Every finding on record at Wellbrooke of Wabash

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency (Indiana Department of Health (IDOH)) for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:Resident B's clinical record was reviewed on 6/3/26 at 9:14 a.m. Diagnoses included psychotic disorder with delusions due to known physiological condition and cognitive communication deficit. A 2/26/26, Significant Change, Minimum Data Set (MDS) assessment indicated Resident B was severely cognitively impaired.An Interdisciplinary Team note, dated 5/8/26 at 4:48 p.m., indicated a nurse heard another resident's family member kiss Resident B. Upon immediate assessment, the resident was not in any distress and was smiling. No injuries were noted. The resident appeared to be in pleasant mood and could not recall the incident. At the time of the occurrence, the visitor walked out of the building. A head-to-toe skin assessment completed revealed no adverse skin issues. The resident's daughter was contacted regarding the potential occurrence with no further concerns.A Facility Reported Incident submitted to the Indiana Department of Health, dated 5/8/26 at 4:13 p.m., indicated a staff member reported to the Director of Nursing (DON) that they heard a visitor (the son of another resident) kiss Resident B while he was visiting in her room. Staff intervened to remove the resident. The alleged visitor left the facility. A head-to-toe assessment was completed with no abnormal findings. The allegation was immediately reported to administration and an investigation was initiated. The resident was assessed for safety, well-being, and any concerns related to the incident. The resident was unable to state what happened but did not show signs of psychosocial distress and was smiling after the incident. Family and physician were notified of the incident. The preventative measures added on 5/8/26 indicated interviews with involved parties and witnesses were ongoing. Due to the nature of the allegation, the visitor was informed he was not permitted to return to the facility until the investigation was completed. The facility would continue to monitor the resident and take any necessary actions based on investigative findings. A police report was filed. Similar residents would be reviewed.A facility investigation summary related to Resident B, dated 5/7/26 at 9:00 p.m. and provided by the Administrator on 6/3/26 10:42 a.m., indicated the 200-hall nurse reported hearing a visitor kiss Resident B. Immediate action was taken to ensure the resident's safety. Staff were interviewed, the resident was interviewed, the physician was notified, Resident B's representative was notified, and the visitor was interviewed. Resident B had severe cognitive impairment. She had no pain and was unable to recall the event. The visitor indicated that he went to tell Resident B goodnight, and she asked him for a kiss. Resident B believed the visitor was her boyfriend, and the incident was not witnessed to know who initiated the kiss. The resident wanted the visitor to kiss her. The visitor kissed the resident per the resident's request, and the resident was not having psychosocial distress. The visitor was asked to leave pending investigation. The police were notified.During an interview, on 6/3/26 at 1:14 p.m., LPN 17 indicated, on 5/4/26, she heard a kissing sound, looked up, and saw a visitor walking away from Resident B. The visitor, who had a family member residing in the facility at that time, had previously sat with Resident B at lunch at times. LPN 17 assessed Resident B and notified the DON.During an interview, on 6/3/26 at 1:24 p.m., the Administrator, with the DON present, indicated the visitor was the son of a resident who was no longer at the facility. They reported the incident to the IDOH due to erroring on side of caution and the visitor's admission to kissing the resident. It was unclear who initiated the kiss. The facility conducted an investigation before reporting the incident to determine whether it needed to be reported to IDOH. LPN 17 reported the incident to the DON, and the DON reported it to the Administrator on 5/7/26 around 9:00 p.m. The incident occurred around shift change, and LPN 17 clocked out at 7:09 p.m. The incident was not reported due to not being 100% sure what had happened. The following day, the Administrator spoke with the visitor and reported it within the two-hour window of speaking with them.A current facility policy revised 10/24/22 titled Reportable Event Guidelines, provided by the Administrator, on 6/4/26 12:32 p.m., indicated the following: .Procedure.1. Occurrences to be reported include.2. The campus shall complete the appropriate State Reporting Form and send to the State Agency within the time set forth in state and federal guidelines.This Citation relates to Intake 3009804.410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to implement interventions to protect a resident pending the investigation of an allegation of abuse according to facility policy for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:Resident B's clinical record was reviewed on 6/3/26 at 9:14 a.m. Diagnoses included psychotic disorder with delusions due to known physiological condition and cognitive communication deficit.A 2/26/26, Significant Change, Minimum Data Set (MDS) assessment indicated Resident B was severely cognitively impaired.During an interview, on 6/3/26 at 1:14 p.m., LPN 17 indicated, on 5/4/26, she heard a kissing sound, looked up, and saw a visitor walking away from Resident B. The visitor, who had a family member residing in the facility at that time, had previously sat with Resident B at lunch at times. LPN 17 assessed Resident B and notified the DON.During an interview, on 6/4/26 at 11:18 a.m., Activity Assistant 2 indicated Resident B's daughter came into the facility on 5/8/26 to discuss an incident involving a visitor who had kissed her mother the previous evening. Upon entering the facility, the daughter walked into the dining room and found Resident B and the visitor sitting together at a dining room table. Activity Assistant 2 indicated she had not been aware of the reported incident between the visitor and Resident B. Activity Assistant 2 immediately went to the dining room and observed Resident B and the visitor sitting across from each other at a table. She removed Resident B from the dining room and took her to the conference room, where she left the resident with her daughter, and then notified the Administrator. Activity Assistant 2 indicated that she may have previously seen Resident B and the visitor sitting in the dining room, but believed another person was also seated with them at that time. Resident B exhibited inappropriate behaviors, including wanting to kiss the male staff members, trying to hold their hands, or saying, he's [NAME]. Most of the time, Resident B was redirectable and just sought attention.During an interview, on 6/3/26 at 1:24 p.m., the Administrator, with the DON present, indicated the visitor was the son of a resident who was no longer at the facility. It was unclear who initiated the kiss. LPN 17 reported the incident to the DON, and the DON reported it to the Administrator on 5/7/26 around 9:00 p.m. The incident occurred around shift change, and LPN 17 clocked out at 7:09 p.m.During the exit conference, on 6/4/26 at 2:11 p.m., the Administrator, with the DON present, indicated that the kiss was not witnessed. A kissing sound was heard but could have been an air kiss. The Administrator was unable to make contact with the visitor and once he was in the building she interviewed him and confirmed the incident. The facility then restricted him from coming back into the facility at that time. A current facility policy revised on 12/16/24, titled Abuse, Neglect and Exploitation Procedural Guidelines, provided by the Administrator on 6/4/26 at 12:49 p.m. indicated the following: .Procedure.4. (e) Protection i. Upon identification of suspected abuse or neglect, immediately provide for the safety of the resident and the person reporting to maintain anonymity as reasonable and necessary.Cross reference F609.This citation relates to Intake 3009804.410 IAC (Indiana Administrative Code) 16.2-3.1-28(d)

Based on observation and interview, the facility failed to store and prepare food under safe and sanitary conditions related to kitchen equipment and storage. This deficient practice had the potential to affect 92 of 92 residents who received food from the facility kitchen. Findings include:During a kitchen observation on 1/8/26 at 9:58 a.m., accompanied by the Dietary Manager, the following was observed:Upon entering the kitchen, numerous food splatters ranged from brown, black and red in color were on the floor in front of the doorway.Brown and black grease buildup was noted to the left side of the stove on the side of the steamer. Numerous grease streaks down the side of the steamer were honey brown and black in color.There were black and brown splatter marks all along the floor between the stove and the steam warmer. A whole top piece of a bun was laying face up between the stove and steamer.The bottom of the left oven had burnt-on, thick, black buildup. The buildup was the thickness of a pencil eraser.The oven face had a thick black grease streak that was the length of a piece of paper running down the front face of the stove to the left side of the griddle grease trap.Numerous grease streaks, from honey to white in color, ran down the right side of the griddle.The prep table in front of the stove had numerous pieces of food substance all over the storage shelves. The food substance ranged from pieces of shredded cheese to breadcrumbs all throughout the shelving. An open white plastic container, which stored pot lids, had a piece of dried egg, pieces of sausage, and shredded cheese in the container with the lids.The Dietary Manager indicated, at the time of observation, that the stove was cleaned weekly while the ovens were cleaned monthly. The floors should be swept nightly.During a kitchen observation on 1/14/26 at 8:39 a.m., the following was observed:Upon entering the kitchen, through the main dining room, numerous food substances were splattered on the floor. Food substances were honey color and black. A quarter-sized dark brown food substance was smeared on the floor.Near the door frame was dark red and light pink dried liquid on the floor.A splatter of a red food substance was seen at the backside of the prep table. Another red food splatter, which looked like smashed berries, was on the floor next to the wheeled bread cart. Numerous food particles were on the floor in front of the flour container.A yellow food substance, the size of a tennis ball, was dried on the floor next to the trash can by the hand-washing station.The oven face remained with a thick black grease streak, the length of a piece of paper, running down the front face of the stove to the left side of the griddle grease trap.The bottom of the left oven remained with a burnt-on, thick, black buildup. The buildup was the thickness of a pencil eraser.Numerous dark brown and black food splatters/ grease marks were on the floor between the stove, steamer and wall.The facility's weekly cleaning schedule indicated the chargrill and ovens were cleaned on Tuesdays, the prep areas and tables were cleaned on Wednesdays, and the stove range was cleaned on Thursdays.The PM aide cleaning list indicated to wipe down all surfaces and counter tops.The PM [NAME] Cleaning list indicated to clean inside and outside of the oven, clean the stop tip and flat top, clean grill grates, wipe down outside, and change foil.The AM aide cleaning list indicated to wipe down all surfaces and counter tops.A December 2025 plan of correction audit indicated, on December 23, 27, and 31 (2025), all areas were compliant.A December 2025 cleaning log was reviewed, on 1/14/25, which indicated on December 24, 27, and 31st, two to three corrections were needed.A current facility policy, dated 2/8/18, titled Kitchen Equipment Preventative Maintenance, provided by the Administrator, on 1/14/26 at 1:19 p.m , indicated the following: .Ranges: check that burner tops are cleaned appropriately; Fryers: Make sure it is free of oil build up internally 3.1-21 (i)(3)

Based on observation, record review, and interview, the facility failed to ensure medications were labeled with required information, including open dates, and failed to maintain medications in a secure and organized manner, as evidenced by loose medications found in a medication cart. This deficient practice had the potential to affect 51 of 51 residents. (Residents 9 and 42)Findings include: During an observation of the 200-hallway medication cart on [DATE] at 2:45 p.m., accompanied by QMA 3, a white round pill with the imprint TCL 340 and a yellow oblong pill with the imprint C55 were found loose in the second drawer from the top of the cart. QMA 3 indicated any loose medications found in the medication cart should be destroyed in the drug buster (a medication disposal system). Medication carts were cleaned out on an as needed basis. The 200-hallway medication cart stored medications for 39 of 51 residents.During an observation of the 100-hallway medication cart on [DATE] at 2:57 p.m., accompanied by RN 4, indicated the following:An unlabeled, prefilled, disposable insulin pen originally containing 300 units of insulin glargine contained approximately 20 units of remaining insulin. The lid of the insulin pen had a handwritten name in black ink (Resident 42) and an opened date of [DATE]. RN 4 indicated the date was either expired or possibly written incorrectly. The pen should have a resident label attached. The 100-hallway medication cart stored medications for 22 of 51 residents.An unlabeled, pre-filled, disposable insulin pen originally containing 300 units of insulin glargine contained approximately 25-30 units of remaining insulin. The lid of the insulin pen had a hand-written name (Resident 42) in black ink with no opened date. RN 4 indicated the pen should have a label and an opened date, but did not.A bottle of olopatadine solution 0.2% eye drops, with a label for Resident 42, lacked an opened date. RN 4 indicated eye drops should have opened dates written on the resident label.An unlabeled, pre-filled, disposable insulin pen, originally containing 300 units of insulin glargine contained approximately 150 units of remaining insulin. The lid of the insulin pen had a handwritten name in black ink (Resident 9) and an opened date of [DATE]. RN 4 indicated the pen itself should have a resident label attached.During an interview with the DON on [DATE] at 1:53 p.m., she indicated all medications should be labeled with the resident's name, ordering provider, date opened, and expiration date. The facility had blank labels which could be filled out with a pen and attached to each medication. Loose medications should be destroyed according to facility policy.A current facility policy, titled Medication Ordering, Receiving and Storage, provided by the Administrator on [DATE] at 1:02 p.m., indicated the following: .3. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 4. If the facility has discontinued, outdated or deteriorated medications or biologicals, contact the dispensing pharmacy for instructions regarding returning or destroying these items.8. Medications shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications between residents.D. Check expiration date on package/container before administering any medications. When opening a multi-dose container, place the date on the container.Medications that cannot be returned to the dispensing pharmacy.will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.3.1-25(j)(o)

Based on interview, observation, and record review, the facility failed to ensure infection prevention and control strategies for transmission-based precautions were followed for 1 of 3 residents reviewed for contact isolation precautions. (Resident 1) Findings include:During an interview, on 1/8/26 at 11:26 a.m., Resident 1 indicated she was unable to recall what type of infection she had. An enhanced barrier precaution (EBP) sign was located under the nameplate of Resident 1's room. A personal protective equipment (PPE) cart was in her room beside the door. During an observation, on 1/8/26 at 3:03 p.m., the EBP sign was no longer present. A contact precautions sign hung above Resident 1's nameplate.During an observation, on 1/12/26 at 2:44 p.m., a large, empty, cardboard biohazard box sat beside the PPE cart in Resident 1's room. During an interview, on 1/12/26 at 3:01 p.m. LPN 6 indicated Resident 1 had been on contact isolation for COVID-19. An EBP sign had been placed in error after the resident was out of COVID-19 precautions. Resident 1 had a qualifying condition that fell under the EBP category; however the contact isolation should have stayed in effect due to Resident 1 having had a lengthy history and current diagnosis of Clostridium difficile (C. diff). EBP was used during hands-on care and contact precautions was used during any contact with the resident, her belongings, or anything in the resident's room. Soap and water were to be used when hand hygiene was performed by the staff and the resident. Staff were to assist the resident with hand hygiene. The resident had bowel incontinence and was able to leave her room if her bowel movements were contained. During an observation, on 1/13/26 at 10:45 a.m., Physical Therapist 7 knocked on Resident 1's door, greeted the resident, and indicated he was there to take her to therapy. He retrieved Resident 1's gait belt and assisted Resident 1 out of her room via her wheelchair. As he held the gait belt in his left hand, he grasped the wheelchair handles with both bare hands and propelled the resident to the therapy room. Neither he nor the resident utilized PPE or performed hand hygiene upon entering or exiting the resident's room. In the therapy room, the therapist placed the gait belt around Resident 1's waist and placed a walker in front of the resident. The resident grasped the walker hand grips and began to ambulate. Once therapy was completed, the therapist removed the gait belt and sat the walker off to the side with other equipment. The therapist returned Resident 1 to her room via wheelchair and placed the gait belt back in the resident's room. The therapist exited Resident 1's room without performing any type of hand hygiene. During an interview, on 1/13/26 at 10:52 a.m., Physical Therapist 7 indicated the contact precaution sign was for the nursing staff who performed wound care and provided personal care. He usually wore gloves. No hand hygiene was performed by him or the resident. Hand hygiene was a task worked on by occupational therapy and he was in physical therapy. During an interview, on 1/13/26 at 11:06 a.m., QMA 8 indicated Resident 1 could not toilet herself. Resident 1's hands needed to be washed with soap and water after toileting due to the resident having C. diff (Clostridioides difficile) (highly contagious bacterium that causes diarrhea and bowel inflammation). During an interview, on 1/13/26 at 11:10 a.m., Housekeeper 9 indicated she cleaned Resident 1's room once a day. She used a disinfectant light with each cleaning. She wore gloves when she cleaned Resident 1's room and performed hand hygiene by either washing her hands with soap and water or with hand sanitizer. During an observation, on 1/13/26 at 5:01 p.m., CNA 10 entered Resident 1's room, moved items so she could get behind Resident 1's wheelchair, and grasped the wheelchair handles bare handed. She propelled Resident 1 to the DR. No PPE was utilized nor was hand hygiene performed by either the resident or staff member upon entering or exiting Resident 1's room. CNA 10 assisted Resident 1 to a dining room table. She walked over to a neighboring dining room, without washing her hands, retrieved a ceramic coffee cup, filled the with coffee, and took it to Resident 1. CNA 10 indicated she did not wash her hands and should have, because Resident 1 had a bacterial infection. By not washing her or Resident 1's hands the disease could spread to others. Resident 1 had been in isolation three times since her admission to the facility. Resident 1 needed assistance with toileting and continued to have loose stools. A gown, mask, and gloves were to be worn when personal care was given and when personal items were touched. During an interview, on 1/14/25 at 9:57 a.m., the Infection Preventionist indicated contact precautions were utilized when a resident had C.diff or Methicillin-resistant Staphylococcus aureus (MRSA) (an antibiotic-resistant infection). Transmission based precautions were utilized for residents who had COVID-19. EBP was for residents who had a PICC line (peripherally inserted central catheter), urinary catheter, or had wounds. Staff were educated at the time isolation was put into place and education was based on a resident's diagnosis. The majority of education was provided to the nursing staff due to other departments did not perform hands-on care. The whole building was educated. She was not sure why Resident 1's EBP sign was switched to the contact precaution sign. Resident 1 was admitted with C.diff and probably should have had remained on contact precautions the whole time. The EBP sign was put into place due to Resident 1 having a wound. Resident 1's clinical record was reviewed on 1/14/25 at 11:32 a.m. Diagnoses included Enterocolitis (inflammation of the small intestine) due to Clostridioides difficile, not specified as recurrent, and 2019-nCoV acute respiratory disease (COVID-19). Current orders included vancomycin (antibiotic)125 milligrams (mg) by mouth daily every three days (12/31/25), probiotic blend 2 billioncell (supplement) 50 mg by mouth twice a day (12/2/25), contact precautions, special instructions: C-diff, every shift (1/9/26), and staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities, every shift (12/30/25). A significant change Minimum Data Set (MDS) assessment, dated 12/10/25, indicated Resident 1 had severe cognitive impairment. She was independent in eating. She needed supervision or touching assistance with oral hygiene and was dependent in toileting hygiene, shower/bathing, footwear, sit to stand, chair/bed to chair transfers, and toilet transfers. Resident 1 was frequently incontinent of her bowels and bladder. A current care plan, dated 12/31/25, indicated Resident 1 required enhanced barrier precautions (EBP) during high-contact care related to presence of C.diff. Interventions included the following: apply, remove, and dispose of PPE systematically and appropriately, per policy, face mask to be utilized as needed, observe for and report any new or worsened signs and symptoms of infection, perform hand hygiene before and after care, per policy and as required, utilize gown and gloves per EBP policy during high contact ADL care (dressing, showering/bathing, hygiene, transfers, toileting/changing briefs) and during linen changes, (12/31/25). A current care plan, dated 11/19/25, indicated Resident 1 had a gastrointestinal infection: C-Difficile. Interventions included the following: administer medications and treatments as ordered, evaluate, report, and record effectiveness, and any adverse side effects, assess for the potential cause of, precipitating and aggravating factors to episodes of nausea, vomiting and diarrhea, notify physician as appropriate, isolation precautions per policy, record the duration and frequency of diarrhea and or emesis; characteristics, consistency, and quantity (11/19/25). A progress note, dated 10/24/25 at 11:19 a.m., recorded as a late entry on 10/25/25 at 11:45 a.m., indicated Resident 1 was admitted to the facility following a hospital stay. Admitting diagnosis included a urinary tract infection and C. diff. The resident was on oral vancomycin. The resident was incontinent of bowel and bladder and did have loose, liquid stool with mucous present. A progress note, dated 10/29/25 at 4:03 p.m., indicated Resident 1 continued to take an antibiotic for C-diff and had diarrhea. A progress note, dated 11/3/25 at 11:28 a.m., indicated isolation precautions were discontinued for Resident 1 due to oral vancomycin was completed on 10/31/25 and the resident's stool was formed. A physician progress note, date 11/17/25 at 1:31 p.m., recorded as a late entry on 11/19/25 at 1:36 p.m., indicated Resident 1 had increased abdominal discomfort and cramping. Stools were loose and watery. Resident 1 had brief improvement regarding stools but loose stools returned. Stool sample results were pending for C.diff. A progress note, dated 11/18/25 at 3:05 p.m., indicated Resident 1's stool sample tested positive for C .diff. New orders were received to place the resident on contact precautions and start vancomycin 125 mg by mouth four times a day for ten days. A skilled nurses note, dated 11/23/25 at 4:21 p.m., indicated Resident 1 required EBP and isolation precautions. A progress note, dated 12/1/25 at 10:24 p.m. indicated Resident 1 remained in isolation, started a probiotic, and an order was received to check stool for C. diff. An interdisciplinary team (IDT) note, dated 12/1/25 at 2:33 p.m., indicated Resident 1 had completed antibiotics for C. diff and the resident continued to have soft, liquid stools. A progress note, dated 12/2/25 at 3:43 p.m., indicated Resident 1's lab results were positive for C. diff. A progress note, dated 12/3/25 at 3:46 p.m., indicated Resident 1 required contact and isolation precautions. A progress note, dated 12/10/25 at 5:50 p.m., indicated Resident 1 continued to have frequent, loose, unformed stools. An Interdisciplinary team (IDT) note, dated 12/15/25 at 10:10 p.m., indicated Resident 1 continued on an antibiotic for C. diff and continued to have multiple loose, soft stools per day. A physician progress note, dated 12/23/25 at 12:31 p.m., indicated Resident 1 continued with abdominal discomfort and loose bowel movements. A physician note, dated 12/26/25 at 12:52 p.m., indicated Resident 1 tested positive for COVID-19 and was on isolation per facility protocol. A progress note, dated 12/31/25 at 6:30 p.m., indicated Resident 1 was in isolation for COVID-19. Resident continued on antibiotic for C. diff and had loose stools with foul odor. A progress note, dated 1/4/26 at 1:00 a.m., indicated Resident 1 had a second negative COVID-19 test in 48 hours and COVID-19 isolation orders were discontinued. A progress note, dated 1/4/26 at 12:03 p.m., indicated Resident 1 did not need isolation precautions. A provider progress note, dated 1/6/26 at 1:19 p.m., indicated Resident 1 continued to have loose stools and was receiving refractory (not responding to antibiotics) treatment for C.diff. A progress note, dated 1/8/26 at 9:03 p.m., indicated Resident 1 did not need isolation precautions. A progress note, dated 1/9/26 at 11:37 a.m., indicated Resident 1 had C. diff precautions in place and new orders were received for vancomycin (antibiotic). A progress note, dated 1/14/26 at 1:29 a.m., indicated Resident 1 continued on precautions for C. diff. A skilled progress note, dated 1/14/26 at 2:40 a.m., indicated no isolation precautions were needed. During an interview, on 1/14/26 at 12:10 p.m., LPN 12 indicated the facility staff were to wear gowns and gloves when entering Resident 1's room and were to wash hands with soap and water when entering and exiting the room. Resident 1 required staff assistance with toileting needs and she was incontinent of bowel at times. Staff were to assist Resident 1 with washing her hands with soap and water. During an interview, on 1/14/26 at 1:53 p.m., the DON indicated if a resident was on contact isolation, a sign should be on the door. If contact was made with a resident on contact isolation the staff were to wear a gown, gloves, mask, and face or eye protection if there was a risk of splashing. Proper hand hygiene was to be done. If caring for a resident with C. diff, soap and water were to be used. No alcohol-based sanitizer was to be used for residents with C .diff but would be acceptable for residents with COVID-19. Staff were made aware verbally of any resident on isolation and of any precautions that were to be taken. All facility departments were notified and each department had their own daily huddle where they passed the information along to their staff, such as if a resident was on isolation or had C. diff. Resident 1 was able to keep loose stools contained, so she was allowed to move about the facility. The precaution signs were changed on Resident 1's entryway due to confusion as to which sign(s) were appropriate. Facility staff were receiving re-education regarding isolation and hand hygiene. During an interview, on 1/14/26 at 1:53 PM, the Clinical Support Specialist indicated contact precautions were to protect the staff, meaning a resident on contact precautions had a diagnosis that could spread to others, whereas EBP protected the resident from staff. Resident 1 had a qualifying diagnosis for both EBP and contact isolation. Resident 1 had orders for contact isolation orders prior to the contact precaution sign being posted. When Resident 1's COVID-19 droplet precautions were discontinued, staff removed the contact precaution sign and left the EBP sign in place. A current facility policy, revised on 11/15/21, titled Infection Prevention and Control Program (IPCP), provided by the Administrator on 1/8/26 at 3:23 p.m., indicated the following: Purpose Statement: The purpose of this policy is to: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.2.a. Reviews and adopts the corporates Infection Prevention and Control guidelines recommending additions or revisions as necessary (Hand Hygiene, Standard Precaution, Contact Precautions, etc). Reviews policies and procedures annually. b. Surveillance activities to identify, investigate, control, and prevent the spread of infection. Infections should be tracked per hall/unit, type of infection, and monitor lab reports to identify organism(s).d. Evaluates implementations and effectiveness of recommended actions. e. Monitors compliance with infection control practices and procedures. A current facility policy, revised on 2/28/24, titled Guidelines for Contact Precaution , provided by the Administrator on 1/14/26 at 1:02 p.m., indicated the following: Purpose Statement: The purpose of this policy is to: To provide guidelines to prevent the spread of infectious disease organisms. Policy: Guidelines for Contact Precautions. Procedure: 1. Contact Precautions is a method designed to reduce the risk of transmission of microorganisms by direct or indirect methods. a. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized resident.b. Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's environment. 2. Contact Precautions are indicated to prevent and control HAI ( health-care associated infections) transmission of infection with any of the following: b. clostridium difficile.5. Personal Protective Equipment: a. Wear gloves before contact with the resident or environmental objects. Change gloves and wash hands after having direct contact with the resident, possible infective material, or potentially contaminated environmental objects in between each resident care intervention.6. Precaution Sign: a. Post a sign at the resident's door that is appropriate according to CDC guidance. 3.1-18 (a)3.1-18 (l)

Based on observation, record review, and interview, the facility failed to ensure required daily staffing information was accurately posted for residents, families, and the public by failing to include the facility census on daily staffing reports. This deficient practice had the potential to affect 51 of 51 residents by limiting residents, families, and the public from complete and accurate information regarding staffing levels in relation to the number of residents receiving care.Findings include:On 1/8/26 at 10:02 a.m., the facility's daily staffing report, located on the wall in the 100 hallway near the Social Services office, listed the number of nursing staff scheduled and/or working for each shift; however, the postings did not include the facility census for the corresponding date.On 1/9/26 at 1:33 p.m., the facility's daily staffing report did not include the facility census for the corresponding date.On 1/12/26 at 9:40 a.m., the facility's daily staffing report did not include the facility census for the corresponding date.On 1/13/26 at 8:39 a.m., the facility's daily staffing report did not include the facility census for the corresponding date.On 1/14/26 at 2:34 p.m., the facility's daily staffing report did not include the facility census for the corresponding date.During a review of Daily Staffing Reports from 12/2/25 through 1/13/25, provided by the Administrator on 01/14/2026 at 1:08 p.m., four reports included census information. The remaining 42 reports lacked census information.During an interview with the DON on 1/14/26 at 1:53 a.m., she indicated she was unaware the Daily Staff Reports lacked census information. The reports were automated and she was unsure why there was no census information included. The census was important because it would affect staffing requirements from one day to the next.

Based on observation, interview, and record review, the facility failed to ensure a resident with dementia did not receive anti-psychotic medications without indication for 1 of 5 residents reviewed for unnecessary medications (Resident 5) Findings include: On 12/2/24 at 10:30 a.m., Resident 5 was sitting in her wheelchair near the main lounge on 200 hall. On 12/3/24 at 10:36 a.m., the resident was propelling herself around in her wheelchair. On 12/5/24 at 11:04 a.m., the resident was propelling herself in her wheelchair, smiling and talking to a resident near her. Resident 5's clinical record was reviewed on 12/3/24 at 10:57 a.m. Diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, psychotic disorder with delusions due to known physiological condition, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder due to known physiological condition, and insomnia due to other mental disorder. She had current physician orders for sertraline (anti-depressant) 50 mg (milligram) daily, trazodone (anti-depressant) 12.5 mg daily, and olanzapine (antipsychotic) 5 mg daily. An annual Minimum Data Set (MDS) assessment, dated 12/6/23, indicated she had no hallucinations or delusions during the assessment period. A quarterly MDS assessment, dated 7/24/24, indicated she had no hallucinations or delusions during the assessment period. A quarterly MDS assessment, dated 11/1/24, indicated she had no hallucinations or delusions during the assessment period. A care plan, dated 3/28/22, indicated the resident demonstrated altered behaviors including delusions, such as (I have to go home to my parents and/or I have to go home to take care of my children). Interventions included checking for unmet needs, toiletings, thirst, and/or hunger, inform resident that the resident's parents wanted her to stay the night at the facility and they will get her tomorrow, observe for behavioral triggers and casual relationships to medical changes with all hands on care and contacts, offer diversionary activities, such as watching TV or doing a puzzle, offer to show resident to her room for the night and to orient to room. A care plan, dated 11/6/21, indicated the resident demonstrated exit-seeking behaviors. Interventions included assess need for wander guard and apply as appropriate, encourage regular family contact and/or visits with others, evaluate need for secured unit and transfer if needed, monitor for wandering triggers such as need for toileting, inactivity, time of day, etc, offer diversional activities as needed, provide structured routine to resident's day, re-direct resident away from doors/ exits as needed, and wander guard on right ankle. Review of a 12/6/24 Behavior Analysis Report indicated the resident had no behaviors noted in the last 120 days. Review of a 7/3/24 psychiatric Nurse Practitioner progress note indicated staff denied any new or worsening symptoms of delusions which was an improvement. The resident had intermittent delusional thoughts however symptoms were not distressing in any way. Review of a July 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. Review of an 8/29/24 psychiatric Nurse Practitioner progress note indicated staff denied any new or worsening symptoms of delusions. She did have intermittent delusional thoughts, however symptoms were not distressing in any way. Olanzapine was reported effective. No current concerns were voiced by staff or observed during the visit. Review of an August 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. Review of a 9/26/24 psychiatric Nurse Practitioner progress note indicated staff reported intermittent delusional thoughts. No reported changes in sleep. She did have intermittent delusional thoughts, however symptoms were not distressing in any way. Olanzapine was reported effective. No current concerns were voiced by staff or observed during the visit. Review of a September 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. Review of a 10/14/24 psychiatric Nurse Practitioner progress note indicated staff reported occasional nervousness. Staff reported that she did have delusional thoughts, however symptoms were not currently distressing. Olanzapine was reported effective. History of failed gradual dose reduction (GDR). No current concerns voiced during visit. A GDR for olanzapine was clinically contraindicated on 10/4/24. Review of an October 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, 1 out of 30 days but she was easily redirected. Review of an 11/20/24 psychiatric Nurse Practitioner progress note indicated staff reported that she had delusional thoughts, however symptoms were not currently distressing. Olanzapine was reported effective. History of failed GDR. No current concerns voiced during visit. A GDR for olanzapine was clinically contraindicated on 10/4/24. Review of a November 2024 Medication Administration Record (MAR) indicated she displayed delusions, such as wanting to go home or saying, I have to take care of my children, zero out of 30 days. During an interview, on 12/5/24 at 10:57 a.m., RN 18 indicated resident states she wants to go home and doesn't understand why she was here. She was easily redirected. During an interview, on 12/5/24 at 11:20 a.m., QMA 19 indicated they were tracking behaviors for tearfulness. She had not displayed any recent hallucinations, and she was easily redirected. During an interview, on 12/6/24 at 2:00 p.m., the psychiatric Nurse Practitioner indicated the resident was admitted to the facility on olanzapine. The resident had failed prior GDR attempts of olanzapine. She had increased confusion, tearfulness, changes in mood, and continued with her intermittent delusional thoughts. The resident's family reported that she had a history of psychosis. Before prescribing a resident an antipsychotic, without a mental health history, she looked at symptoms lasting longer than 6 months. Then she would question are the symptoms distressing to the resident; has the facility tried any non-pharmacological interventions, etc. She reassesses the need for an antipsychotic at every visit, which is usually weekly. The resident's psychosis caused her frequent delusions, tearfulness, and difficulty calming her down. She contraindicated the GDR of olanzapine if she has supporting documentation and input from the staff to support why she wouldn't GDR a medication. A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, provided by the Nurse Consultant, on 12/6/23 at 3:23 p.m., indicated the following: .Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage The Olanzapine manufacturer guidelines website at https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/020592s062021086s040021253s048lbl.pdf indicated olanzapine has a black box warning for elderly patients with dementia- related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa (olanzapine) is not approved for the treatment of patients with dementia- related psychosis. 3.1-37(a)

Based on record review, and interview, the facility failed to ensure physician's orders were followed for 3 of 18 residents reviewed for medications (Resident 29, 37, and 44). Findings include: 1. Resident 29's clinical record was reviewed on 12/4/24 at 9:46 a.m. Diagnoses included, but were not limited to, unspecified dementia with unspecified severity or behavioral disturbances, anxiety, respiratory failure with hypoxia (oxygen deficiency), hypertensive heart disease, and restlessness and agitation. A current physician's order, dated 7/30/21, indicated the resident's head of bed (HOB) should be elevated to alleviate/reduce shortness of breath while lying flat related to a diagnosis of emphysema, and low oxygen saturations. A current care plan, dated 7/30/21 and last reviewed on 10/25/24, indicated the resident had a potential for shortness of breath while lying flat. Shortness of breath was related to chronic obstructive pulmonary disease, emphysema, and a history of pneumonia. An intervention, dated 7/30/21, was to elevate the head of the bed or place in an upright position as needed. During an observation on 12/4/24 at 10:46 a.m., Resident 29 was observed lying flat on her back in bed. The head of the bed was not elevated. During an observation on 12/4/24 at 2:08 p.m., the resident's bed was in a low position and the head of the bed was flat. During an observation on 12/4/24 at 2:36 p.m., Certified Nursing Assistant (CNA) 14 and CNA 15 transferred the resident from chair to bed. The CNAs settled the resident in the bed and the bed remained flat when they left the room. During an interview, after the CNAs left the room, CNA 14 and CNA 15 both indicated they were not sure if the head of the bed was supposed to be elevated. During an observation on 12/5/24 at 10:59 a.m., Resident 29 was lying flat on her back in bed. The head of the bed was not elevated. During an interview with LPN 16 on 12/6/24 at 12:11 p.m., she indicated she was unsure whether the head of Resident 29's bed was supposed to be elevated. During an interview on 12/6/24 at 12:17 p.m., CNA 11 indicated there was nothing in the resident's profile in the clinical record to indicate the head of the bed should be elevated. A current facility document, titled Guidelines for Medication Orders, was provided by the nurse consultant on 12/6/24 at 3:23 p.m. The policy indicated the following: .2) A current list of orders will be maintained in the electronic clinical record for each resident .9) Treatment Orders - a. When recording treatment orders specify 1). What is to be done, location and frequency and duration of treatment The facility did not provide a policy regarding following physician orders not pertaining to medications 49411 2. During an observation, on 12/2/24 at 10:10 a.m., Resident 37 was wearing support hose on her bilateral lower legs. Resident 37's clinical record was reviewed on 12/03/24 at 10:30 a.m. Diagnoses included hypertension, heart failure, shortness of breath, chronic obstructive pulmonary disease, and sepsis. Resident 37 had a past physician order for support hose to be applied in the morning and removed at bedtime, initiated 10/4/22 and discontinued on 7/23/24. A nursing progress note, dated 9/18/24 at 10:54 p.m., indicated the resident stated this morning when staff applied the support hose, her right lower leg was scratched, and a small scab was intact without drainage or edema. During an observation, on 12/3/24 at 11:18 a.m., Resident 37 walked out of her room wearing support hose on her bilateral lower legs. Resident 37 indicated the staff put support hose on her legs every morning. During an interview, on 12/3/24 at 11:19 p.m., LPN 6 indicated the resident was wearing her support hose, but she was unsure why she didn't have an order for them. During an interview, on 12/3/24 at 11:26 a.m., CNA 13 indicated Resident 37 normally wore support hose and staff applied them daily. A new physician order, dated 12/3/24 at 12:05 p.m., indicated the resident was to wear support hose. During an interview, on 12/6/24 at 2:22 p.m., the DON indicated the resident wanted staff to put the support hose on so the facility got the order for them. A current facility policy, dated 5/2016, Titled Guidelines for Medication Orders, provided by the corporate nurse, on 12/6/24 at 3:23 p.m., indicated the following: .Treatment orders: When recording treatment orders specify what is to be done, location, frequency and duration of treatment 45122 3. Resident 44's clinical record was reviewed on 12/3/24 at 12:25 p.m. Diagnoses included acute posthemorrhagic anemia and anemia. Current physician orders included apixaban (blood thinner) 5 milligrams (mg) twice a day (2/9/24) and occult blood fecal one time (4/9/24). A quarterly 11/7/24 Minimum Data Set (MDS) assessment indicated the resident had anemia and received an anticoagulant (blood thinner). A care plan for risk of excessive bleeding and bruising related to medications was initiated on 2/6/24. Interventions included labs as ordered and notify physician of abnormal labs (2/6/24). A Progress Note, dated 4/8/24 at 11:19 a.m., indicated the resident was seen by the Nurse Practitioner (NP) for multiple concerns including abdominal distention with an eight-pound weight gain over one month. The family was concerned about ongoing urinary and bowel and reported the resident's abdomen had been bloated and hard. The resident had been having dark, tarry stools. The resident was taking iron and apixaban. The resident had a positive fecal occult blood test on 9/25/23. The NP's assessment/plan included the resident had black, tarry stools with a history of melena (black, tarry stools indicating bleeding in the upper gastrointestinal tract). Hemoccult stools daily x 3 days and complete blood count (CBC) on the next day were ordered. For the abdominal distention with mild lower abdominal tenderness an abdominal X-ray was ordered. Orders were discussed with the family and nursing staff. A Nurses Note, dated 4/8/24 at 11:30 p.m., indicated written orders were received from the NP for hemoccult stools for 3 days, CBC 4/9/24, and abdominal X-ray. A Progress Note, dated 4/10/24 at 8:39 a.m., indicated the resident was seen by the NP. The abdominal X-ray was negative. Hemoccult stools and labs were still pending. A Progress Note, dated 4/25/24 at 7:46 a.m., indicated the resident was seen by the NP. The hemoccult stools were pending. CBC on 4/10/24 was stable. The resident's clinical record lacked indication of completion of hemoccult testing and the results. During an interview, on 12/4/24 at 2:45 p.m., the Nurse Consultant indicated she would look for the results of the resident's hemocult testing. During an interview, on 12/5/24 at 2:05 p.m., the Nurse Consultant indicated she had been unable to locate documentation of the resident having had the hemoccult testing completed. During an interview, on 12/6/24 at 2:22 p.m., the Director of Nursing (DON) indicated the facility did not have documentation of performing the hemoccult testing. The NP had given a verbal order to discontinue the hemoccult order when her labs came back okay, but no one had removed the order. During an interview, on 12/9/24 at 2:45 PM, the Nurse Consultant indicated she was unable to locate a facility policy for physician orders for labs and diagnostics. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to maintain a resident's dignity and provide privacy during a random observation of personal care. (Resident 46) Findings include: Resident 46's clinical record was reviewed on 12/3/24 at 9:50 a.m. Current diagnoses included morbid (severe) obesity, multiple sclerosis, depression, anxiety, chronic pain syndrome, overactive bladder, constipation, muscle weakness, paresthesia of skin, and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], indicated the resident was frequently incontinent of both bowel and bladder. The resident was cognitively intact and required total assistance for personal hygiene, including pericare. A current care plan, initiated 9/20/24, indicated the resident had impairment in functional status and required assistance with all activities of daily living (ADLs). During a personal care observation on 12/4/24 at 11:45 a.m., CNA 11 and CNA 12 were performing pericare for Resident 46 in her room. Resident 46 was fully undressed, with an adult brief open. CNA 12 assisted the resident to her side and CNA 11 removed the adult brief from underneath the resident. The two CNAs continued to assist the resident. During that time, the resident remained without any clothing or covering. The resident's sheet and blanket were observed on the chair next to her bed. At 11:52 a.m., the resident was left lying flat on top of her brief. CNA 11 indicated to Resident 46 to finish moving her bowels and that they (the CNAs) would return to complete peri care after she was finished. At that time, CNA 12 helped the resident put on her shirt. No other coverings were provided to the resident. During an interview with CNAs 11 and 12, on 12/4/24 at 12:00 p.m., CNA 12 indicated she had forgotten to cover the resident up with a sheet. It was not her practice to leave the resident exposed during peri care, and she should have put the resident's shirt on before continuing. A facility policy, titled Perineal Care for Incontinence, was provided by the Nurse Consultant on 12/6/24 at 11:40 a.m. The policy did not address ensuring dignity was maintained during the procedure. The Indiana State Department of Health Nurse Aide Curriculum, retrieved from https://www.in.gov/health/files/Indiana_Nurse_Aide_Curriculum.pdf indicated the following instructions for bed baths and perineal care on Page 196 - .3) Provide resident privacy - Maintains resident's dignity and right to privacy by not exposing body. Keeps resident warm .13) Place towel over chest and abdomen - Maintains resident's right to privacy .14) Exposing only the area of the body necessary to do the procedure maintains resident's dignity and right to privacy 3.1-3(a)

Based on record review and interview, the facility failed to ensure a resident with a change in condition was assessed prior to hospitalization for 1 of 1 residents reviewed for hospitalization (Resident 51). Findings include: During an interview, on 12/2/24 at 10:04 a.m., Resident 51 sat in her recliner with her feet elevated. The resident indicated she had been hospitalized shortly after she had been admitted because she had become incoherent. Her blood sugar had been very low. Resident 51's clinical record was reviewed on 12/3/24 at 11:05 a.m. Diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for close fracture with routine healing (9/23/24), type 2 diabetes mellitus with diabetic chronic kidney disease (9/23/24), and anxiety disorder, unspecified (9/23/24). Physician orders included glimepiride (for high blood sugar) 2 milligrams (mg) daily (started 9/23/24 and discontinued 9/30/24), metformin (for high blood sugar) 500 mg twice a day (started 9/23/24 and discontinued 9/30/24), and pioglitazone (for high blood sugar) 15 mg daily (started 9/23/24 and discontinued 9/30/24). An admission Minimum Data Set (MDS) assessment, dated 10/7/24, indicated the resident was cognitively intact. A current care plan for hypoglycemic (lower blood sugar) medications was initiated on 9/24/24 with a long-term goal to be free from adverse effects associated with hypoglycemic medications. The interventions included the following: Monitor blood sugar as ordered or as needed (9/24/24) and observe for and report signs and symptoms of adverse effects of medication such as dizziness, drowsiness, nausea, and hypoglycemia (9/24/24). A current care plan for a risk for hypo/hyperglycemia related to diabetes mellitus was initiated on 9/24/24. The interventions included observe the resident for hypoglycemia such as sweating, cold, clammy skin, numbness of the fingers, toes, mouth, rapid heartbeat, tremors, and dizziness. A Nurses Note, dated 9/28/24 at 5:32 p.m., indicated the resident was alert and oriented to person, place, time, and event. A Nurses Note, dated 9/28/24 at 9:53 p.m., indicated the resident was lying in her bed and put on her call light. She was unable to tell the certified nurse aide (CNA) what she needed. She did not know why she turned on the call light. The resident turned on her call light again within five minutes. Another CNA entered her room and asked what she needed, and she did not know what she needed. The resident put on her call light after five more minutes. The nurse obtained vital signs. The resident stared into space with pinpoint slow reactive pupils and with involuntary twitching all over her body. The resident was unable to answer any questions or speak any clear words. The resident was sent to the hospital via emergency medical services for evaluation. A Nurses Note, dated 9/29/24 at 5:01 a.m., indicated the resident was admitted to the hospital for hypoglycemia. The resident's clinical record lacked blood sugar tests taken by the facility during the change in condition and prior to hospitalization . A hospital history and physical with the hospital admission paperwork on 10/1/24 indicated the resident presented with aphasia to the hospital on 9/28/24. She was normally alert and oriented but around 9:30 the staff stated the resident was unable to speak, had jerky movements and had pinpoint pupils. The medics obtained a blood sugar of 29 mg/dL (milligrams per deciliter). During an interview, on 12/4/24 at 9:46 a.m., LPN 4 indicated Resident 51 had a lot of anxiety when she was first admitted . The change in the resident's condition started as increasing anxiety, and LPN 4 tried to calm the resident. When LPN 4 went to check on the resident she had body shakes, and her blood pressure was low. The resident's family wanted her sent to the hospital. LPN 4 had not realized the resident's diabetes was not stable. LPN 4 indicated it did not register for her to check the resident's blood sugar. During an interview, on 12/4/24 at 12:31 p.m., NP 10 indicated she remembered the resident had several hypoglycemics ordered when she was admitted . She did not recall seeing the resident prior to the rehospitalization as she had been at the facility for only a few days before going back to the hospital. She would not have typically ordered routine blood sugars for a resident on oral hypoglycemics if there was not a history of problems with the blood sugar. During an interview, on 12/4/24 at 2:25 p.m., the Director of Nursing (DON) indicated she would expect a blood sugar to be obtained with a change in condition of a resident with diabetes. A facility policy, dated 12/31/23, provided by the Corporate Nurse Consultant on 12/6/24 at 11:41 a.m., titled HYPER/HYPOGLYCEMIA, indicated the following: .All residents diagnosed with diabetes mellitus, will receive interventions according to their physician orders. If the attending physician (s) have not provided specific orders on what treatment is to be provided to treat hypoglycemic episodes, the following guidelines will be followed until the attending physician can be contacted .Symptoms of hypoglycemia (<60) may consist of (not necessarily limited to) the following: 1. tremors .anxiety .altered mental capacity such as confusion or abnormal behaviors .PROCEDURE: 1. Finger stick blood glucose will be done when the resident exhibits signs of hyper/hypoglycemia. 2. Notify the physician of the result of the resident's finger stick glucose level and report the resident's condition .If the resident does not have specific order for treatment, the following procedure will be followed: .BLOOD GLUCOSE < 50 MG/DL and ALERT - Give 30-gram carbohydrate oral feeding of one of the following: 2 tubes of glucose gel, 8 ounces of any juice without added sugar, 8 ounces of regular soda pop. Wait 15 minutes and recheck blood sugar. If resident continues to have hypoglycemic symptoms or blood sugar < 70, repeat 15-gram carbohydrate oral feeding. Recheck blood sugar every 15 minutes and repeat 15-gram carbohydrate oral feeding until symptoms are resolved or blood sugar is >70. Notify resident's primary physician of condition and what has been done (including current diabetes medication, blood glucose results at the time of discovery and past treatment, vital signs at the time of discovery and past treatment, signs and symptoms, action taken and response .BLOOD GLUCOSE < 50 MG/DL AND UNABLE TO SWALLOW - If a resident has a decreased level of consciousness and is unable to safely take oral treatment: Administer 1 mg glucagon IM. Resident should awaken within a couple of minutes. If resident continues to be unresponsive, administer additional 1 mg glucagon IM and call emergency assistance. Notify resident's primary physician of condition and what has been done (including current diabetes medication, blood glucose results at the time of discovery and past treatment, vital signs at the time of discovery and past treatment, signs and symptoms, action taken and response 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control procedures during blood glucose testing for 2 of 4 residents reviewed for medication administration (Residents 51 and 106) and during perineal care for 1 of 1 residents observed during perineal care (Resident 46). Findings include: 1. During a random medication administration observation on 12/4/24 at 11:30 a.m. LPN 4 removed a bottle of glucometer strips from the top of the medication cart and a plastic bag containing Resident 51's glucometer from the right-side top drawer of the medication cart. When LPN 4 went into Resident 51's room, she placed the plastic bag and the bottle of glucometer strips on Resident 51's bedside table. No barrier was placed on the bedside table prior to placing the plastic bag and bottle of glucometer strips. LPN 4 performed hand hygiene, applied gloves, used an alcohol wipe to cleanse the resident's finger, performed a finger stick with a lancet, wiped off the first drop of blood, and used the next drop of blood for the blood sugar test. Upon completion of the blood sugar test, LPN 4 removed her gloves, washed her hands, and gathered the glucometer bottle and plastic bag with supplies. She placed the bottle of glucometer strips on top of the medication cart. The plastic bag was placed on top of the medication cart until the glucometer was disinfected, then the glucometer was put into the plastic bag and back into the top right drawer of the medication cart with other plastic bags. She did not clean or disinfect the bottle of glucometer strips or the plastic bag prior to placing on or in the medication cart. Resident 51's clinical record was reviewed on 12/4/24 at 2:30 p.m. Diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease. Physician's orders included blood sugar check before meals and at bedtime (10/1/24). 2. During a random medication administration observation on 12/4/24 at 11:52 a.m. LPN 4 removed a bottle of glucometer strips from the top of the medication cart and a plastic bag containing Resident 106's glucometer from the right-side top drawer of the medication cart. When LPN 4 went into Resident 106's room, she placed the plastic bag and the bottle of glucometer strips on Resident 106's bedside table. No barrier was placed on the bedside table prior to placing the plastic bag and bottle of glucometer strips. LPN 4 performed hand hygiene, applied gloves, used an alcohol wipe to cleanse the resident's finger, performed a finger stick with a lancet, wiped off the first drop of blood, and used the next drop of blood for the blood sugar test. Upon completion of the blood sugar test, she removed her gloves, washed her hands, and gathered the glucometer bottle and plastic bag with supplies. She placed the bottle of glucometer strips on top of the medication cart. The plastic bag was placed on top of the medication cart until the glucometer was disinfected, then the glucometer was put into the plastic bag and back into the top right drawer of the medication cart with other plastic bags. She did not clean or disinfect the bottle of glucometer strips or the plastic bag prior to placing on or in the medication cart. Resident 106's clinical record was reviewed on 12/4/24 at 2:35 p.m. Diagnoses included diabetes mellitus. Physician orders included insulin lispro (rapid acting insulin) 100 unit/milliliter (ml) per sliding scale. If blood sugar is 121 to 150, give 2 units. If blood sugar is 151 to 200, give 4 Units. If blood sugar is 201 to 250, give 6 Units. If blood sugar is 251 to 300, give 8 Units. If blood sugar is 301 to 350, give 10 Units. If blood sugar is greater than 350, call MD (physician). Give subcutaneously (12/2/24). During an interview, on 12/4/24 at 12:08 p.m., LPN 4 indicated she had not thought about putting the strips on the table then back onto the cart and should not have moved the supplies from dirty to clean. During an interview, on 12/6/24 at 2:05 p.m., the Director of Nursing (DON) indicated the bottle of glucometer strips and the plastic bags should not have been placed on the residents' tables without a barrier. A facility policy, dated 12/31/23, provided by the Nurse Consultant on 12/6/24 at 2:50 p.m., titled Glucometer SOP [standard operating procedure], indicated the following: .Appropriate infection control technique shall be followed during testing procedures 48384 3. Resident 46's clinical record was reviewed on 12/3/24 at 9:50 a.m. Diagnoses included, but were not limited to, morbid (severe) obesity, multiple sclerosis, depression, anxiety, chronic pain syndrome, overactive bladder, constipation, muscle weakness, parasthesia of skin, and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], indicated the resident was frequently incontinent of both bowel and bladder. The resident was cognitively intact and required total assistance for personal hygiene, including peri-care. A current care plan, dated 9/20/24, indicated the Resident 46 had impairment in functional status and required assistance with all activities of daily living (ADLs). During an observation of incontinence care on 12/4/24, at 11:45 a.m., CNA 11 and CNA 12 began to perform perineal care for Resident 46. CNA 12 assisted the resident to a side-lying position. CNA 11 performed perineal care by cleansing the peri-area with wet wipes. She was observed to wipe from front to back and from back to front. The resident continued to be incontinent of bowel at that time. Each swipe with the wet wipes produced additional amounts of fecal matter. CNA 11 indicated they would leave the resident to finish the bowel movement before completing peri care. During an interview with CNA 11 on 12/4/24 at 12:00 p.m., she indicated it was not appropriate to wipe the peri-area from back to front. An undated facility policy, titled Perineal Care for Incontinence, provided by the Nurse Consultant on 12/6/24 at 11:40 a.m. indicated the following: The procedure included the following instruction(s): .7) Pay particular attention to infection prevention and control techniques when performing peri-care, to prevent introduction of contamination that may lead to a urinary tract infection The Indiana State Department of Health Nurse Aide Curriculum, retrieved from https://www.in.gov/health/files/Indiana_Nurse_Aide_Curriculum.pdf indicated the following: .Procedure 33 - Bed Bath/Perineal Care - Step 23) Wipe from front to back and from center of perineum to thighs. If washcloth is visibly soiled, change cloths. Rationale 23 - . Prevents spread of infection. Females: Removes secretions in skin folds which may cause infection or odor .Step 28) Clean anal area from front to back. Rinse and pat dry thoroughly. Rationale 28 - Prevents spread of infection 3.1-18(l) 3.1-18(a)

Based on record review and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by deficiencies cited and to ensure quality assurance procedures were followed and plans of action implemented to prevent deficiencies from re-occurring. This affected 1 of 3 residents reviewed for unnecessary medications. (Resident 5) Finding includes: Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey completed on 12/7/24, indicated the facility had deficiencies related to failure to ensure a resident with dementia did not receive anti-psychotic medications without indication. During an interview, on 1/30/25 at 11:18 a.m., the Administrator indicated the Quality Assessment and Assurance (QAA) committee met monthly. Since the Plan of Correction, staff had been educated on properly documenting Resident 5's behaviors. A facility policy, revised on 11/14/19, titled, Quality Assessment and Assurance Committee/ Quality Assurance and Performance Improvement (QAPI) Program, provided by the Administrator on 1/30/25 at 11:18 a.m., indicated the following: . Performance Improvement plans (PIP) will include facility development, monitoring, and evaluation of performance indicators, and include the methodology and frequency for such development, monitoring an evaluation . Reporting to the Quality Assessment and Assurance Committee will include improvement/lack of improvement, with changes to the action plan as deemed necessary to meet compliance .The facility shall set priorities for its performance improvement activities, track adverse resident events, and perform an improvement project as indicated. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the campus' services and available resources, as reflected by the campus assessment Cross reference F744. 3.1-52(b)(2)

Based on record review and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by deficiencies cited and to ensure quality assurance procedures were followed and plans of action implemented to prevent deficiencies from re-occurring. This affected 1 of 3 residents reviewed for unnecessary medications. (Resident 5) Finding includes: Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey completed on 12/7/24, indicated the facility had deficiencies related to failure to ensure a resident with dementia did not receive anti-psychotic medications without indication. During an interview, on 1/30/25 at 11:18 a.m., the Administrator indicated the Quality Assessment and Assurance (QAA) committee met monthly. Since the Plan of Correction, staff had been educated on properly documenting Resident 5's behaviors. A facility policy, revised on 11/14/19, titled, Quality Assessment and Assurance Committee/ Quality Assurance and Performance Improvement (QAPI) Program, provided by the Administrator on 1/30/25 at 11:18 a.m., indicated the following: . Performance Improvement plans (PIP) will include facility development, monitoring, and evaluation of performance indicators, and include the methodology and frequency for such development, monitoring an evaluation . Reporting to the Quality Assessment and Assurance Committee will include improvement/lack of improvement, with changes to the action plan as deemed necessary to meet compliance .The facility shall set priorities for its performance improvement activities, track adverse resident events, and perform an improvement project as indicated. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the campus' services and available resources, as reflected by the campus assessment Cross reference F744. 3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident with recurrent urinary tract infections received sufficient fluids for 1 of 2 residents reviewed for hydration. Findings include: During an observation, on 12/4/24 at 9:29 a.m., Resident 29 was not in her room. Her full water jug was on the table next to her bed, did not contain any ice, and was warm to the touch. Resident 29's clinical record was reviewed on 12/4/24 at 9:46 a.m. Diagnoses included anxiety disorder, paranoid personality disorder, hypertensive heart disease without heart failure, cognitive communication deficit, and urinary tract infection. A physician's order, dated 1/21/24 at 1:14 a.m., indicated regardless of urinalysis results, fluids were to be pushed. A current care plan, dated 3/1/22 and last reviewed on 12/4/24, indicated the resident had a history of urinary tract infections. Interventions included to encourage the resident to drink fluids. A current care plan, dated 8/10/21 and last reviewed on 10/25/24, indicated the resident had impairment in functional status in regards to bed mobility, transfers, toileting, and eating. Interventions included to encourage the resident to eat and drink as able. A current care plan, dated 8/10/21 and last reviewed on 12/4/24, indicated the resident experienced episodes of incontinence. Interventions included to encourage fluids, unless contraindicated. On 12/4/24 at 10:32 a.m., the full water jug remained in the same position on the table next to the resident's bed. There was no ice in the water and the jug was warm to the touch. On 12/4/24 at 2:08 p.m., the water jug had not been moved. It was in the same position, at the same (full) level, did not have ice, and was warm to the touch. On 12/5/24 at 10:59 a.m., the resident's water jug was on the table next to her bed. The water jug was full, with no ice, and was warm to the touch. On 12/6/24 at 12:02 p.m., the resident's water jug was on the table next to her bed. The water jug was full, with no ice, and was warm to the touch. The resident was diagnosed with urinary tract infections (UTI's) on the following dates: 12/14/23, 1/20/24, 3/23/24, 7/19/24, 8/16/24, and 9/21/24. During an interview with LPN 16 on 12/6/24, at 12:11 p.m., she indicated fresh water with ice was provided to residents at 6:00 a.m., 2:00 p.m., and 11:00 p.m. Resident 29 was able to hold a cup if offered to her. The resident was not able to reach from her bed to the side table to retrieve the water jug. During an interview with LPN 17, on 12/6/24 at 12:18 p.m., she indicated Resident 29 was not able to drink water independently. If handed the jug of water, the resident would drink from a straw. The resident would sometimes refuse the water, depending on her mood. A current facility policy, titled Guidelines for Hydration Management, provided by the Nurse Consultant on 12/6/24 at 3:56 p.m., indicated the following: .Purpose - To identify residents at risk for dehydration and implement individualized interventions which promote sufficient fluid intake to maintain proper hydration 3.1-46(2)(b)

Based on record review and interview, the facility failed to ensure medications were available and provided as ordered for 1 of 1 residents reviewed for medication availability. (Resident 28) Findings include: During an interview with Resident 28's representative, on 11/2/23 at 11:50 a.m., they expressed concern regarding a three day period in which the resident was not administered her carbamazepine, a drug used to treat trigeminal neuralgia (TN). (TN is a chronic pain disorder which causes sudden, severe pain on one side of the face.) The daughter indicated her mother began to experience extreme discomfort and jaw pain by the third day. She thought the resident was having a seizure. The DON told her the reason the medication had not been administered was because it was not available. Resident 28's clinical record was reviewed on 11/2/23 at 3:30 p.m. Diagnoses included, but were not limited to, unspecified dementia and trigeminal neuralgia. A physician's order, dated 7/5/23, indicated carbamazepine tablet, extended release 12 hour, 200 mg, 1 tablet twice a day for trigeminal neuralgia. A physician's order, dated 8/16/23, indicated carbamazepine tablet, extended release 12 hour, 200 mg, 2 tablets every morning for trigeminal neuralgia. A progress note, dated 10/12/23 at 4:53 p.m., indicated a STAT request for carbamazepine from the pharmacy. The medication was to be delivered that evening. A progress note, dated 10/12/23 at 6:55 p.m., indicated the resident was complaining of jaw pain. The NP was notified and provided a new order for Ibuprofen 400 mg every eight hours. A progress note, dated 10/12/23 at 1:46 p.m., indicated the carbamazepine was received from the pharmacy and administered as ordered at 8:16 p.m. A progress note, dated 10/13/23 at 1:57 p.m., indicated the resident had ongoing, occasional jaw pain. She was encouraged to not drink cold liquids. Review of the 10/2023 medication administration report (MAR), on 11/2/23 at 3:32 p.m., indicated carbamazepine was not administered on 10/10/23, 10/11/23, and 10/12/23, and each entry indicated the Medication (was) Not Available. During an interview with LPN 2, on 11/3/23 at 10:53, she indicated she did witness the resident's pain on 10/12/23. Carbamazepine was a difficult medication to get because Resident 28 was the only resident who received that medication and it was not kept in the emergency drug kit. She did recognize the resident was in extreme pain and had received Tylenol for the pain. The resident was back to her normal self once the carbamazepine had been reintroduced. She could understand why the resident's family thought their mother might be having a seizure, because the resident was in extreme pain. During an interview with two of the resident's representatives, on 11/3/23 at 11:15 a.m., they indicated they felt the need to routinely check to make sure the facility had the carbamazepine in stock because they were concerned she might miss her medication again. They were fearful of a repeat of the events on 10/12/23. During an interview with the DON on 11/08/23 at 11:01 a.m., she indicated she found out on 10/12/23 that the medication was not available. A request was made to the pharmacy to resupply the medication. had spoken with the family and explained to them what she was doing to remedy the situation. There should be a way to re-order from the pharmacy. The current process for reordering medications did not provide a way to know when and if an order had gone through to the pharmacy. There was a system in place where the facility could get medications from a back-up pharmacy. She was aware of the potential adverse effects that could be triggered when the medication was missed. A document titled Miscellaneous Special Situations .Unavailable Medications, with a revised date of 11/2018, was provided by the DON on 11/8/23 at 3:52 p.m. and indicated the following: .Medications used by residents in the facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident B) Facility personnel shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and option therapies that are available. a) If the facility personnel is unable to obtain a response from the attending physician, the personnel should notify the supervisor and contact the Facility Medical Director for orders and/or directions 3.1-25(a)

Based on interview and record review, the facility failed to ensure a resident was assisted with transfers in accordance with the plan of care for 1 of 5 residents reviewed for accidents. (Resident 36) Finding includes: Resident 36's clinical record was reviewed on 11/2/23 at 2:26 p.m. Diagnoses included hemiplegia and hemiparesis following non-traumatic subarachnoid hemorrhage affecting left non-dominant side (7/15/22), unspecified fracture of the lower end of left radius (7/24/23), age-related osteoporosis without current pathological fracture (7/10/23), morbid (severe) obesity due to excess calories (7/15/22), unsteadiness on feet (7/12/23), history of falling (7/12/23), muscle weakness (generalized) 7/12/23, and repeated falls (7/12/23). A quarterly Minimum Data Set (MDS) assessment, dated 5/3/23, indicated the resident was cognitively intact and required substantial/maximal assistance with the ability to safely come to a standing position from sitting in a chair or on the side of the bed, the ability to safely get on and off a toilet or commode, and walk 10 feet. A Nursing Progress Note, dated 3/15/23 at 4:30 a.m., indicated the resident was assisted to the bathroom and turned around before she was aligned with the toilet. She sat down onto the floor. No apparent injuries were identified. A fall care plan, initiated on 7/19/22, indicated the resident was at risk for falling related to required assistance. An intervention, dated 3/15/23, indicated the resident was to be verbally cued to sit on the toilet. A Nursing Progress Note, dated 4/6/23 at 8:15 p.m., indicated the resident was holding onto the bar in the bathroom with assistance of a nurse aide when her legs weakened. She was lowered to the floor by the nurse aide. No apparent injuries were identified. An intervention, added to the fall care plan on 4/7/23, indicated the resident required assistance of two staff members for transfers to the toilet. A Nursing Progress Note, dated 4/7/23 at 11:08 a.m., indicated the resident was assisted to the floor. The resident indicated her legs gave out when being transferred from bed to wheelchair. She complained of pain to her left knee and right toes. No apparent injuries were identified. An intervention, added to the fall care plan on 4/10/23, indicated the resident required assistance of two staff members for all transfers. A Point of Care Response, dated 5/17/23 at 8:13 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/17/23 at 3:32 p.m., indicated the resident was transferred with limited assistance of one person. A Point of Care Response, dated 5/18/23 at 12:34 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/18/23 at 10:28 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/19/23 at 12:18 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/19/23 at 11:07 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/19/23 at 3:19 p.m., indicated the resident was transferred with extensive assistance of one person. A Nursing Progress Note, dated 5/19/23 at 7:10 p.m., indicated when a nurse aide attempted to assist the resident to bed, the bed rolled due to being unlocked. The resident acquired a light purple bruise to her left buttock of 3 centimeters (cm) by 2 cm and a skin tear to her the front of her middle finger of 0.4 cm by 0.2 cm. A Point of Care Response, dated 5/19/23 at 11:20 p.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/20/23 at 10:07 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 5/20/23 at 2:53 p.m., indicated the resident was transferred with extensive assistance of one person. An intervention, added on 5/22/23 to the fall care plan, indicated the staff should ensure the bed was locked before transferring the resident. A Physical Therapy Discharge Summary for a discharge date of [DATE], provided by the Administrator on 11/8/23 at 9:50 a.m., indicated the resident required partial/moderate assistance with ambulation on level surfaces with hemi-walker and with transfers A Point of Care Response, dated 7/9/23 at 2:40 a.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 7/9/23 at 2:50 p.m., indicated the resident was transferred with extensive assistance of one person. A Point of Care Response, dated 7/10/23 at 12:23 a.m., indicated the resident was transferred with total dependence on the assistance of one person. A Point of Care Response, dated 7/10/23 at 12:25 p.m., indicated the resident was transferred with extensive assistance of one person. A Nursing Progress Note, dated 7/10/23 at 5:00 p.m., indicated the resident was assisted by a nurse aide to the restroom via quad cane. As the resident turned, she fell forward onto the floor and landed on her affected side. Resident complained of left shoulder and wrist pain. A Point of Care Response, dated 7/11/23 at 2:47 a.m., indicated the resident was transferred with total dependence on the assistance of one person. A Nursing Progress Note, dated 7/11/23 at 10:01 a.m., indicated the Interdisciplinary Team reviewed the fall. Intervention was for the resident to use wheelchair for locomotion in room. A Progress Note, dated 7/12/23 at 10:31 a.m., indicated the NP saw the resident to follow up on pain after a fall. X-rays obtained on 7/10/23 indicated the left ankle had an avulsed (when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) fracture tip of lateral fibula, age indeterminate. The fracture was likely an old fracture as the resident no longer experienced left ankle pain. The resident continued to complain of left wrist pain of 10 of 10 on a 1 to 10 scale. The NP ordered ibuprofen (pain med) 400 mg by mouth every 8 hours for 7 days for left wrist pain and consider repeat imaging if needed. A Nursing Progress Note, dated 7/13/23 at 2:11 p.m., indicated the resident went to the orthopedic walk-in clinic in the morning regarding the left wrist and knee pain. The orthopedic clinic sent the resident back with a wrist splint for stabilization. The resident was given an injection to the left knee for the pain and swelling. The resident rated her pain a 10 out of 10 on a 1 to 10 scale and received ibuprofen. An annual Minimum Data Set (MDS) assessment, dated 7/22/23, indicated the resident was cognitively intact and required substantial/maximal assistance with the ability to safely come to a standing position from sitting in a chair or on the side of the bed, the ability to safely get on and off a toilet or commode, and walk 10 feet. A Physician's Note, from the orthopedic office, dated 7/24/23, indicated the resident had no acute ankle problems. The wrist was positive for fracture and would do well with continued treatment. The resident was to follow up with the orthopedic clinic as needed. An orthopedic office visit summary, dated 7/24/23, indicated the reason for the resident's visit was pain, swelling, an injury, and a fracture to the left ankle which had been present for two weeks. X-rays were taken of the left ankle and of the left wrist. The wrist x-rays indicated a non-displaced distal radius fracture. The ankle x-rays showed nothing acute. The brace to the left wrist was to be continued. During an interview, on 11/6/23 at 2:24 p.m., CNA 7 indicated the resident's profile on the computer told what kind of assistance was needed for the resident. Resident 36 required assistance of two for all transfers. During an interview, on 11/8/23 at 9:25 a.m., QMA 8 indicated the resident's profile in her electronic chart provided information on the assistance a resident required including specific orders and care plan interventions. Resident 26 required assistance of two for all transfers. During an interview, on 11/8/23 at 9:50 a.m., the Administrator indicated the resident required assistance of two with transfers, and not ambulation. She did not have assistance of two people with the fall on 5/19/23 during the transfer to bed. When the resident fell on [DATE], she was ambulating to the bathroom with her quad cane and one assist. The DON indicated the resident had received therapy between her falls in April and July with the intent to return home and once the resident was ambulating, she was fine. The current resident's profile from the resident's chart, provided on 11/8/23 at 3:50 p.m. by the Administrator, indicated the resident required assistance for transfers and two staff for all transfers. The Administrator indicated, when providing the profile, that the start dates for each intervention were not on the profile. All the dates on the profile were the original start date of the care plan. A current policy with a review date of 3/16/22, provided by the Administrator on 11/8/23 at 3:50 p.m., indicated .Trilogy health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures 3.1-45(a)(2)

Based on interview and record review, the facility failed to complete the screening for mental illness for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR) (Resident 38). Finding includes: Resident 38's record was reviewed on [DATE] at 2:14 p.m. Diagnoses included major depressive disorder, hallucinations, and delusional disorders. Current physician orders included lorazepam (antianxiety) 0.5 milligrams (mg) daily at bedtime, quetiapine (antipsychotic) 25 mg on Wednesdays at bedtime, quetiapine 50 mg on Sunday, Monday, Tuesday, Thursday, Friday, and Saturday at bedtime, and sertraline (antidepressant) 100 mg daily. A current care plan, initiated on [DATE] and last reviewed on [DATE], indicated the resident demonstrated altered behaviors including delusions of wife texting other men and/or running around town and meeting other men. During an interview, on [DATE] at 9:47 a.m., the Social Services Director was unable to produce a PASARR for the resident. He indicated the resident's PASARR screening was expired, would have to be redone, and he should have caught the lack of a completed PASARR for the resident. The hospital, prior to the pandemic, would do the screenings, but now with the pandemic waiver he completed the PASARR screenings with the admission assessments. Review of an undated, current facility policy, titled Indiana PASRR, provided by the Corporate Clinical Support RN (Registered Nurse) on [DATE] at 4:45 p.m., indicated the following: .with admission from the hospital the facility ensures the hospital has completed the appropriate screenings. During the admission process, the facility logs into Ascend (the website for PASARR screening) and prints the outcome letter out. For changes in status and Level II (in-depth assessment determining if a person has a qualifying PASARR condition such as a serious mental illness, intellectual disability and/or developmental disability) follow up, Social Services ensures paperwork is submitted, prints outcome letter and uploads it to the resident's clinical record 3XXX,d+[DATE](d)(1)

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents reviewed for medication administration. This deficient practice resulted in a resident being given the wrong mediations and being sent to the emergency room then admitted to the hospital for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: An investigation into the medication error was provided by the Administrator on 7/20/22 at 10:52 a.m. Review of the facility investigation included the following: a. A statement by LPN 1, dated 7/8/22, indicated she administered the wrong medication at 8:57 a.m. She immediately recognized the error and reported to the Nurse Practitioner (NP). New orders were received to check blood pressure and pulse every 4 hours for 24 hours. The resident was alert and responsive at that time but when she returned from breakfast, she had a small amount of emesis. She appeared pale and lethargic and her blood pressure was 76/46 at 9:30 a.m. The resident was taken to her room and assisted to bed. A new order was received to give [MEDICATION(S)] (emergency medical treatment to treat very low blood sugar) Intramuscular (IM) and start an intravenous line and give [MEDICATION(S)] (consists primarily of water and electrolytes) fluids. Her blood pressure and pulse were to be monitored every 15 minutes. The first 500 mL bolus was given and her blood pressure was 91/45. The NP gave an order to infuse another 250 mL of [MEDICATION(S)] (LR). Family arrived and requested another blood pressure check at 11:41 a.m. and it was 91/50. The family requested the resident be sent to the emergency room (ER). b. An investigation summary, dated 7/8/22, indicated the resident received the wrong medication because the nurse did not follow the medication administration policy. c. LPN 1 received counseling related to medication administration on 7/8/22. d. Audits of medication administration would be completed on residents for a total of 5 months. e. Facility-wide 5-Rights of Medication Administration was completed on 7/8/22 for all nursing staff. The clinical record for Resident B was reviewed on 7/20/22 at 8:20 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/2/22, indicated the resident had moderate cognitive impairment. A health care plan, dated 2/7/22, indicated the resident had the potential for cardiovascular distress related to heart failure, [CONDITION(S)] and hypertension. Interventions included, but were not limited to, medications as ordered and observe for signs and symptoms of cardiovascular distress. A progress note, dated 7/8/22 at 1:09 p.m., indicated the resident was brought to cart for morning medication. The nurse had prepared the medication and had given Resident B the wrong medication at 8:57 a.m. The Nurse Practitioner (NP) was in the facility and was immediately notified. Initial orders were to check blood pressure and pulse every 4 hours for 24 hours. Resident B returned from breakfast at about 9:25 a.m. and had a small amount of emesis. Her blood pressure was 76/46 and her pulse was 77. New order were received to give [MEDICATION(S)] IM and start an Intravenous(IV) line and give 500 mL of LR fluid at 500 mL per hour. Her blood pressure and pulse were to be assessed every 10-15 minutes. The NP was notified of blood pressure of 91/45 when 500 mL was completed. An order to continue another 250 mL of the LR fluid was received. The intravenous infusion was completed at 11:35 a.m. and her blood pressure was 95/50. A family member entered facility at 11:41 a.m. and requested her blood pressure be checked and it was 91/50. Resident's family requested she be sent to local hospital for evaluation and treatment. Vital signs included the following: a. 7/8/22 at 9:30 a.m., blood pressure 76/46 and pulse 77 b. 7/8/22 at 10:15 a.m., blood pressure 83/45 and pulse 69 c. 7/8/22 at 10:30 a.m., blood pressure 92/46 and pulse 65 d. 7/8/22 at 10:40 a.m., blood pressure 91/45 and pulse 60 e. 7/8/22 at 10:50 a.m., blood pressure 91/45 and pulse 63 f. 7/8/22 at 11:05 a.m., blood pressure 88/41 and pulse 60 g. 7/8/22 at 11:25 a.m., blood pressure 81/41 and pulse 60 h. 7/8/22 at 11:41 a.m., blood pressure 95/50, respirations 18 and pulse 59 i. 7/8/22 at 12:00 p.m., blood pressure 95/50, respiration 18 and pulse 59. Physician order's for Resident B included included [MEDICATION(S)] (used to prevent heart attack or stroke) 75 mg, [MEDICATION(S)] (to treat fluid retention) 40 mg, [MEDICATION(S)] (an oral diabetes medicine) 2.5 mg, [MEDICATION(S)] (to treat high blood pressure) 25 mg and [MEDICATION(S)] (to treat high blood pressure). Resident B received the following medications on 7/8/22 that were to be given to another resident: a. [MEDICATION(S)] 5 mg b. aspirin 81 mg c. [MEDICATION(S)] (to treat anxiety disorders) 10 mg d. [MEDICATION(S)] (to treat high blood pressure) e. [MEDICATION(S)] (to treat high blood pressure) 50 mg f. [MEDICATION(S)] 50 mg (to treat high blood pressure) g. [MEDICATION(S)] (management of chest pain) 40 mg h. omeprazole (to treat excess stomach acid) 40 mg i. [MEDICATION(S)] (to treat neuropathic pain) 200 mg j. [MEDICATION(S)] (to treat high blood pressure) 10 mg. Review of the hospital discharge summary, the resident was seen in the emergency room (ER) on 7/8/22 and then admitted to the hospital with significant PAF, congestive heart failure and hypertension. The resident was accidentally given someone else's medication that included [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The resident was found to be very pale and sleepy with low blood pressure. The resident was assessed and found to be frail and lethargic. She was having a difficult time staying awake and speaking. The resident's blood pressure was low on arrival but had since improved. The resident was also noted to have a urinary tract infection. The hospital course indicated there was concern for [CONDITION(S)] ([CONDITION(S)]) but the resident had a pacemaker and unable to undergo a Magnetic Resonance Imaging (MRI). The resident had a Computerized Tomography (CT) scan done on 7/8/22 with no abnormalities. The resident was discharged back to the facility on [DATE] on oral antibiotics. Following readmission to the facility on [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A NP progress note, dated 7/11/22 at 4:10 p.m., indicated the resident was readmitted from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was currently receiving antibiotic for the infection. During an interview on 7/20/22 at 10:52 a.m. with the Administrator, Director of Nursing and Clinical Support, both of the residents medications were covered by the facility so reimbursement was not necessary. They were not aware her readmitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They did not report the incident since the Nurse Practitioner (NP) was in the facility and the resident was not in any distress. The other resident received the correct medications. The nurse did not follow their medication administration policy and they have since completed a facility-wide inservice, as well as, audits. The family was trying to rule out a [CONDITION(S)] and her baseline of confusion varied day to day. During an telephone interview on 7/20/22 at 11:28 a.m., LPN 1 indicated she had went into Resident C's room to give him his morning medication, but he was in the bathroom and told her to come back. She placed his medication cup on top of the med cart. A staff person then brought Resident B to the med cart for her medications. She took her vital signs and got all of her pills and put into a medication cup and put her name on the cup. She set the cup down to pour her a glass of water and picked up the wrong cup. She then realized she gave the wrong medication because her cup was still on the med cart. Her intention was to give Resident C his medications but then staff brought Resident B for her medications. During an interview on 7/21/22 at 10:30 a.m. with the Administrator, Director of Nursing and Clinical Support, they felt the hospital kept the resident in an attempt to rule out a [CONDITION(S)] and for the urinary tract infection. The hospital would put a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a current policy revised 11/18, titled MEDICATION ADMINISTRATION GENERAL GUIDELINE,S provided by the Administrator on 7/21/22 at 10:30 a.m., indicated the following: Policy Medications are administered as prescribed in accordance with good nursing principles and practices Procedures .4) FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended 4) When medications are administered by mobile cart and taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. .14) Medications supplied for one resident are never administered to another resident. 15) During administration of medications No medications are kept on top of the cart This deficient practice was corrected on July 8, 2022 and is therefore past noncompliance. This Federal Tag relates to complaint IN 300. 3.1-25(b)(7)

A. Based on record review and interview, the failed to provide adequate supervision to prevent further falls for 1 of 8 residents reviewed for falls (Resident 43). This deficient practice resulted in Resident 43 sustaining a femur fracture. B. Based on observation, interview, and record review the facility failed provide adequate supervision to a resident with a known diagnosis of dysphagia for 1 of 3 residents reviewed for dysphagia (Resident 150). Findings include: 1. During an observation on 2/1/22 at 9:36 a.m., Resident 43 was sitting in a wheel-chair in the common area across from the nurses' station, she had a cast to right wrist that extended to the top of her hand, she mumbled help me Jesus and oh my God and some nonsensical verbalizations. Her clinical record was reviewed on 2/1/22 at 1:14 p.m. Diagnoses included, but were not limited to, unspecified fracture of lower end of right ulna, initial encounter for closed fracture, added 12/25/21, unspecified fall, subsequent encounter, added 12/25/21, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, added 1/11/22 and fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter, added 1/11/22. Current physician orders included, but were not limited to, [MEDICATION(S)] (opioid) with acetaminophen (analgesic), 7.5-325 mg (milligram), one tablet four times a day for pain, the order date was 1/20/22. A 12/13/21 significant change Minimum Data Set (MDS) assessment indicated she had moderate cognitive impairment. She required limited assistance to walk in room and in corridor, with locomotion on and off the unit, and extensive assistance with transfers, dressing and personal hygiene. She had one fall with major injury since her prior MDS assessment. A current care plan, initiated on 9/3/20 and edited on 1/17/22, indicated she had impairment in functional status in regards to bed mobility, transfers, toileting and eating. Interventions included, but were not limited to, she required assistance with eating, assistance with transfers, assistance with bed mobility, and assistance with toileting, the start date was 9/3/20. A current care plan, initiated on 9/3/20 and edited on 1/17/22, indicated she was at risk for falls. Interventions included, but were not limited to, staff to assist her with transfers as needed, the start date was 9/3/20. A current care plan, initiated on 12/27/21 and edited on 1/18/22, indicated she had an acute fracture of the distal radius and ulna right wrist area and had a cast applied at the hospital. Interventions included, but were not limited to, assess effects of pain on the resident (disturbances in sleep, activity, self care, appetite, psychosocial and role/relationships), the start date was 12/27/21. A current care plan, initiated on 1/12/22 and edited on 1/17/22, indicated she had a left hip fracture with repair. Interventions included, but were not limited to, assess effects of pain on the resident (disturbances in sleep, activity, self care, appetite, psychosocial and role/relationships), the start date was 1/12/22. A progress note, dated 12/25/21 at 6:33 a.m., indicated the resident had been rushing toward the front door at 6:00 a.m. because she believed her daughter was picking her up for the day. She had some belongings on the walker and her heavy coat on one side of the walker. She fell in the hallway onto her hands and knees. She had indicated her walker got away from her and went sideways with her coat. The walker was on its side off to the side of the resident. Her right wrist was hurting. Nurse Practitioner (NP) was notified and an order to obtain an x-ray was received. Her daughter had chosen to wait until later in the day to pick her up for Christmas celebration, after the x-ray results were known. A fall event, with a date recorded as 12/25/21 at 10:36 a.m., indicated she was at risk for falls related to cognitive or memory impairment that affects safety and judgement, she required use of an assistive device and/or often forgot to use device and required assistance to transfer. A progress note, dated 12/25/21 at 1:05 p.m., indicated the x-ray results indicated acute fracture of the distal radius and ulna. The NP was notified, new orders were obtained for her to see a walk-in orthopedic on 12/27/21, start [MEDICATION(S)] with acetaminophen 5-325 mg every four hours as needed for pain, utilize ace wrap for stabilization and apply ice as needed. An IDT (Interdisciplinary Team) progress note, dated 12/27/21 at 10:04 a.m., indicated for fall on 12/25/21 the intervention was she had been educated to not put heavy items on her walker that would cause tipping. Basket was to be put on walker when it was available. A progress note, dated 12/30/21 at 9:48 p.m., indicated the resident had been seen by the Nurse Practitioner and a new order had been received to increase [MEDICATION(S)]-acetaminophen order to 7.5-325 mg every four hours as needed for pain to right arm fracture. A progress note, dated 1/6/22 at 5:10 p.m., indicated she had a soft brace in place to her right arm, swelling and bruising had improved, able to move fingers with some tenderness. A progress note, dated 1/7/22 at 7:52 a.m., indicated she had been ambulating in the hallway with a rolling walker, missed the chair in the common room and landed on the floor beside the chair. External rotation noted to the left leg. She rated her pain at 8/10. 911 called for transfer to emergency room for evaluation. A fall event, with a date recorded as 1/7/22 at 7:52 a.m., indicated the fall was not witnessed. An IDT (Interdisciplinary Team) progress note, dated 1/7/22 AT 10:16 a.m., indicated she had moderate cognitive impairment, had been needing staff assistance with ADL's (Activity of Daily Living) and transfers due to fracture in right wrist. Staff to offer assistance with transfer to recliner after breakfast. A progress note, dated 1/7/22 at 12:01 p.m., indicated emergency room had been called for an update, informed the resident has fractured her femur and would be sent to an out of town hospital for surgery as soon as a bed opened. A progress note, dated 1/11/22 at 2:54 p.m., indicated the resident had returned to the facility. She had a hard cast to the old fracture to her right arm, hand was swollen. She had nine staples to her left thigh and ten in her left hip. A progress note, dated 1/15/22 at 3:48 p.m., indicated she was dependent on staff for ADL's and feeding. Routine acetaminophen utilized for pain control with as needed [MEDICATION(S)]-acetaminophen utilized for breakthrough pain. A progress note, dated 1/22/22 at 12:09 a.m., indicated the cast remained intact to wrist ulna/radius fracture and dressings clean, dry and intact on left hip/thigh. Routine [MEDICATION(S)]-acetaminophen administered four times a day for pain. A progress note, dated 1/26/22 at 1:02 p.m., indicated cast remained to right upper extremity and dressing was intact to left hip/thigh region. She had been up in a wheel-chair for meals, complained of pain at 7/10 at lunch with routine [MEDICATION(S)]-acetaminophen given for pain management. She had been confused at lunch and did not understand to feed herself. During an interview, on 2/8/22 at 1:05 p.m., the DON indicated the resident had not been assessed by therapy after her fall on 12/25/21. Review of a current facility policy, titled Fall Management Program Guidelines, with a revised date of 5/31/17 and provided by the Nurse Consultant on 2/9/22 at 2:22 p.m., indicated .2. Should the resident experience a fall the attending nurse shall complete the Fall Event This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode 2. On 2/7/22 at 1:31 p.m., Resident 150 was sitting upright in bed, he had eaten half of his coined carrots and meat that had been cut up. He indicated the staff would cut up his meat before they left the room, they typically did not stay in his room while he ate and of course, that was why he was at the facility. He had not had any choking episodes since he had been at the facility. On 2/9/22 at 1:40 p.m., he had eaten 1/2 of his chicken nuggets and his baked potato and 3/4 of his diced peaches. His wife was present and indicated he had a hard time with the skin on the chicken nuggets and she had to remove it. He had one severe episode of choking at the facility and it was on liquid a couple of weeks ago. She was most generally at the facility during lunch. Staff assisted the resident with cutting up food and one staff member was in the room one time assisting the resident with his meal when she arrived to visit. Resident 150's clinical record review was reviewed on 2/1/22 at 1:37 p.m. Diagnoses included, but not limited to, metabolic [CONDITION(S)], [CONDITION(S)], acute [CONDITION(S)] with [CONDITION(S)], pneumonia, [CONDITION(S)], acute lower respiratory infection, other intestinal obstruction unspecified as to partial versus complete obstruction, muscle weakness (generalized), other abnormalities of breathing, hypoxemia, weakness and dysphagia. His orders included, but not limited to, [MEDICATION(S)]-[MEDICATION(S)] (treat [CONDITION(S)]) 25-100 mg (milligram) four times daily, [MEDICATION(S)]-acetaminophen (narcotic pain reliever)10-325 mg every 6 hours, omeprazole 20 mg daily and regular diet with thin liquids. A 1/24/22 admission MDS (Minimum Data Set) indicated he was cognitively intact. He required extensive assistance of one staff member for eating. He coughed or choked during meals or when swallowing medications. He complained of difficulty or pain with swallowing, He had an impaired swallowing careplan related to dysphagia, difficulty with swallowing at times, and coughing at times with food or fluids, dated 1/31/22. His goal was he would use compensatory swallowing strategies during intake of food/liquids. His interventions included, but were not limited to, document and report refusal of meals/liquids, monitor and record intake of food, monitor and report difficulties swallowing, offer available substitutes if resident has problem with the food being served, provide adequate time for resident to feed self, assist resident as needed. A nurses note, dated 1/17/22 at 9:57 p.m., indicated he was alert and oriented and received hospice care. Resident along with his wife and paperwork was able to provide a through history and current health work up. Resident had extreme dysphagia and did not want liquids thickened or meals pureed, wife present on admission and was aware. A registered dietician admission note, dated 1/31/22 at 1:45 p.m indicated he was able to make needs known. He ambulated with walker or wheelchair he had his own teeth. He had dysphagia and refused to have fluid thickened or food pureed. He was on hospice services for palliative care and understood risks up to and included death. No noted episodes of choking on regular diet thin liquids and intakes average 50-75% with some noted lower meal intakes here and there fluids 350 ml (milliliters) average. During an interview with QMA 33, on 2/8/22 at 8:47 a.m., she indicated Resident 150 fed himself, she assisted him with cutting up his food and put straws in his drinks, his wife came in and sat with him at lunch. She was not aware that she needed to stay with him while he ate. But knew he had signed a waiver and did not want mechanical soft foods. On 2/8/22 at 9:38 a.m., the Clinical Support Nurse indicated they did not have a policy related to dysphagia. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 by failing to ensure personal protective equipment (PPE) was applied appropriately for 3 of 3 random observations of staff (CNA 42, QMA 44, MDS Coordinator, CNA 39, SSD). Findings include: During a random observation, on 2/01/22 at 1:32 p.m., CNA 42, prior to entering resident room [ROOM NUMBER] which signage indicated required TBP, applied gown, N95 mask over surgical mask, and gloves. During an interview, at the time of the observation, CNA 42 indicated the facility told him he could put the N95 over his surgical mask then he did not have to remove his surgical mask. During a random observation, on 2/01/22 at 1:51 p.m., QMA 44 applied an N95 mask over her surgical mask when preparing to enter resident room [ROOM NUMBER] which signage indicated required TBP. During an interview, at the time of the observation, QMA 44 indicated she usually applied an N95 mask over her surgical mask whenever she enters TBP rooms. During random observations on 2/1/22 the following was observed: At 1:11 p.m., the MDS (Minimum Data Set) Coordinator applied a gown, gloves and N95 mask over her surgical mask and entered a room on the 200 hall with a yellow stop sign on door that indicated PPE were required to enter the resident's room. At 1:15 p.m., the MDS Coordinator indicated she thought that was policy to wear the surgical mask under the N95 mask. At 1:49 p.m., CNA 39 applied gown, gloves and N95 mask over her surgical mask and entered the same room. At 1:50 p.m., CNA 39 indicated she would normally wear a surgical mask under her N95 mask and it was the policy to wear it that way. At 4:18 p.m., the SSD (Social Service Director) applied N95 mask over his surgical mask, he applied a gown and gloves to enter same room and indicated she just needed her blankets pulled up. At 4:27 p.m., the SSD came out of the room and changed his surgical mask and performed hand hygiene. Review of an Indiana Department of Health resource document, retrieved from the IDOH Long Term Care Newsletter dated 1/22/22, with CDC link, Improve How Your Mask Protects You, last updated 4/6/21, indicated the following: .Do not: Combine a N95 or KN95 mask with any other mask . 3.1-18(b)

Based on observation, interview and record review, the facility failed to protect a cognitively impaired resident (Resident B) from a resident (Resident C) with sexually aggressive behaviors. This deficient practice resulted in a non-consensual sexual act with a cognitively impaired resident for 1 of 3 residents reviewed for abuse. (Resident B) The immediate jeopardy began on 11/16/21 when Resident C was observed to have his pajama pants folded down with his penis exposed, and Resident C's was in Resident B's mouth. The Administrator was notified of the immediate jeopardy on 11/23/21 at 4:29 p.m. The immediate jeopardy was removed on 11/24/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an observation on 11/23/21 at 9:10 a.m., Resident C was noted to be sitting outside the door of Resident B, looking outside. Resident B was asleep in her room. An Indiana Department of Health (IDOH) reportable was provided by the Administrator on 11/23/21 at 11:32 a.m. The reportable, dated 11/16/21 at 6:10 p.m., indicated a staff person noted two residents being intimate with one another. The residents were separated and 15-minute checks were initiated. On 11/23/21 at 12:30 p.m., the Administrator provided the investigation and statements obtained related to the allegation. A written statement by CNA 1, dated 11/16/21, indicated around 6:10 p.m., she was on the 200-hall and noticed Resident B had her head down on Resident C's lap. He had his arm on her shoulder. When she realized what was happening, she attempted to separate them but was unable. She then left to get the nurse. A typed witness statement form obtained by the former Director of Nursing (DON), dated 11/16/21, indicated LPN 2 was told by CNA 1 she thought Resident B and Resident C were doing something inappropriate. LPN 2 walked toward the residents and found Resident C with his pajama pants folded down and his penis was out. Resident C had his penis in Resident B's mouth and was in the middle of a sexual act in the hallway. When approached, Resident C covered himself up and Resident B told LPN 2 she hated her. The residents were placed on separate halls. During a telephone interview on 11/23/21 at 3:20 p.m., CNA 1 indicated it was after dinner and she was pushing another resident down the hall by the fire doors. She then saw Resident B and her head was bobbing up and down and Resident C's hands were resting on her head. She went over and asked him what he was doing, he got nervous, made eye contact and smiled at her. Resident B yelled at her. She left and got the 2 nurses on the floor. She was unable to redirect either resident. Resident C was then taken to the 100-Hall where a male nurse was working. During an interview on 11/23/21 at 3:52 p.m., LPN 2 indicated CNA 1 came and got her because she was unable to separate the two residents. As soon as she got there, they both sat up. She was able to get Resident C to the 100-Hall. Resident B was upset and wanted to stay with Resident C. When she started working at the facility, she was told they liked each other and they do not seem to be interested in other residents. 1. The clinical record for Resident C was reviewed on 11/23/21 at 10:37 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) significant change assessment, dated 10/20/21, indicated the resident was severely cognitively impaired. The resident was unable to correctly identify the correct year, date or day of the week. The resident used a wheelchair for mobility and had a family member in place as Power of Attorney (POA). A health care plan, dated 11/2/21, indicated the resident demonstrated inappropriate behaviors including sexual advances and physical aggression towards staff. Interventions included, but were not limited to, assist the resident away from other residents and remind the behaviors were inappropriate. A progress note, dated 7/14/21 at 6:13 p.m., indicated Resident C was in the dining room and grabbed a CNA's butt. A psychiatric progress note, dated 7/21/21 at 11:54 a.m., indicated staff reported Resident C was seeking out female residents and wanting to be within close proximity of them. A progress note, dated 7/22/21 at 3:36 p.m., indicated Resident C was kissing a female resident in the hallway. Resident C was moved to another room, away from the female resident. A progress note, dated 7/23/21 at 4:33 p.m., indicated the resident grabbed the SSD's hand and stated you know what I need and want. I want what is right between your legs. He was remined the comment was inappropriate then grabbed her hand tighter and pulled her closer to him. An Interdisciplinary Team (IDT) note, dated 8/3/21 at 12:37 p.m., indicated the resident has not had any inappropriate sexual behaviors. A progress note, dated 8/12/21 at 2:50 p.m., Resident C made inappropriate comments regarding buttocks and breasts. A progress note, dated 8/29/21 at 3:34 p.m., indicated Resident C was redirected away from another resident room. At approximately 2:50 p.m., the resident was talking to the female resident and when approached by staff, he quickly placed his hands over his groin and was asked by staff to zip his pants. A progress note, dated 9/15/21 at 11:29 p.m., Resident C was sitting at the nurses' station and patted his groin area a couple of times and stated his d_ _ k no longer worked. The resident stated he needed to use the bathroom, then grabbed the CNA and said I want to eat your p_ _ [NAME]. A Social Service Directors (SSD) progress note, dated 9/16/21 at 4:35 p.m., indicated the facility spoke with a family member related to the inappropriate behaviors towards staff. A progress note, dated 9/28/21 at 12:55 p.m., indicated Resident C was sitting in the hallway, attempting to grab female residents. Staff intervened and offered the resident a walk. The resident indicated he'd like to go with her and see what he could get away with. A progress note, dated 9/28/21 at 4:03 p.m., indicated the resident continued to wander and exit seek. He had been redirected from a female resident's room several times. A progress note, dated 9/29/21 at 3:09 p.m., Resident C entered another resident's room and when redirected by staff, he stated he wanted to get in your pants. A psychiatric progress note, dated 9/30/21 at 5:15 p.m., indicated the staff reported he continued to have inappropriate thoughts and had sexually inappropriate behaviors towards staff. A new order was received to start [MEDICATION(S)] (antipsychotic medicine) 12.5 mg twice daily for hypomania. A SSD progress note, dated 10/7/21 at 12:55 p.m., indicated [CONDITION(S)] medications were discussed at the behavior meeting. The resident had recently been started on [MEDICATION(S)] due to physical aggression with staff. On 10/7/21, [MEDICATION(S)] was decreased to 12.5 mg at night for hypomania. A progress note, dated 11/5/21 at 10:40 p.m., Resident C grabbed a CNA's buttock while she was getting him ready for bed. A progress note, dated 11/16/21 at 7:20 p.m., indicated the facility contacted the resident's POA related to his sexual expression with another resident. The family was aware and agreed with the relationship. A late entry note on 11/23/21 at 10:08 a.m., indicated on 11/17/21 at 10:03 a.m., the SSD and psych Nurse Practitioner (NP) spoke to the resident about his sexual expression. The resident stated he was unsure why it happened in the hallway. A psychiatric progress note, dated 11/17/21 at 5:50 p.m., indicated the resident was seen for reported inappropriate behavior with a female resident; reported as possible oral sex. The resident indicated the staff were making more of it than it was. He was close to the female resident and his pants were unzipped, but she never did anything that was said. Resident C did admit there was some touching of one another. A progress note, dated 11/20/21 at 4:15 p.m., indicated staff attempted to redirect the resident from the bistro area because he was making inappropriate comments to the females who were sitting there at the bistro. Staff continued to keep him separated from female residents. An IDT note, dated 11/23/21 at 10:29 a.m., indicated the team discussed the resident's sexual expression and at the time of the incident, both families gave consent and staff were trained on family wishes. Since that time, considering their cognitive status, staff must first attempt to redirect the behavior. 2. The clinical record for Resident B was reviewed on 11/23/21 at 9:29 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS significant change assessment, dated 10/12/21, indicated the resident was severely cognitively impaired. The resident was unable to correctly identify the correct day of the week or date. The resident used a wheelchair for mobility and had a family member in place as POA. A health care plan, dated 11/16/21, indicated the resident chooses to engage in sexual expression with another resident. The family was aware of relationship and agreed with the relationship. Interventions included, but were not limited, respect their privacy, redirect as needed for places of sexual expression and notify family as needed. Another health care plan, dated 6/16/21, indicated the resident demonstrated altered behaviors including delusions which included believing male residents on the hall were her boyfriend/husband. Interventions included, but were not limited to, resident's delusions will not result in injury to self and others. During an interview 11/24/21 at 10:30 a.m., Nurse Consultant 5 indicated prior to the event on 11/16/21, they did not assess the resident's capacity to consent to the sexual relationship. On 11/24/21 at 11:09 a.m., the Administrator indicated when he started to in-service staff, he realized the residents could not consent so they separated them. He indicated staff were made aware they were to attempt to keep the residents apart through private mobile messaging platform and during shift change. On 11/24/21 at 11:18 a.m., the SSD indicated he was not aware of any resident to resident interactions with either resident. There was not a care plan put in reference to the event because the former Director of Nursing (DON) at the time had called the families and they were ok with the behavior so they care planned that. During an interview on 11/24/21 at 11:48 a.m., LPN 2 indicated Resident B was alert and oriented with confusion at times. She knew some of the other residents, her children's names and where the dining room was located, but was not aware she was in a nursing home. The resident was also able to use her call light to get out of bed in the morning and asked for bathroom assistance. On 11/24/21 at 12:40 p.m., the SSD indicated Resident B was able to make her basic needs known and recognized people, but unsure if she would remember their names. She also had intermittent confusion. He indicated it up to the nurse practitioner and physician to do a competency exam. The former DON indicated she called around 7:10 a.m. and spoke with the families and they would talk about it in the morning. The families consented to the relationship and she gave explicit information to the families. On 11/24/21 at 1:06 p.m., Clinical Support 6 indicated they did not do 15-minute checks on Resident B, only on Resident C. Review of a current facility policy, dated 8/29/19, titled Abuse, Neglect and Exploitation Procedural Guidelines, which was provided by the Corporate Consultant on 11/23/21 at 10:57 a.m., indicated the following: PURPOSE Trilogy Health Services (THS), LLC, has developed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident abuse or neglect. PROCEDURES .3. Definitions: ABUSE is the willful infliction .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse .d. SEXUAL ABUSE - is non-consensual sexual contact of any type with a resident. .b. Training .5. How to identify those residents at risk for abusing other residents, monitoring for changes in which may trigger abuse behavior. .c. Prevention .3. Identification of residents with needs and/or behaviors which might lead to conflict or neglect . The Immediate Jeopardy (IJ) that began on 11/16/21 was removed on 11/24/21 when the facility began in-servicing staff on abuse and placed Resident C on one to one supervision. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because monitoring was on-going. This Federal tag relates to Complaint IN 377. 3.1-27(b)