Every finding on record at Westside Retirement Village

Based on observation, and interview, the facility failed to ensure proper food storage when opened meat was found stored among lettuce, expired and improperly wrapped unidentified foods were stored in the walk-in refrigerator, and opened boxes of foods were found under a prep table; and the facility failed to maintain clean and sanitary conditions in the kitchen, dish room, and walk-in refrigerator for 2 of 2 food storage and food preparation observations. These deficient practices had the potential to affect 88 of 88 residents who received food from the kitchen. Findings include:A confidential concern during the survey process indicated the kitchen was not clean and there were concerns about the health and safety of all the residents who received food from the kitchen. Examples of the concerns verbalized included the dishwasher did not operate correctly and there was standing water in the dish room. There were maggots in the dish room and trash cans, and the walk-in cooler had food that had been molded for over 2 months. The kitchen and walk-in cooler floors were dirty, the steam table was nasty, and the stove top was filthy. An initial kitchen observation with the Executive Director (ED), on 6/24/26 at 10:45 a.m., included, a. The dish room had steaming water over the entire floor that was being swept towards a drain by Dietary Aide 8. The water extended out into the prep areas of the kitchen and was covering the floor where dietary staff were moving about with no effort being made by additional staff to get rid of the standing water. b. There were food crumbs around the rim of the deep fryer, an excessive buildup of grease on the rim and outside of the deep fryer, and old food crumbs floating in the grease of the fryer. c. There was food debris to include French fries on the floor behind the deep fryer and stove. d. There was debris to include food, paper scraps, a sharpie marker and clear fruit cups on the floor around the kitchen and under metal prep stations. e. There was an opened bag of grits that was not dated and a box of iodized salt with an opened hole on the side dated 1/31 that were sitting among cooking utensils underneath the cook prep station. f. The bottom metal shelf underneath the steam table had food crumbs and unidentified dried liquid among stored metal pans. f. There were gallon zip lock bags of sausages and unidentified breaded food that were not sealed in the walk-in freezer. g. The walk-in refrigerator was observed with a large container of vanilla yogurt with an expiration date of 6/21/26, an opened undated package of ham wrapped in the original juice soaked packaging that was sitting among bags of lettuce, a gallon baggie of cooked sausages not dated, an opened quart of heavy whipping cream with no opened date with the spout open, an opened undated lemon pie with a piece missing, an opened undated angel food cake with a piece missing, and an unidentified loaf-formed meat product wrapped in torn foil thawing in a metal pan exposing the part of the meat. There were 2 opened gallons of milk, one that was not dated and the other marked as expired on 6/14, pudding in a large plastic container covered with loose plastic wrap and dated 6/16, unidentified food in a large plastic container with loose plastic wrap and undated, and a bag of shredded cheese in an unsealed gallon baggie with no opened date. h. The floors throughout the kitchen and walk-in storage were sticky and slick with grease. On 6/24/26 at 11:05 a.m., during observation of the kitchen, there was not a visibly posted cleaning schedule. The ED indicated, he did not know the last time the kitchen and equipment had been cleaned. The dietary staff were supposed to document cleaning logs. On 6/25/26 at 10:52 a.m., a second observation of the kitchen was completed with the ED. The Registered Dietician (RD) was observed in the walk-in refrigerator and indicated she was providing education to Dietary Aide 8 while she disposed of expired and opened foods, and rearranging food on the shelves. The floors in the dish room and kitchen no longer had standing water but remained sticky and slick. Kitchen appliances and metal prep stations had not yet been cleaned and remained littered with food debris, dried liquids, and a buildup of grease. The deep [NAME] continued to have old food crumbs around the top and floating in the grease. [NAME] 9 indicated the deep [NAME] was wiped down when the grease was changed every 2 weeks. There was a stack of clear plastic glasses that had fallen on the floor and remained under a wire rack, a pen on the floor, and paper and food debris on the floor throughout the kitchen. The RD indicated there were concerns with the sanitation of the kitchen and food storage areas, and there was staff education that needed to be completed with the entire dietary staff. Kitchen cleaning schedules were not provided during the survey process. During an interview on 6/24/26 at 10:29 a.m., the ED indicated he had been transferred to the facility the prior month. On 6/1/26 the Dietary Manager (DM) had quit without notice after failing to manage the dietary department and voicing concerns about staffing in her department. The ED, RD, and other staff had since worked in the dietary department to fill scheduling needs while a new DM and additional dietary personnel were being hired. The ED was currently responsible for the dietary schedule and indicated he was ridiculously overscheduling to help staff. There had been no formal dietary training conducted recently, but the RD visited and had been verbally prompting/correcting staff as needed. The ED indicated, the dishwasher was currently broken with a hole in the bottom of the garbage disposal that required a bucket underneath to catch water that leaked with the dishwater cycled, and staff to sweep the water that overflowed from the bucket towards a drain in the floor. A new garbage disposal had been ordered but would not arrive until the end of the month. During an interview on 6/25/26 at 10:20 a.m., the ED indicated all the current residents received their meals from the kitchen. During an interview on 6/25/26 at 11:47 a.m., The RD indicated she had worked for the company since February 2026. During that time, she had been in the facility weekly and helped in the kitchen as needed. The ED indicated, his concern during his 6-week tenure had been to get good food out on time and hire staff, his focus had not yet been on sanitation or staff education. On 6/25/26 at 10:20 a.m., the ED provided a Food Safety policy, dated 4/26/23, and indicated the policy was the one currently being used by the facility. The policy indicated, Policy: Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth.Procedure.2. Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date [when the item is transferred to the new container.] [Use by date] is noted on the label or product when applicable.Cold Food Storage.6. All cooked and ready-to-eat food is stored above all raw food. 7. Raw food items are separated from each other, and raw meats are stored on shelves and below fruits and vegetables or other ready to eat foods.13. Manufacturers' directions are followed regarding the refrigeration of previously frozen meat that has been thawed. The date begins with the date the meat is deemed thawed, which is approximately three days from the date pulled from the freezer.Dry Storage.2. Opened packages of food are resealed tightly to prevent contamination of the food item and [used by date] will be used when applicable.Food Service/Meal Service.10. Leftovers must be cooled, covered, labeled, dated, and stored in a refrigerator.12. Steam tables.c. Must be kept in clean and sanitary condition through regular cleaning.13. Cold tables.b. Must be kept in clean and sanitary condition with regular cleaning. On 6/25/26 at 10:20 a.m., the ED provided a Cleaning Schedule policy, dated 4/30/25, and indicated the policy was the one currently being used by the facility. The policy indicated, Policy: The Director of Food and Nutrition Services shall develop a routine cleaning schedule to ensure that the Food and Nutrition Services department is maintained in a clean and sanitary manner in accordance with regulatory requirements.Procedure: 1. The Director of Food and Nutrition Services establishes a regular cleaning schedule to include equipment and areas to be cleaned.3. Designated cleaning tasks are assigned to each position. 4. The cleaning schedule is posted in a visible location where it can be easily read. 5. The Director of Food and Nutrition Services monitors the cleaning schedule for timely and appropriate completion of tasks to maintain the department in a clean and sanitary manner according to regulatory guidelines. This citation relates to Intake 3027945. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the resident's right to be informed of and choose her treatment when the facility transferred a resident to a psychiatric facility against her will for 1 of 3 residents reviewed for abuse and neglect (Resident C). Findings include:The clinical record review for Resident B was completed on 3/18/26 at 10:51 a.m. Diagnoses included bipolar disorder, anxiety disorder, and mild cognitive impairment. The resident was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 2/11/26, indicated the resident was cognitively intact. She was independent with all activities of daily living. She had no behaviors or rejection of care during the assessment period. An Application for Emergency Detention of Mentally Ill and Dangerous and/or Gravely Disabled Person document, dated 1/21/26 at 10:02 a.m., indicated [Resident B] has a psyshitric [SIC] condition that impairs her judgement and reasoning and is unwilling to accept treatment voluntaryly [SIC] with in her skilled nursing facility as driected [SIC] by attending geriatric psychaitry [SIC] provider. For more than 14 days. [Resident B] has demonstrated impaired judgement and has the physical capityy [SIC] to induce grave harm to herslef [SIC] and other [SIC]. She has been verbily [SIC] aggressive and has threatned [SIC] residents and staff verbally and with spraying chemicals. The order provided that law enforcement was to take the individual into custody and transport to the psychiatric facility listed on the order. A care management progress note, dated 1/21/26 at 4:16 p.m., indicated Resident B had been taken to a psychiatric (pysch) hospital. The resident had refused to go. A court order had been obtained, and the resident was escorted by police to the psych provider facility. A readmission Nurse Practitioner (NP) progress note, dated 2/1/26, included Resident B was irritable during examination and indicated she was going to sue the pants off of this place for sending me to another facility without my permission. During an interview on 3/20/26 at 9:54 a.m., the Director of Nursing (DON) indicated the reason that Resident B was transferred by court order to a psych facility was that she had become manic and was pacing up and down the hallways and refusing her medications. The DON had told the resident she wanted her to go to the hospital to get her medications under control. The resident was okay with going to the hospital but refused when she realized it was for a psych hospital. She had not displayed any aggressive behaviors. The DON indicated the documentation of the refused medication and manic behaviors was documented in the Court order. A progress note from the psychiatric facility, dated 1/21/26, indicated the facility had reported Resident B was displaying the following behaviors: physical and verbal aggression over the last 72 hours per staff. The resident had been cursing and yelling at her new roommate. The resident had also refused to clean up all of her items from her roommate's side of the room. It was reported Resident B had sprayed a staff member in the face with chemicals after her roommate had a bowel movement in the bathroom to cover up the smell. Resident B had indicated she was unclear why she had been sent to the facility, sharing that she knows she has problems. She indicated she planned to contact her legal attorney and guardian to file a lawsuit against the facility for sending her to another facility because she was unaware exactly why she was sent and the reason was never explained to her. During an interview on 3/20/26 at 12:39 p.m., the Social Service Director (SSD) indicated she had given a verbal report regarding Resident B's behaviors to the psychiatric facility. This information had been provided to her by staff and not specifically documented in the clinical record. She was unable to say who reported being sprayed in the face with air freshener, but she recalled being informed about it. If she documented something in a note that was said to her, it must have happened. She could not remember specifics regarding Resident B's comment of making her roommate's life miserable, but she must have said it, because she documented it. During an interview on 3/20/26 at 1:18 p.m., the Nurse Practitioner (NP) indicated she completed the Emergency Detention form at the request of the SSD. There had to be certain verbiage included in order to qualify for eligibility to initiate an emergency detention. She felt Resident B was the most capable resident to cause another harm given her independence. The information she was provided by the SSD regarding her behaviors was used to document on the Emergency Detention Order (EDO). In her clinical documentation the term verbally abusive to residents was not a good choice of words. She could be uninhibited, coarse, direct, and rude. They use an Artificial Intelligence software program to document her visits. During the visits Resident B would swear and sound aggressive, but she was not personally aware of resident incidents of behaviors with others. During an interview on 3/20/26 at 3:15 p.m., the DON indicated upon reviewing the Resident B's medication administration record and progress notes, there had been no documented refusal of medications. Refusal of medications had been documented by the SSD, but not by nursing staff. She was unsure why the resident had been sent out to a psychiatric hospital. She had overhead the previous Administrator and SSD talking about behaviors Resident B had displayed but had not been brought in the loop about her behaviors. She had been notified of a conflict over a phone, but no specifics regarding threats or aggression. She was not notified of any type of abuse. This citation relates to Intake 2800757. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(n)(2) 410 IAC (Indiana Administrative Code) 16.2-3.1-3(n)(3)

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for 1 of 3 residents reviewed for abuse and neglect (Resident B). Findings include:An Adult Protective Services (APS), Elder Abuse online report, dated 2/3/26, indicated Resident C as an endangered adult, Resident B was the perpetrator, and the allegation was battery. The narrative/description of the incident indicated Resident C had arrived at the facility and moved into Resident B's room. Resident B was sent out to a psychiatric (pysch) facility that day. Resident C was in the room by herself for a week. The night Resident B returned from her psych hospital stay, she started to threaten to physically harm Resident C. Resident C's sister was on the phone and overhead the entire conversation between Resident B and Resident C. Resident C was moved within hours of the threats to a new room. The clinical record review for Resident C was completed on 3/18/26 at 11:17 a.m. Diagnoses included history of malignant brain neoplasm (tumor), need for assistance with personal care, muscle weakness, and depression. An admission Minimum Data Set (MDS) assessment, dated 1/26/26, indicated the resident was cognitively intact. She required staff assistance for bed mobility, dressing, showering, transfers, and personal hygiene. During an interview on 3/18/26 at 1:38 p.m., Resident C indicated she was admitted to the facility on [DATE]. She used her cell phone to talk with her sister throughout the day and night. The following day, on 1/21/26, her phone stopped working and her charger would not charge her phone. Her roommate, Resident B, had been sent out to a hospital and the staff had switched the landline phone for her so she could contact her sister. When Resident B returned to the facility on 1/28/26, she became very upset that Resident C was using her landline phone and told Resident C, if anyone touches my stuff, I'm going to kill you. Then she told Resident C's sister on the phone that she was gonna kill her too. She told the aids what had happened. She had not reported the threats to a nurse, but the aide said she would tell the nurse. Resident C was moved out of her room that evening to another room. She stayed in her room and did not attend activities because of her fear of Resident B. Now, when Resident B walked by her door, she looked at her and pointed her fingers like a gun at her. She used to go to activities in her old facility (Bingo, church, etc.) but does not go to activities here because of her fear of Resident B. She had spoken to the Social Services Director (SSD) regarding finding another facility because of not feeling safe with Resident B in the facility. Resident C indicated she had not met the Director of Nursing (DON) or spoken with her. The Administrator had visited her in her room and spoke to her and her sister, on the phone, during the visit. During a telephone interview on 3/20/26 at 3:00 p.m., Resident C's sister indicated during the incident on 1/28/26, Resident B had told her that if she called the phone again, she would kill her. She heard Resident B say to Resident C, If you touch my things, I will kill you. I will kill anyone who touches my things. A care management progress note, dated 1/29/26 at 10:30 a.m., indicated Resident C had spoken to the SSD about the night before. She had been moved out of her room to a new room due to difficulties with her roommate (Resident B). Resident C was happy about the move but was still upset with her former roommate. A care management progress note, dated 1/29/26 at 12:27 p.m., included that Resident C had a room move on 1/28/26 due to roommate incompatibility. Resident C was not showing any psychosocial or concerns with new roommate. A nurse practitioner's progress note, dated 1/17/26 at 6:19 p.m., indicated Resident B had bipolar disorder and had a two-week escalation of behaviors that was now putting others at risk of harm. She had been non-compliant and belligerent at times with staff and her treatment plan. She had multiple episodes of verbal aggression, treatment refusal, verbal abuse of her roommate and spraying a substance at a CNA. An SSD progress note, dated 1/19/26 at 10:54 a.m., indicated Resident B had been informed she would be getting a roommate. The resident indicated she would not be nice to the roommate. A health status progress note, dated 1/28/26 at 11:20 a.m., indicated Resident B had been readmitted from her stay at the psychiatric facility. The resident was in her room re-arranging her personal belongings. A care management progress note, dated 1/29/26 at 11:02 a.m., indicated the SSD and DON had met with Resident B in her room. The resident argued about the incident that happened with her roommate the night before. The resident had been spoken to regarding her treatment of residents and staff at the facility. During an interview on 3/18/26 at 2:22 p.m., Resident B was observed in her room, seated on her bed. She was well groomed and had a steady gate. She indicated she had been looking into going to an Assisted Living facility with the help of the SSD. She had no current issues with any other residents. She had some issues from time to time, but everyone does; she chose not to answer as to an example of an issue with another resident. She indicated she did not have any concerns regarding her time at this facility even though she had some tough times but did not want to talk about them. During an interview on 3/19/26 at 9:58 a.m., the SSD indicated on 1/28/26, she was called after hours at home by a CNA and told that Resident B was threatening Resident C and being verbally aggressive towards her. She could not recall who had called her. She instructed staff to move Resident C as far away as possible depending on room availability. The room Resident C was moved to had the nurse's station in between them so the residents would have had to cross in front of staff and could be monitored. She also instructed them to call the police to file a report. She reported the incident the following day to Adult Protective Services (APS). She followed up with Resident C the following day and she seemed to be doing well. Resident C had not told her that she did not feel safe. Resident B attended most activities, so that may be why Resident C did not go to activities. Resident C had told her once that Resident B would walk by her room and make a finger gun gesture at her. She had not observed Resident B walk by Resident C's room or had not observed her make that gesture. She had not interviewed any staff regarding Resident B making that gesture. She was sure staff would have reported it to her if they had witnessed something like that. She talked to Resident C about every couple of days when she called her into her room. Resident C had reported yesterday (3/18/26) during a care plan meeting about Resident B making finger gun gestures. Resident C usually kept her door shut. The facility staff were aware of avoiding interaction between the two residents. The SSD had witnessed Resident B behave verbally aggressive with other residents, but she had not known her to threaten to kill anyone. She cannot recall what other residents had been involved in the verbal aggressions. As far as she knew, no one had talked with Resident B about any of these behaviors, but she would deny them anyway, even if true. The reason she was called about the incident was because it required a room move and that was something she would handle. The investigation of the incident would be completed by the DON. She was unsure if the DON was called or informed. During an interview on 3/19/26 at 10:46 a.m., the DON indicated the only thing reported to her was that Resident C's sister was told by Resident B on the phone not to call her phone again, in not nice terms but did not know what was said. The SSD notified her that she wanted to move Resident C out of the room because Resident B had an altercation with Resident C's sister on the phone. She could not recall how she was notified by the SSD and was unsure if she had spoken to her on the phone or received a text, or how the contact occurred. To her knowledge, the sister talked with the SSD and had not felt safe for Resident C to remain in the room. She had no further knowledge regarding the incident. There was not an investigation because the incident was between Resident B and Resident C's sister, not with the resident. She had spoken to Resident C sometime after the room move and as far as she recalled, Resident C was fine. As far as Resident B performing the shooting gesture, Resident C was four doors down from her office and she had not observed Resident B going down the hall. When she had observed her going down the hall, it had been to attend an activity. She had not spoken with the SSD any further regarding the incident. She had not been aware an Adult Protective Service report had been filed or that the police had been contacted. She had not known Resident C had not felt safe until yesterday's (3/18/26) care plan meeting with Resident C. If Resident B had threatened to kill Resident C, this would definitely have been reported to the state agency within two hours and investigated. This was not done because she had no idea there were threats, police involvement or an APS report. During an interview on 3/19/26 at 1:50 p.m., the DON indicated she had spoken with someone (unable to identify staff member) who reported that Resident B had returned and Resident C had kept calling her sister. Resident B had answered the phone and told the sister she was going to whoop her ass. She had spoken to the SSD as to why she had filed the APS report, and she had indicated it was requested by the family and Resident C's case manager. The DON indicated she had not done staff or resident interviews because there had been no resident abuse. During an interview on 3/19/26 at 2:19 p.m., the Unit Manager (UM) indicated she recalled an argument in Resident B and Resident C's room over a phone on the morning on 1/28/26. On 1/21/26, when Resident B had been sent to a psych facility, there had been an issue with Resident C calling her sister. She was passing by the room during her shift and Resident C indicated her cellphone was not working and her charger was not charging. She asked about her room's landline phone. She went to the SSD and reported that Resident C's phone charger was not working. The SSD said she had a charger she could use and would help Resident C. When Resident B returned to the facility, she overheard an argument regarding the landline phone. Later in the evening, around 6 to7:00 p.m., she received a call from the DON. She told her to move Resident C to another room immediately. The staff pulled together and moved her in about 15 minutes. Resident C indicated to her she just wanted to leave the room. She had not explained her reason. She asked if there was another concern beside the phone and she said no, I just want to move. She had not heard Resident B say anything threatening. During an interview on 3/20/26 at 10:36 a.m., the DON indicated that she felt with Resident B not having a prior history of resident agitation/concerns, it was appropriate to place a new resident as her roommate while arranging for police transport to a psych facility. She wanted Resident C transferred out of the room with Resident B so that the altercation with Resident C's sister did not spill over on to Resident C. She had checked in with Resident C the following day and she had indicated she was fine. During an interview on 3/20/26 at 11:03 a.m., CNA 5 indicated Resident B and Resident C's call light was on in the late afternoon on 1/28/26. When she answered the call light, Resident B indicated to her she was fine. Resident C indicated I need to get out of this room, it's upsetting [Resident B] and she's being mean. At the time, Resident C was on the phone with her sister, and indicated, She keeps threatening me. CNA 5 got on the phone with Resident C's sister, who indicated Resident B kept threatening her sister. CNA 5 indicated she would report this to the nurse. Resident B had left the room, so CNA 5 left and reported the allegation to the Unit Manager (UM). Regarding Resident B, she had not known her to have issues with other residents. Resident B had issues with roommates because she was very independent and clean. She had a hard time with incontinent residents or residents who required staff help. During an interview on 3/20/26 at 12:01 p.m., the DON indicated she called the non-emergency number for Indianapolis Metropolitan Police Department (IMPD) to obtain a copy of the police report that the SSD had indicated was made. She gave the dates of 1/28/26 to 2/2/26 and IMPD reported there had been no reports that had been filed from the facility. During an interview on 3/20/26 at 12:13 p.m., the Activity Director indicated Resident C had come to her, maybe the second week she was at the facility, and spoke with her about a church she was familiar with that had done volunteer activities with facilities. She was going to reach out to them to see if they would be willing to come to the facility in the future. Resident C contracted COVID 19 shortly after their conversation and stayed in her room after that. She offers her activities, but she declined to come out of her room. She felt Resident C might have had some depression. During an interview on 3/20/26 at 1:51 p.m., the Activities Assistant indicated Resident C had come to the main dining room a couple times the first week she was a resident. The following week she said she preferred to eat in her room and had not returned since to the dining room. She had declined to attend activities since her arrival at the facility. She reapproached her frequently, but she always declined to attend. A current facility policy, reviewed 5/6/25, titled, Abuse-Identification of Types, provided by the Administrator on 3/20/26 at 3:18 p.m., included the following: .Definition Abuse - is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Mental or Verbal Abuse Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, [NAME], agitation, or degradation. Involuntary seclusion occurs when separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative. This citation relates to Intake 2800757. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(b)

Based on interview and record review, the facility failed to ensure staff reported an allegation of resident-to-resident verbal abuse for 1 of 3 residents reviewed for abuse and neglect. (Resident C)Findings include:During an interview on 3/18/26 at 1:38 p.m., Resident C indicated she was admitted to the facility on [DATE]. She used her cell phone to talk with her sister throughout the day and night. The following day, her phone stopped working and her charger would not charge her phone. Her roommate, Resident B, had been sent out to a hospital and the staff had switched the landline phone for her so she could contact her sister. When Resident B returned to the facility on 1/28/26, she became very upset that Resident C was using her landline phone and told Resident C if anyone touches my stuff, I'm going to kill you. Then she told her sister on the phone that she was gonna kill her too. She told the aids what had happened. She had not reported the threats to a nurse, but the aide said she would tell the nurse. She was moved out of her room that evening to another room. She does not feel safe in the facility. Now, when Resident B walked by her door, she looked at her and pointed her fingers like a gun at her. She had not met the Director of Nursing (DON) or spoken with her. The Administrator had visited her in her room and spoke to her and her sister, on the phone, during the visit. During a telephone interview on 3/20/26 at 3:00 p.m., Resident C's sister indicated during the incident on 1/28/26, Resident B had told her that if she called the phone again, she would kill her. She heard Resident B say to Resident C, If you touch my things, I will kill you. I will kill anyone who touches my things.The clinical record review for Resident C was completed on 3/18/26 at 11:17 a.m. Diagnoses included history of malignant brain neoplasm (tumor), need for assistance with personal care, muscle weakness, and depression.An admission Minimum Data Set (MDS) assessment, dated 1/26/26, indicated the resident was cognitively intact. She required staff assistance for bed mobility, dressing, showering, transfers, and personal hygiene.An Adult Protective Services (APS), Elder Abuse online report, dated 2/3/26, indicated Resident C as an endangered adult, and Resident B as the perpetrator, and the allegation as battery. The narrative/description of the incident indicated Resident C had arrived at the facility and moved into Resident B's room. Resident B was sent out to a psychiatric (pysch) facility that day. Resident C was in the room by herself for a week. The night Resident B returned from her psych hospital stay, she started to threaten to physically harm Resident C. Resident C's sister was on the phone and overhead the entire conversation between Resident B and Resident C. Resident C was moved within hours of the threats to a new room. The confirmation email indicated the form was received and was addressed to the Social Services Director.During an interview on 3/19/26 at 9:58 a.m., the SSD indicated on 1/28/26, she was called after hours at home by a Certified Nursing Aide (CNA) and told that Resident B was threatening Resident C and being verbally aggressive towards her. She could not recall who had called her. She instructed staff to move Resident C as far away as possible depending on room availability. The room Resident C was moved to had the nurse's station in between them so the residents would have had to cross in front of staff and could be monitored. She also instructed them to call the police to file a report. She reported the incident the following day to Adult Protective Services (APS). She followed up with Resident C the following day and she seemed to be doing well. Resident C had not told her that she did not feel safe. Resident C had told her once that Resident B would walk by her room and make a finger gun gesture at her. She had not observed Resident B walk by Resident C's room or had not observed her make that gesture. She had not interviewed any staff regarding Resident B making that gesture. She was sure staff would have reported it to her if they had witnessed something like that. She talked to Resident C about every couple days when she called her into her room. Resident C had reported yesterday (3/18/26) during a care plan meeting about Resident B making finger gun gestures. Resident C usually kept her door shut. The facility staff were aware of avoiding interaction between the two residents. The SSD had witnessed Resident B behave verbally aggressive with other residents, but she had not known her to threaten to kill anyone. She cannot recall what other residents had been involved in the verbal aggression. As far as she knew, no one had talked with Resident B about any of these behaviors, but she would deny them anyway, even if true. The reason she was called about the incident was because it required a room move and that was something she would handle. The investigation of the incident would be completed by the DON. She was unsure if the DON was called or informed.During an interview on 3/19/26 at 10:46 a.m., the DON indicated the only thing reported to her was that Resident C's sister was told by Resident B on the phone not to call her phone again, in not nice terms but does not know what was said. The SSD notified her that she wanted to move Resident C out of the room because Resident B had an altercation with Resident C's sister on the phone. She could not recall how she was notified by the SSD and was unsure if she had spoken to her on the phone or received a text, or how the contact occurred. To her knowledge, the sister talked with the SSD and had not felt safe for Resident C to remain in the room. She had no further knowledge regarding the incident. There was not an investigation because the incident was between Resident B and Resident C's sister, not with the resident. She had spoken to Resident C sometime after the room move and as far as she recalled, Resident C was fine. As far as Resident B performing the shooting gesture, Resident C was four doors down from her office and she had not observed Resident B going down the hall. When she had observed Resident B going down the hall, it had been to attend an activity. She had not spoken with the SSD any further regarding the incident. She had not been aware an Adult Protective Service report had been filed or that the police had been contacted. She had not known Resident C had not felt safe until yesterday's (3/18/26) care plan meeting with Resident C. If Resident B had threatened to kill Resident C, this would definitely have been reported to the state agency within two hours and investigated. This was not done because she had no idea there were threats, police involvement or an APS report. During an interview on 3/19/26 at 2:19 p.m., the Unit Manager (UM) indicated she recalled an argument in Resident B and Resident C's room over a phone on the morning on 1/28/26. On 1/21/26, when Resident B had been sent to a psych facility, there had been an issue with Resident C calling her sister. She was passing by the room during her shift and Resident C indicated her cellphone was not working and her charger was not charging. She asked about her room's landline phone. She went to the SSD and reported that Resident C's phone charger was not working. The SSD said she had a charger she could use and would help Resident C. When Resident B returned to the facility, she overheard an argument regarding the landline phone. Later in the evening, around 6-7:00 p.m., she received a call from the DON. She told her to move Resident C immediately. The staff pulled together and moved her in about 15 minutes. Resident C indicated to her she just wanted to leave the room. She had not explained her reason. She asked if there was another concern beside the phone and she said no, I just want to move. She had not heard Resident B say anything threatening. During an interview on 3/20/26 at 10:36 a.m., the DON indicated she wanted Resident C transferred out of the room with Resident B so that the altercation with Resident C's sister did not spill over on to Resident C. She had checked in with Resident C the following day and she had indicated she was fine. During an interview on 3/20/26 at 11:03 a.m., CNA 5 indicated the resident's call light was on in the late afternoon. When she answered the call light, Resident B indicated to her she was fine. Resident C indicated I need to get out of this room, it's upsetting [Resident B] and she's being mean. At the time she was on the phone with her sister, and indicated, She keeps threatening me. CNA 5 got on the phone with Resident C's sister, who indicated Resident B kept threatening her sister. CNA 5 indicated she would report this to the nurse. Resident B had left the room, so she left and reported the allegation to the UM. Regarding Resident B, she had not known her to have issues with other residents. Resident B had issues with roommates because she was very independent and clean. She had a hard time with incontinent residents or residents who require staff help. During an interview on 3/19/26 at 1:50 p.m., the DON indicated she had spoken with someone (unable to identify person/position) who reported that Resident B had returned and Resident C had kept calling her sister on the landline phone. Resident B had answered the phone and told the sister she was going to whoop her ass. She had spoken to the SSD as to why she had filed the APS report, and she had indicated it was requested by the family and Resident C's case manager. The DON indicated she had not done staff or resident interviews because there had been no resident abuse.During an interview on 3/20/26 at 12:01 p.m., the DON indicated she called the non-emergency number for Indianapolis Metropolitan Police Department (IMPD) to obtain a copy of the police report that the SSD had indicated was made. She gave the dates of 1/28/26 to 2/2/26 and IMPD reported there had been no reports that had been filed from the facility. A current facility policy, reviewed 5/7/25, titled, Abuse-Reporting and Response-Suspicion of a Crime, provided by the Administrator on 3/20/26 at 3:18 p.m., included the following: .Reporting Procedures 1. Once an associate or other covered individual at the facility (e.g., medical director) forms a reasonable suspicion that a crime has been committed against a resident or other individual receiving services at the facility, he or she must immediately notify the Executive Director of their suspicion. Cross reference F600.This citation relates to Intake 2800757.410 IAC (Indiana Administrative Code) 16.2-3.1-27(b)

Based on interview and record review, the facility failed to document, report, or conduct a thorough investigation of an allegation of resident-to-resident verbal abuse for 1 of 3 residents reviewed for abuse and neglect. (Resident C)Findings include:During an interview on 3/18/26 at 1:38 p.m., Resident C indicated she was admitted to the facility on [DATE]. She used her cell phone to talk with her sister throughout the day and night. The following day, her phone stopped working and her charger would not charge her phone. Her roommate, Resident B, had been sent out to a hospital and the staff had switched the landline phone for her so she could contact her sister. When Resident B returned to the facility on 1/28/26, she became very upset that Resident C was using her landline phone and told Resident C if anyone touches my stuff, I'm going to kill you. Then she told her sister on the phone that she was gonna kill her too. She told the aids what had happened. She had not reported the threats to a nurse, but the aide said she would tell the nurse. She was moved out of her room that evening to another room. Now, when Resident B walked by her door, she looked at her and pointed her fingers like a gun at her. She has spoken to the Social Services Director (SSD) regarding finding another facility because of not feeling safe with Resident B here. She had not met the Director of Nursing (DON) or spoken with her. The Administrator had visited her in her room and spoke to her and her sister, on the phone, during the visit. During a telephone interview on 3/20/26 at 3:00 p.m., Resident C's sister indicated during the incident on 1/28/26, Resident B had told her that if she called the phone again, she would kill her. She heard Resident B say to Resident C, If you touch my things, I will kill you. I will kill anyone who touches my things.The clinical record review for Resident C was completed on 3/18/26 at 11:17 a.m. Diagnoses included history of malignant brain neoplasm (tumor), need for assistance with personal care, muscle weakness, and depression.An admission Minimum Data Set (MDS) assessment, dated 1/26/26, indicated the resident was cognitively intact. She required staff assistance for bed mobility, dressing, showering, transfers, and personal hygiene.An Adult Protective Services (APS), Elder Abuse online report, dated 2/3/26, indicated Resident C as an endangered adult, and Resident B as the perpetrator, and the allegation as battery. The narrative/description of the incident indicated Resident C had arrived at the facility and moved into Resident B's room. Resident B was sent out to a psych facility that day. Resident C was in the room by herself for a week. The night Resident B returned from her psych hospital stay, she started to threaten to physically harm Resident C. Resident C's sister was on the phone and overhead the entire conversation between Resident B and Resident C. Resident C was moved within hours of the threats to a new room. The confirmation email indicated the form was received and was addressed to the Social Services Director.During an interview on 3/19/26 at 9:58 a.m., the SSD indicated on 1/28/26, she was called after hours at home by a Certified Nursing Assistant (CNA) and told that Resident B was threatening Resident C and being verbally aggressive towards her. She could not recall who had called her. She instructed staff to move Resident C as far away as possible depending on room availability. The room Resident C was moved to had the nurse's station in between them so the residents would have had to cross in front of staff and could be monitored. She also instructed them to call the police to file a report. She reported the incident the following day to Adult Protective Services (APS). She followed up with Resident C the following day and she seemed to be doing well. Resident C had not told her that she did not feel safe. Resident B attended most activities, so that may be why Resident C did not go to activities. Resident C had told her once that Resident B would walk by her room and make a finger gun gesture at her. She had not observed Resident B walk by Resident C's room or had not observed her make that gesture. She had not interviewed any staff regarding Resident B making that gesture. She was sure staff would have reported it to her if they had witnessed something like that. She talked to Resident C about every couple days when she called her into her room. Resident C had reported yesterday (3/18/26) during a care plan meeting about Resident B making finger gun gestures. Resident C usually kept her door shut. The facility staff were aware of avoiding interaction between the two residents. The SSD had witnessed Resident B behave verbally aggressive with other residents, but she had not known her to threaten to kill anyone. She cannot recall what other residents had been involved in the verbal aggression. As far as she knew, no one had talked with Resident B about any of these behaviors, but she would deny them anyway, even if true. The reason she was called about the incident was because it required a room move and that was something she would handle. The investigation of the incident would be completed by the DON. She was unsure if the DON was called or informed.During an interview on 3/19/26 at 10:46 a.m., the DON indicated the only thing reported to her was that Resident C's sister was told by Resident B on the phone not to call her phone again, in not nice terms but does not know what was said. The SSD notified her that she wanted to move Resident C out of the room because Resident B had an altercation with Resident C's sister on the phone. She could not recall how she was notified by the SSD and was unsure if she had spoken to her on the phone or received a text, or how the contact occurred. To her knowledge, the sister talked with the SSD and had not felt safe for Resident C to remain in the room. She had no further knowledge regarding the incident. There was not an investigation because the incident was between Resident B and Resident C's sister, not with the resident. She had spoken to Resident C sometime after the room move and as far as she recalls, Resident C was fine. As far as Resident B performing the shooting gesture, Resident C was four doors down from her office and she had not observed Resident B going down the hall. When she had observed Resident B going down the hall, it had been to attend an activity. She had not spoken with the SSD any further regarding the incident. She had not been aware an Adult Protective Service report had been filed or that the police had been contacted. She had not known Resident C had not felt safe until yesterday's (3/18/26) care plan meeting with Resident C. If Resident B had threatened to kill Resident C, this would definitely have been reported to the state agency within two hours and investigated. This was not done because she had no idea there were threats, police involvement, or an APS report. During an interview on 3/19/26 at 1:50 p.m., the DON indicated she had spoken with someone (unable to identify person/position) who reported that Resident B had returned and Resident C had kept calling her sister on the landline phone. Resident B had answered the phone and told the sister she was going to whoop her ass. She had spoken to the SSD as to why she had filed the APS report, and she had indicated it was requested by the family and Resident C's case manager. The DON indicated she had not done staff or resident interviews because there had been no resident abuse. During an interview on 3/20/26 at 12:01 p.m., the DON indicated she called the non-emergency number for Indianapolis Metropolitan Police Department (IMPD) to obtain a copy of the police report that the SSD had indicated was made. She gave the dates of 1/28/26 to 2/2/26 and IMPD reported there had been no reports that had been filed from the facility. A current facility policy, reviewed 5/7/25, titled, Abuse-Reporting and Response-Suspicion of a Crime, provided by the Administrator on 3/20/26 at 3:18 p.m., included the following: .Reporting Procedures 1. Once an associate or other covered individual at the facility (e.g., medical director) forms a reasonable suspicion that a crime has been committed against a resident or other individual receiving services at the facility, he or she must immediately notify the Executive Director of their suspicion. Cross reference F600. Cross reference F609. This citation relates to Intake 2800757. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(b)

Based on observations, interviews, and record review, the facility failed to ensure staff responsible for food service and kitchen sanitation demonstrated competency in monitoring food service equipment and maintaining required temperature documentation for safe food preparation and storage. This deficient practice had the potential to affect 86 of 86 residents served from the kitchen.Findings include:On 3/2/26 at 10:06 a.m., during the initial tour of the kitchen, the dish machine and refrigeration monitoring records were reviewed. The following was observed: Dishwasher temperature logs for February 2026 were missing. January dishwasher logs contained gaps, with multiple entries missing and several recorded temperatures that did not reach the required 180 F sanitizing temperature for high-temperature dish machines. Wash temperatures were documented as only getting to 160 F, and rinse temps only as high as 122 F. Posted instructions indicated staff were to notify the manager if water temperatures were below 120 degrees Fahrenheit ( F) or greater than 150 F. The logs showed wash temperatures of 160 F and rinse temperatures of less than 120 F, with no documentation that management had been notified or corrective actions implemented. Walk-in refrigerator temperature logs for February 2026 were missing, preventing verification that food was consistently maintained at safe storage temperatures. During an interview on 3/2/26 at 10:06 a.m. the Kitchen Manager indicated February refrigerator temperature logs were missing and that all staff were responsible for completing daily logs but the records were not present for review. During testing of the dish machine, several dishwasher cycles were observed with the Kitchen Manager, but the machine failed to reach the required 180 degrees Fahrenheit and the Kitchen Manager indicated she did not know why. The kitchen staff attempted to verify sanitation levels using test strips. The test strip reading registered 10 parts per million (ppm, a unit of concentration of the solution) after three attempts to obtain a reading, and staff demonstrated difficulty properly performing the test procedure. On 3/3/26 at 9:31 a.m., the Kitchen Manager indicated the facility had contacted the contract company technician, who discovered fuses on the booster heater had blown, preventing the dish machine from reaching appropriate sanitizing temperatures and staff had been unaware. On a return visit to the kitchen on 3/3/26 at 12:16 p.m., a mechanical technician from the contract company indicated the heat boosters for the dishwasher were broken, so until they could be repaired, he adjusted the temperature and sanitation requirements so that the machine could run and sanitize dishes via chemical rinse. The technician instructed kitchen staff that 50 to 100 ppm chlorine sanitizer was an appropriate sanitizing range when operating under a chemical sanitation process and demonstrated how to test the machine's ppm. On 3/5/26 at 11:03 a.m., during an observation of the pureed food process was scheduled, the following was observed: [NAME] 13 failed to perform hand hygiene before, during or after a puree demonstration. Failed to follow a standardized recipe. Once the puree chicken was completed, [NAME] 13 proceeded to the dish room and ran the equipment through the dishwasher. When asked if she would check the parts per million (PPM), she indicated she did not know how, so the Kitchen Manager came to read the PPM. The Kitchen Manager ran a small plate through the machines and placed a test strip on a puddle of water once the wash was complete. The strip did not change colors. It was brought to the Kitchen Manager's attention that the sanitizer container, located under the machine was empty.The Kitchen Manager replaced the chemical sanitizer with a new bucket and indicated if the machine was being run on a lower temperature with chemical sanitizer, staff should ensure the sanitizer bottle was full and/or functional. During an interview on 3/5/26 at 11:43 a.m., the Kitchen Manager indicated she contacted the contract company and received clarifying instructions on how to test the machine's ppm, she had been doing it incorrectly. Instead of dropping the test strip into standing water that came out on the washed plate, she needed to drain the water from the plate, and place the strip directly on the porcelain. Upon a final observation, at that time, the test strip changed to the appropriate color. Cross reference F812. On 3/6/26 at 12:20 p.m., the Director of Nursing (DON) indicated there was no specific policy which spoke to Kitchen Staff Competency, but it was expected that they would meet and execute the required competencies related to their job-specific descriptions and training. The DON, provided copies of those requirements for the Kitchen Manager at that time which indicated, .position summary. plans organizes, develops and directs the overall operations of food services to ensure daily provisions of quality nutritional services in accordance with all applicable laws, regulations and Life Care standards. must be knowledgeable of food service practices and procedures as well as laws, regulations and guidelines governing food service functions in the post-acute care facility. must perform proficiently in all competency area including but not limited to: general food service responsibilities, planning, supervisory responsibilities, patient rights and safety and sanitation. 410 Indiana Administrative Code (IAC) 16.2-3.1-20(h).

Based on observations, interviews and record review, the facility failed to ensure general cleanliness, proper sanitation and infection control practices during food preparation and dishwashing activities. This deficient practice had the potential to affect 86 of 86 residents who received food from the kitchen.Findings include:1. During an initial tour of the kitchen on 3/2/26 at 10:06 a.m., the following was observed: Sticky floors in and around the dishwashing area. Food crumbs and debris scattered across the floor throughout the kitchen areas. Several dented cans which had not been removed from the service rack. The dishwashing table where clean dishes were stacked to air dry was observed to have standing water with soggy food crumbs throughout. There were no readily accessible temperature logs for the walk-in refrigerator. Several dishwasher cycles were observed with the Kitchen Manager, but the machine failed to reach the required 180 degrees Fahrenheit and the Kitchen Manager indicated she did not know why. There were no readily accessible dishwasher temperature logs for the month of February, and the January had several missing temperatures with wash temperatures only getting to 160, and rinse temps only as high as 122. The Kitchen Manager could not account for the discrepancies and would call the contract company to come out and look at the dishwasher. On a return visit to the kitchen on 3/3/26 at 12:16 p.m., a mechanical technician from the contract company indicated the heat boosters for the dishwasher were broken, so until they could be repaired, he adjusted the temperature and sanitation requirements so that the machine could run and sanitize dishes via chemical rinse. 2. On 3/5/26 at 11:03 a.m., an observation of the pureed food process was scheduled, however upon entry into the kitchen, the Kitchen Manager indicated the lunch pureed foods had already been prepared. She called [NAME] 13 over and indicated, Just puree something to get it over with. Upon entry into the kitchen for this observation, the floor were observed with various food crumbs, and sticky in several locations that caused the bottom of shoes to stick. There was standing water which splashed when stepped in throughout the entire dish area, including where the clean dishes were stacked. [NAME] 13 was wearing a pair of blue rubber gloves and did not wash hands prior to beginning food preparation and continued wearing a previously used pair of blue gloves. She selected a previously cooked chicken breast to add to the blender. Without following a standardized recipe, [NAME] 13 first added an unmeasured amount of water, and when the mixture became too thin, she added an unmeasured amount of thickener. During the blending process, [NAME] 13 wiped her face after puree splash back and touched other surfaces without performing hand hygiene before continuing food preparation. Once the puree chicken was completed, [NAME] 13 proceeded to the dish room and ran the equipment through the dishwasher. When asked if she would check the parts per million (PPM), she indicated she did not know how, so the Kitchen Manager came to read the PPM. The Kitchen Manager ran a small plate through the machines and placed a test strip on a puddle of water once the wash was complete. The strip did not change colors. It was brought to the Kitchen Manager's attention that the sanitizer container, located under the machine was empty.The Kitchen manager replaced the chemical sanitizer with a new bucket and indicated, if the machine was being run on a lower temperature with chemical sanitizer, staff should ensure the sanitizer bottle was full and/or functional. During this observation, standing water was observed on the table for the clean dishes with soggy food crumbs. The Kitchen Manager indicated the table should be cleared after every wash to avoid splash back and potential contamination of the newly cleaned dishes. She did not know why water puddled and did not drain. On 3/3/26 at 9:16 a.m., the Director of Nursing provided a copy of current facility policy titled, Food Safety, dated 5/1/25. The policy indicated, Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. 410 Indiana Administrative Code (IAC) 16.2-3.1-21(i)(1).

Based on observation, interview, and record review, the facility failed to ensure residents and/or their family members were treated with respect and dignity by the Social Services Director (SSD) and the Kitchen Manager who spoke to and interacted with residents in a dismissive, argumentative, and disrespectful manner for 5 of 5 residents who participated in a resident council meeting (Residents 35, 43, 57, 75 and 85) and 1 of 2 randomly observed resident/staff interactions (Resident 12).Findings include:1. On 3/2/26 at 11:13 a.m., the SSD approached Resident 12, without invitation/request who was expressing concerns regarding the care of birds in a therapeutic bird habitat utilized in the facility. Rather than redirecting the conversation to a more private setting or responding empathetically, the SSD engaged the resident in a public argumentative exchange at the nurses' station. During the interaction, the SSD used dismissive and sarcastic language including stating Well I'll just have to take your word on that, and there's nothing we can do. The interaction resulted in the resident becoming increasingly distressed and stating the facility was a damn prison.On 3/3/26 at 11:59 a.m., Resident 12's record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, Alzheimer's with late onset, anxiety disorder, and a cognitive communication deficit.Her comprehensive care plans lacked implementation of person-centered dementia specific goals and/or interventions.She was also being seen on a regular basis by geriatric neuro-psych specialists to address and treat the progression of her Alzheimer's disease.On 3/6/26 at 9:43 a.m., the Director of Nursing provided a copy of current facility policy titled, Care of the Cognitively Impaired (Dementia Care) dated 9/2/25. The policy indicated, .ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. 2. On 3/5/26 at 10:00 a.m., during a meeting with the Resident Council, with 5 residents present (Residents 35, 43, 57, 75 and 85), Resident 43 indicated residents frequently complained about the Kitchen Manager's poor attitude and concerns regarding the manner in which the Social Services Department and Kitchen Manager spoke with and interacted with the residents. Resident 43 stated the SSD was rude and often spoke to residents like they are children. On one occasion, the Resident 43 and two of her peers, Residents 75 and 35, expressed their concerns about a lunch meal, and the Kitchen Manager ran up on the table became defensive and argumentative with the resident which left them feeling embarrassed and afraid to make additional complaints. Resident 43 indicated, she filed a grievance related to the incident but it was not resolved and she was afraid to eat anything from the kitchen for fear the Kitchen Manager tampered with it.On 3/5/26 at 2:00 p.m., the DON provided a copy of a grievance form which was completed by Resident 43 on 2/19/26. Her grievance stated, [Kitchen Manager] just walked up on me. She is trying to intimidate people. She's so disrespectful. I'm not comfortable eating anything from that kitchen.Investigation steps indicated, Talked with Dietary Manager regarding concerns and appropriate approach. With follow up as needed.The grievance response lacked documentation of the concerned party's response to the action plan/outcome, but was signed as completed on 3/5/26.During an interview on 3/4/26 at 10:56 a.m., the DON indicated no staff should argue with a resident, and all residents should be treated with dignity and respect at all times. If conversations with residents or family members escalated, staff should offer a private place to discuss their concerns.410 Indiana Administrative Code (IAC) 16.2-3.1-3(a).

Based on record review and interview, the facility failed to ensure discharge communication and documentation was completed for 4 of 5 residents reviewed for transfers and discharges (Residents 9, 87, 89, and 84). Findings include:1. Resident 9's record was reviewed on 3/3/26 at 1:26 p.m. Census information indicated the resident was hospitalized from [DATE] to 1/1/26. A quarterly Minimum Data Set (MDS) assessment, dated 1/28/26, indicated the resident received dialysis (treatment for kidney failure that filters waste, toxins, and excess fluid from the blood when the kidneys can no longer function properly). A progress note, dated 12/29/25, indicated the Certified Nurse Aide (CNA) answered the resident's call light and immediately notified the nurse. The nurse found blood saturated through the resident's long sleeves, side of the bed and on the floor. The source of the bleeding was determined to be the fistula (a surgical connection between an artery and a vein created to provide reliable, long-term vascular access for dialysis) to the resident's left upper extremity. Pressure was applied, and the nurse instructed the CNA to call 911. A second nurse assisted with applying pressure. The paramedics arrived and the resident was transferred to the hospital. The progress note lacked documentation the nurse communicated with the hospital where the resident was being transferred. A progress note, dated 1/2/26, indicated the resident was back at the facility and resting quietly. The resident's record lacked documentation the facility communicated with the hospital where the resident was being transferred, lacked documentation a notice of transfer or discharge and bed hold policy were provided to the resident or resident's representative, and lacked documentation the ombudsman was notified of the resident's hospital transfer. During an interview, on 3/5/26 at 9:24 a.m., the Director of Nursing (DON) indicated she reviewed the resident's record and was unable to find documentation of the notice of transfer or discharge and bed hold policy were provided to the resident or the resident's representative. If the resident was transferred in an emergency, and they were unable to provide the notice of transfer or discharge and the bed hold policy at the time of the transfer, it should have been provided as soon as possible. The DON indicated she was unable to find documentation the nurse communicated with the hospital where the resident was being transferred. The nurse should have called and talked to someone in the emergency room (ER). During an interview, on 3/5/36 at 9:26 a.m., the Social Services Director (SSD) indicated she was not sure who was responsible for notifying the ombudsman of the facility's transfers and discharges. During an interview, on 3/5/26 at 9:39 a.m., the Corporate Nurse indicated he was unable to find documentation the ombudsman was being notified of the residents' transfers and discharges. 2. On 3/3/26 at 12:32 p.m., a record review was completed for Resident 89. A Discharge summary, dated [DATE], indicated Resident 89 was being discharged to another skilled nursing facility. His record lacked a notice of transfer and discharge. The Ombudsman was not notified of his transfer to the hospital. During an interview on 3/6/26 at 10:40 a.m., the DON indicated there were a few progress notes but the discharge summary in the electronic medical record was incomplete and she could not locate ombudsman notification, a bed hold, or a discharge (DC) summary. The Social Services Director (SSD) was responsible for ensuring all that was completed and documented in the resident records. 3. On 3/3/26 at 11:21 a.m., a record review was completed for Resident 87. An Event Note, dated 12/5/25 at 5:01 a.m., indicated the Nurse Practitioner gave an order to send the resident out to the emergency room for evaluation and treatment, and report was given to the nurse at the hospital. Resident 87's record lacked a notice of transfer and discharge and the Ombudsman notification that he was discharged to the hospital. 4. On 3/3/26 at 1:35 p.m. Resident 84's medical record was reviewed. The record lacked documentation about Resident 84's discharge and the events leading up to his discharge. The record lacked documentation the facility communicated with the hospital where Resident 84 was being transferred to, a notice of transfer or discharge and bed hold policy were provided to Resident 84 or Resident 84's representative at the time of Resident 84's discharge. On 3/4/26 at 11:01 a.m. the Director of Nursing (DON) indicated Resident 84 was emergently transferred so they were unable to get the paperwork completed before sending the resident out. On 3/6/26 at 10:00 a.m. Licensed Practical Nurse (LPN) 12 indicated she was the nurse who sent Resident 84 out to the hospital on 3/2/26. LPN 12 indicated he had had trouble swallowing his morning medications and breakfast that morning, and his vitals at 12:00 p.m. showed his heart rate was in the 30's so she called the doctor and received an order to send Resident 84 to the hospital immediately for evaluation. On 3/2/26 at 1:08 p.m. Resident 84 was observed being wheeled out of his room on a gurney by ambulance staff with several family members at his side. That was approximately one hour after LPN 12 called the ambulance for Resident 84's transfer. On 3/5/26 at 10:29 a.m. a copy of a current facility policy titled, Notice of Transfers and Discharges, dated 2/17/2026 was provided. That policy indicated, .The facility will notify the resident and the resident representative(s), and Office of the State Long-Term Care (LTC) Ombudsman of the transfer or discharge and the reasons for the move in writing. On 3/5/26 at 10:29 a.m. a copy of a current facility policy titled, Notice of Transfers and Discharges, dated 2/17/2026, was provided. That policy indicated, .The bed hold policy should be given. upon transfer of a resident to the hospital (if an emergency within 24 hours). 410 Indiana Administrative 410 Indiana Administrative Code (IAC) 16.2-3.1-12(a)(25)(A). 410 Indiana Administrative 410 Indiana Administrative Code (IAC) 16.2-3.1-12(a)(25)(B). 410 Indiana Administrative 410 Indiana Administrative Code (IAC) 16.2-3.1-12(a)(26).

Based on observation, interview, and record review, the facility failed to ensure the resident was provided with adaptive equipment related to a visual impairment for 1 of 28 residents reviewed for accommodation of needs (Resident 15). Findings include: During an observation, on 3/2/26 at 12:09 p.m., Resident 15 was at the nurse's station yelling. The resident indicated he was tired of waiting and wanted his stuff. Two staff members approached the resident, and the resident told them he wanted his lunch, and that it was 2:00 p.m. One of the staff members told the resident it was actually around noon and offered to bring the resident's lunch to his room. The resident agreed and went to his room. During an observation, on 3/2/26 at 12:17 p.m., the resident was in his room. A clock next to his bed indicated the time was a little after 2:00 p.m. At the same time, the resident indicated he was legally blind, and the clock said the time out loud each hour so he could know what time it was. He was not aware the clock was set two hours fast. During an observation, on 3/2/26 at 1:00 p.m., Resident 15 was served lunch in the dining room. The resident's lunch was served in Styrofoam containers, and no adaptive equipment was provided. During an observation, on 3/3/26 at 11:25 p.m., the resident was observed in his room, and the clock remained approximately two hours fast at 1:21 p.m. During an observation, on 3/4/26 at 1:20 p.m., the resident was observed in his room, and the clock remained approximately two hours fast. Resident 15's record was reviewed on 3/4/26 at 1:40 p.m. Diagnoses on the resident's profile included, but were not limited to, legal blindness. A care plan, dated 1/31/24, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to impaired eyesight. Interventions included, but were not limited to, the resident required adaptive equipment including divided plate and Kennedy cup (a lightweight, spill-proof, and adaptive drinking cup designed to prevent mess, even when turned upside down) for all meals and a blue placemat. During an observation, on 3/5/26 at 12:20 p.m., Resident 15 was observed in the dining room eating lunch. The resident's lunch was served on a regular white plate. The resident's drinks were served in a small glass with no lid and a Styrofoam cup with a lid and straw. The table had a white tablecloth in place. There was no divided plate, blue placemat, or specialized cups provided. During an interview, on 3/5/26 at 12:23 p.m., Resident 15 indicated he used to receive a divided plate for meals, and it was helpful for him because it kept him from getting his food all mixed up. The resident indicated he used to get sippy cups which he liked, and they were helpful. He also used to get a blue placemat. The resident indicated, due to his visual impairment, he was unable to see a white plate on a white tablecloth. The blue placemat helped him see his plate. The resident indicated he had not received any of these items in a long time.During an interview, on 3/5/26 at 1:42 p.m., the Director of Nursing (DON) indicated residents should have received their adaptive equipment as indicated in their care plan. On 3/5/26 at 3:13 p.m., the DON provided a document titled, Assistive Devices-Special Eating Equipment, last reviewed on 5/1/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The facility provides residents with special eating equipment and assistive devices as deemed necessary. 410 Indiana Administrative Code (IAC) 16.2-3.1-3(v)(1).

Based on interview and record review, the facility failed to ensure behavior monitoring and documentation in the medical record to support rationales for denying gradual dose reductions (GDR) for antipsychotic and antidepressant medications for 2 of 5 residents reviewed for unnecessary medications (Resident 81 and 2). Findings include:1. On 3/3/26 at 10:37 a.m. Resident 81's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, dementia, major depressive disorder, and psychotic disorder. A pharmacy review was done on 7/14/25 indicating Resident 81 had Zyprexa (an atypical antipsychotic medication) 2.5 milligrams (mg) at bedtime ordered. The recommendation was to Gradual Dose Reduction (GDR) (a required process in nursing homes to taper psychotropic or antipsychotic medications to the lowest effective dose, thereby minimizing side effects.) the medication with the goal being to discontinue the medication. The recommendation was denied. The Nurse Practitioner (NP)'s reason for denying the recommendation was, Resident 81 was stable with the medication regimen she was currently on. The NP indicated the resident had also been in a recent resident to resident altercation and had had mixed delusional behaviors. A progress note, dated 7/13/25, indicated an unidentified male resident put his hand on Resident 81's shoulder. Resident 81 asked the male resident not to touch her again, but the male resident would not listen, and he put his hand back on Resident 81's shoulder. Resident 81 then hit the male resident. The record lacked documentation of delusional behaviors in the month leading up to the review.A pharmacy review was done on 8/11/25 indicating the resident had Lexapro (a prescription antidepressant) 10 mg at bedtime ordered. The recommendation was to GDR the medication to 5 mg. The recommendation was denied. The NP's reason for denying the recommendation was, Resident 81 had recent negative behaviors including intrusiveness. The record lacked documentation of increased behaviors, aside from the resident-to-resident altercation mentioned above, or intrusiveness in the month leading up to the review. A pharmacy review was done on 10/13/25 indicating Resident 81 had Zyprexa 2.5 mg at bedtime ordered. The recommendation was to GDR the medication by doing a trial discontinuation of the medication. The recommendation was denied. The providers' reason for denying the recommendation was, Resident 81 had a history of verbal aggression. A pharmacy review was done on 2/9/26 indicating Resident 81 had Lexapro 10 mg at bedtime ordered. The recommendation was to GDR the medication by doing a trial discontinuation of the medication. The recommendation was denied. The NP's reason for denying the recommendation was, Resident 81 had previously failed a GDR of this medication, and the resident had COVID at the time. The record showed a discontinued order for Lexapro 5 mg on 2/12/25 with a restart date of 2/20/25 at 10 mg. A progress note, dated 2/12/25, indicated Resident 81 had been transferred to a medical behavior center. The record lacked documentation of a failed GDR for this medication. 2. On 3/3/26 at 10:37 a.m. Resident 2's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to dementia and major depressive disorder with psychotic symptoms. A pharmacy review was done on 2/19/25 indicating Resident 2 had Quetiapine (an atypical antipsychotic medication) 200 mg at bedtime ordered for Schizophrenia. The recommendation was to attempt a GDR to 150 mg at bedtime. The recommendation was denied. The NP's reason for denying was, Resident 2 required that dose to maintain/control symptoms related to Schizophrenia. The record lacked documentation of Schizophrenia being a medical diagnosis for Resident 2.A pharmacy review was done on 11/25/25 indicating Resident 2 had fluoxetine (a prescription antidepressant) 40 mg daily ordered. The recommendation was to attempt a GDR to 30 mg daily. The NP declined the recommendation. The NP's reason for denying was, Resident 81 had recently had to increase the dose of Fluoxetine due to continued mood issues and depression.The record lacked documentation of an increase in Resident 2's fluoxetine dose. On 3/6/26 at 9:43 a.m., the Director of Nursing provided a copy of current facility policy titled, Care of the Cognitively Impaired (Dementia Care) dated 9/2/25. The policy indicated, .A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Procedure 1. Identify, address, and/or obtain necessary services for the dementia care needs of residents; 2. Develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment; 3. Develop individualized interventions related to the resident's symptomology and rate of progression (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks); 4. Review and revise care plans that have not been effective and/or when the resident has a change in condition; 5. Modify the environment to accommodate resident care needs. 410 Indiana Administrative Code (IAC) 16.2-3.1-48(b)(2)

Based on observation, record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 of 19 residents' MDS assessments reviewed (Residents 15, 12, and 3). Findings include:1. During an observation, on 3/2/26 at 12:17 p.m., Resident 15 was observed with no natural teeth (edentulous). Resident 15's record was reviewed on 3/4/26 at 1:40 p.m. An annual MDS assessment, dated 1/16/26, indicated the resident had no oral/dental issues, including being edentulous. During an interview, on 3/5/26 at 3:17 p.m., the Corporate Nurse indicated Resident 15 was edentulous, and the MDS assessment should have been coded accordingly. The facility used the Resident Assessment Instrument (RAI) manual and did not have a separate policy for MDS assessments. The Centers for Medicare and Medicaid Services (CMS) MDS RAI Manual, version 3.0, dated October 2025, indicated, .Section L: Oral/Dental Status. Intent: This item is intended to record any dental problems present in the 7-day look-back period. Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth. 2. Resident 12's record was reviewed on 3/6/26 at 10:01 a.m. A quarterly MDS assessment, dated 12/1/25, indicated the resident received one insulin injection during the assessment look-back period. Medication Administration Records (MARs), dated November and December 2025, lacked documentation the resident received any injections, including insulin. During an interview, on 3/6/26 at 10:53 a.m., the Director of Nursing (DON) indicated the resident had not received an insulin injection, and the MDS assessment should not have indicated they had. 3. Resident 3's record was reviewed on 3/6/26 at 9:28 a.m. A quarterly MDS assessment, dated 2/4/26, indicated the resident received one insulin injection during the assessment look-back period. Medication Administration Records (MARs), dated January and February 2026, lacked documentation the resident received insulin injections. The resident received an Ozempic injection one day of the assessment look-back period, 1/29/26.During an interview, the Director of Nursing (DON) indicated Ozempic should have been coded as an injection, but not insulin. Ozempic was not an insulin. The facility used the Resident Assessment Instrument (RAI) manual as their policy. The Centers for Medicare and Medicaid Services (CMS) MDS RAI Manual, version 3.0, dated October 2025, indicated, .Section N: Medications. Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. 410 Indiana Administrative Code (IAC) 16.2-3.1-31(c)(9)410 Indiana Administrative Code (IAC) 16.2-3.1-31(c)(13).

Based on interviews and record reviews, the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) level one was completed after a new major mental illness diagnoses was added to the diagnoses lists for 2 of 2 residents reviewed for PASRR compliance (Resident 81 and 2). Findings include:1. On 3/3/26 at 10:37 a.m. Resident 81's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, dementia, major depressive disorder, and psychotic disorder. On 5/12/25 Resident 81's medical chart was updated to add psychotic disorder as a new diagnosis. The record lacked documentation of the facility submitting a new level one PASRR to include the new diagnosis added to her medical record. On 3/4/26 at 12:13 p.m. the Executive Director (ED) indicated the most current PASRR level 1 was completed on 3/19/25, so the new psychotic disorder diagnosis added on 5/12/25 would not have been on that level one. 2. On 3/3/26 at 10:37 a.m. Resident 2's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to dementia and major depressive disorder with psychotic symptoms. On 2/10/26 Resident 2's medical chart was updated to add major depressive disorder with psychotic symptoms as a new diagnosis. The record lacked documentation of the facility submitting a new level one PASRR to include the new diagnosis added to her medical record. On 3/6/26 10:35 a.m. the Director of Nursing (DON) indicated the most current PASRR level 1 was completed on 11/20/25, so the new major depressive disorder with psychotic symptoms diagnosis added on 2/10/26 would not have been on that level one. On 3/5/26 at 11:23 a.m. a copy of a current facility policy titled, Pre-admission Screening and Resident Review (PASARR), dated 9/26/25. That policy indicated . A negative level 1 screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder.arises later. Procedure:.13. Any resident with newly evident or possible serious mental disorder. must be referred, by the facility to the appropriate state-designated mental health.authority for review. 410 Indiana Administrative Code (IAC) 16.2-3.1-16(d)

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided to residents who required assistance to maintain their personal hygiene for 2 of 28 residents reviewed for ADLs (Residents 6 and 15). Findings include:1. During an observation, on 3/2/26 at 10:45 a.m., Resident 6 was lying in bed. Resident 6 had untrimmed facial hair around her mouth, and the fingernails on her left hand were long and untrimmed with dark debris underneath them. During an observation, on 3/3/26 at 11:28 a.m., Resident 6 was lying in bed. The resident had untrimmed facial hair around her mouth. The resident's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. During an observation, on 3/3/26 at 2:05 p.m., Resident 6 was lying in bed. The resident had untrimmed facial hair around her mouth. The resident's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. During an observation, on 3/4/26 at 1:17 p.m., Resident 6 was lying in bed. The resident had untrimmed facial hair around her mouth. The resident's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. During an observation, on 3/4/26 at 2:30 p.m., Registered Nurse (RN) 7 completed wound care for Resident 6. During the care, the resident continued with untrimmed facial hair around her mouth, and fingernails remained long and untrimmed, with dark debris underneath them. During an observation, on 3/5/26 at 10:02 a.m., Resident 6 was observed up in a chair, next to her bed. The resident had untrimmed facial hair around her mouth. The resident's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. At the same time, the resident indicated she did not like having long fingernails. Resident 6's record was reviewed on 3/5/26 at 11:01 a.m. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (a decline in mental ability severe enough to interfere with daily life, characterized by loss of memory, reasoning, and language). A five day Minimum Data Set (MDS) assessment, dated 1/20/26, indicated the resident had a severe cognitive impairment and was dependent on staff for bathing. The assessment lacked documentation the resident exhibited any behaviors, including rejection of care. A care plan, initiated on 1/6/26, indicated the resident had an ADL self-care performance deficit. Interventions included, but were not limited to, the resident was totally dependent on one to two staff members for personal hygiene. Progress notes, dated February and March 2026, lacked documentation the resident was offered, provided, or refused shaving and fingernail care. A behavior task in the electronic record, dated 2/4/26 to 3/4/26, lacked documentation the resident refused hygiene care. Shower sheets, dated 2/3/26, 2/6/26, 2/10/26, 2/13/26, 2/17/26, 2/20/26, and 2/24/26, lacked documentation fingernail care or shaving was offered, provided, or refused. A shower sheet, dated 2/27/26, indicated the resident's fingernails were cleaned, but not trimmed or filed. The shower sheet lacked documentation shaving was offered, provided, or refused. During an interview, on 3/5/26 at 10:07 a.m., Certified Nurse Aide (CNA) 8 indicated Resident 6 did not refuse care, including fingernail care and shaving. Fingernail care and shaving should have been completed with showers. 2. During an observation, on 3/2/26 at 12:17 p.m., Resident 15's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. At the same time, Resident 15 indicated he was legally blind was unable to safely take care of his own fingernails but would have allowed the staff to provide the care if offered. The resident indicated the staff had not offered to clean or trim his fingernails. During an observation, on 3/3/26 at 11:25 a.m., Resident 15 was observed with long and untrimmed fingernails with dark debris underneath them. During an observation, on 3/3/26 at 2:07 p.m., Resident 15 was observed with long and untrimmed fingernails with dark debris underneath them. During an observation, on 3/4/26 at 1:20 p.m., Resident 15 was observed with long and untrimmed fingernails with dark debris underneath them. Resident 15's record was reviewed on 3/4/26 at 1:40 p.m. Diagnoses on the resident's profile included, but were not limited to, legal blindness. An annual Minimum Data Set (MDS) assessment, dated 1/16/26, indicated the resident had a moderate cognitive impairment and required set-up or clean-up assistance with personal hygiene. The assessment lacked documentation the resident exhibited any behaviors, including rejection of care. A care plan, initiated 1/31/24, indicated the resident had an ADL self-care performance deficit. Interventions included, but were not limited to, the resident required the assistance of one staff member for personal hygiene. Shower sheets, dated 2/4/26, 2/11/26, 2/14/26, 2/18/26, 2/25/26, and 2/28/26, indicated the resident's fingernails were cleaned, but lacked documentation they were trimmed or filed. Shower sheets, dated 2/7/26 and 2/21/26, lacked documentation fingernail care was offered, provided, or refused. Progress notes, dated February and March 2026, lacked documentation fingernail care was offered, provided, or refused. The task section of the electronic record lacked documentation refusal of care was a behavior the resident was monitored for. During an interview, on 3/5/26 at 10:07 a.m., Certified Nurse Aide (CNA) 8 indicated Resident 15 did not refuse care, including fingernail care. Fingernail care should have been completed with showers. During an interview, on 3/5/26 at 10:13 a.m., the Director of Nursing (DON) indicated if a resident refused ADL care it should have been documented in the CNA's charting. The nurse should have re-attempted and documented refusals in the progress notes. On 3/5/26 at 3:13 p.m., the DON provided a document titled, Activities of Daily Living [ADLs], last revised 9/4/26, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy The resident will receive assistance as needed to complete activities of daily living.A resident who is unable to carry out activities of daily living receives the necessary services to maintain.grooming, and personal.hygiene. 410 Indiana Administrative Code (IAC) 16.2-3.1-38(a)(3)(D).410 Indiana Administrative Code (IAC) 16.2-3.1-38(a)(3)(E).

Based on observations, interviews, and record review, the facility failed to maintain a functional resident call system for 1 of 1 resident reviewed for call light concerns (Resident 7). Findings include:On at 3/2/26 at 10:11 a.m., Resident 7 called out repeatedly for help. Her call light was not illuminated. During an interview on 3/2/26 at 10:13 a.m., Resident 7 indicated her call light had not been working for months. Resident 7 pressed her call button, but the light did not illuminate outside of her room. On 3/2/26 10:32 a.m., the Maintenance Director began to work on repairing her call light. In the meantime, Resident 7 was provided a small hand-held bell. Additional observations throughout the survey period revealed missing hallway call light covers for multiple rooms which included, but were not limited to: 118, 117, 115, 114, 112, and 121, making call lights difficult to see if they were on or not. On 3/4/26 at 10:00 a.m., Resident 7's call light was illuminated and the alarm sounded. An unidentified passing nurse indicated, someone was in the room with Resident 7, but her call light was malfunctioning and wouldn't turn off. They were waiting for someone to come out and repair the light. During an interview on 3/4/26 at 10:12 a.m., the Maintenance Director indicated, he tried everything he could think of from replacing the chord, the room wall-box, the above the door box, and even attempted to replace a fuse, but the light was still not working consistently. He indicated they system was very old and constantly having problems. During an interview on 3/5/26 at 1:25 p.m., the Administrator indicated, the call light system for the building was very old and nearly obsolete. Repairs parts were hard to find and very expensive. Issues with the call light system were ongoing and as a back up, residents were provided with hand-held bells as needed. Resident 7 filed a grievance, dated 12/19/25, which indicated she pushed the call light several times but it wasn't answered in a timely manner. On 3/6/26 at 9:43 a.m., the Director of Nursing provided a copy of current facility policy titled, Resident Call System, dated 12/23/25. The policy indicated, The nurses' stations in the facility will be equipped to receive resident calls with a communication system through audible or visual signals from resident rooms, toilets, and bating facilities. All portions of the system will be maintained and function accordingly. 410 Indiana Administrative Code (IAC) 16.2-3.1-19(u).

Based on interview and record review, the facility failed to complete a physician's order by documenting fluid intakes for a resident on restricted fluid intake for 1 of 4 residents reviewed for quality of care. (Resident E) Findings include:The clinical record for Resident E was reviewed on 7/22/24 at 10:43 a.m. Diagnoses included cirrhosis of the liver, diastolic congestive heart failure, and obesity. The resident was admitted [DATE].An acute care hospital physician's discharge note, dated 3/27/25, indicated the resident had hepatic cirrhosis and chronic diastolic heart failure and to continue plan of fluid restriction. A current physician's order, dated 3/27/25, indicated the resident was to have a regular diet with thin liquids with a 1500 ml (milliliter) fluid restriction. A review of the residents clinical record lacked fluid intake documentation or a care plan regarding the fluid restriction. During an interview on 7/22/25 at 1:34 p.m., the ADON indicated the fluid restriction was viewed as a dietary recommendation as the fluid restriction was in the directions of the order and not the order itself. The order was part of the resident's discharge orders from the hospital and was signed by the facility's physician, but was not tracked due to the placement of the fluid restriction in the order. A current facility policy, undated, titled, Fluid-Restriction Diet, provided by the Nurse Consultant on 7/22/25 at 3:08 p.m., included the following: Definition: The fluid-restriction diet order limits an individual's daily fluid intake Counting Liquids and Foods for a Fluid Restriction Diet. A fluid is anything that is liquid or any foods that melt at room temperature. These foods and liquids must be counted as part of the daily food intake.The tag relates to Complaint 1669976.3.1-37(a)

Based on observation, interview, and record review, the facility failed to keep a resident's call light in reach and to apply ordered oxygen for 1 of 4 residents reviewed for neglect. (Resident D)Findings include:During an interview on 7/21/25 at 11:33 a.m., Resident D was observed seated on the side of her bed. An oxygen concentrator was observed on the opposite side of the bed, out of reach of the resident. The resident indicated she had recently gotten dressed with the assistance of staff and had forgotten to put her oxygen back on. She reached for her call light to get staff assistance and the light was observed coiled on the floor next to the bed, out of reach of the resident. During an observation on 7/21/25 at 11:46 a.m., accompanied by the Administrator, the oxygen concentrator with the resident's nasal cannula was observed out of reach on the opposite side of the bed where the resident was seated. The Administrator handed the tubing to the resident who applied the oxygen and indicated staff should have reapplied the oxygen following care. The call light tubing was observed coiled on the floor next to the resident's bed. The Administrator indicated this should have been placed so the resident can call staff for assistance. The clinical record for Resident D was reviewed on 7/21/25 at 12:38 p.m. Diagnoses included history of a stroke with left sided weakness, chronic obstructive pulmonary disease, diastolic congestive heart failure, and depression. A health care plan, dated 6/24/25, indicated the resident had activities of daily living performance deficits related to activity intolerance. Interventions included, the resident required assistance of one staff to dress and to move between surfaces (transfer).A current facility policy, revised 9/12/22, titled, Resident Call System, provided by the Administrator on 7/22/25 at 11:54 a.m., included the following: Procedure: 5. The call light should be positioned within reach of the resident .a) The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.A current facility policy, revised 4/8/25, titled, Oxygen Administration, provided by the Administrator on 7/22/25 at 11:54 a.m., included the following: Policy. To ensure that oxygen is administered and stored safely within the facility or in an outside storage area .Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia.The tag relates to Complaint 1669976.3.1-47(a)(6)

Based on observation and interview, the facility failed to maintain a clean, orderly shower room for resident use on 1 of 3 shower rooms observed for cleanliness. (100 hall) Findings include:During an observation of the 100 Hall shower room on 7/22/25 at 2:10 p.m., accompanied by the Assistant Director of Nursing (ADON), the following was observed: the floor had feces on the floor in three different areas outside the shower area. A used plastic bag, wet paper towels and a used nicotine patch were on the floor. The floor was visibly dirty throughout the room. There was a used nicotine patch stuck to the shower wall. Around the base of the shower area, where the wall and floor meet, there was a black substance. During an interview at the time of the observation, the ADON indicated the shower rooms should not be in this condition and was an unacceptable way to leave the shower room. During an interview on 7/22/25 at 2:21 p.m., the Lead Housekeeper indicated the room was unclean. The floors should be swept and mopped and all debris thrown away. The dark substance between the tiles on the floor and walls just remain when cleaned. She had tried to clean it and would try another product.The Administrator indicated there was not a specific policy or checklist that she was aware of, regarding cleaning of the bathrooms.This tag relates to Complaint 1669993.3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure the temperature and palatability of food served for 5 of 6 residents reviewed for food temperature (Residents C, D, E, F, and M). This had the potential to affect 89 of 89 residents who received food from the kitchen. Findings include: On 5/19/25 at 10:30 a.m., Resident E was observed lying in bed with a breakfast tray on an over the bed table in front of her with half a biscuit and a sausage patty left. The resident indicated, food served in her room was often cold, and staff would not reheat the food, citing no microwave as the reason. On 5/19/25 at 10:56 a.m., Resident F was observed lying in bed speaking with a visitor who was at bedside. The resident indicated he usually had no concern with the temperature of his food, but he did not always get the food he ordered. Resident F gestured to his menu selections from the day prior, and indicated he did not get the roasted chicken and broccoli, and the nursing staff would not contact the kitchen for a replacement. On 5/19/25 at 11:25 a.m., Resident D indicated she ate meals in her room per her choice, but the food was always cold, and she liked her food hot. The resident indicated, sometimes she did not like the food choices, and would not eat that particular food. She was unaware the facility offered an alternative menu. On 5/19/25 at 2:05 p.m., an unidentified dietary employee was observed taking a kitchen transport cart back to the kitchen with resident food trays from lunch, the plates were observed to have warming plates under them, and plastic domes for covering the food. The cart was covered with a plastic food cart cover. On 5/19/25 at 2:41 p.m., Resident C was observed sitting on an electric wheelchair (WC) in his room watching television (TV), and a lunch tray with the food untouched was sitting on a bedside dresser. The resident indicated he had ridden his electric WC down the side of the road and gotten food from a fast-food restaurant approximately 1/4 mile away for lunch. Resident C indicated that morning he had been served a pancake with no syrup or butter, scrambled eggs, corn flakes, and a sausage patty. He had only eaten the cereal as the remainder of his breakfast was cold after being served from a cart with no insulation. On 5/20/25 at 8:40 a.m., fifteen breakfast trays were observed on a metal dietary transport cart in the front 100 hallway waiting to be passed, and the plastic covering that was used to maintain hot temperatures had been removed. There were two nurses observed at the 100-hallway nurse's desk charting while the trays sat in the hallway. On 5/20/25 at 8:50 a.m., there was an unidentified certified nursing assistant (CNA) observed to start passing the breakfast trays on the front and middle 100-hallways. The two nurses continued to sit at the 100 nurse's desk charting. On 5/20/25 at 8:56 a.m., Resident C was observed sitting on the side of the bed. The resident indicated his breakfast was cold and he was not eating it. The resident insisted the visitor touch the food, and although the food was covered with the hard plastic dome, it was cold to the touch. Resident C indicated complaints about cold food had been brought up at several monthly resident council meetings, and the residents had been told by management that enclosed transport food warmers were being ordered, but nothing had changed. On 5/20/25 at 9:02 a.m., Resident D was observed sitting in a recliner at bedside, her breakfast tray on an over the bed tray in front of her, she had not eaten her scrambled eggs, bacon, or half of the toast. The resident indicated that the food had been delivered while she was in the bathroom and was cold when she came out to eat. Resident D indicated that the plates were sitting on a plate warmer, but the plate warmer was also cold. On 5/20/25 at 9:54 a.m., observation of two separate metal dietary transport carts positioned near the 100-hallway nurse's desk with Dietary Aide 23. The two transport carts contained 25 resident breakfast trays, and all but four trays had the eggs returned, and 2 had the toast and bacon returned. Dietary Aide 23 indicated she was not sure why the residents had refused their breakfast, citing cold food, due to dietary staff having made sure this morning that the 100 hallway breakfast trays had been delivered on time at 8:30 a.m. On 5/20/25 at 11:55 p.m., Resident C indicated he used to warm up soup for meals on his own if he did not like what was being served by the facility, but there were no longer microwaves available for resident use, and staff would not allow the residents to use the microwaves or staff breakroom vending machines. On 5/20/25 at 12:18 p.m., Resident C indicated he had once again gone down the road and gotten lunch from a fast-food restaurant. On 5/20/25 at 12:50 p.m., a metal dietary transport cart with five resident lunch trays was observed sitting in the front 100 hallway with the plastic cover off the cart. On 5/20/25 at 12:54 p.m., an extra resident tray on the 300 hallway was tested for temperature. There was pork, pinto beans, zucchini, cornbread, pie and a drink. The cooked foods were tepid in temperature. On 5/20/25 at 12:55 p.m., Resident D's lunch tray was observed on an over the bed table in her room, she was out of the facility. On 5/21/25 at 12:01 p.m., Resident D was observed sitting in a WC at bedside awaiting lunch. She indicated that her breakfast that morning had been cold again. The DON came in to speak with her about another issue and had reheated her food in a microwave. A grievance log, dated 4/5/25, indicated Resident M had voiced being unhappy that the lunch and supper meals were cold, and the breakfast meals on the past two occasions of being cold had seemed frozen. Resident Council Minutes, dated 3/17/25, 4/14/25, and 5/15/25, documented resident concerns regarding the temperature of the food, limited food choices, and edibility of the food. Confidential interviews conducted during the course of the survey indicated, a. The food was horrible, always cold, and not edible. b. The resident was not offered alternative food when unable to eat the meal served from the kitchen, and not always served the proper diet prescribed by the physician. During an interview on 5/21/25 at 11:15 a.m., the Dietary Manager (DM) indicated to her knowledge, the kitchen had just been approved for heated transport carts on 5/20/25 due to turnover of Administration, but there was the possibility of at least another month or more before delivery, and in the interim food would continue to be transported on open metal carts. The current plan for keeping resident food warm during transport included the use of top and bottom plate warmers, and heated plates. Unfortunately, within minutes of being plated, 15% of the cooked food's heat was lost and all the food on the tray would eventually become the same temperature. The DM indicated dietary staff attempted to get meal delivery carts to the resident hallways timely, but if the trays were not passed immediately by nursing staff, the food would get cool quicker. During an interview on 5/21/25 at 11:20 a.m., the DM indicated resident complaints of cold food had been brought up in interdisciplinary team (IDT) meetings, and a discussion about meal pass should be an all-hands-on deck process. There was a meal manager scheduled for each meal to oversee meal service at the point of cart delivery on the resident hallway, the schedule was posted at the nurse's desks, and the assigned meal manager of the day was discussed during every morning meeting, but compliance of meal manager participation was hit or miss. During an interview on 5/21/25 at 1:19 p.m., the Administrator (ADM) indicated heated transport carts were to be ordered. In the interim, there was nothing from a kitchen perspective to be added to keep resident food hot until delivered to the resident rooms, but there was a need for all nursing staff and department head participation in passing out food tray. The 300-hallway satellite kitchen equipment was being assessed and looked at with the thought of once again utilizing the 300-hallway dining room in addition to the main dining room. On 5/21/25 at 2:42 p.m., the Administrator (ADM) provided a Food Temperature Control policy, dated 4/28/25, and indicated the policy was the one currently being used by the facility. The policy indicated, Policy: Food temperatures are maintained during mealtimes to ensure residents receive safe food served at acceptable temperatures .3. If food temperatures are unsatisfactory, the problem areas are corrected before serving the food item[s] . This citation relates to Complaint IN00459628. 3.1-21(a)(2)

Based on observation and interview, the facility failed to maintain a safe, clean, and sanitary environment on 1 of 2 units (100) observed for cleanliness. Findings include: On 5/19/25 at 2:41 p.m., Resident C indicated his bathroom was not stocked with toilet paper or paper towels, the bathroom sink was loose and about to fall off the wall, the carpet had not been vacuumed or shampooed and was stained with unidentified dried substances, and his room surfaces had not been dusted leaving an accumulation of dust. He indicated he spilled his urinal almost daily on his bed or the carpet which made his room stink, but staff did not see his room concerns as a priority. Resident C gestured to paper debris and food on the floor throughout the room, to include nuts and a blue colored chocolate coated candy along the wall near the entry and indicated the mess had been on the floor for at least 2 weeks. On 5/19/25 at 4:00 p.m., Housekeeper 19 was observed sweeping and mopping on the front 100 unit hallway during the day. There were no other housekeepers observed on the remaining two 100 unit hallways or the three 300 unit hallways. On 5/20/25 at 8:56 a.m., Resident C was observed sitting on the side of the bed, and indicated the wound nurse had just emptied his overflowing trash that contained smelly soiled briefs and plastic under pads. The bathroom was observed and there was no toilet paper, the paper towel dispenser was empty, the toilet rim had a dark dried unidentified substance on the front rim, and a styrofoam cup was sitting upside down on the seat. The carpet was observed and had not yet been vacuumed or shampooed leaving a foul odor, unidentified food and paper debris, and unidentified stains covering the entire carpet. There was still dust on the flat surfaces and furniture. The resident gestured to debris he had swept into the hallway from his room, and indicated maybe the housekeeping staff would vacuum the hallway carpet if not his. On 5/20/25 at 9:50 a.m., during observation of resident rooms 122 through 130, the floors in the bedrooms and bathrooms were randomly soiled with unidentified dried dark, sometimes sticky substances. The carpets were heavily soiled with unidentified dried stains, paper products included used tissues, scraps of paper and styrofoam cups were on the floors and under the beds, and unidentified food debris was observed throughout the rooms. On 5/20/25 at 9:55 a.m., the facility surfaces in the common areas throughout the facility were observation with visible dust. The white baseboards in the front entry, front common areas, hallway leading to the main dining room (MDR), and ice cream shoppe were observed to be heavily soiled with dirt buildup, and an unidentified substance. There was no observation of housekeeping staff on the 100 and 300 units during the morning tour. On 5/20/25 at 12:40 p.m., Resident C's bathroom was observed there was no toilet paper, the paper towel dispenser was empty, the toilet rim had a dark unidentified substance on the front rim, and a styrofoam cup was sitting upside down on the seat. The carpet was observed and had not yet been vacuumed or shampooed leaving a foul odor, unidentified food and paper debris, and unidentified stains covering the entire carpet. There was still dust on the flat surfaces and furniture. On 5/20/25 at 12:49 p.m., Housekeeper 19 was observed mopping resident rooms on the front hallway on the 100 unit. There were no other housekeepers observed cleaning on the remaining 100 unit hallways, the 300 unit hallways, main dining room, or front common areas of the facility on this date. On 5/20/25 at 1:20 p.m., the debris Resident C indicated he had swept from his room remained on the carpet in the hallway. A review of housekeeping schedules, dated 5/19/25 through 5/21/25, indicated Housekeeper 20 was assigned to all occupied resident rooms on the 300 unit, and the 300 unit common areas and bathroom, and Housekeeper 21 was assigned to resident rooms 116 through 130 and assist with the nurse's station were not observed working in the facility during the survey. During an interview on 5/20/25 at 2:07 p.m., Housekeeper 19 indicated each housekeeper was assigned a different section of the facility to clean. He was responsible for the MDR, front entry common areas, and resident rooms 100 through 115. The housekeeping department was currently down a housekeeper, therefore the remaining rooms on the 100 hallways had no assigned housekeeper. The residents' rooms on the far 100 hallway were carpeted, the residents tended to be up more, and they made less messes, so they were spot checked and cleaned as needed by himself or the Housekeeping Supervisor. Housekeeper 19 indicated that every morning he was required to vacuum the carpet in the MDR and front entry, sweep and mopped the offices and to take out their trash, and to clean the front public bathrooms. The activity room and ice cream shoppe were only cleaned as needed. Housekeeper 19 indicated that the front entry tile was not swept and mopped every day due to the foot traffic, dusting in the front lobby and common areas was completed about once weekly, and he had cleaned the baseboards recently by using a mop. Housekeeping staff were required to leave early at times due to a low census, so got cleaning done as time allowed. During an interview on 5/21/25 at 12:52 p.m., the Housekeeping Supervisor indicated she had been on vacation and just returned the day before, but Housekeeper 20 had told her Resident C's room had been cleaned and vacuumed on 5/19/25. Resident C's room was stocked with paper products daily, and she was not sure what he was doing with the paper towel and toilet paper. The Housekeeping Supervisor indicated that Resident C did not like staff that were not Americans, to include Housekeeper 20 that was assigned to his hallway, and would yell at her and tell her to leave his room. To accommodate the resident, Housekeeper 20 was trying to go in and restock and clean while the resident was out of the room, but there had been no plan to replace the housekeeper's assignment of Resident C's room. The Housekeeping Supervisor indicated that common areas in the facility and resident rooms were to be cleaned daily to include sweeping, mopping and vacuuming floors, dusting high touch surfaces, and cleaning the bathrooms. Dusting in common areas was done weekly, and the baseboards in the front common areas and ice cream shoppe were supposed to be cleaned daily or as needed. On 5/21/25 at 2:42 p.m., the Administrator (ADM) provided a Housekeeping Services policy, dated 6/4/24, and indicated the policy was the one currently being used by the facility. The policy indicated, The facility will provide a safe, clean, comfortable, and homelike environment .1. Lobby and resident common areas. a. Clean high-touch areas daily and as needed. b. Clean low-touch areas weekly and as needed. 2. Resident rooms. a. clean high-touch surfaces at least daily to include handwashing sinks and floors .c. Clean low-touch surfaces on a scheduled basis [i.e., weekly] .3. Resident bathrooms. a. Clean and disinfect high touch/frequently contaminated surfaces [sinks, faucets, handles, toilet seats, door handles] at least daily. b. Clean and disinfect any surface visible soiled with blood or body fluids .1. Carpeting will be vacuumed regularly, cleaned promptly if spills occur, and shampooed routinely and when indicated by appearance This citation relates to Complaint IN00459628. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for abuse was free from abuse which resulted in actual harm as Resident B was seen crying out and verbally indicated she was afraid when she was roughly put into bed, scolded, and threatened by nursing staff members. Using the reasonable person concept, the staff abuse was likely to have caused chronic and recurrent fear and anxiety for the resident (Resident B). Findings include: During a confidential interview it was indicated that Resident B had been mishandled and mistreated by several nursing staff members. She often complained that staff were too rough with her and when family reviewed video footage of her care, they were shocked to see how rough and unkind the staff treated and spoke to her. A complaint was made to the Executive Director (ED), on 5/17/23, when a family member came into the building to formally request copies of the resident's medical record. At that time, the ED was shown screen shot pictures from the video footage of different staff members who had been seen mistreating Resident B, but the ED dismissed the concerns. The family member did not feel that the matter had been taken seriously. On 10/11/23 at 9:52 a.m., Resident B's family indicated Resident B would indicate, They [staff] would talk rudely, yell at her, thrust her legs on the bed after resident asked them to be gentle. Point their fingers in her face. When she requested her bottle of soda, the nurse tossed it to her instead of politely handing it to her. One staff member even threatened, you won't get anything until tomorrow. Video footage of Resident B's abuse was provided by the family. Videos provided showed the following: Video 1: Resident B was seated on the edge of her bed. Certified Nursing Aide (CNA) 7 lifted and quickly swung the Resident's legs into bed which caused the resident to fall back in bed without support. She cried out in pain and indicated she had already asked them not to throw her legs up like that. CNA continued to position her in bed without speaking or slowing down. Resident B continued to cry. Video 2: Resident B was seated on the edge of her bed and attempted to lay herself backward into bed. She had difficulty lifting her legs. CNA 7 picked up her foot and swung her legs into bed. Resident B shook her arms in frustration and said it hurt. CNA 7 scolded Resident B indicating, .your legs weight 300 pounds apiece! I can't just lift them real slow, I gotta go fast! I tell you that all the time, I can't go slow, it hurts my back Video 3: Resident B was reclined in bed and asked CNA 7 to get her 7-Up from over there. CNA 7 was out of frame, and tossed the bottle from where she stood in the room onto Resident B's bed, which dropped onto her thigh. Resident B picked up the bottle but indicated, it was not the cold one she wanted. CNA 7 comes to the side of Resident B's bed, leaned over her and pointed her finger in the Resident's face and scolded, you're P------me the F--- off! You won't get it again because I'm not a F------ dog, do you understand me! Resident B again asked for a cold soda. CNA 7 continued to lean over the Resident and wag her finger in her face then threatened, I bet you won't get anything until tomorrow, I guarantee it! Video 4: Resident B was reclined in her bed crying. Licensed Practical Nurse (LPN) 6 and CNA 8 were in the room setting up her breakfast tray. LPN 6 indicated as she waved her finger, we are not going out there. Resident B asked why, and LPN 6 indicated, I can't stay, I stayed here all day yesterday. LPN 6 interrupted Resident B in midsentence so Resident B raised her arm and pointed her fingers and indicated, hey you wait a minute, but LPN 6 cut her off again and pointed her finger in the Resident's face and indicated, don't you yell at me! Resident B persisted and called CNA 7 by name and indicated, she threw me in the bed, and then yelled at me and shut the door, her voice breaks with tears and she continued, I don't like that one, you wonder why I'm afraid in here! LPN 6 and CNA 8 continue to reposition the Resident in bed as she cried. When they pulled her up in bed, Resident B indicated, no I'm getting out of bed, I can't lay here, I can't lay on this side I need to lay on my back, they continued to position her in bed without speaking to her. LPN 6 raised the head of her bed with the remote, Resident B continued, what are you doing? CNA 8 pointed to her breakfast tray and indicated, you need to eat your breakfast, then we will get you up. Resident B turned to LPN 6 and indicated, you think I do it intentionally, you're wrong. LPN 6 replied, I didn't say that. Resident B indicated while she cried, that's what they've been doing to me. LPN 6 put the table over her bed and uncovered her tray to set up breakfast, but Resident B shook her head no, and indicated, I've got to get out of the bed outside, LPN 6 interrupted her again and indicated, We'll get you up after breakfast, I want you to eat first. Resident B continued to cry. During an interview on 10/11/23 at 3:00 p.m., LPN 6 was asked questions about the residents right to be free from abuse. LPN 6 indicated all staff received education on Residents Rights and abuse, and it was unacceptable to abuse a resident. LPN 6 indicated it was not appropriate to point a finger in a resident's face and tell them not to talk back or yell. She was required to report immediately to her supervisor if a resident told her about mistreatment or abuse from another staff member. On 10/12/23 at 10:22 a.m., a copy of the April 2023-current grievance log was provided by the Director of Nursing (DON). The record lacked documentation of any concerns/grievances related to Resident B. During an interview on 10/12/23 at 10:46 a.m., the Executive Director indicated the grievance log had been updated and there were no grievances related to Resident B. When asked if she had a conversation with Resident B's family member on 5/17/23, the ED indicated, I don't remember. On 10/12/23 at 12:15 p.m., the videos were shown to the ED, DON, the Regional Clinical Consultant (RCC) and [NAME] President of Operations (VPO). After viewing the videos, it was indicated in consensus, staff had mistreated Resident B when roughly putting her to bed, yelling at her with curse words and pointing fingers in her face, and throwing her soda bottle instead of handing it to her. If a resident made allegations of mistreatment or abuse to a staff member, that staff member was required to report it to their supervisor so that it could be investigated. On 10/11/23 at 11:57 a.m., Resident B's medical record was reviewed. She was a long-term care resident who had diagnoses which included, but were not limited to, fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body), rheumatoid arthritis (an autoimmune and inflammatory disease which causes inflammation and painful swelling to the affected areas of the body), dementia (a degenerative disease of the brain which causes permanent and irreversible cognitive decline and memory loss), and anxiety. Her most recent comprehensive assessment was an annual Minimum Data Set (MDS) assessment dated [DATE]. The MDS indicated Resident B was severely cognitively impaired, no behavioral concerns were coded, and she required extensive to total assistance with most activities of daily living, (ADLS) such as bed mobility, transfers and personal hygiene. She had a comprehensive care plan, dated 11/11/22, which indicated she had an ADL self-performance deficit related to her diagnoses, poor safety awareness and lack of coordination. Interventions for the plan of care included, but not limited to, her need to have extensive assistance with bed mobility and needed a sit-to-stand lift for transfers. She had a comprehensive care plan, dated 6/23/21, indicated she sometimes made false accusation about staff related to her dementia. An intervention for this plan of care included, but was not limited to, .when resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmy in conversation; If response is aggressive, staff to walk away calmly, and approach later She had a compressive care plan, dated 11/11/22, which indicated she had difficulty understanding or being understood due to her severe dementia. Interventions for this plan of care included, but were not limited to, .allow adequate time to respond, do not rush Using the reasonable person concept, the staff abuse was likely to have caused chronic and recurrent fear and anxiety for the resident. On 10/12/23 at 10:00 a.m., the DON provided a copy of current facility policy titled, Area of Focus: Resident Rights, reviewed 11/21/22. The policy indicated, At the time of admission, a resident is afforded certain rights while residing in a long-term care facility. The facility and its associates have the responsibility for ensuring these rights are always upheld the residents is in their care . The facility will ensure its associates are educated to the importance of resident's rights. Any violation or potential violation should be reported immediately to their supervisor, the DON, Social Service, or the ED On 10/12/23 at 10:00 a.m., the DON provided a copy of current facility policy titled, Abuse- Prevention, reviewed 7/18/23. The policy indicated, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation This citation relates to complaint IN00410616.

Based on interview and record review, the facility failed to ensure fall prevention interventions were implemented after a resident had an unwitnessed fall which resulted in actual harm when a resident (Resident D) had a second fall that resulted in a [CONDITION(S)] for 1 of 3 residents reviewed for falls. Findings include: On 3/16/21 at 11:50 a.m., Resident D's medical record was reviewed. Resident D was with diagnoses to include, but were not limited to, acute on chronic [CONDITION(S)], shortness of breath, pneumonia, and anxiety. An admission nursing assessment, dated 4/3/20, indicated Resident D was alert, oriented, and could make her needs and wants known. The assessment indicated she was at risk for falls. An immediate baseline care plan, dated 4/6/20, indicated Resident D was at risk for falls and interventions put in place were assist with ADLs (activities of daily living), call light within reach, complete fall risk assessment, and orient resident to room. A comprehensive care plan, dated 4/6/20, indicated Resident D was at risk for falls related to deconditioning. Interventions for this care plan were assist with ADLs, call light within reach, complete fall risk assessment, and orient resident to room. A weekly skin integrity assessment, dated 4/8/20 at 4:19 p.m., indicated, Resident D had a new skin tear located on her left upper arm, and measured: 1 cm (centimeter) long, by 3 cm wide, and 0.1 cm deep. A nursing progress note, dated 4/8/20, at 4:35 p.m., indicated Resident D was found to have a skin tear on her left upper arm. The nurse asked what happened to her arm, and Resident D indicated, at bedtime last night, I was trying to get in my bed myself and I fell . The note indicated the nurse completed a full assessment and notified the MD (medical doctor). The record lacked additional documentation related to the fall including: a complete set of neuro checks, any new fall interventions put in place, a new fall risk assessment, or any IDT (interdisciplinary team) fall follow up. A Nurse Practitioner progress note, dated 4/9/20, indicated Resident D was seen to evaluate her anxiety control. She was due for a refill of her antianxiety medication. Resident D was alert and not showing any signs of symptoms of ill effects of her antianxiety medication, such as no sedation, no falls recently, and no respiratory depression. She was very anxious and visibly shaking, she was so anxious she could barely participate in therapy. The note did not indicate Resident D's fall from the previous day, or the skin tear she sustained from the fall. A nursing progress note, dated 4/11/20 at 4:33 p.m., indicated at approximately 5:10 a.m. Resident D was found sitting on the floor away from her bed with both legs out in front of her. Resident D indicated she was trying to get to her wheelchair. She was assisted back into her bed and complained of pain in her left hip. A new order for a bilateral hip x-ray was obtained. An initial neuro check assessment, dated 4/11/20 at 5:10 a.m. A pain evaluation, dated 4/11/20 at 5:10 a.m., indicated Resident D complained of pain in her left hip on a scale of 4 out of 10. Physician orders from April 2020 indicated Resident D had a physician order to give 2 tablets of Acetaminophen (Tylenol) 325 mg (milligram) every six hours as needed for pain. Resident D's Medication Administration Record (MAR) was reviewed. No pain medication had been given on 4/11/20 after her complaint of pain. A nursing progress note, dated 4/11/20 at 12:57 p.m., indicated Resident D was having difficulty breathing and her oxygen needed to be increased to 6 L (liters) per minute, and her family insisted Resident D be sent to the ER. A nursing progress note dated 4/11/20 at 1:03 p.m., indicated, Resident D became short of breath an hour before the paramedics arrived. She was not speaking at this time, she was very pale, and her oxygen levels ranged from 90-93%. She was assessed by the paramedics and taken to the ER. On 3/16/21 at 4:44 p.m., the Administrator provided a copy of a Resident D's x-ray results. The x-ray, dated 4/15/20, indicated the resident had a displaced left femoral neck fracture. During an interview on 3/15/21 at 3:32 p.m., the Director of Nursing (DON) indicated if a resident had or was suspected to have had an unwitnessed fall, the nursing staff should assess the resident for any injury, complete a head-to-toe assessment, a new fall risk assessment, a pain evaluation, and initiate neuro checks. The doctor should always be notified of a resident's fall and any new orders or treatments provided by the doctor should be put in place. Additionally, a new intervention should be put into place, and the care plan would be updated. During an interview on 3/16/21 at 3:10 p.m., the DON indicated fall interventions were put in place for resident safety. If a resident was having falls, then staff needed to figure out why they were falling, what caused the fall, and put new interventions in place in order to try and prevent any more falls. On 3/15/21 at 4:00 p.m., the Administrator (ADM) provided a copy of current facility policy titled, Fall Management, dated effective 12/13/18 and reviewed 4/15/19. The policy indicated, .Purpose- to promote safety and reduce patient falls by proactively identifying, care planning, and monitoring of patients' fall indicators . the facility must ensure that the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Accidents refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Avoidable accident means that an accident occurred because the facility failed to . implement interventions . monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice . procedure: residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition, and with any new fall event . the interdisciplinary team will review and revise the care plan, if indicated . upon a fall event During an interview on 3/17/21 at 10:30 a.m., the ADM indicated there was no additional fall policy, or unwitnessed fall procedure. He indicated when a fall incident was triggered into the electronic health system, the software would prompt nurses to complete all fall follow up documentation which included neuro checks. New nurses should have been instructed on the fall process and documentation requirements when following other nurses during orientation. This Federal tag relates to Complaint IN 377. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident admitted to the facility's red zone (COVID-19 positive unit) was provided necessary assessments, monitoring related to diabetes and positive COVID-19 status and medications when the resident was not entered into the electronic health record (EHR) system upon admission, and the agency nurse failed to give report to the oncoming nurse which resulted in the facility failing to ensure the resident received necessary nursing care, treatment, and medications for multiple days for 1 of 3 residents reviewed for Quality of Care (Resident B). The immediate jeopardy began on 12/31/2020 when Resident B, who had [DIAGNOSES REDACTED]. Upon admission to the facility, the admitting nurse left without giving report or correctly admitting the resident into the EHR system which resulted in the nursing staff being unaware of the resident, and medications and treatments were not ordered or administered for multiple days. The resident was not assessed for potential complications of her [DIAGNOSES REDACTED]. The Administrator and the Regional Vice President (RVP) were notified of the immediate jeopardy at 2:04 p.m. on 1/07/21. The immediate jeopardy was removed on 1/04/21, 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 a confidential interview during the survey, dated 1/06/21 to 1/08/21, the interviewee indicated Resident B had been discharged from the hospital and taken to the facility on [DATE]. She was in the hospital because she was having a hard time waking up and fell a couple times. Her family called an ambulance to check on her, and the resident's blood sugar was really low. She had not been eating or drinking well and was weak. At the hospital she tested positive for COVID-19. The hospital got her blood sugar under control and sent her to the facility for therapy. The plan was after a few days the resident was supposed to be moved to the attached assisted living center. The facility had not called the family to let them know anything about her condition or her planned move to assisted living. The facility had not contacted the family for three or four days, and the resident's husband had not heard anything and could not get any information. The facility could not find her and did not know if she was there. Friends of the family called the hospital and were told the resident had been discharged . The Administrator called over the weekend on 1/02/21 around 8 or 9 p.m. to inform the family the resident was located. During a phone interview, on 1/06/21 at 12:42 p.m., Resident B's husband indicated the resident came to the facility by ambulance on 12/31/20. He had not heard from the facility about how she was doing. He called to check on her and the nurse told him Resident B was not there. It was a couple of days before they knew she was there. He talked to someone and they said, we haven't received her yet. He indicated, I was going crazy! Can you imagine? My wife out there and no one knowing where she is? On 1/06/21 at 11:37 a.m., a comprehensive record review for Resident B was completed. A hospital discharge summary, dated 12/31/20 at 2:44 p.m., indicated, XXX[AGE] year old female with history of pancytopenia (a condition that occurs when a person has low counts for all three types of blood cells: red blood cells, white blood cells, and platelets), [MEDICAL CONDITION], (an irregular often rapid heartbeat), CAD ([MEDICAL CONDITION]- narrowing or blockage of the coronary arteries) who presented with weakness over last several weeks and mild lower abdominal pain. Due to weakness she had multiple falls at home. She is having cognitive impairment at baseline .patient was admitted under hospitalist service for generalized weakness and frequent falls. She was tested for COVID-19 and was found positive although patient was not having any symptoms . patient was continued on her home medications for her comorbidities .generalized weakness likely secondary to COVID-19 infection, frequent falls secondary to generalized weakness .medications to continue: . carvedilol (a medication for high blood pressure) two times a day for blood pressure/afib ([MEDICAL CONDITION]) .[MEDICATION NAME] (a medication for high blood pressure) five pills a day .sitagliptin (a medication for diabetes) one time a day An Entry MDS (Minimum Data Set) assessment, dated 12/31/2020, indicated Resident B admitted to the facility on [DATE] from an acute hospital stay. Resident B had physician orders [REDACTED]. Admit to Westside Village Nursing Center, initiated 1/02/21 Accuchecks blood glucose level. Call MD (medical doctor) if blood sugar <70 or >350 four times a day for DM (diabetes), initiated 1/03/21. Complete respiratory assessment under Resp Tab every 4 hours initiated 1/02/21 Carvedilol Tablet 6.25mg (milligram) give 1 tablet by mouth two times a day [MEDICAL CONDITION](hypertension), initiated 1/02/21 Glimepiride Tablet 1000 MCG (microgram) give 1 tablet orally one time a day for DMII (type 2 diabetes), which was not initiated until 1/03/21 [MEDICATION NAME] HCI Tablet 25mg give 1 tablet orally two times a day for HTN, initiated 1/03/21. A late entry nursing progress note, dated 1/02/21 at 9:10 p.m., indicated, .abnormal heart rhythm . incontinence of bowel and bladder . resident has a [DIAGNOSES REDACTED]. Nursing will monitor for any side effects of the anticoagulant. Resident has a [DIAGNOSES REDACTED]. A nursing progress note, dated 1/03/21 at 8:06 a.m., indicated, .spoke with on call MD (medical doctor) and they are aware of the residents (sic) missed doses of medications .resident received 0600 medications and pharmacy is sending the (rest) of the resident's meds STAT A nursing progress note, dated 1/03/21 at 1:05 p.m., indicated, .BP (blood pressure) slightly elevated this AM, decreased with administration of routine [MEDICATION NAME] Blood Pressures documented in Vital Signs for Resident B included, but were not limited to, the following: 1/2/21 at 9:10 a.m. 114/64 mmHg 1/3/21 at 10:10 a.m. 190/52 mmHg 1/3/21 at 11:43 a.m. 190/52 mmHg 1/3/21 at 12:41p.m. 150/64 mmHg 1/3/21 at 4:51 p.m. 138/78 mmHg 1/3/21 at 7:57 p.m. 125/74 mmHg 1/3/21 at 11:10 p.m. 130/70 mmHg 1/4/21 at 1:04 a.m. 150/61 mmHg 1/4/21 at 3:39 a.m.143/69 mmHg 1/4/21 at 12:37 p.m. 168/59 mmHg Blood sugars documented in Vital Signs for Resident B included, but were not limited to, the following: 1/2/21 at 9:10 p.m. 116.0 mg/dL 1/3/21 at 2:07 p.m. 109.0 mg/dL 1/3/21 at 7:57 p.m. 101.0 mg/dL 1/4/21 at 12:34 p.m. 187.0 mg/dL 1/4/21 at 5:20 p.m. 207.0 mg/dL 1/4/21 at 7:58 p.m. 199.0 mg/dL 1/5/21 at 6:15 a.m. 174.0 mg/dL Resident B's physician order, dated 1/3/21, indicated blood sugar levels should not be below 70, or above 350. A care plan, initiated on 1/02/21 and revised on 1/3/21, indicated, . (Resident B) has missed doses of medications on admission A care plan, initiated on 1/03/21, indicated, .Resident is at risk for falls (related to) history of falls pre-admission, COVID-19, weakness, recent joint replacement, abnormal gait, [DIAGNOSES REDACTED]. A care plan, initiated 1/03/21, indicated, .Diabetes Mellitus .blood sugar checks as ordered, diet as ordered, medications as ordered A care plan, initiated 1/03/21, indicated, .the resident is on anticoagulant therapy . observe and report as needed adverse reactions During a phone interview, on 1/06/21 at 1:18 p.m., Licensed Practical Nurse (LPN) 11, the Red Zone (COVID-19 positive unit) Nurse Manager, indicated Resident B was admitted to the facility on New Year's Eve on the night shift. He had not worked that night but was aware there had been an incident with the resident's admission. LPN 11 indicated the nurse who admitted Resident B failed to properly input the resident's information into the computer. So, there was no communication documented and the nurse did not give report to the oncoming nurse the next morning. This resulted in the resident not receiving her medications or nursing assessments. During a phone interview, on 1/06/21 at 1:30 p.m., LPN 12 indicated she received a call from the facility on the evening of 1/02/21 asking if she had admitted Resident B on 12/31/2020. LPN 12 had not, because Resident B admitted on the night shift after LPN 12 left for the day. She suggested the facility call the EMS (Emergency Medical Staff) and find out who signed for the resident upon her admission. LPN 12 indicated the facility was able to find out the nurse had been another agency nurse who did not input the resident into the system, or report to the next nurse, so the nurses did not know she was there. On 1/06/21 at 2:45 p.m., during an interview, the Administrator (ADM) indicated, he knew the resident was supposed to admit to the facility. The IDT (interdisciplinary) team had discussed and approved the resident for admission. The dietary department had already printed a card for her and prepared to start sending meal trays on 12/31/20. On the evening of 1/02/21, the ADM was out of the building when he received a call that there was some confusion about if Resident B had come to the facility. The ADM indicated he knew she was there, but figured there had been some confusion about whether she had been sent to the Assisted Living building on the same campus because they share the same physical address or if she had been brought directly to the Skilled Nursing facility Red Zone unit. He immediately told the nurse to do a head count, and they realized Resident B was on the Red Zone. When the ADM investigated, he found out the nurse who admitted her, had incorrectly entered her into the Electronic Health System; she had been entered as an outpatient and not inpatient resident. This meant the computer-initiated admission paperwork was not triggered or completed. Further, the nurse failed to give report to the next oncoming nurse which resulted in her missing more nursing assessments and several doses of medications. On 1/06/21 at 3:55 p.m., Resident B was observed on the Red Zone, COVID-19 positive unit. Her door was closed, and signs were posted for droplet isolation. Resident B was lying in bed. The bed was in its lowest position, and the head of the bed was elevated 30 degrees. Resident B's eyes were closed, her eyes fluttered open then closed again in response to verbal stimuli. She rocked her head back and forth several times, but her eyes remained closed. She was wearing a hospital gown, her hair was flat and tangled, and several white hairs had grown out on her chin. On 1/06/21 at 3:57 p.m., during an interview, LPN 11 indicated Resident B was a small, frail little lady who slept a lot and was not really alert to her surroundings, she had moderate confusion and did not eat or drink very much. On 1/06/21 at 4:00 p.m., during an interview, Certified Nursing Assistant (CNA) 14 indicated she had worked on the night Resident B was admitted . The nurse only told her Resident B needed help eating and was incontinent of both bowel and bladder and needed extensive assistance from staff for all her Activities of Daily Living. She helped get Resident B settled in her room, and offered her a snack, that she did not eat very much of it. Resident B was not in the system, so she could not chart the care she had provided. During the survey, there were attempts to interview additional Certified Nursing Assistants scheduled from 12/31/20 and 1/3/21, but no additional CNAs answered. On 1/07/21 at 11:27 a.m., during an interview, the Dietary Manager (DM) indicated, she had been informed Resident B would be admitted on [DATE]. The only thing missing was the actual diet order, and until nursing staff clarified the diet, the kitchen sent a regular tray. The DM had called back to the Red Zone nurse on 1/01/21 to let them know she still had not received Resident B's diet order, the nurse told her to send a regular tray and she would look into it. But the DM did not receive the official diet order until 1/02/21, which was for a regular diet, no added salt, regular texture, and no known food allergies [REDACTED].>On 1/07/21 at 11:44 a.m., during an interview, the Administrator indicated LPN 17 worked the shift after LPN 13 who admitted the resident. LPN 17 gave a statement that he had not been told about the new resident in report, and the resident was not on his assignment sheet. There were multiple attempts to interview LPN 17 during the survey, but LPN 17 did not answer. On 1/07/21 at 11:44 a.m., during an interview, the Administrator provided a copy of a packet which he indicated was at every nurses' station, including the COVID-19 Red Zone unit, to be used when a resident was admitted to the facility. He indicated all staff should enter the resident's information into the EHR system immediately or as soon as feasibly possible, after the resident arrived at the facility. If the staff were unable or did not know how to use the system, they should have notified the ADM or the DON (Director of Nursing) for help. The packet included the steps of admitting a resident and indicated the following user defined assessments (UDAs) automatically trigger on admission: Admission/Readmission Collection tool; AIMS (Abnormal Involuntary Movement Scale) (if required related to medications ordered); Braden scale (for pressure ulcer risk); elopement risk evaluation; evaluation for bowel & bladder training (if incontinence indicated); fall risk evaluation; pain evaluation; restraint evaluation; smoking safety evaluation (if current smoker); skin integrity data collection tool, and baseline care plan. On 1/07/21 at 12:14 p.m., during an interview, Registered Nurse (RN) 16 indicated she came on shift on 1/01/21 at 7:02 a.m. When she arrived for her assignment, the night nurse (who had admitted Resident B) had already left because he had a flight to catch. He had given the keys to the other nurse, LPN 17, but no report had been left. There was no formal census or assignment sheet, and she received a sheet with nine names on it. She was responsible for another hall and was not working on Resident B's hall that morning. She indicated she was unsure how LPN 17 would have known Resident B was there, since the night nurse had not given any information in report and had not told him about the new resident. They kept the doors shut in the Red Zone because of the droplet isolation protocol, and with them not having received any information in report, she indicated they would just not have known about the new resident. On 1/07/21 at 11:30 a.m., the ADM provided a copy of a dictated interview with LPN 13, the agency nurse who left without giving report on Resident B's new admission. The conversation was a phone conversation between LPN 13 and the DON. LPN 13 indicated, I worked 12/31/2020 from 9:30 p.m., until 6:00 a.m. I signed/received pt. (patient/Resident B) in facility. I tried to admit patient in (name of EHR system) .but I failed. The patient would not populate in active residents. I took resident's VS (vital signs) I kept them comfortable through the night. I gave them a snack. I knew someone would be in the facility in the morning to fix the admission. We checked and changed the patient. I assessed patient, she did not have any issues . 'why didn't you call ADM to report failure to admit resident?' .I didn't have to call, I knew someone would fix it in the morning. I have a flight to catch I got to go, I took care of the patient and kept her comfortable all through the night There were multiple attempts to interview LPN 13 during the survey, but LPN 13 did not answer. On 1/07/21 at 11:35 a.m., the ADM provided a copy of current facility policy titled, Admission Policy, dated/reviewed 5/18/2020. The policy indicated, .The facility must: provide uniform guidelines for the admission of patients to the facility, reduce the fears and anxieties of the patient and family during admission process . Procedure, Admission of Patients: . #2. The health referral form submitted by the attending physician will contain medical findings, diagnosis, treatment to follow, prescribed diet, medication/treatment orders, patients functional state, long or short term goals, rehabilitation potential, and signed orders for immediate care. These should be available at the time of admission On 1/07/21 at 12:00 p.m. a review of CDC guidance, titled, Preparing for COVID-19 in Nursing Homes, updated 11/20/2020, included the following: .Residents with known or suspected COVID-19 should be cared for using all recommended PPE . Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection The immediate jeopardy that began on 12/31/2020 was removed on 1/4/2021 after the facility completed a comprehensive assessment on Resident B, ordered and administered her medications, and ensured she had received food and incontinent care. The facility provided education to all staff on the admission process, implemented a room to room check on each hall at the beginning of each shift to ensure all residents were accounted for, a new procedure for new admission to be reported to the Director of Nursing/designee was created, and a plan for monitoring staff compliance was created. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 843. 3.1-37(a)

Based on interview, observation, and record review, the facility failed to ensure infection control practices for COVID-19 were followed to ensure residents free from symptoms of the COVID-19 infection, on the dementia care unit, were not exposed to and roomed with residents who were positive for the COVID-19 infection for 2 of 22 residents on the dementia unit (Residents B and K). This deficiency had the potential to affect 15 of 22 residents on the dementia care unit. The immediate jeopardy began on 4/11/20, when the facility elected to make the dementia care unit the COVID-19 isolation unit. The day prior, 4/10/20, two residents who already resided on the dementia care unit had been determined to be positive for the COVID-19 infection (Residents F and G). On 4/11/20, Residents C, D and E were moved from the 300 hall (the facility's initial isolation unit) into the dementia care unit. The other residents, who resided on the dementia care unit, were not transferred out of the unit when the COVID-19 positive residents were moved onto the unit. Two of the positive COVID-19 residents (Residents C and H) were placed into rooms with two residents (Residents B and K) who were not symptomatic of COVID-19. This placed the two dementia care residents, as well as the other residents on the dementia care unit, at risk of developing the COVID-19 infection. The Executive Director (ED) and the Director of Nursing (DON) were notified of the immediate jeopardy on 4/16/20 at 1:43 p.m. The immediate jeopardy was removed on 4/19/20, but noncompliance remained at pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on 4/16/20 at 9:58 a.m., the Executive Director (ED) indicated there were seven positive COVID-19 infection cases in the facility. They had established the dementia care unit the isolation unit. On 4/10/20, two of the residents who resided on the dementia unit had tested positive for the COVID-19 infection. Both of the residents wandered around the unit regularly. The ED indicated, since the residents had been in close contact with the other residents on the unit, prior to being determined as positive with the infection, the remainder of the residents on the unit were considered presumptive positive for the infection. It was at this time, the facility elected to make the dementia care unit the isolation unit for COVID-19 infections. Prior to that time, they had been using a small portion of the 300 hall as the isolation unit, since it had fire doors that could close it off from the remainder of the facility. On 4/11/20, the other COVID-19 positive residents were transferred to the dementia care unit. Due to lack of available beds, they had to place a positive female (Resident C) into a room with a female dementia resident (Resident B) who was asymptomatic and had not been tested , and a positive male resident (Resident H) into a room with a male dementia resident (Resident K) who was asymptomatic and had not been tested . No communal activities or communal dining were being held on the unit. The staff would redirect any wandering residents in an attempt to maintain social distancing. During an interview, on 4/16/20 at 11:15 a.m., the ED indicated there were 22 residents who resided on the dementia care unit, including the seven residents who were positive for COVID-19. The facility did not have a plan to test any resident unless they exhibited sign/symptoms, or unless requested by physician or family. During an observation, on 4/16/20 at 11:52 a.m., the 200 hall was observed to be the locked dementia and isolation unit. On 4/16/20 at 12:20 p.m., the ED provided a document, titled Number of Residents Presenting with Infectious Symptoms, and indicated it contained the current facility information for residents with active COVID-19 infection. The document indicated the dates of the COVID-19 testing and dates when the residents had been determined to be COVID-19 positive. The information on the document included, but was not limited to: -Resident D: The resident had been tested on [DATE], due to cough. Positive results had been received on 4/7/20. The resident had been initially placed on the 300 hall and had been transferred to the dementia unit on 4/11/20. The resident had been placed into a room with another COVID-19 positive resident (Resident E). -Resident E: The resident had been tested on [DATE], due to change in Activities of Daily Living (ADL) status. Positive results had been received on 4/9/20. The resident had been initially placed on the 300 hall and had been transferred to the dementia unit on 4/11/20. The resident had been placed into a room with another COVID-19 positive resident (Resident D). -Resident F: The resident had been tested on [DATE], due to complaint of sore throat. Positive results had been received on 4/10/20. The resident already resided on the dementia care unit, with a COVID-19 positive resident (Resident G). -Resident G: The resident had been tested on [DATE], due to her roommate's complaint of sore throat and the roommate being tested . Positive results had been received on 4/10/20. The resident already resided on the dementia care unit, with a COVID-19 positive resident (Resident F). -Resident C: The resident had been tested on [DATE], due to a family request. Positive results had been received on 4/11/20. The resident had been initially placed on the 300 hall and had been transferred to the dementia unit on 4/11/20. The resident had been placed into a room on the dementia unit with Resident B, who was asymptomatic. -Resident H: The resident had been tested on [DATE], due to cough and change in ADL status. Positive results had been received on 4/14/20. The resident was moved from his room on the 100 hall to the dementia unit on 4/14/20. The resident had been placed into a room on the dementia unit with Resident K, who was asymptomatic. -Resident J: This resident's name did not appear on the document. According to the ED, the resident had transferred from a sister facility. The resident had been determined positive for the COVID-19 infection prior to being transferred. The resident required [MEDICAL TREATMENT], and the [MEDICAL TREATMENT] unit he had used prior to the transfer had refused to serve him due to his COVID-19 positive status. He was approved for [MEDICAL TREATMENT] in the area of the facility and had been transferred and had been placed on the dementia unit in a room by himself. During an observation of the 200 hall dementia unit on 4/17/20 from 4:20 p.m. to 4:50 p.m., Resident B's and Resident C's names were observed on a room with a droplet isolation sign on the door. Resident K's and Resident H's names were also observed on a room with a droplet isolation sign on the door. During an observation of the 200 hall dementia unit and interview on 4/17/20 at 4:35 p.m., the Nurse Consultant came out of a room with a droplet isolation sign on the door wearing a gown and mask. She indicated she had taken her gloves off and washed her hands before exiting the room. She had not removed her gown because they were wearing the same gown to all positive rooms then changing into a new gown and mask before entering a negative person's room. She indicated staff was changing gowns for non positive resident rooms to preserve gowns. However, she was leaving the unit, so she would be doffing her PPE. Nurse Consultant was observed to go into a staff-only room next to the nurse's station and doff gown and wash hands. The CDC (Center for Disease Control) guidance for Use of PPE (personal protective equipment) when caring for Patients with a Confirmed or Suspected COVID-19 was reviewed. The removal of PPE guidance included, but was not limited to: 1. Remove gloves. 2. Remove gown. 3. Healthcare provider may now exit room. 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove respirator. 7. Perform hand hygiene. 1. On 4/17/20 at 5:10 p.m. Resident B's record was reviewed. A form titled, Admission Record, printed 4/17/20, indicated Resident B had [DIAGNOSES REDACTED]. A physician order, dated 3/19/20, indicated check vital signs every shift for 90 days. A form titled, Weights and Vitals Summary, dated 3/25/20 to 4/17/20, indicated Resident B had temperatures below 99 degree Fahrenheit (F) except for 2 days. On 3/30/20 Resident B had a temporal artery temperature of 99 degrees F and on 4/16/20 she had a temporal artery temperature of 99.5 F. A physician order, dated 4/17/20, indicated Contact/Droplet isolation for positive COVID- 19. A physician order, dated 4/17/20, indicated check vital signs every 4 hours for 90 days. 2. On 4/17/20 at 5:15 p.m. Resident K's record was reviewed. A form titled, Admission Record, printed 4/17/20, indicated Resident K had [DIAGNOSES REDACTED]. A physician order, dated 3/19/20, indicated check vital signs every shift for 90 days. A physician order, dated 4/17/20, indicated check vital signs every 4 hours for 90 days. A physician order, dated 4/17/20, indicated Contact/Droplet isolation for exposure to COVID- 19. A form titled, Weights and Vitals Summary, dated 3/26/20 to 4/17/20, indicated Resident K had temperatures below 99 degree Fahrenheit (F) except for one day. On 4/9/20 Resident K had a temporal artery temperature of 99.1 degrees F. During an interview on 4/19/20 at 12:54 p.m., the ED indicated the remainder of the residents on the dementia unit had been tested for COVID-19 on 4/17/20, and the results of COVID-19 testing had indicated Resident B was positive for COVID-19. They had not received all of the results for the residents yet. Resident K's results were inconclusive, and the facility was going to swab them today to get results. During a telephone interview on 4/19/20 at 3:40 p.m., the ED indicated he had received a call with results for the three residents who had been inconclusive, and they were positive. The ED indicated all of the residents on the locked dementia unit were now positive for COVID-19 except for two residents. The Indiana State Department of Health (ISDH) Guidance for out-of-hospital facilities, dated 3/29/20, indicated, The following is guidance for out of hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles: .Patients/residents with known or suspected COVID-19 should be cared for in a single-person (private) room with the door closed .Patients/residents with known or suspected COVID-19 should not share bathrooms with other patients/residents. All patients/residents returning from the hospital with suspected or confirmed COVID-19 should be cared for in a private room, or cohorted with other patients of the same status in the same unit, wing, hallway, or building CDC guidance, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, on 4/17/2020, entitled, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, included the following: Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period could be considered to increase certainty that the resident is not infected. If an observation area has been created, residents in the facility who develop symptoms consistent with COVID-19 could be moved from their rooms to this location while undergoing evaluation. All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. CDC guidance, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, on 4/17/2020, entitled, Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, included the following: It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens might be housed on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should ideally not be housed in the same room as a patient with an undiagnosed respiratory infection. The immediate jeopardy that began on 4/11/20 was removed on 4/19/20 when the facility had inserviced staff, tested all residents on the dementia unit and cohorted and/or isolated residents appropriately. Noncompliance remained at the reduced scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because of the facility's need to continue to monitor. This Federal tag related to Complaints IN 612 and IN 657. 3.1-18(a)

Based on observation, record review, and interview, the facility failed to ensure weights were obtained, interventions were implemented, and the physician and resident's responsible party were notified of a severe weight loss resulting in a weight loss of 10.1 percent in 180 days (Resident B) for 1 of 3 residents reviewed for nutrition. Findings include: During an observation and interview, on 8/7/19 at 12:13 p.m., Resident B was in her room visiting with a family member who was Resident B's responsible party. Resident B's responsible party indicated she was able to see the resident had lost weight, however, she had not been notified by facility staff of any significant weight changes. At 12:15 p.m., Resident B's tray was served and included Swedish meatballs, rice, and vegetables. Resident B indicated, Oh that looks good! She picked up her fork and began feeding herself without difficulty. Resident B's record was reviewed on 8/7/19 at 11:12 a.m. A significant change Minimum Data Set (MDS) assessment, dated 6/26/19, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED]. A review of the resident's electronic record for weights indicated: 2/8/19, 150 pounds. 3/1/19, 150 pounds. 3/7/19, 149 pounds. 5/3/19, 149.3 pounds. 7/23/19, 134.2 pounds. 8/1/19, 136.7 pounds. The electronic weight record lacked documentation of weekly weights and a weight for (MONTH) and (MONTH) 2019. The record lacked documentation the resident was re-weighed in (MONTH) 2019. A weight, dated 3/26/19, of 158 pounds, was struck out as a documentation error on 5/3/19. A paper weight log, dated (MONTH) 2019, indicated the resident weighed 144.3 pounds. The log lacked documentation of what date in (MONTH) the resident was weighed. The weight was not recorded in the electronic weight record. A dietitian progress note, dated 3/27/19, indicated the resident had a significant weight gain of 5.3 percent in 30 days and 10.5 percent in 180 days. The resident had shown weight gain since the weight on 3/1/19. The resident was hospitalized from [DATE] to 3/26/19, and received intravenous (IV) fluids. Some of the weight gain may be fluid related. Recommended weekly weights for four weeks related to the eight pound weight gain. A dietitian progress note, dated 7/26/19, indicated the resident had a significant weight loss of 10.1 percent from 5/3/19 at 134.2 pounds, and 1/3/19 at 144.4 pounds. Recommended Med Pass 90 ml three times a day for 30 days. Progress notes, dated 3/1/19 to 8/7/19, lacked documentation the resident's weight on 3/26/19 of 158 pounds, was inaccurate or the resident had refused to be weighed at any time. Progress notes, dated 3/1/19 to 8/7/19, lacked documentation the physician or resident's responsible party were notified of the resident's significant weight loss. A physician's orders [REDACTED]. This was 6 days after the recommendation was made. A care plan, last revised 8/7/19, indicated the resident had a nutritional problem or potential nutritional problem related to dementia. Weight on 3/27/19, showed a weight gain of 5.3 percent since 3/1/19. Resident received IV fluids, weight fluctuation anticipated. Weight on 7/26/19, showed a weight loss of 10.1 percent since 5/3/19. Resident noted to leave 25 percent or more of most meals uneaten. Weight on 8/7/19, showed a weight loss of 8.4 percent since 5/3/19 and a loss of 10.5 percent since 2/8/19. Interventions included, but were not limited to, observe and report to the physician any significant weight loss and provide and serve supplements as ordered. The care plan lacked documentation of any updates when the weight, dated 3/26/19, was determined to be inaccurate. During an interview, on 8/7/19 at 11:50 a.m., the Interim Director of Nursing (DON) indicated if the resident refused to be weighed, it should have been documented in the progress notes. Physician and responsible party notification of significant weight changes should have been documented in the progress notes. During an interview, on 8/7/19 at 1:50 p.m., the Interim DON indicated the resident was weighed in (MONTH) 2019, but the weight was not entered into the electronic record. She was unable to find any documentation the resident's physician or responsible party were notified of the resident's significant weight loss. They should have been notified. During an interview, on 8/7/19 at 2:17 p.m., the Registered Dietitian (RD) indicated the nursing staff should have obtained weekly weights and put them into the electronic record when they had been requested. RD recommendations should have been addressed within 72 hours. When the RD reviewed weights, she ran a report in the electronic record. If a resident did not appear on the significant weight change report, she would assume they had not had a significant weight change. If a resident's weight was not put into the electronic record, a significant weight change could have been missed. When a resident experienced a significant weight change, the physician and resident's responsible party should have been notified. The two-cal Med Pass should have been put in place within 72 hours of the recommendation. She thought the resident had a significant weight gain on 3/27/19 because the weight indicated that at the time. She did not currently think the resident experienced a significant weight gain in (MONTH) 2019 because the weight had been struck out from the electronic record. During an interview, on 8/7/19 at 3:00 p.m., the interim DON indicated she was unable to find any documentation weekly weights were completed for four weeks after they were requested by the RD on 3/27/19. On 8/8/19 at 9:50 a.m., the RD provided a document titled, Nutrition Intervention Program Manual, and indicated it was the policy currently being used by the facility. The policy indicated, For evaluation weight changes: Weight variances are reviewed for residents with a 5% weight change in 30 days, 7.5% weight change in 90 days, and 10% weight change in 180 days. This includes gain or loss .Any resident who experiences an unplanned weight loss, significant weight change, or undesirable weight change. Notification will be made to the physician and responsible party .Weight monitoring .Standard: The facility has a process in place to obtain, record, and track residents' weights and ensure accuracy. Accurate height and weight measurements are the most reliable, inexpensive, quick, and specific indicators of malnutrition in older adult population. Practice Guidelines: .All residents, with the exception of new admissions and new enterals, are weighed monthly unless their condition indicates more frequent weighing .Weekly weights are obtained for the following residents: .Any other resident identified by the RAR Committee who requires a weekly weight .The criteria for reweighs are as follows. A reweigh is obtained when a resident's weight varies by 5 lbs. in a month or 3 lbs. in a weekly of bimonthly weight .4. If follow up is required after the RD completes the assessment, he or she uses the Nutrition Assessment Recommendations form .d. Recommendations are addressed in a timely manner (within 72 hours) 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to prevent a fall resulting in a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) involving the right temporoparietal (area of the brain where the temporal and parietal lobes meet) (Resident 29), failed to ensure an intervention was in place for a previous fall (Resident 80), and failed to complete a full investigation for a resident reported fall (Resident 98) for 3 of 4 residents reviewed for accidents. Findings include: 1. On 9/26/18 at 8:53 a.m., Resident 29 was observed up in her wheelchair in the dining room, with a dressing to her forehead. Resident 29's record was reviewed on 9/26/18 at 11:56 a.m. An annual Minimum Data Set (MDS) assessment, dated 6/8/18, indicated the resident had a severe cognitive impairment for daily decision making. The resident was totally dependent upon two staff members for transfers. [DIAGNOSES REDACTED]. A care plan, dated 6/26/18, indicated the resident had an activities of daily living (ADL) self performance deficit related to dementia and required assistance with transfers. Interventions included, but were not limited to, the resident required a hoyer (mechanical) lift with two staff member assistance for transfers. A care plan, dated 6/26/18, indicated the resident was at risk for falls. Interventions included, but were not limited to, assist with ADL's as needed. A nursing progress note, dated 8/22/18 at 7:00 a.m., indicated the resident was on the floor and bleeding from the head and right hand. A laceration (a deep cut or tear in the skin) was noted on the head and the right hand. The Certified Nursing Assistant (CNA) stated she transferred the resident from her bed to the wheelchair, tripped on the wheelchair, and both the CNA and the resident fell . The CNA stated the resident hit her head on the floor. The nurse attempted to stop the bleeding, and wrapped the resident's head and hand. The physician was notified and ordered to send the resident to the emergency room (ER). The resident was transferred to the hospital. A nursing progress note, dated 8/23/18, indicated the interdisciplinary team (IDT) met and reviewed the fall with injury. The resident was not in the facility and had been admitted to the hospital. Staff members were educated on transfers and gait belt (a device used for transfers) use. A nursing progress note, dated 8/24/18, indicated the resident was readmitted to the facility at 2:00 p.m., with a [DIAGNOSES REDACTED]. A comuted tomography (CT) scan of the head, dated 8/22/18, indicated the scan was completed post trauma, dropped from bed. The impression was a subarachnoid hemorrhage involving the right temporoparietal sulcus. A hospital discharge instructions form, dated 8/24/18, indicated the resident's [DIAGNOSES REDACTED]. A physician's nursing home re-admission progress note, dated 8/24/18, indicated the resident was transferred to the hospital due to an accident in the facility. The CNA attempted to transfer the resident from bed to wheelchair and tripped on the wheelchair. The CNA and the resident fell , and the CNA stated the resident hit her head on the floor. The resident was bleeding from the forehead and was sent to the emergency room . The [DIAGNOSES REDACTED]. The resident had numerous bruises from the fall and extensive bruises on her hands. The resident required total care for all transfers, and had an overall decline since the last visit. A fall risk assessment, dated 8/22/18, indicated the resident was at risk for falls. A physician's orders [REDACTED]. An undated care guide indicated the resident required a hoyer lift with 2 staff members for transfers. During an interview, on 9/26/18 at 2:06 p.m., Registered Nurse (RN) 35 indicated the resident transferred with a mechanical hoyer lift. During an interview, on 9/26/18 at 2:14 p.m., Licensed Practical Nurse (LPN) 34 indicated the resident had not fallen before the fall on 8/22/18. The resident had required a mechanical hoyer lift since her admission to the facility. A new CNA had attempted to transfer the resident, made a mistake, and had not used the lift. CNA's were notified of residents' transfer status on the care guides. The care guide indicated this resident should have been transferred with a mechanical hoyer lift. The CNA's were provided training on where to find transfer information during orientation. This CNA had not used the information. The CNA attempted a stand and pivot transfer, and had not used a gait belt. The CNA and the resident fell , and the resident hit her head on the floor. The resident was sent to the ER. The fall resulted in a subarachnoid hemorrhage. The CNA was suspended, and was allowed to return to work with further training. On 9/26/18 at 1:13 p.m., the Director of Nursing (DON) provided a document titled, FALL MANAGEMENT, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. Pertinent Regulatory Requirements: Based on comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the patient's choice. The patient environment remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents On 9/27/18 at 8:46 a.m., the DON provided a document titled, Mechanical Lift Use, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: The purpose of this procedure is to help lift residents using a mechanical lifting device. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident .General Guidelines: .2. Staff will be competent in how to use a mechanical lifting device. 3. Two (2) persons are required to perform this procedure 2. Resident 80's record was reviewed on 9/25/18 at 2:39 p.m. A significant change Minimum Data Set (MDS) assessment, dated 8/7/18, indicated the resident had a severe cognitive impairment. [DIAGNOSES REDACTED].(a broken bone that does not go through the skin) with routine healing. A nursing progress note, dated 7/25/18 at 9:40 p.m., indicated the nurse walked down the hall and heard the resident screaming for help. The resident was lying on her right side holding onto her left hip and yelled, I'm in so much pain! The resident was sent to the hospital. A nursing progress note, dated 7/26/18, indicated the resident was admitted to the hospital with [REDACTED]. A fall risk assessment, dated 7/31/18, indicated the resident was at risk for falls. A nursing progress note, dated 8/1/18, indicated the resident was re-admitted to the facility on [DATE], with a new fall intervention of anti-rollbacks (a device that prevents the wheelchair from rolling back when a resident stands up) to the wheelchair. A care plan, dated 8/1/18, indicated the resident had an actual fall with fracture related to poor balance, poor communication and comprehension, unsteady gait when transferring from bed to wheelchair. Interventions included, but were not limited to, anti-rollbacks to wheelchair. On 9/26/18 at 10:41 a.m., the resident was observed in her wheelchair, in her room, no anti-rollbacks were in place. On 9/26/18 at 10:42 a.m., Certified Nursing Assistant (CNA) 32 observed the resident up in her wheelchair and indicated there were no anti-rollbacks in place. During an interview, on 9/26/18 at 10:57 a.m., the Director of Nursing (DON) indicated the resident attempted to transfer herself from her bed to the wheelchair and fell . The intervention to prevent another fall was anti-rollbacks to the wheelchair. The anti-rollbacks should have been placed on the wheelchair. On 9/26/18 at 11:11 a.m., the DON observed the resident up in her wheelchair and indicated there were no anti-rollbacks in place. She was not sure why they had not been put on the wheelchair. On 9/26/18 at 1:13 p.m., the DON provided a document titled, FALL MANAGEMENT, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators .Pertinent Regulatory Requirements: .Based on comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the patients' choice. The patient environment remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents .Policy: .An individualized fall management care plan will be developed and initiated upon ALL patient admissions and readmissions 3. On 9/24/18 at 11:58 a.m., during a dining observation, on the secured memory care unit, Resident 98 was observed entering the dining room with 3 (three) family members. He had 2 (two) large [MEDICATION NAME] (a clear adhesive bandage) dressings on his left arm. The first one on the upper arm, and a second one on the lower arm. There was dark liquid and torn skin visible under the dressings. On 9/25/18 at 10:42 a.m., during an interview, a family member indicated, Resident 98 had fallen on Friday (9/21/18) and family was not notified. They came in to visit on Monday (9/24/18), and inquired about the injuries seen on his arms. They spoke to the nurse and she could not find any documentation in the chart, to explain the injuries. During the interview, Resident 98 was lying on his bed, watching TV (television). He would say a few words when spoken to, but was unable to carry on a conversation. His responses indicated he was not alert and oriented. On 9/27/18 at 9:35 a.m., the medical record for Resident 98 was reviewed. His [DIAGNOSES REDACTED]. A review of Resident 98's MDS (Minimum Data Set) assessment, dated 9/20/18 indicated, a BIMS (Brief Interview for Mental Status) score of four (4 out of 15) and a score of 0-7 indicated severe cognitive impairment. A Social Service progress note, dated 8/13/18, indicated, a care plan meeting had been held. Resident 98 was invited but did not attend due to confusion and cognition. A family member, therapy, the business office, and Social Service attended. Therapy indicated the Resident was doing well physically but recommendation was for care 24/7 due to cognition. On 9/22/18 at 8:04 a.m., RN (Registered Nurse) 45 indicated, in a nurse's note, Reapplied dressing to forearm and wrest (sic) due to spoilage (sic) and dislodgement. A physician's orders [REDACTED]. Leave in place for 14 days and monitor every shift for placement. Then reassess in 14 days. On 9/23/18 at 3:21 p.m., LPN (Licensed Practical Nurse) 46 indicated, in a progress note, monitoring skin tears to left forearm and left wrist area, dressings in place with no breakthrough drainage seen, denies any pain to extremities at this time, stated to writer, they happened from previous fall a few days ago, will continue to monitor changes. On 9/24/18 at 1:19 p.m., the Weekend Manager, LPN 17, indicated, in a nursing progress note, with effective date 9/22/18 at 1:02 p.m., late entry: Writer received report from N[NAME] (night) nurse that resident dressings to left forearm and wrist skin tears were changed on N[NAME] shift, related to soilage and drainage. Resident alert to self with confusion . On 9/24/18 at 1:00 p.m. (created date) , the TAR (treatment administration record) indicated, order date 9/23/18 at 12:49 p.m., [MEDICATION NAME] absorbent dressing. Created by LPN 17. On 9/25/18 at 2:15 p.m., in a progress note, with effective date 9/22/18 at 2:11 p.m., the DON (Director of Nurses) indicated, Late entry: S/T (skin tear) noticed by Noc nurse. When asked resident what happened told nurse he fell . [MEDICATION NAME] was placed on arm. Day shift nurse did a complete head to toe assessment and no other injuries noted. When writer went to clarify about fall (bc (sic) it was unwitnessed) writer asked resident what happened resident showed writer that he stood up and faced toward the bed , showed me how his leg kind of gave out and he fell hitting his arm on the chair beside him. He stated he did not have any socks or shoes on. On 9/27/18 at 10:32 a.m., during an interview, the DON indicated, it was an unwitnessed fall between Friday night, and Saturday day shift. LPN 17 , the weekend unit manager had talked to him (the resident) on Saturday. The DON talked to him on Monday. She (the DON) talked to POA (power of attorney) on Monday, when she came to visit and asked about the Resident's arm. The family should have been notified by the next morning, as it was not a major injury, Major injuries should be called within 2 hours. The physician was notified, but documentation would have to checked to determine when that occurred. On 9/27/18 at 11:48 a.m., the DON provided copies of the physician's telephone order, dated 9/22/18 and the TAR (treatment administration record), dated 9/23/18 (created 9/24/18 at 1:00 p.m.). In an interview she indicated LPN 17 made a mistake when she dated the TAR 9/23/18. She should have dated it 9/22/18, to match the date on the order, when she created it on 9/24/18. The nursing note created by RN 45 was the first documentation in the chart, she didn't know why he charted he reapplied the dressing, but she believed that was the initial dressing, she has not had a chance to talk with him (RN 45) yet, about the incident. There was not any documentation of when the fall actually occurred, or a description of the injuries at that time. A complete assessment, at the time of the incident had not been documented. On 9/28/18 at 1:59 p.m., during an interview, the DON indicated, a full investigation and incident report was not done because it was a self reported fall. An incident report was not required. She still had not spoken to the nurse, RN 45, who did the first documentation of a dressing change, she had left a message for him. On 10/02/18 at 9:43 a.m., during a telephone interview, RN 45 indicated, he worked the night shift on Friday, 9/21/18. Resident 98 did not fall during that shift, he went to resident 98's room, to check on him, he was asleep in his bed. He had wounds on his left arm. They were old wounds, they were not bleeding, it was dry. There was some old dried blood on his arm. There was an old dirty [MEDICATION NAME] dressing in the trash can. The resident could not tell him how it got there (if the resident had removed it). When asked what happened the resident indicated he fell in the bathroom, yesterday. He said,She picked me up off the floor in the bathroom. RN 45 did not know who the resident was referring to. The resident was confused and unable to identify who she was. They did not do a bedside report, when he came on shift. The nurses did report in the Nurses' Station, so the new shift staff didn't see anyone there until they checked on them, during rounds. RN 45 indicated he put a dressing on Resident 98's left arm, 2 tegederm dressings to cover the upper arm and wrist areas, and he documented it in the progress note, and told the Weekend Manager about it. On 9/28/18 at 11:06 a.m., LPN 16 provided a current policy, dated 11/16, titled Fall Management. This policy indicated, .to promote patient safety and reduce falls by proactively identifying, care planning and monitoring of patients' fall indicators .Based on comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patient's choice .The patient environment remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents .With the event of a patient fall, a complete nursing assessment will be performed by the nurse. The nurse will communicate with other associates and caregivers regarding patient's fall event, assessment findings and fall indicators . 3.1-45(a)(2)

Based on observation, record review and interview the facility failed to avoid use of adaptive equipment known to cause a pressure area to the foot, resulting in a stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) for 1 of 3 residents reviewed for pressure ulcers. (Resident 63) Findings include: During observation on 6/18/14 at 10:27 a.m., the wound nurse provided a treatment to Resident #63's right outer ankle and right lateral foot. During interview of the "Wound Nurse" on 6/16/14 at 1 p.m., the nurse indicated the resident's two pressure areas on the right foot were caused by a boot that had been placed on the resident's foot. The wound nurse indicated the boot had been implemented in May of 2013, from a therapy recommendation, hoping to improve the contracture of the resident's right foot and that the boot had caused pressure areas to the resident's foot and the boot was removed. The nurse indicated the wounds healed, however on April 30th, 2014 the boot was placed back in the resident's room, and a CNA placed the boot on the resident. The resident was then taken out for a Physician's appointment and was out of the facility for several hours and when returned, the boot was removed and two pressure areas were observed on the resident's right foot. During interview of the DON (Director of Nursing) on 6/19/14 at 9:30 a.m., the DON indicated when the boot was discontinued in May of 2013, the boot was placed in the unit manager's office. When the unit manager was cleaning her office, she placed the boot back in therapy. The DON indicated on, 4/30/14, the boot was placed back in the resident's room. The DON indicated she wasn't sure how the boot was removed from the therapy department and ended up back in the resident's room. The DON indicated the CNA caring for the resident on 4/30/14, was a new employee. Resident #63's clinical record was reviewed on 6/18/14 at 10:44 a.m. A NP's (nurse practitioner) progress note, dated 4/30/14, indicated "Nursing requested visit (due to) OA (open area) found on (right ankle) today. Has been wearing shoe to foot this week. Hx (history) of OA (open area) (with)[MEDICAL CONDITIONS] to same area." (R) (Right) ankle OA with yellow slough and area of black eschar 4 X 2 cm (centimeter) plus serous d/c (discharge). (R) (right) Lat (lateral) foot 2 x 1 cm (centimeter) area of hyperpigmentation. Review of a form titled "Pressure Ulcer Status Record", documentation on, 5/6/14, indicated the resident's open area on the right lateral foot was unstageable and measured 1.0 cm x 2.0 cm. Documentation on, 6/7/14, indicated the area was a stage 3 measuring 0.3 cm x 0.7 cm with 0.1 cm depth. An "IU (Indiana University) Geriatrics Subsequent Visit Form", dated 6/12/14, had a NP (Nurse Practitioner) progress note indicating, "PU (pressure ulcer) (stage) 3 (R) right ankle-improving. Continue with dressing change orders and pressure relief. A policy and procedure titled "Pressure Ulcer Prevention Program Overview" dated, 10/07/2010, received on 6/19/14 at 11:20 a.m. from the Administrator, indicated, but was not limited to, "Follow the residents' care plans and update as necessary." This federal tag relates to complaint IN 427. 3.1-40(a)(1)