical lift for transfers. A facility policy, titled Accident Incident Reporting Policy, undated and received from the Executive Director on 1/9/24 at 10:26 a.m., indicated .Any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge .If a resident is involved in an accident/incident an immediate assessment of the resident will be completed This Federal tag relates to Complaints IN00425077 and IN00425307. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to monitor the cursing and wandering behaviors of a resident causing other residents to voice concerns (Resident #49, #62, and #119) and to vocalize fear (Resident #34 and #69) for 1 of 1 residents reviewed for behaviors (Resident #133). Findings include: The record of Resident #133 was reviewed on 10/29/2015 at 11:07 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Behavior Tracking Documentation Survey Report indicated the following behaviors were tracked for August and September 2015: .Document Mood behavior #1: increased anxiety aeb (as evidenced by) yelling out, asking repetitive questions .Interventions: (1) Offer reassurance, support and tlc (tender loving care) (2) Redirect to another activity, offer beverage and/or snack, distract with conversation (3) Assure Res (resident) she is safe (4) Encourage Res (resident) to voice her concerns and address ASAP A social services progress note, dated 09/30/15, indicated .Res (resident) has noted to be more irritable, yelling out .not easily redirectable. Resident was just yelling loudly at this writer (social services) cursing .Resident's seroquel was discontinued 9-2-15. Reviewed behavior tracking and behavior has been occurring nearly dly (daily) of yelling out. Appears to have increased anxiety aeb (as evidenced by) restless and yells out .Not able to redirect A Nursing Behavior Assessment, dated 9/30/15, indicated Resident #133 was .found by social services at front entrance to facility yelling obscenities and screaming at visitors coming into building. Resident stated, 'I don't know where the h--- to go' and 'What the h--- is going on?' Resident has shown an increase in anxiety and nervousness since Seroquel was discontinued a few weeks ago in September .Behavior begins occurring in the afternoon around 3:00 p.m. and continues until resident goes to bed approximately at 8:00 p.m. At times there is an activity going on and the resident is taken to the activity but she will not stay there. She continues to ambulate through the hallways yelling and wandering around the facility A follow up note to the Nursing Behavior Assessment, dated 10/1/15, indicated when staff or other residents would try to talk to Resident #133 she would state shut the h--- up or who gives a d---. This occurred all during the shift. Resident #133's response to interventions was to state, .leave me the d--- alone. A follow up note to the Nursing Behavior Assessment, dated 10/1/15, indicated .Resident yelling, 'help me' and 'where do I go now?' Also says 'oh well, who gives a d---?' Resident chews on nails until they bleed and cannot be still, constantly moving around. Yells during activities and is disruptive to others The note indicated the behavior occurred all shift and interventions were not effective. A follow up note to the Nursing Behavior Assessment, dated 10/3/15, indicated .continues to yell out in hall way, lounge, and dining room. Help me, who do you think you are when they answer she will state then go to h--- .occurred all during first shift A Nursing Behavior Assessment IDT(interdisciplinary team) Evaluation, dated 10/5/15, indicated .Resident's seroquel has been discontinued on 9-2-15 and yelling out/repetitive questions/anxiety has notably gotten worse since the medication was discontinued. Resident has been cursing more lately which is not a norm for her .Will update her physician and (psychiatrist). Will see (psychiatrist) on next visit. continue with current behavior tracker, SSD (Social Service Director) will slightly adjust what we are monitoring, but otherwise continue as is A Psychiatry Progress Note and Treatment Summary, dated 10/9/15, indicated .asked to check. Staff reports she's been more agitated/irritable with episodes of yelling out, 'help me, where do I go?' Yelled @ (at)/cursed nurse who simply greeted her. She is unable to stay focused in activities, is in and out of room(multiple) times as she can't sit still. (Psychiatrist) was called and adjusted some of her meds, started depakote Behavior tracking Documentation Survey Report indicated the following behaviors were monitored for October 2015: .Document Mood behavior #1: increased anxiety aeb yelling out, asking repetitive questions .Interventions: (1) Offer reassurance, support and tlc (2) Redirect to another activity, offer beverage and/or snack, distract with conversation (3) Assure Res she is safe (4) Encourage Res to voice her concerns and address ASAP Behaviors of wandering and cursing were not monitored by the facility. During an observation on 10/28/2015 at 12:45 p.m., Resident #133 was observed cursing in the Meadows lounge area. She was also observed yelling out, hey, hey and what are we going to do? to people as they passed by the lounge. During an interview on 10/29/15 at 10:14 a.m., Resident #49 indicated Resident #133 had .cussed (her) out a few times and told (her) where to go. Resident #49 indicated Resident #133 was constantly yelling up and down the hall. She indicated Resident #133 yelled at her yesterday about her shoes when she was trying to help her. Resident #49 indicated Resident #133 wandered into other resident's rooms and tried to get in their beds, as well as yelled at other residents. Resident #49 indicated she felt the staff did not do anything about the cursing and wandering and indicated the staff stated that she (Resident #133) can't help herself. During an interview on 10/29/2015 at 11:30 a.m., Resident #34 indicated she was afraid of Resident #133 because she (Resident #34) had one leg and she could not get up by herself to get out of her room if needed. She indicated neither she nor her roommate could defend themselves if Resident #133 attempted to do something to either one of them. Resident #34 indicated Resident #133 came into her room yesterday. When Resident #34 asked Resident #133 what she was doing in her room, Resident #133 told Resident #34 to shut up. Resident #34 indicated Resident #133 got into her bathroom one day and Resident #34 had to yell to get the staff to get her out of her room. She indicated Resident #133 came into her room everyday and she had to have her taken out. During an interview on 10/29/2015 at 11:43 a.m., Resident #69 indicated he was afraid of Resident #133. Resident #69 indicated Resident #133 cursed and yelled in the facility and was intrusive during activities. Resident #69 indicated Resident #133 last yelled at him approximately one week ago. During an interview on 10/29/2015 at 12:02 p.m., Resident #62 indicated Resident #133 wandered into his room at times and seemed very confused. During an interview on 10/30/2015 at 2:37 p.m., Resident #119 indicated Resident #133 shouted on the unit randomly and disrupted meal time. Resident #119 indicated staff did not always intervene. During an interview on 10/29/2015 at 11:48 a.m., LPN #10 indicated Resident #133 yelled out a lot. She indicated Resident #133 cursed, but it was usually directed at another resident who had passed away. She thought he was her husband. They used to sit at the same table and spar back and forth. It would bother those around them, so staff would separate them. LPN #10 indicated Resident #133 yelled towards a group of residents one other time to her knowledge. LPN #10 indicated the residents were talking and Resident #133 yelled something like, shut the h--- up! LPN #10 indicated staff attempted to redirect behaviors. She also indicated Resident #133 wandered to the doorway of other residents' rooms and the downstairs area of the facility. During an interview on 10/29/2015 at 11:48 a.m., CNA #12 indicated Resident #133 sometimes argued with some of the residents and yelled at them. CNA #12 indicated the arguments usually occurred because Resident #133 did not want other residents to sit by her. CNA #12 indicated she heard one resident complain about Resident #133. During an interview on 10/29/2015 at 12:05 p.m., the Activities Director indicated Resident #133 typically yelled out towards the end of activities, so she was the first resident to be taken back to her room. She indicated she saw Resident #133 in the facility, outside of activities, and observed her cursing in general. She indicated she had not been concerned about this because it was just a part of who Resident #133 was. On 10/29/2015 at 1:40 p.m., the Administrator and Director of Nursing were informed of concerns related to cursing and wandering behaviors of Resident #133. They indicated they had no awareness Resident #133 was wandering into resident rooms. During an interview on 11/05/2015 at 11:07 a.m., the Social Service Director (SSD) indicated she did not feel cursing was a behavior that required monitoring for Resident #133 because it was not causing her any distress. It was a part of who she was as a person. The SSD indicated she felt Resident #133 was not aware of what she was doing due to her dementia diagnosis. She indicated wandering could be put in a careplan, but was not something that was really trackable. A current policy titled Psychotropic Drug Use Policy, dated 06/01/2011, provided by the Director of Nursing on 11/5/15 at 10:56 a.m., indicated .Anticonvulsant . used for managing behavior, stabilizing mood, or treating psychiatric disorders .target behaviors must be clearly identified and monitored. Episodes will be documented in the clinical record as they occur along with the results of the interventions used to reduce the behavior or symptom 3.1-34(a)

Based on record review and interview, the facility failed to ensure appropriate follow up communication was completed in order to provide appropriate transfer and placement for a resident with physical aggressive behaviors and to attain and maintain the safety of the other residents, resulting in a terminal injury for a fell ow resident (Resident B), for 1 of 3 residents reviewed for physical behaviors, in a sample of 6. (Resident C) Findings include: The record for Resident C was reviewed on [DATE]. [DIAGNOSES REDACTED]. Nursing notes, dated [DATE] at 9:37 p.m., indicated Resident C hit another resident (Resident D) and swatted at kitchen staff. Family was notified of the altercation and stated Resident C did have a "mean streak" and had acted this way, at home, towards family, including Resident C's husband. Nursing notes indicated Resident C continued to demonstrate physical agitation and aggression toward others, intermittently, through July, August, September, and [DATE]. For evaluation and treatment, Resident C was placed at a geriatric psychological facility from [DATE] to [DATE]. After the return from the geriatric psychological facility, Resident C's agitation and physical aggression toward others continued. Nursing notes indicated the following: [DATE]- Resident C punched another resident on the back, leaving a 7 x 9 centimeter (cm) red area on the other resident's back. [DATE]- Resident C punched another resident, twice, on the arm, and tried to take away the other resident's jacket. [DATE]- Resident C pushed a nurse, during care. Social Services notes, dated [DATE], indicated Resident C's power of attorney (POA) agreed to the transfer of Resident C to a behavioral facility. Documentation did not indicate further correspondence was completed related to the transfer. During an interview on [DATE] at 10:45 a.m., the Social Services Director (SSD) indicated she spoke with Resident C's POA regarding a more appropriate facility placement for Resident C. The POA agreed to the transfer. The SSD indicated referral calls were not made. Staff told the SSD Resident C was doing better, and the management team decided to give Resident C another chance. Behavior monitoring logs for [DATE] indicated Resident C had 42 episodes related to mood behavior: anger at staff, intrusive episodes with peers and 51 episodes related to physical behavior: hitting staff during care. The behavior monitoring log for [DATE] - 29, 2014 indicated Resident C had 31 episodes related to mood behavior: anger at staff, intrusive episodes with peers and 47 episodes related to physical behavior: hitting staff during care. Nursing notes, dated [DATE] at 11:20 a.m., indicated Resident C physically pushed Resident B to the floor. Resident B complained of leg pain and was transferred to the emergency room . Hospital x-ray results, dated [DATE], indicated a spiral fracture of the right femoral shaft with 100% posterior and medial displacement. Hospital physician notes, dated [DATE], indicated Resident B was suffering a CHF (congestive heart failure) exacerbation as a result of the stressor of fall/fracture. Resident B was not a surgery candidate and palliative care was put in place. Resident B expired [DATE]. This federal tag relates to Complaint #IN 301. 3XXX,[DATE](a)

Based on record review and interview, the facility failed to provide adequate supervision and intervention to protect residents from a resident with known aggressive physical behaviors toward others, resulting in terminal injury, for 2 of 3 residents reviewed for accidents, in a sample of 6. (Resident B and C) Findings include: 1. The clinical record for Resident B was reviewed on [DATE]. [DIAGNOSES REDACTED]. Nursing fall risk assessment indicated the following: Date and time of occurrence: [DATE] at 11:20 a.m. Summary of occurrence: Resident B was pushed to the floor by another resident (Resident C). Injury: Unknown at this time. Root cause of fall: agitated resident. Resident B was sent to the hospital for evaluation and treatment. Hospital documentation and Trauma Progress Note, dated [DATE] and titled Final Report, indicated a "displaced spiral right femur fracture secondary to fall, was pushed (from standing) by another resident at nursing home. Patient is not a surgical candidate at this time. We can minimally optimize patient by treating acute CHF exacerbation exacerbated by stressor of fall/fracture...." A hospital Palliative Care Initial Consult Note, dated [DATE], indicated "...this injury was likely a terminal event for the patient ...." Facility nursing notes indicated Resident B returned on [DATE]. Orders for comfort measures only. Facility nursing notes indicated Resident B expired on [DATE]. 2. The record for Resident C was reviewed on [DATE]. [DIAGNOSES REDACTED]. Nursing notes, dated [DATE] at 9:37 p.m., indicated Resident C hit another resident (Resident D) and swatted at kitchen staff. Family was notified of the altercation and stated Resident C did have a "mean streak" and had acted this way, at home, towards family, including Resident C's husband. Nursing notes indicated Resident C continued to demonstrate physical agitation and aggression toward others, intermittently, through July, August, September, and [DATE]. For evaluation and treatment, Resident C was placed at a geriatric psychological facility from [DATE] to [DATE]. After the return from the geriatric psychological facility, Resident C's agitation and physical aggression toward others continued. Nursing notes indicated the following: [DATE]- Resident C punched another resident on the back, leaving a 7 x 9 cm. red area on the other resident's back. [DATE]- Resident C punched another resident, twice, on the arm, and tried to take away the other resident's jacket. [DATE]- Resident C pushed a nurse, during care. Social Services notes, dated [DATE], indicated Resident C's power of attorney (POA) agreed to the transfer of Resident C to a behavioral facility. Documentation did not indicate further correspondence was completed related to the transfer. During an interview on [DATE] at 10:45 a.m., the Social Services Director (SSD) indicated she spoke with Resident C's POA regarding a more appropriate facility placement for Resident C. The POA agreed to the transfer. The SSD indicated referral calls were not made. Staff told the SSD Resident C was doing better, and the management team decided to give Resident C another chance. Behavior monitoring logs for [DATE] indicated Resident C had 42 episodes related to mood behavior: anger at staff, intrusive episodes with peers and 51 episodes related to physical behavior: hitting staff during care. The behavior monitoring log for [DATE] - 29, 2014 indicated Resident C had 31 episodes related to mood behavior: anger at staff, intrusive episodes with peers and 47 episodes related to physical behavior: hitting staff during care. Nursing notes indicated the following: [DATE] at 10:52 p.m.- "Resident refused care, was combative and yelling during toileting ...." [DATE] at 3:55 p.m.- "Resident very combative during toileting, required 2- assist. Resident kicking, smacking and pushing.... Resident still seemed agitated after toileting in hallways towards people walking by. Nurse offered food/drinks, resident did not accept." [DATE] at 11:06 a.m., indicated Resident C "swung her fist at dietary staff member while they were putting tablecloths on tables. Has had occasional episodes of crying and agitation so far today." A nursing document titled incident investigation, indicated on [DATE] at 11:20 a.m., Resident B was pushed to the floor by Resident C. The incident investigation indicated previously planned interventions were not in place at the time of the event (fall). "Staff unable to do interventions due to agitation. 1:1 (one one one supervision) provided until transport arrived." During an interview on [DATE] at 3:45 p.m., the SSD indicated staff were aware of Resident C's agitation and physical aggressive behaviors, since her admission. CNA #1 indicated awareness of Resident C's agitation and aggressive behaviors toward others, during an interview on [DATE] at 9:30 a.m. CNA #1 indicated when Resident C displayed agitated behaviors, staff were expected to provide one on one supervision, if enough staff were available. Resident C showed agitation and aggression, frequently, and the behaviors were unpredictable. CNA #1 explained staff did not know what triggered the aggression and/or agitation. There was no way to tell if a combative moment was coming. She (Resident C) acted this way toward staff and residents, equally. Resident C did not single out one person. CNA #1 explained the following, as she recalled the morning of [DATE]. The unit was staffed with a nurse, CNA #1, and a CNA orientee. This was the CNA orientee's first day. Resident C was very aggressive, that day. The unit staff did not call any other staff for assistance, that morning, because three people (staff) were on the unit, including the orientee. Despite unfamiliarity with the residents, the orientee was supposed to be able to help to allow CNA #1 to provide one on one supervision, if needed. Due to Resident C's increased agitation and combativeness, two staff (CNA #1 & the nurse) were required to assist her (Resident C) with toileting. After Resident C was toileted, the nurse and CNA #1 left her room. Resident C was still agitated, at that time. CNA #1 was walking on the unit, with another resident and the nurse was approaching Resident B to provide care. Resident B was standing with her walker, against the wall, outside her (Resident B) room. Resident C exited her room, walked very fast, and pushed Resident B, hard, to the floor, unexpectedly. Resident C continued to be aggressive. This federal tag relates to Complaint #IN 301. 3XXX,[DATE](a)(2)

Based on interview and record review, the facility failed to ensure the correct medication was given, causing hallucinations, confusion and combativeness, resulting in an emergency room visit for 1 of 6 residents reviewed for medication errors in a sample of 6 residents. (Resident Q) Findings include: On 10/23/14 at 2:50 p.m., the Director of Nursing (DON) provided three Medication Error Reports for the period of 9/21/14 through 10/4/14. On 10/23/14 at 3:30 p.m., the record review for Resident Q was completed. [DIAGNOSES REDACTED]. A request was made to the Director of Nursing for medication errors for the last two weeks of September and the first two weeks of October. Three medication error reports were reviewed. The document titled, "Medication and Treatment Error Report" for Resident Q indicated, "...Date and time of error: 10/3/14 at 2 p.m....Medication/Treatment Involved:[MEDICATION NAME] milligrams...Explanation of error: Resident was [MEDICATION NAME](a sleep medication) 10 milligrams x 3 instead of [MEDICATION NAME] (a pain medication)100 (sic) milligrams x 3...Negative Outcomes from Error : Resident with increased hallucinations, increased combativeness, increased restlessness, and increased confusion. Action Taken for Resident :Attempted to redirect resident multiple times unsuccessfully, sent resident to (hospital name) for evaluation and treatment...." The assessment dated [DATE] 6:30 p.m., indicated the physician was notified and an order received to transfer the resident to the hospital or other health care setting. The resident was sent to (hospital name) by ambulance. The reason for the transfer: 30 [MEDICATION NAME]. The resident returned to the facility on [DATE] at 9:00 p.m. The Medication Administration Record [REDACTED]." There were initials inside the [MEDICATION NAME] 30 milligrams box for 2 p.m. and the order for [MEDICATION NAME] no signature inside of the box. The nurse who gave the medication was unable to be identified. On 10/22/14 at 4:45 p.m., the DON indicated according to the nurse who gave the medications, the nurse indicated the medications were bundled together with a rubber band. The nurse read the label for the medication of [MEDICATION NAME], and when she punched the pills out, she punched the pills out of [MEDICATION NAME] instead. The nurse did not realize this until after the medication was given. The DON indicated there was no other action taken other than a Medication Error Report. This Federal tag relates to Complaint IN 731. 3.1-25(b)(9)

Based on interview and record review, the facility failed to ensure the correct medication was given, causing hallucinations, confusion and combativeness, resulting in an emergency room visit for 1 of 6 residents reviewed for medication errors in a sample of 6 residents. (Resident Q) Findings include: On 10/23/14 at 2:50 p.m., the Director of Nursing (DON) provided three Medication Error Reports for the period of 9/21/14 through 10/4/14. On 10/23/14 at 3:30 p.m., the record review for Resident Q was completed. [DIAGNOSES REDACTED]. A request was made to the Director of Nursing for medication errors for the last two weeks of September and the first two weeks of October. Three medication error reports were reviewed. The document titled, "Medication and Treatment Error Report" for Resident Q indicated, "...Date and time of error: 10/3/14 at 2 p.m....Medication/Treatment Involved:[MEDICATION NAME] milligrams...Explanation of error: Resident was [MEDICATION NAME](a sleep medication) 10 milligrams x 3 instead of [MEDICATION NAME] (a pain medication)100 (sic) milligrams x 3...Negative Outcomes from Error : Resident with increased hallucinations, increased combativeness, increased restlessness, and increased confusion. Action Taken for Resident :Attempted to redirect resident multiple times unsuccessfully, sent resident to (hospital name) for evaluation and treatment...." The assessment dated [DATE] 6:30 p.m., indicated the physician was notified and an order received to transfer the resident to the hospital or other health care setting. The resident was sent to (hospital name) by ambulance. The reason for the transfer: 30 [MEDICATION NAME]. The resident returned to the facility on [DATE] at 9:00 p.m. The Medication Administration Record [REDACTED]." There were initials inside the [MEDICATION NAME] 30 milligrams box for 2 p.m. and the order for [MEDICATION NAME] no signature inside of the box. The nurse who gave the medication was unable to be identified. On 10/22/14 at 4:45 p.m., the DON indicated according to the nurse who gave the medications , the nurse indicated the medications were bundled together with a rubber band. The nurse read the label for the medication of [MEDICATION NAME], and when she punched the pills out, she punched the pills out of [MEDICATION NAME] instead. The nurse did not realize this until after the medication was given. The DON indicated there was no other action taken other than a Medication Error Report. This Federal tag relates to Complaint IN 731. 3.1-25(b)(9)